title: A framework for evaluating the appropriateness of clinical decision support alerts and responses.
abstract: OBJECTIVE
  Alerting systems, a type of clinical decision support, are increasingly prevalent in healthcare, yet few studies have concurrently measured the appropriateness of alerts with provider responses to alerts. Recent reports of suboptimal alert system design and implementation highlight the need for better evaluation to inform future designs. The authors present a comprehensive framework for evaluating the clinical appropriateness of synchronous, interruptive medication safety alerts.
  
  
  METHODS
  Through literature review and iterative testing, metrics were developed that describe successes, justifiable overrides, provider non-adherence, and unintended adverse consequences of clinical decision support alerts. The framework was validated by applying it to a medication alerting system for patients with acute kidney injury (AKI).
  
  
  RESULTS
  Through expert review, the framework assesses each alert episode for appropriateness of the alert display and the necessity and urgency of a clinical response. Primary outcomes of the framework include the false positive alert rate, alert override rate, provider non-adherence rate, and rate of provider response appropriateness. Application of the framework to evaluate an existing AKI medication alerting system provided a more complete understanding of the process outcomes measured in the AKI medication alerting system. The authors confirmed that previous alerts and provider responses were most often appropriate.
  
  
  CONCLUSIONS
  The new evaluation model offers a potentially effective method for assessing the clinical appropriateness of synchronous interruptive medication alerts prior to evaluating patient outcomes in a comparative trial. More work can determine the generalizability of the framework for use in other settings and other alert types.
authors.affiliation: Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee 77030, USA. allison.b.mccoy@uth.tmc.edu
authors.forename: Allison B
authors.initials: AB
authors.lastname: McCoy
authors.forename: Lemuel R
authors.initials: LR
authors.lastname: Waitman
authors.forename: Julia B
authors.initials: JB
authors.lastname: Lewis
authors.forename: Julie A
authors.initials: JA
authors.lastname: Wright
authors.forename: David P
authors.initials: DP
authors.lastname: Choma
authors.forename: Randolph A
authors.initials: RA
authors.lastname: Miller
authors.forename: Josh F
authors.initials: JF
authors.lastname: Peterson
mesh_terms: D058186:Acute Kidney Injury / Q000517:prevention & control; D020000:Decision Support Systems, Clinical; D004360:Drug Therapy, Computer-Assisted; D057286:Electronic Health Records; D006801:Humans; D008485:Medical Audit / Q000379:methods*; D050316:Medical Order Entry Systems; D008508:Medication Errors / Q000517:prevention & control*; D008510:Medication Systems, Hospital; D008962:Models, Theoretical; D017010:Reminder Systems; D012189:Retrospective Studies; D016037:Single-Blind Method; D013714:Tennessee; D014584:User-Computer Interface