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Appl Clin Inform 2025; 16(05): 1457-1464
DOI: 10.1055/a-2702-6872
Special Issue on CDS Failures

Applying an Empirical Taxonomy to Alert Malfunctions in a Pragmatic Trial for Hypertension Management in Chronic Kidney Disease

Authors

  • Sarah W. Chen‡   *

    1   Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
    2   Rowan-Virtua School of Osteopathic Medicine, Stratford, New Jersey, United States

  • Michael Gannon‡   *

    1   Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
    3   Eastern Virginia Medical School, Norfolk, Virginia, United States

  • John L. Kilgallon

    1   Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
    4   Hackensack Meridian School of Medicine, Nutley, New Jersey, United States

  • Weng Ian Chay

    1   Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
    5   Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States

  • David Rubins

    6   Mass General Brigham, Somerville, Massachusetts, United States
    7   Department of General Medicine, Beth Israel Lahey Health, Boston, Massachusetts, United States

  • Hojjat Salmasian

    8   Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States

  • Sayon Dutta

    9   Harvard Medical School, Boston, Massachusetts, United States
    10   Massachusetts General Hospital, Boston, Massachusetts, United States
    11   Department of Emergency Medicine, Massachusetts General Brigham Digital, Boston, Massachusetts, United States

  • Dustin S. McEvoy

    12   Trinity Health, Livonia, Michigan, United States

  • Edward Wu

    1   Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
    13   Department of Urology, Maimonides Medical Center, Brooklyn, New York, United States

  • Adam Wright

    14   Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee, United States

  • Allison McCoy

    14   Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee, United States

  • Lipika Samal

    1   Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
    9   Harvard Medical School, Boston, Massachusetts, United States

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

Background

Clinical decision support (CDS) systems have been widely adopted across clinical settings to promote evidence-based practice for clinicians. CDS malfunctions often affect the user experience and indirectly or directly interfere with patient care. To enhance optimal performance, it is critical to constantly monitor the performance of the tool and react promptly when malfunctions are identified.

Objectives

This study aimed to describe malfunctions identified in the development and implementation of a CDS alert as well as lessons learned.

Methods

A pragmatic randomized controlled trial of a CDS alert for primary care patients with chronic kidney disease and uncontrolled blood pressure was conducted. The alert included prechecked default orders for medication initiation or titration, basic metabolic panel, and nephrology electronic consult. Alert monitoring involved retrospective chart review and review of alert firing reports.

Results

Eight CDS malfunctions were identified. The most common causes of malfunctions were due to conceptualization and build errors. Provider feedback and retrospective chart review were the primary methods of identifying the root cause of malfunctions.

Conclusion

Our findings highlight the need for CDS interventions to be continuously monitored through chart review, alert firing reports, and opportunities for provider feedback. Lessons learned from CDS malfunctions can be implemented to improve provider trust in automated electronic health record-based alerts, reduce administrative burden, and prevent inappropriate alert recommendations that can negatively affect patient outcomes. This study is registered with Clinivaltrials.gov (identifier: NCT03679247).

Keywords

clinical decision support - electronic health records and systems - alerting - error management and prevention - ambulatory care - primary care

Data Sharing Statement

To protect patient privacy and confidentiality, we will not be sharing individual-level deidentified 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.


* Denotes equal contribution.




Publication History

Received: 19 February 2025

Accepted: 16 September 2025

Article published online:
28 October 2025

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