perceived as a potential nuisance by nurses when the alert was discussed in planning sessions Instead the group intentionally delayed the firing of the alert to the end of triage when the nurse was cognitively deciding what triage severity to assign Person: Directing the alert to that the person most able to influence the desired action is key to alert design For the sepsis alert, only the nurse received the initial vital sign alert, as firing it for all providers would have been unnecessary and might have created alert fatigue for physicians The second level alert recommending a sepsis huddle fired for all team members, to emphasize that this was a team responsibility Channel: The EHR was perceived to be the appropriate channel for initial alerting, since it is embedded in the workflows of assessment and ordering in the ED Other channels of alerting may be appropriate for different parts of the workflow For example, in the sepsis example, once the decision was made to initiate the sepsis protocol, the nurse pushed an alarm button on a panel in the room that sent out a text page to the charge nurse, pharmacist and other team members to alert them to provide assistance Format: Considerable attention should be paid to the appearance of an alert Similar alert displays may increase the attention required by clinicians to determine the message Consistent color coding can help clinicians prioritize importance of alerts, and inclusion of images can convey information in a nonverbal manner that may reduce cognitive burden Sequential alerts: Achieving these goals may require creative approaches, such as nesting or sequential firing of multiple alerts, as was done in the sepsis project Separating the nursing and provider alerts allowed a more targeted approach, reducing the potential for alert fatigue for any one provider Similarly, if there are specific actions to be made suggested based on varying risk assessments, separate alerts for each risk category with specific actionable recommendations may be more effective than a single alert for all risk categories Testing and monitoring: Careful planning and review is key to successful implementation of an alert The team designing an alert should determine in advance how likely it is to fire through retrospective data review or allowing the alert to fire silently without displaying to providers during a pilot period The alert should be tested by others not involved in its development Many institutions have committees with multidisciplinary expertise available to approve alerts before roll-out After implementation, data should be collected on alert frequency and responses by clinician, which can be done with EHR log data and/or inperson qualitative assessments Many EHR systems allow alerts to also send messages in the background that can notify the alert design team who can then follow up and review the clinical processes An ongoing monitoring system is important, as alerts may display differently or stop firing altogether with later modifications of the system TABLE 3.2 IMPLEMENTATION OF SEQUENTIAL ALERTS IN AN ELECTRONIC HEALTH RECORD TO IMPROVE SEPSIS RECOGNITION AND REDUCE PATIENTS MISSED FOR TREATMENT ON A SEPSIS CLINICAL PATHWAY IN A PEDIATRIC EMERGENCY DEPARTMENT a Alert principle Nursing alert Right information Need to additional assessments in patient with fever and tachycardia or hypotension Right person Triage or bedside nurse Right channel EHR alert integrated into standard nursing assessment Right format Pop-up alert with links for nurse to input further assessment of capillary refill, high-risk condition, mental status (if not already documented) Right time Delayed to end of triage assessment when acuity level being decided Team alert Need to a team assessment at the bedside of a high-risk patient All team members Interruptive EHR alert Pop-up alert with links to sepsis order set and area to input outcome of bedside team assessment As soon as nursing alert indicates high-risk status a See Balamuth et al.8 and illustrations of alerts and process at https://www.chop.edu/clinicalpathway/sepsis-emergent-care-clinical-pathway Disposition and Post-Visit CDS can assist providers with planning for admission or discharge through discharge order sets, reminder alerts or other methods As technology extends its reach through mobile devices and other methods, CDS can extend beyond the clinical team to patients and families For example, Bloch describes integration of discharge instructions as videos available through the EHR or mobile applications can assist families with carrying out the plan after leaving the ED Automated communication to other providers can assist with making sure that appropriate follow-up occurs and results are reviewed and acted on In summary, CDS is a robust field with many opportunities to improve healthcare that is growing exponentially through the integration of the EHR and other technologies into clinical settings Enthusiasm about the potential applications of CDS should be tempered by the potential for alert fatigue and other unintended consequences Successful CDS implementation requires involving a multidisciplinary team of individuals who will be impacted by the change, application of sound design principles, thoughtful planning and postimplementation monitoring While these can be accomplished through formal methods of sociotechnical and usability analysis, less labor-intensive processes organized around these guiding concepts can be effective as well Suggested Readings and Key References Clinical Decision Support Principles Bates DW, Kuperman GJ, Mang E, et al Ten commandments for effective clinical decision support: making the practice of evidence-based medicine a reality In: Sittig DF, ed Electronic Health Records: Challenges in Design and Implementation Toronto and New Jersey: Apple Academic Press, 2014:135–156 Osheroff J, Teich J, Levick D, et al Improving outcomes with clinical decision support HIMSS Publishing; 2012 Osheroff JA, Teich JM, Middleton B, et al A roadmap for national action on clinical decision support J Am Med Inform Assoc 2007;14(2):141– 145 Patterson BW, Pulia MS, Ravi S, et al Scope and influence of electronic health record–integrated clinical decision support in the emergency department: a systematic review Ann Emerg Med 2019;74(2):285–296 Clinical Decision Support Applied in Acute Pediatric Care ... SEPSIS RECOGNITION AND REDUCE PATIENTS MISSED FOR TREATMENT ON A SEPSIS CLINICAL PATHWAY IN A PEDIATRIC EMERGENCY DEPARTMENT a Alert principle Nursing alert Right information Need to additional assessments... record–integrated clinical decision support in the emergency department: a systematic review Ann Emerg Med 2019;74(2):285–296 Clinical Decision Support Applied in Acute Pediatric Care ... Ten commandments for effective clinical decision support: making the practice of evidence-based medicine a reality In: Sittig DF, ed Electronic Health Records: Challenges in Design and Implementation