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Appl Clin Inform 2025; 16(04): 1200-1207
DOI: 10.1055/a-2605-4510
Special Issue on CDS Failures

Right Idea, Wrong Time: Focusing on Alert Timing for Effective Decision Support

Authors

  • Averi E. Wilson

    1   Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, United States
    2   Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas, United States

  • Andrew P. Bain

    2   Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas, United States
    3   Department of Surgery, University of Texas Southwestern, Dallas, Texas, United States

  • Janet Webb

    1   Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, United States
    2   Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas, United States

  • Christoph U. Lehmann

    1   Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, United States
    2   Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas, United States

  • Brett Moran

    4   Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, United States
    5   Department of Clinical Informatics, Parkland Health, Dallas, Texas, United States

  • Nainesh Shah

    2   Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas, United States
    4   Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, United States
    6   Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, United States

  • Ellen O'Connell

    2   Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas, United States
    5   Department of Clinical Informatics, Parkland Health, Dallas, Texas, United States
    6   Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, United States

Funding None.
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Abstract

Background

Effective clinical decision support (CDS) interventions improve adherence to care guidelines, reduce prescribing errors, and, in some settings, decrease patient mortality. However, misalignment with the “Five Rights” framework, particularly regarding CDS timing in clinical workflows, can lead to implementation failures, alert fatigue, and physician burnout.

Objectives

This case series aimed to evaluate and redesign three interruptive CDS alerts at a large safety net health system to better align with clinician workflows, reduce interruptions, and improve compliance with care guidelines.

Methods

We analyzed three interruptive alerts using data from Epic's SlicerDicer tool, focusing on alert frequency, contributors to alert triggering, and user responses before and after intervention. Alerts were modified to improve their timing and relevance within the workflow.

Results

Modifications included retiming a human immunodeficiency virus screening alert to trigger during laboratory test orders, reducing alert firings by 87% while increasing monthly screening orders from 3,561 to 4,547 (p < 0.001). An administrative alert's firing frequency decreased by 86% through the introduction of a 4-hour lockout period, maintaining compliance rates. Finally, restricting a pediatric head circumference discrepancy alert to in-person visits only eliminated interruptions during telehealth encounters, addressing a major source of clinician frustration.

Conclusion

Aligning CDS tools with clinical workflows through adherence to the “Five Rights” framework reduces interruptions and improves outcomes. Iterative review, user feedback, and proactive redesign are essential to ensure CDS effectiveness, particularly as health care evolves to include novel care delivery models like telehealth.

Keywords

clinical decision support - alert fatigue - workflow

Protection of Human and Animal Subjects

This study was approved as nonhuman subjects research by the University of Texas Southwestern Institutional Review Board.




Publication History

Received: 13 January 2025

Accepted: 09 May 2025

Accepted Manuscript online:
13 May 2025

Article published online:
26 September 2025

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