Change Management in Practice: Using Choice Architecture to Ensure Workflow

This post is taken from a scholarly presentation submission at SIIM 2016 by Mark Watts, VP of Enterprise Imaging Solutions at Novarad. This post includes only the text portion. To see the abstract on SIIM’s website, click here.


Choice architecture, as proposed by Richard Thaler and Cass Sunstein in the book Nudge, Improving Decisions About Health, Wealth, and Happiness, can be used to positively influence change management in healthcare IT implementation and support.


The success and return on investment (ROI) of an IT solution is based on the effective use of that solution. Although it may be considered effective from a technical perspective, a solution may not be well-received or properly implemented. IT implementations can answer who should do what and when, but if the choice architect neglects to address the why (and does not create a choice architecture that influences the decisions made by the end user), participating parties will fall back into old workflows or work around the newly implemented product.

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The term “choice architecture” refers to the framework in which choices are made. For example, if your friend is looking for a good doctor and you make a recommendation that could influence that choice, you have become a choice architect for their decision.


The method to test this hypothesis was a systematic comparison of EKG management system deployment at different hospitals within the IASIS Healthcare System. Error rates (instances of EKG not in the system vs. ordered by doctors) were measured and adjustments made to positively influence implementation of management systems. Post-choice architecture implementation method error rates at problem sties were then compared with those at subsequent installs.

This project was part of a standardization initiative to reduce the length of stay caused by a delay in cardiologists signing off on EKG exams. The CPACS administrator at each facility was given instruction to train all necessary site personnel. Each administrator was given the same training through a standardized PowerPoint presentation and accompanying explanation of his or her responsibility as a trainer and the proper workflow to follow.

The 19-hospital chain had success in its first two EKG sites; however, a third site failed to adjust to new workflow for the IT solution. The failed third site had reported missing EKG exams from the system. A follow-up evaluation of the site found over 600 orphaned exams, completed by the technician but not placed into the EKG system. A follow-up evaluation of the other two hospital sites confirmed that they were not experiencing the same problem. No error in the technical solution was found.

Although the same trainer education method and teaching material was used at the third site as at the first two, the error rate at the third site was tracked and proved to be a general pattern for all end users. A review of the trainer’s instructions showed that the workflow information had been given clearly and consistently with the first two sites. When the end user followed the workflow as taught, the system worked perfectly.

Image Credit: Shutterstock

The discrepancy between the third site and the first two was the way in which end users were employing the new IT solution. They were not using it in the intended manner frequently enough to make a difference–specifically, these users were not placing an order for exams, which had been deemed a necessary part of tracking studies and ensuring they made it into the medical record. The challenge was then to find a way to help them choose the correct workflow each time, starting with why the error was taking place, or why they were not placing order. Technicians were doing a good job up to the point of hand-off to the EKG system. The EKG system by itself would accept all data, regardless of whether or not an order had been placed. This, of course, was a different workflow than the previously used paper print-outs. The third site could not be successful unless each technician could internalize and verbalize the reason that the new EKG system supported the wellness of the patients and understood their part in getting the data in to the system. To combat this problem, a new teaching IT workflow diagram was created to help the end users find their way through the system, complete with where and why points of failure could occur. This diagram was posted on each EKG machine.

The third site’s failure to implement the IT solution proved that humans will fall back into old habits if not guided to make new, better ones. A checklist was established for the end of the shift in order to validate all ordered exams and their locations within the system. this brought accountability to the workflow by building in key points of mandated choice in the form of a required check box. If the box were to remain unchecked, the workflow would stop and the data would not be accepted. The list required that the orders be placed for the EKG before associating the image to the patient in the system, thus eliminating the majority of orphaned studies.


Error rates dropped 90 percent in three weeks after reworking the training given to the end user during the choice architecture at the problematic site and the following 16 sites did not have issues with this failure to adopt.


Healthcare needs Information Technology solutions to meet the ever-changing demands placed upon it through the advancement of new technology. This segment is littered with failed implementation due to various factors–poor design, cost, and competing resource requirements. This discussion is about the human factor in the use of a well-designed IT product. The question is: How do we get people to use the solution as designed, and how do we help them make the right decisions each time?


The success of an IT project can have a positive impact if the product deployment uses the Nudge choice architecture method. A choice architect should strive to explain who, what, when, and why of the products during training so that a system stop is not necessary, but in problem cases the architect may need to limit people’s choices.


You may view the original abstract on the SIIM website here:

#efficiency #workflow #healthcareIT #implementation #choicearchitecture #healthcare

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