Purpose: Prescription medication costs represent more than 10% of American healthcare costs and are continuing to increase (CMS 2010). Substituting generic drugs in place of brand-name ones would result in considerable cost savings. Generics also have lower out-of-pocket expenses for patients and are associated with better adherence. Point-of-care electronic decision support in electronic health records (EHR) could affect clinician prescribing patterns. This study, however, is designed to evaluate a much simpler health information technology intervention, i.e., a user interface redesign.
Method: At our institution, the electronic prescribing interface was redesigned so that all medication searches defaulted to a generic equivalent if available, even if the provider had searched using a brand name. However, providers still had the option of selecting the brand medication through one extra mouse-click. In many domains, setting one option as the default markedly increases the chance it will be chosen (Johnson and Goldstein, Science2003). To determine whether this default setting would have as strong an effect among physicians in a practice setting, we conducted a retrospective before-after study of new outpatient prescriptions written during the year before and the year after the redesign.
Result: 886 clinicians wrote nearly 1 million new prescriptions during the two years. Generics made up 28.2% of newly prescribed medications before the change, more than doubling (65.2%) after the redesign. Only 2.1% of medications with generic equivalents were still prescribed as brands. The large increase in generic prescribing remained in regression models of the pre-post change that controlled for patient characteristics.
Conclusion: A relatively simple interface change led to a dramatic change in physician decision-making about generic drugs. Generic names are generally difficult to recall compared to strategically named, marketed and memorable brand-name drugs.The simple user interface redesign removed the onus of memorizing tedious generic names and offered a seamless workflow, steering clinicians towards generic equivalents. Further refinements are needed to ensure that physicians are not directed toward the generic option when it is less than appropriate, for example, when the generic has a narrower therapeutic index than the brand option. Such well-designed “choice environments” (Thaler and Sunstein 2008) can facilitate optimal choices without adding the cognitive burden or distractions that are typically associated with electronic decision support alerts.