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

Objective: 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 pre-checked default orders for medication initiation or titration, basic metabolic panel (BMP), and nephrology electronic 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 electronic consult (1243) and BMP (1243). 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), 38.8% vs 14% for angiotensin II receptor blockers (ARB).

Conclusions: Findings suggest that users are hesitant to commit to immediate action within the alert. Conclusions: Evaluating user interaction within alerts reveals nuances in physician preferences and workflow that should inform CDS alert design.