Program optimizes clinical-decision support alerts and helps build a culture of continuous evaluation.

An innovative program at Vanderbilt University Medical Center’s Clinical Informatics Center has optimized clinical-decision support, sparking a reduction in the overall number of EHR alerts issued and increasing clinician engagement.

Clinical-decision support (CDS) systems provide physicians and staff with specific information about patients, filtered and ideally presented in a timely manner to enhance health care delivery.

These systems commonly help with diagnoses. They may also track negative drug interactions through computerized alerts and reminders to health care providers. A new Vanderbilt literature review of 45 relevant studies from 2020 to 2022 found the most frequent CDS type (33.3 percent) was point-of-care alerts or reminders. 

Meanwhile, clinicians report encountering a growing information overload. While health information technologies are designed to improve clinical decision-making, too many alerts may contribute to health care provider interruptions and burnout, the authors noted.

Clickbusters to Optimize EHR

To improve safety and care quality and reduce burnout, Vanderbilt researchers developed and implemented a 10-step Clickbusters program to optimize the medical center’s Epic EHR system.

“We came up with a way to better evaluate CDS using Clickbusters. We invited clinicians to review and improve alerts.”

The program, described in the Journal of the American Medical Informatics Association, focused on improving clinical decision support alerts, including turning off unnecessary alerts, correcting errors and targeting alerts more precisely. It included a curriculum of videos and knowledge-based articles, a management process and database to support tracking participants’ progress, support for participants, and a game to enhance user engagement.

“We came up with a way to better evaluate CDS using Clickbusters,” said lead author Allison B. McCoy, Ph.D., an associate professor and director of the Clinical Informatics Core at Vanderbilt. “In the past, we evaluated reports of data and reviewed alert logs. Working with the operational Health Information Technology department and Department of Biomedical Informatics, we invited clinicians to review and improve alerts.”

Expert Users Recruited

Two dozen clinicians who expressed interested in informatics or were expert users of the Epic EHR system were recruited to try out the program. After two three-month rounds, the Clickbusters program led to detailed, comprehensive reviews of 84 CDS alerts. After turning these off or modifying them as needed, the number of weekly alerts went down by more than 15 percent. In total, 71,227 weekly clicks were “busted” and no longer fired from the EHR.

“One alert fired for a cardiac rehab program that doesn’t exist anymore,” McCoy said. “One user noticed a lot of alerts for flu shots while the patient was under anesthesia. Yes, it’s important to remind clinicians to ask patients about flu shots, but it’s not appropriate to do that everywhere.”

In one example of the shift, a pediatric hypertension alert would no longer pop up to interrupt workflow, but instead be coded to display in a passive area of the medical chart.

In addition to such direct improvements, the initiative increased user engagement and involvement.

“Clickbusters brought in new participants who were highly invested to help with the review process.”

“The program helped build a culture of continuous evaluation and improvement of clinical content in the EHR,” McCoy said. “Clickbusters brought in new participants who were highly invested to help with the review process.”

Some spent as little as two hours completing their work, while others devoted 20 or more hours.

“We developed a game and handed out trophies to make it fun. Each alert was assigned points based on how complex it was or how many times it fired and was ignored by clinicians,” McCoy said. Participants received points to review an alert to see how well it performed, make plans to change the alert, and then evaluate the changes. “Some found quick wins for points, while others dug into complicated alerts by talking to users and enacting changes,” she said.

Expanding Clickbusters

McCoy believes the Clickbusters process can be replicated at other sites. “We put together an extensive packet of instructions on how the program works with a lengthy description of each step, and shared that on the Epic user website,” she said. Already, a Vanderbilt Clickbusters participant has implemented the process to identify and improve alerts after moving to an Iowa children’s hospital, she said.

The research team noted that process could also be applied to other functions of the EHR, such as order sets, clinical documentation tools, and information displays.

“In the future, we hope that Clickbusters becomes ingrained in the process to develop new alerts and evaluate them. Users know they can come to us for feedback to alerts,” McCoy said.

About the Expert

Allison McCoy, Ph.D., portrait

Allison B. McCoy, Ph.D.

Allison B. McCoy, Ph.D., is an associate professor of biomedical informatics at Vanderbilt University Medical Center and director of the Vanderbilt Clinical Informatics Core. She is interested in developing and implementing novel, generalizable approaches to analyzing and improving EHRs and clinical-decision support using existing data sources and making them available at point-of-care to improve health care quality and safety across organizations.