Using the Electronic Health Record User Context in Clinical Decision Support Criteria

Background Computerized clinical decision support (CDS) used in electronic health record systems (EHRs) has led to positive outcomes as well as unintended consequences, such as alert fatigue. Characteristics of the EHR session can be used to restrict CDS tools and increase their relevance, but implications of this approach are not rigorously studied. Objectives To assess the utility of using "login location" of EHR users-that is, the location they chose on the login screen-as a variable in the CDS logic. Methods We measured concordance between user's login location and the location of the patients they placed orders for and conducted stratified analyses by user groups. We also estimated how often login location data may be stale or inaccurate. Results One in five CDS alerts incorporated the EHR users' login location into their logic. Analysis of nearly 2 million orders placed by nearly 8,000 users showed that concordance between login location and patient location was high for nurses, nurse practitioners, and physician assistance (all >95%), but lower for fellows (77%) and residents (55%). When providers switched between patients in the EHR, they usually did not update their login location accordingly. Conclusion CDS alerts commonly incorporate user's login location into their logic. User's login location is often the same as the location of the patient the user is providing care for, but substantial discordance can be observed for certain user groups. While this may provide additional information that could be useful to the CDS logic, a substantial amount of discordance happened in specific user groups or when users appeared not to change their login location across different sessions. Those who design CDS alerts should consider a data-driven approach to evaluate the appropriateness of login location for each use case.