On the alert: future priorities for alerts in clinical decision support for computerized physician order entry identified from a European workshop

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This was adopted from the Coleman JJ et al.'s article "On the alert: future priorities for alerts in clinical decision support for computerized physician order entry identified from a European workshop".[1]


Computerized physician( or provider) order entry(CPOE) and clinical decision support(CDS)[1]

CPOE systems allow users to prescribe using a computer system,reducing the risk of prescribing errors resulting from illegible handwriting or transcription errors. They also have shown to reduce medication errors and adverse drug events(ADEs) in hospitals. [2] [3] [4] [5] [6] [7] CPOE systems often have integrated CDS which has the potential to improve clinicians' decisions through guidance, alerts, and reminders. In principle, clinicians support the idea of CDS alerts in identifying and preventing erroneous or less optimal prescribing. [8] [9] [10] [11]

Alert specificity and sensitivity

In a CDS system,sensitivity is the ability of the system to alert prescribers correctly when patients are risk of experiencing drug-induced harm. The specificity of the CDS system is a measure of it's ability to distinguish between events that cause harm and non-events that will not. Safe alerting systems should have high specificity and sensitivity, present clear information, not unnecessarily disrupt workflow, and facilitate safe and efficient handling of alerts. [12]

Knowledge of alert fatigue in CDS systems

CDS alerts have the potential to cause harm to patients by occurring too frequently. [8] [9] [10] [11] In most systems, majority of the alerts are overridden. [13] [14] [15] [16] Exposure to frequent false alarms can desensitize users so that they ignore and increasingly mistrust alarms. [17] Most of the focus on reducing override rates in CDS systems considers strategies such as the customization of the third party providers' set of alerts, [18] [19] [20] [21] implementation of highly specific algorithms [15] and use of tiered severity to stratify and reduce the number of interruptive alerts.[22] [23] Other suggested strategies to counteract the alert fatigue include turning off frequently overridden alerts and directing time-dependent drug-drug interaction alerts to nurses.[24] [25] Despite various improvement strategies,alert fatigue continues to occur and frustrate users.[26] To address the issues, European experts on CDS attended a workshop in Birmingham,UK where they agreed on a consensus on the current gaps in the research and the challenges of improving alerting in CDS systems.


Researchers with a strong publication record in the field of CDS were identified and were invited to attend a two day workshop in Birmingham,UK in November 2011. The objectives of this workshop were:

  1. to identify key knowledge gaps in the study of CDS-based alerting;
  2. to identify research priorities on CDS-based alerting; and
  3. to identify research methodologies to evaluate alerts


Knowledge gaps in the study of alerts in CDS systems

  1. Sensitivity and specificity of a CDS system
  2. Presentation and personalization of alerts
  3. Timing of alerts
  4. Relevance of the outcome measures in the study of alerts
  5. Measurement of the quality of alerts
  6. Design and firing of alerts/rules
  7. Legal issues- This was discussed in a American context,[27] with particular emphasis on the liability implications of CDS with drug-drug interactions [28] [29]
  8. Human factors and usability

Important research priorities

Determine the optimum sensitivity and specificity of a CDS system in practice

A perfect CDS system would be both 100% specific and 100% sensitive. Current systems tend to have high sensitivity but low specificity.[30] Sensitivities below 100% are risky and may contribute to patient harm, especially for the most injurious events. It is important that the system is able to draw in additional information from beyond the knowledge base(KB) to increase specificity,for example through the integration of individual patient information such as lab values and co-morbidities with information on medicines.[31] [32] [33] [34] The challenge is in ensuring that drug information is accurate,comprehensive and up-to-date,whilst keeping the process manageable in terms of expertise,time and resources. One solution may be the collaborative development and sharing of KBs between countries.[35] [36] However, system quality may differ with regards to different alert categories, and differences when alerting for medications only,as opposed to a combination of medications and patient parameters.[37] [38] By comparing differences in the design of current systems,it may be possible to identify a gold standard on which to base future CPOE systems.

