Human Factors Design and Clinical Decision Support

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In 2014, JAMIA published a study conducted by Phansalkar et al. entitled Evaluation of Medication Alerts in Electronic Health Records for Compliance with Human Factors Principles. [1] The Authors assert that the propensity of clinicians to over-ride clinical decision support (CDS) alerts significantly diminishes the potential benefits of CDS, and by extension EHRs in general. They hypothesize that adherence to principles of human factors design will improve the acceptance rates of these alerts.


Using a tool previously developed by the authors and descriptively named the Instrument for Evaluating Human-Factors Principles in Medication-Related Decision Support Alerts (I-MeDeSA), the drug-drug interaction alerts of 14 EHRs were evaluated for compliance with nine human factors characteristics. Results were used to produce a recommendation for an appropriate design for alerts.

Results & Conclusion

14 EHRs received scores with a range of 8 to 18.33 on a 26 point scale. High inter-rater reliability was calculated by Cohen’s kappa value (k=0.86). EHRs were then ranked by score. Examples of recommendations included:

  • integration of corrective action recommendations with the alerts
  • linking of: ordering -> alert - > modification of the order
  • integration of an option to report a problem with the alert
  • use of color scheme to distinguish alerts by type
  • use of intuitive and familiar icons (e.g. stop sign)

The authors conclude that, based on the EHRs in the study, developers are inconsistent applying human factors principles. Further, they state that all 14 EHRs “fell short in meeting the principles of good alert design” [1]


These results are consistent with the notion that, for an EHR used by clinicians at the point of care (and specifically when ordering medications), the importance of the interface far exceeds conventional notions of “user friendly”. This study lends empirical support to importance of interface design as a matter of patient safety and quality of care.


  1. 1.0 1.1 Evaluation of Medication Alerts in Electronic Health Records for Compliance with Human Factors Principles