Special issue on CDS failures: Challenges to reduce alert burden using current decision support infrastructure in two commercial EHR systems: lessons learned and path forward

Background: Despite the proven usefulness of appropriate clinical decision support (CDS) alerts, many CDS systems fire excessive, clinically irrelevant alerts that are often ignored by clinicians. We have developed a method to suppress false-positive alerts based on prior drug tolerance but encountered substantial barriers to integrate the method into widely adopted commercial electronic health record (EHR) systems. Objective: To describe the challenges faced while attempting to integrate our method into the CDS infrastructure of two commercial EHR systems and provide recommendations for future research and CDS design. Methods: Using a multifaceted approach, we investigated 1) the use of emergent CDS standards (e.g., CDS Hooks) to create a scalable solution to augment off-the-shelf EHR-based alerts with patient-specific custom alerts, 2) customize CDS rules of commercial medication knowledge bases (MKBs) to reduce false-positive alerts, and 3) manually inactivate allergy documentation in patients with prior drug tolerance. Results: We were unable to implement the standards-based approach because support for CDS Hooks was found to be tailored to specific scenarios that involve creation of new drug allergy alerts (DAAs) but not the suppression of vendor-supplied DAAs. Likewise, we were unable to suppress alerts imported from MKBs into the EHR systems investigated because these systems do not support discrete clinical documentation changes that drive DAAs. Lastly, we determined that although manually inactivating allergy documentation in patients with prior drug tolerance is possible, doing so requires the impractical solution of creating and maintaining individual rules for each drug at the ingredient level. Conclusion: We describe the barriers that precluded implementation of a novel method to suppress clinically irrelevant CDS alerts in two commercial EHR systems. Overcoming these barriers will require a more flexible CDS infrastructure, as well as collaboration and shared responsibility across diverse stakeholders.