Special Issue on CDS Failures: Qualitative Study of Inpatient Hospital Medicine Interruptive Alerts and Clinical Decision Support.

Background Though interruptive alerts, or pop-ups, are one of the most common forms of clinical decision support (CDS) tools within the electronic health record (EHR), they are often ignored. Interruptive alerts have the potential to enhance patient care and reduce clinician burden, but end-users frequently experience alert fatigue and override alerts, defeating their purpose. Few studies have elicited the perspectives of all stakeholder groups involved in the development, experience, and review of inpatient interruptive alerts in the modern vendor EHR era. Objectives To understand the perspectives of multiple stakeholders involved in development, governance, and use of inpatient interruptive alerts. Methods We conducted a qualitative study, interviewing 22 participants, including 15 end-users, four governance group members, two clinical leads, and one information systems staff member. The semi-structured interview guides were designed to explore different participant perspectives on interruptive alerts. Results We found three domains across end-users related to interruptive alert helpfulness, proportionality, and alarm fatigue. We found three domains across the governance, clinical lead, and information system groups about the causes of high volume and high sensitivity interruptive alerts, differing definitions of interruptive alert success from end-users, and reluctance to add new interruptive alerts but limited changes or retirement of existing interruptive alerts. Barriers to successful CDS could be grouped into end-user, technical, and governance-level barriers. We found one governance level facilitator and gathered several recommendations for CDS improvement from all stakeholder groups, including changing alert "interruptiveness," customizability, design, responsiveness, and involving end-users in alert analysis. Conclusions This study highlights the need for robust, user-centered alerts and CDS development and evaluation to improve clinician experiences and potentially patient outcomes.