Alert acceptance: are all acceptance rates the same?

In a recent paper by Alison McCoy et al “Clinician collaboration to improve clinical decision support: the Clickbusters initiative,” the author noted how the acceptance rates of alerts were quite poor with override rates of ∼90%. The acceptance rates cited were for drug-drug, drug-allergy alerts, and other drug safety alerts. An area of confusion exists generally around equating medication decision support (MDS) override rates with those of system alerts. The term system alerts refers to a form of clinical decision support (CDS) that cover a wide range of topics, is available at multiple times during clinical workflow, can be triggered by diagnoses orders, medications, labs, etc., and content usually has to be configured and built. MDS is another form of CDS but is only available during medication ordering and e-prescribing.^1,2 MDS provides drug-drug, drug-allergy, drug-lab, etc., at the point of order, uses a drug database as its knowledge base, content often is pre-built, has very high override rates, and is delivered quite differently than system alerts. The knowledge base and rules engine for system alerts and MDS are usually located quite separately in the clinical information system. If one looks at papers on system alerts, at least 2 prior studies and 1 recent study suggest significantly higher acceptance rates.^3–5 Our study described in “A Framework for Usable and Effective Clinical Decision Support: Experience from the iCPR Randomized Clinical Trial” found that study alerts were adopted by 57.4% of users and accepted by 42.7% of users, respectively.³ In the “Impact of an Electronic Clinical Decision Support Tool for Emergency Department Patients With Pneumonia,” the authors cite an acceptance rate of 62.6%.⁴ A subsequent publication study looking at alerts for problem list deficiencies had an acceptance rate of 22.1%.⁵

Yet, MDS (medication decision support) override rates are often used as a proxy for the comparison of alert override rates because there is no systematic review of override rates for system alerts that we have been able to find. We suspect that is in part because of the wide variety, settings, and use of such alerts. Further research is needed to determine the full range of acceptance rates of alerts across CDS interventions. The citation of MDS rates in Dr McCoy’s paper does not detract from nor diminish their findings describing an approach to improve the low acceptance of alerts.

FUNDING

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

AUTHOR CONTRIBUTIONS

The author listed is solely responsible for all content in this letter to the editor.

CONFLICT OF INTEREST STATEMENT

The author has no competing interests to declare.

REFERENCES