Determine whether personalization of alerts will reduce alert fatigue

Customization of the setting in which the system is used could provide an opportunity to eliminate inappropriate alerts and requires further evaluation. This may improve usability and receptivity of CDS alerts. Allowing individual users to personalize the interface design,like in smartphones,of CDS alerts may also reduce alert fatigue. Personalization of alerts may also be done in a automatic way based upon a user's familiarity with certain risk situations,training and expertise. For example,frequent users may require fewer alerts. The development of individualized alerts will require structured and systematic design to ensure that they are appropriately generated for each patient.

Determine whether appropriate timing of an alert within the prescribing process will reduce alert fatigue

Ideally, alerts should be displayed very early in the prescribing process. Alerting the user as early as possible and having complete information that can be integrated into a single CDS alert are not easily compatible. The authors described a grading such as:

  • prescribing absolutely absolutely contraindicated;
  • prescribe but only if certain conditions are met; and
  • prescribe where benefits outweigh harm.

New research should focus on assessing the impact of the timing and number of alerts generated during one drug prescription.

Determine the relevance of the outcome measures in evaluating alerts

  1. Patient harm: This entails identifying harm specific to the prescribing process that may be prevented by the CDS
  2. Length of stay in the hospital: Easily measured but depends on several factors other than the quality of prescribing
  3. Mortality: Easily measured but depends on several factors other than the quality of prescribing
  4. Quality measures as stated by National Quality Forum,USA [2][39]
  5. Measures of clinical improvement
  6. Medication errors [40]
  7. Costs

The correct balance needs to be established.

Research methods to evaluate alerts

Expert opinion

Expert opinions may provide information on some research gaps,such as determining which outcome is most relevant to the specific research question.

Observations(Naturalistic) studies

This involves careful observation and recording of behaviors and events in their natural setting and can be very powerful when based on strong theoretical foundations. Such studies have an important role in the study of alerts in CDS systems.An evaluation of the outcomes pre- and post-introduction of a CDS system in one setting may provide useful information in the effect of CDS alerts.

Experimental studies

These can allow for the manipulation and testing of CDS alerts in a controlled environment. This may be the most practical way to investigate the ideal level of sensitivity and specificity,as well as determining the effects of the personalization of alerts for the user. However, they may not take into account the effect of stressful working environments on the user.

Challenges to implementing research methods

The sequencing of events within the study design is important: the effectiveness of a naturalistic system depends on having a suitable audit trail and capturing the data reproducibly. Randomization and masking in experimental studies can be difficult in such circumstances. [41] There are also screen capturing problems with the naturalistic method. It would be beneficial to work with organizations that are looking to implement CPOE/CDS and monitor the steps to full implementation. One of the approaches could be a purposeful synthesis /integration of different studies leading to new insights. If supported by an expert panel,an iterative prospective study may be valuable.


Summary of findings

The authors have identified several research priorities including:

  1. the need to determine the optimal sensitivity and specificity of alerts;
  2. whether adaptation to the environment or characteristics of the user may improve alerts; and
  3. whether timing and number of alerts improves alerts.

They recommend that the reduction of alert fatigue may be possible through the integration of patient, illness and medicine information, and through the development of an alert hierarchy. Specificity can be increased without sacrificing sensitivity through integration of and linkage of solid KBs and patient parameters,using well-tailored algorithms.

Strengths and limitations of the approach

Workshop participants were experts in the use of CDS. However majority of the participants are academic researchers and other potentially relevant groups,such as CDS vendors,are not consulted.


The use of CDS systems within the CPOE is becoming an essential component of patient care. Research should be undertaken to determine whether the use of CDS alerts really improves patient outcomes,suing appropriate methodologies and appropriate outcome measures. Strategies must be developed to reduce the burden of CDS alerts without compromising patient safety.


Though very useful for patient care, CDS alerts have the potential to harm the patient by causing alert fatigue. The authors did commendable work in identifying the knowledge gap parameters and the research criteria to accomplish that,especially by improving CDS sensitivity and specificity and also improve the timing and number of alerts. Further research is advised by the authors which hopefully leads to a CDS system which has 100% sensitivity and 100% specificity.


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