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Objectives: In a randomized controlled trial, we found that applying implementation science (IS) methods and best practices in clinical decision support (CDS) design to create a locally customized, "enhanced" CDS significantly improved evidence-based prescribing of β blockers (BB) for heart failure compared with an unmodified commercially available CDS. At trial conclusion, the enhanced CDS was expanded to all sites. The purpose of this study was to evaluate the real-world sustained effect of the enhanced CDS compared with the commercial CDS., Methods: In this natural experiment of 28 primary care clinics, we compared clinics exposed to the commercial CDS (preperiod) to clinics exposed to the enhanced CDS (both periods). The primary effectiveness outcome was the proportion of alerts resulting in a BB prescription. Secondary outcomes included patient reach and clinician adoption (dismissals)., Results: There were 367 alerts for 183 unique patients and 171 unique clinicians (pre: March 2019-August 2019; post: October 2019-March 2020). The enhanced CDS increased prescribing by 26.1% compared with the commercial (95% confidence interval [CI]: 17.0-35.1%), which is consistent with the 24% increase in the previous study. The odds of adopting the enhanced CDS was 81% compared with 29% with the commercial (odds ratio: 4.17, 95% CI: 1.96-8.85). The enhanced CDS adoption and effectiveness rates were 62 and 14% in the preperiod and 92 and 10% in the postperiod., Conclusion: Applying IS methods with CDS best practices was associated with improved and sustained clinician adoption and effectiveness compared with a commercially available CDS tool., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: Clinical decision support (CDS) alerts built into the electronic health record (EHR) have the potential to reduce the risk of drug-induced long QT syndrome (diLQTS) in susceptible patients. However, the degree to which providers incorporate this information into prescription behavior and the impact on patient outcomes is often unknown., Methods: We examined provider response data over a period from October 8, 2016 until November 8, 2018 for a CDS alert deployed within the EHR from a 13-hospital integrated health care system that fires when a patient with a QTc ≥ 500 ms within the past 14 days is prescribed a known QT-prolonging medication. We used multivariate generalized estimating equations to analyze the impact of therapeutic alternatives, relative risk of diLQTS for specific medications, and patient characteristics on provider response to the CDS and overall patient mortality., Results: The CDS alert fired 15,002 times for 7,510 patients for which the most common response (51.0%) was to override the alert and order the culprit medication. In multivariate models, we found that patient age, relative risk of diLQTS, and presence of alternative agents were significant predictors of adherence to the CDS alerts and that nonadherence itself was a predictor of mortality. Risk of diLQTS and presence of an alternative agent are major factors in provider adherence to a CDS to prevent diLQTS; however, provider nonadherence was associated with a decreased risk of mortality., Conclusion: Surrogate endpoints, such as provider adherence, can be useful measures of CDS value but attention to hard outcomes, such as mortality, is likely needed., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Medication nonadherence and unaffordability are prevalent, burdensome issues in primary care. In response, technology companies are capitalizing on clinical decision support (CDS) to deliver patient-specific information regarding medication adherence and costs to clinicians using electronic health records (EHRs). To maximize adoption and usability, these CDS tools should be designed with consideration of end users' values and preferences., Objective: This article evaluates primary care clinicians' values and preferences for a medication adherence and cost CDS., Methods: We conducted semistructured interviews with primary care clinicians with prescribing privileges and EHR access to identify clinicians' perceptions of and approaches to assessing medication adherence and costs, and to determine perceived values and preferences for medication adherence and cost CDS. Interviews were conducted until saturation of responses was reached. ATLAS.ti was used for thematic analysis., Results: Among 26 clinicians interviewed, themes identified included a high value, but moderate need for a medication adherence CDS and high value and need for cost CDS. Clinicians expressed the cost CDS would provide actionable solutions and greatly impact patient care. Another theme identified was a desire for medication adherence and cost CDS to be separate tools yet integrated into workflow. The majority of clinicians preferred a medication adherence CDS that integrated claims data and actively displayed data using color-coded adherence categories within patients' medication lists in the EHR. For the cost CDS, clinicians preferred medication out-of-pocket costs and a list of cheaper or payor-preferred alternatives to display within the order queue of the EHR., Conclusion: We identified valuable insights regarding clinician values and preferences for medication adherence and cost CDS. Overall, primary care clinicians feel CDS for medication adherence and cost are valuable and prefer them to be separate. These insights should be used to inform the design, implementation, and EHR integration of future medication and cost CDS tools., Competing Interests: C.G.D. reports other from Amgen Inc, other from Amarin Corporation, outside the submitted work., (Georg Thieme Verlag KG Stuttgart · New York.)