Electronic Health Record Integration of a Calculator for Cesarean Risk During Labor Induction

Our group developed a calculator to predict individualized likelihood of cesarean delivery for patients undergoing labor induction. We aimed to determine whether nudge theory informed EHR integration of the cesarean risk calculator would increase (1) calculator utilization, and (2) documentation of patient counseling on the result.

This was a prospective cohort comparing 6 months pre (10/2022-4/2023) versus 6 months post EHR-release of the cesarean risk calculator (4/2023-10/2023) in two labor units. Prior to EHR-integration, Site #1 had a 2018 focused effort towards calculator website use, while Site #2 had no previous use. EHR-integration was automated to recognize eligible patients and allowed clinicians to confirm and utilize EHR variables for score automation, visible on electronic display. Counseling recommendations, specific to the patient's cesarean risk level, were then available for insertion into an EHR-note. The primary outcomes were (1) calculator utilization measured as a score generated in the EHR and (2) risk counseling defined as documentation of score discussion with the patient. The primary outcomes were also analyzed stratified by site.

A total of 2018 patients met eligibility criteria for the cesarean risk calculator (pre:998; post:1010). Clinician calculator utilization significantly increased POST-EHR implementation from 13.4% to 77.4% (p < 0.001). Site #2, without a prior effort towards calculator use, had greater increase in use with EHR integration compared to Site #1 (Site#1 pre: 28.8% vs. post: 62.3%, p < 0.001; Site#2 pre: 0.4% vs. post: 91.8%, p < 0.001). Documentation of patient counseling also increased overall (4.0% vs. 9.9%, p < 0.001); when stratified by site, this difference was only seen at Site #2.

Behaviorally designed EHR integration of a cesarean risk calculator for labor induction was associated with significant increases in calculator utilization and documentation of patient counseling. This model could be applied to other evidence-based health-related risk calculators.