The 2024 Nudges in Health Care Symposium will take place September 26–27 in Philadelphia. Learn more and register

Active Choice to Increase Flu Vaccination Throughout the Day

Active Choice to Increase Flu Vaccination Throughout the Day

Project status

Pilot/study with results


Susan Day, MD, MPH 

Dylan Small, PhD

Innovation leads


The influenza (flu) virus contributes significantly to morbidity and mortality each year. Although the vaccine has been shown to effectively reduce disease and economic burdens, vaccination rates remain low at under 50 percent nationally. 


A quality improvement study conducted by our team revealed that flu vaccination rates dropped significantly throughout the day at 11 Penn Medicine primary care clinics – from 44 percent at 8 AM to 32 percent at 4 PM.  

In the third year of this study, we implemented a nudge in the electronic health record (EHR) at three of the clinics that prompted medical assistants to ask eligible patients about flu vaccination during check-in and template vaccination orders for clinicians to review during visits.  


The active choice intervention was associated with a 9 percent increase in vaccination rates, which was nearly a 20 percent relative increase compared to practices with no intervention. In addition, vaccination rates increased similarly across times of the day. 

This research builds off a 2017 study by our team, which found that an active choice nudge to physicians significantly increased order rates for the flu vaccine.