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Decline in Physicians’ Response to a Non-Interruptive Clinical Decision Support Alert


Introduction: Clinical decision support (CDS) alerts have shown promise in improving health care quality and patient outcomes. Although repeated exposure to alerts may lead to declined responses by physicians, known as “alert fatigue,” little is known about how the introduction of competing alerts may affect uptake over time.

Methods: We examined alert responses over time and identified factors associated with decreased alert effectiveness. We analyzed the audit data from all occurrences of a CDS alert at a single, large academic health system. For patients screening positive for depression during ambulatory visits, a non-interruptive CDS alert is presented to the physician, offering a number of appropriate documentation actions. Alert uptake was defined as the selection of any option offered within the alert during the patient encounter. We assessed the effect of (1) the number of competing clinical guidance alerts presented during the same encounter and (2) the total number of all clinical guidance alerts that the same provider had seen in the prior 90 days, on the probability of depression screen alert uptake, adjusting for physician and patient characteristics.

Results: A total of 55,649 office visits involving 418 physicians and 40,474 patients between September 1, 2017, and February 28, 2021, were included. After adjustment for potential confounders, physicians who had seen the most CDS alerts in the prior 90 days were less likely to utilize the depression alert than those who had seen it the least (adjusted uptake rate, 19.8% at the highest quartile versus 39.3% at the lowest quartile; adjusted odds ratio, 0.38; 95% CI 0.35 to 0.42; p<0.001). The negative impact of competing alerts in the same visit on depression alert uptake was only seen among physicians in the middle two quartiles of alert exposure in the prior 90 days.

Conclusion: Among physicians at a single large academic health care system, the declining use of a non-interruptive depression alert was strongly associated with the provider’s 90-day prior exposure to alerts. Health systems should monitor providers’ recent alert exposure as a measure of potential alert fatigue.

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