Interruptive Versus Noninterruptive Clinical Decision Support: Usability Study

Abstract

Background Clinical decision support (CDS) has been shown to improve compliance with evidence-based care, but its impact is often diminished because of issues such as poor usability, insufficient integration into workflow, and alert fatigue. Noninterruptive CDS may be less subject to alert fatigue, but there has been little assessment of its usability. Objective This study aimed to study the usability of interruptive and noninterruptive versions of a CDS. Methods We conducted a usability study of a CDS tool that recommended prescribing an angiotensin-converting enzyme inhibitor for inpatients with heart failure. We developed 2 versions of the CDS: an interruptive alert triggered at order entry and a noninterruptive alert listed in the sidebar of the electronic health record screen. Inpatient providers were recruited and randomly assigned to use the interruptive alert followed by the noninterruptive alert or vice versa in a laboratory setting. We asked providers to “think aloud” while using the CDS and then conducted a brief semistructured interview about usability. We used a constant comparative analysis informed by the CDS Five Rights framework to analyze usability testing. Results A total of 12 providers participated in usability testing. Providers noted that the interruptive alert was readily noticed but generally impeded workflow. The noninterruptive alert was felt to be less annoying but had lower visibility, which might reduce engagement. Provider role seemed to influence preferences; for instance, some providers who had more global responsibility for patients seemed to prefer the noninterruptive alert, whereas more task-oriented providers generally preferred the interruptive alert. Conclusions Providers expressed trade-offs between impeding workflow and improving visibility with interruptive and noninterruptive versions of a CDS. In addition, 2 potential approaches to effective CDS may include targeting alerts by provider role or supplementing a noninterruptive alert with an occasional, well-timed interruptive alert.

Clinical Decision Support and Implications for the Clinician Burnout Crisis

“…The 75 non-review, non-opinion articles used a variety of metrics to evaluate the usability and acceptability of their CDS tools, with many using more than one metric. The most common evaluation was via interviews (n=29) 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 , followed by surveys or questionnaires (n=16) 27 29 50 53 55 56 57 58 59 60 61 62 63 64 65 66 . Other qualitative feedback responses were obtained by focus groups or workshops (n=5) 43 57 61 67 68 .…”

“…One study of a CDS tool for deprescribing found that only 1.2% of alerts resulted in medication discontinuation, which was overall branded ineffective [45]. Another study compared interruptive vs. non-interruptive alerts for ACE inhibitor prescription, finding that the non-interruptive alerts were less annoying but less seen [51]. Unintended consequences should be assessed in addition to expected outcomes [59].…”

“…Customizability can be at the scale of the hospital or clinic [69,73] or by the end-user altering, for example, which alerts are seen [44]. Additionally, role-tailoring, in which CDS is targeted to users by role such as nurse, pharmacist, physician, etc., was also seen as a way to reduce burnout and increase acceptability in CDS [21,51]. In one study, non-physician care-coordinators were responsible for data entry to support CDS [46].…”

Evaluation of a clinical decision support system for rare diseases: a qualitative study

“…Especially in CDSS, the evaluation of usability plays a decisive role. Usability refers to the quality of a system, which allows users to complete a task effectively, fast, and with high satisfaction [ 22 ]. While many studies propose methods to improve the performance and accuracy of diagnostic CDSS, to our knowledge, there is no study available that focuses on the design of a CDSS for RDs [ 17 ].…”

Evaluation of a Clinical Decision Support System for Rare Diseases - A Qualitative Study

“…Especially in CDSS, the evaluation of usability plays a decisive role. Usability refers to the quality of a system, which allows users to complete a task effectively, fast and with a high satisfaction [22]. To our knowledge, there is no study available that has assessed a CDSS for RDs regarding the usability and the acceptance by the users.…”