Special Issue on CDS Failures: Redesigning Clinical Decision Support for Retinopathy of Prematurity Screening After Alert Failure

Background: Retinopathy of prematurity (ROP) is the leading cause of preventable childhood blindness. Guidelines recommend screening for infants with gestational age at birth < 31 weeks or birthweight ≤ 1500g. However, ensuring timely screening during readmissions after birth is challenging. Objectives: To analyze the performance of an interruptive alert at a large academic pediatric hospital for identifying premature infants needing ROP screening upon hospital readmission and to describe how data informed the transition to a non-interruptive dashboard. Methods: The alert appeared for patients 1-365 days of age hospitalized in acute care or pediatric intensive care and instructed providers to order an ophthalmology consult from within the alert and to call ophthalmology for at-risk patients. For quality improvement, the clinical decision support (CDS) advisory group evaluated the effectiveness and efficiency of the alert. We exacted alert metrics from the hospital's enterprise data warehouse, including the user response and feedback, patient characteristics (age, birth gestational age, and birth weight), and any ophthalmology consultations. We analyzed the percentage of encounters seen by ophthalmology using a statistical process control chart during alert implementation and 6 months before and after. Results: The alert appeared 3309 times during 2194 patient encounters usually. Users chose "Accept and place order" for 43% (943/2194) of encounters, but only 11% (102/943) had an ophthalmology consult; 34% (53/155) of ophthalmology consultations occurred in encounters with a final response other than "Accept and place order". The intervention was redesigned using a non-interruptive surveillance dashboard with greater specificity, and the alert was deimplemented. Conclusions: Analysis of a failed interruptive alert for identifying patients at risk for ROP led to a transition to targeted surveillance using a dashboard. This case emphasizes the importance of aligning the CDS modality to the clinical workflow, information availability, and user decision-making needs and should be supported by governance.

Publication History

Received: 31 December 2024

Accepted after revision: 24 April 2025

Accepted Manuscript online:
25 April 2025