Disappearing Text as a Clinical Decision Support Layer: A Case Series

Abstract

Objectives

This case series aims to evaluate several applications of inline disappearing text (DT) clinical decision support (CDS) tools within clinician documentation.

Methods

DT blocks were created to prompt documentation for perioperative anticoagulation planning (scenario 1), predischarge intravenous antibiotic planning (scenario 2), and advanced care planning (ACP; scenario 3). In scenario 1, DT was the only intervention. In scenario 2, DT was paired with a documentation SmartList. In scenario 3, DT was paired with a documentation SmartList and an OurPractice advisory. The number of documented perioperative anticoagulation plans, predischarge intravenous antibiotic plans, and ACP notes was measured pre- and postintervention and compared using chi-square analyses.

Results

In scenario 1, there was no statistically significant change in the percentage of perioperative anticoagulation plans documented at 0 to 24 and 24 to 48 hours before surgery. In scenario 2, documentation of antibiotic contingency planning in patients expected to be discharged within 24 hours increased from 60% (54/90 notes) to 93% (1,850/1,994 notes) X ² (1, n = 2,084) = 113.1, p < 0.001. In scenario 3, ACP note documentation by discharge in patients with a positive mandatory surprise question increased from 43% (821/1,909 encounters) to 52% (975/1,874 encounters) X ² (1, n = 3,783) = 30.5, p < 0.001.

Conclusion

Utilizing DT in conjunction with other forms of CDS was associated with an improvement of documentation quality in predischarge IV antibiotics and ACP. A sociotechnical analysis explores how interactions between technology, people, workflow, and culture could contextualize how utilizing DT with other forms of CDS was more effective than DT alone.

Keywords

clinical decision support - socio-technical aspects of information technology - clinical documentation and communications - inpatient care - human–computer interaction

Authors' Contributions

All authors contributed to the conception and design of the work and final drafting of the document.

Publication History

Received: 27 May 2025

Accepted: 03 August 2025

Accepted Manuscript online:
05 August 2025

Article published online:
17 September 2025

• References

• 1 Kwan JL, Lo L, Ferguson J. et al. Computerised clinical decision support systems and absolute improvements in care: meta-analysis of controlled clinical trials. BMJ 2020; 370: m3216
• 2 Bright TJ, Wong A, Dhurjati R. et al. Effect of clinical decision-support systems: a systematic review. Ann Intern Med 2012; 157 (01) 29-43
• 3 Chakravartty E, Silberlust J, Blecker S. et al. Clinical decision support leveraging health information exchange improves concordance with patient's resuscitation orders and end-of-life wishes. Appl Clin Inform 2025;
• 4 Dunn Lopez K, Gephart SM, Raszewski R, Sousa V, Shehorn LE, Abraham J. Integrative review of clinical decision support for registered nurses in acute care settings. J Am Med Inform Assoc 2017; 24 (02) 441-450
• 5 Gani I, Litchfield I, Shukla D, Delanerolle G, Cockburn N, Pathmanathan A. Understanding “alert fatigue” in primary care: qualitative systematic review of general practitioners attitudes and experiences of clinical alerts, prompts, and reminders. J Med Internet Res 2025; 27: e62763
• 6 Cecil E, Dewa LH, Ma R, Majeed A, Aylin P. General practitioner and nurse practitioner attitudes towards electronic reminders in primary care: a qualitative analysis. BMJ Open 2021; 11 (07) e045050
• 7 Ancker JS, Edwards A, Nosal S, Hauser D, Mauer E, Kaushal R. with the HITEC Investigators. Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system. BMC Med Inform Decis Mak 2017; 17 (01) 36
• 8 Gardner RL, Cooper E, Haskell J. et al. Physician stress and burnout: the impact of health information technology. J Am Med Inform Assoc 2019; 26 (02) 106-114
• 9 Chong AZ, Lee B, Hollenbach K, Kuelbs CL. Disappearing help text: implementing a note-based tool for in-line clinical decision support and note bloat reduction. Appl Clin Inform 2022; 13 (05) 1033-1039
• 10 Martin TB, Bell DS, Gornbein JA, Lukac PJ. Optimizing resident charge capture with disappearing help text in note templates. Appl Clin Inform 2025; 16 (02) 267-274
• 11 Singh H, Sittig DF. A sociotechnical framework for safety-related electronic health record research reporting: the SAFER reporting framework. Ann Intern Med 2020; 172 (11) S92-S100
• 12 Jeffries M, Salema NE, Laing L. et al. Using sociotechnical theory to understand medication safety work in primary care and prescribers' use of clinical decision support: a qualitative study. BMJ Open 2023; 13 (04) e068798