CC BY 4.0 · Appl Clin Inform 2025; 16(03): 595-603
DOI: 10.1055/a-2554-3969
Research Article

User Actions within a Clinical Decision Support Alert for the Management of Hypertension in Chronic Kidney Disease

Lipika Samal*
1   Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
2   Harvard Medical School, Boston, Massachusetts, United States
,
Sarah W. Chen*
1   Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
,
Stuart Lipsitz
1   Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
2   Harvard Medical School, Boston, Massachusetts, United States
3   Division of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States
,
Heather J. Baer
1   Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
2   Harvard Medical School, Boston, Massachusetts, United States
4   Division of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States
,
John L. Kilgallon
1   Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
5   Hackensack Meridian School of Medicine, Nutley, New Jersey, United States
,
Michael Gannon
1   Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
6   Eastern Virginia Medical School, Norfolk, Virginia, United States
,
Ryan Dunk
1   Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
,
Weng Ian Chay
1   Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
,
Richard Fay
1   Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
,
Michael Sainlaire
1   Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
,
Chenxi Gao
1   Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
,
Matthew Wien
1   Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
,
Pamela M. Garabedian
7   Department of Clinical and Quality Analysis, Mass General Brigham, Somerville, Massachusetts, United States
,
Edward Wu
1   Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
8   Alabama College of Osteopathic Medicine, Dothan, Alabama, United States
,
Hojjat Salmasian
9   Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
,
David W. Bates
1   Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
2   Harvard Medical School, Boston, Massachusetts, United States
,
Patricia C. Dykes
1   Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
2   Harvard Medical School, Boston, Massachusetts, United States
,
Adam Wright
10   Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee, United States
,
Allison B. McCoy
10   Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee, United States
› Author Affiliations

Funding This work was supported by a grant from the National Institutes of Health (grant no.: 5R01DK116898).
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Abstract

Objective

This study aimed to examine user actions within a clinical decision support (CDS) alert addressing hypertension (HTN) in chronic kidney disease (CKD).

Methods

A pragmatic randomized controlled trial of a CDS alert for primary care patients with CKD and uncontrolled blood pressure included prechecked default orders for medication initiation or titration, basic metabolic panel (BMP), and nephrology electronic consult (e-consult). We examined each type of action and calculated percentages of placed and signed orders for subgroups of firings.

Results

There were firings for medication initiation (813) and medication titration (430), and every firing also included orders for nephrology e-consult (1,243) and BMP (1,243). High rates of override (59.6%) and deferral (14.6%) were observed, and CDS-recommended orders were only signed about one-third of the time from within the alert. The percentage of orders that were signed after being placed within the alert was higher for medication initiation than for medication titration (33 vs. 12.0% for angiotensin-converting enzyme inhibitors [ACEi] and 38.8 vs. 14% for angiotensin II receptor blockers [ARBs]). Findings suggest that users are hesitant to commit to immediate action within the alert.

Conclusion

Evaluating user interaction within alerts reveals nuances in physician preferences and workflow that should inform CDS alert design. This study is registered with the Clinicaltrials.gov Trial Registration (identifier: NCT03679247).

Note

Neither this manuscript, nor the data it contain, has been previously presented at any meetings, or in any other forum.


Authors' Contributions

L.S. had full access to all the data in the study and agrees to take responsibility for the integrity of the data and the accuracy of the data analysis.


Data Sharing Statement

To protect patient privacy and confidentiality, we will not be sharing individual-level de-identified data. Aggregate datasets will be made available upon reasonable request.


Protection of Human and Animal Subjects

This study was approved by the Mass General Brigham Institutional Review Board.


Role of the Funder/Sponsor

The National Institutes of Health had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.


* These authors should be considered co-first authors.


Supplementary Material



Publication History

Received: 31 May 2024

Accepted: 19 December 2024

Accepted Manuscript online:
17 March 2025

Article published online:
02 July 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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