Clinical decision support alert appropriateness: A review and proposal for improvement

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This article was derived from McCoy AB, Thomas EJ, Krousel-Wood M, and Sittig DF's "Clinical decision support alert appropriateness: A review and proposal for improvement".[1]


Most health care professionals(HCPs) are adopting EHRs with integrated clinical decision support system(CDS)[1] to improve patient safety.[2] [3] Computerized alerts that prompt clinicians about drug-allergy, drug-drug interaction, and drug-disease warnings or provide dosing guidance are most common.[4] [5] Despite promise, CDS implementation in diverse settings have not consistently improved patient outcomes.[6] [7] [8] [9] Alert overrides occur in most organizations and may be a barrier to improve patient and process outcomes[10] and detailed evaluation of the alerts abd provider responses is necessary to determine appropriateness.[11] [1] Efficient approaches to effectively evaluate alert appropriateness are necessary for optimizing patient safety.


Medication errors,which occur in 4%-6% of orders, can be prevented by computerized provider order entry(CPOE) and CDS.[12] [13] [14] [15] [16] [17] [18] CDS has reportedy contributed to substantial savings.[19] Meaningful Use(MU) objectives also require institutions to implement drug-drug interaction and drug-allergy interaction checks,and track CDS compliance.[2] Multiple CDS approaches exist,including alerts,simple guided-dosing algorithms,order sets,and complex ordering advisors.[20] [21] Alerts are implemented in 61%-78% of hospitals and included in all major commercial EHRs.[4] [5] [21] [22]


Alert overrides

Alert overrides occur in 49%-96% of alerts and is a potential barrier to success.[10] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] Studies concluded that many overrides are justifiable because of the clinical irrelevance of the alert,known patient tolerance for a drug, or documented clinician intention to monitor the patient, indicating a need for institutions to evaluate alerts to prevent alert fatigue.[23] [24] [26] [28] [31] [32] [33] [34] [35]

Alert and response appropriateness

Some alerts are inappropriate,and adhering to the alert advice cause harm to the patient. [1] Detailed evaluations of alert appropriateness are necessary to identify such undesirable,unintended consequences and to institute efforts to reduce such error.[36] [37] [38] The related evaluation methods are labor intense and difficult to replicate for every alert utilized. More efficient,semiautomated evaluation approaches are necessary to understand alert responses and overrides.

Surveillance tools for alert evaluation

Zimmerman et al.[39] displayed retrospective CDS data in a spreadsheet-based dashboard, and Reynolds et al.[40] developed a web-based,graphic dashboard to allow monitoring of order and alert volume. A real-time surveillance dashboard displayed lists of patients receiving high-risk medications,CDS interactions,and detailed patient views to clinical pharmacists to augment decision making.[41]

Methods for improving alerts

Duke and Bolchini[42] developed a model for creating context-aware drug-drug interaction alerts that allowed tailoring alert displays based on relevant patient-specific information,resulting in improved acceptance of the alerts.However,alerts deemed inappropriate in some clinical scenarios should also be suppressed.Unfortunately,there is no perfect method.


Predicting inappropriate alerts and responses

To better evaluate and improve CDS alert appropriateness, the authors first propose a retrospective chart review based alert evaluation framework to determine which alerts are relevant and which overrides are justifiable.[1] This approach aims to first identify predictors of alert and response inappropriateness,not merely alert overrides. The authors plan to develop a gold standard for the appropriateness of each alert and clinician response.

Novel metrics for predicting inappropriate alerts and responses

Integrating clinical context can increase alert inappropriateness and improve alert acceptance.[10] [42] The first variable that the authors will incorporate into the model is the indication of an alerted medication,whether entered by the clinician during e-prescribing or inferred from a previously developed knowledge bases(KBs).[43] [44] [45] Additional variables derived from these KBs will be included in the predictive models to determine if additional data improve detection of inappropriate alerts. By considering clinicians as users and alert responses as user-generated content, alert evaluators may adopt reputation metrics to identify inappropriate alerts.

Designing and implementing an interactive alert evaluation dashboard

During previous research, the authors developed a condition-specific,web-based surveillance tool that allowed clinical pharmacist,informatics personnel,and clinicians to review CDS alert responses in the context of patients at high risk of ADEs.[41] [46] They propose to develop and implement InSPECt (Interactive Surveillance Portal for Evaluating Clinical decision support),an EHR-independent dashboard that will permit further assessment of the use of surveillance in evaluating CDS implementations. InSPECt will consist of two types: the alert detail,and the patient detail. After development and validation of InSPECt are complete the authors will collaborate with CDS managers and clinicians at study sites to review alerts which may improve the rate of appropriateness,potentially reduce the rates of overrides. They will then work with other IT staff,clinician leaders,and informatics investigators to design an intervention to improve the alerts and evaluate it's effect.


Despite increased implementation of CDS alerts,detailed evaluations occur rarely.The author's proposed research introduces several innovations to address this gap. This can transform alert evaluation processes across healthcare settings,leading to improved CDS,reduced alert fatigue,and increased patient safety.


Computerized alerts are extremely common in today's healthcare but majority of them are overridden. Detailed evaluation of the alerts and the provider responses is necessary to determine appropriateness. I totally agree with the authors' thesis that alert evaluations are inadequate and their proposed innovations should improve CDS,reduce alert overrides,and improve patient safety.

Related article reviews:


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