Background Electronic health record (EHR) alert fatigue, while widely recognized as a concern nationally, lacks a corresponding comprehensive mitigation plan. Objectives The goal of this manuscript is to provide practical guidance to clinical informaticists and other health care leaders who are considering creating a program to manage EHR alerts. Methods This manuscript synthesizes several approaches and recommendations for better alert management derived from four U.S. health care institutions that presented their experiences and recommendations at the American Medical Informatics Association 2019 Clinical Informatics Conference in Atlanta, Georgia, United States. The assembled health care institution leaders represent academic, pediatric, community, and specialized care domains. We describe governance and management, structural concepts and components, and human–computer interactions with alerts, and make recommendations regarding these domains based on our experience supplemented with literature review. This paper focuses on alerts that impact bedside clinicians. Results The manuscript addresses the range of considerations relevant to alert management including a summary of the background literature about alerts, alert governance, alert metrics, starting an alert management program, approaches to evaluating alerts prior to deployment, and optimization of existing alerts. The manuscript includes examples of alert optimization successes at two of the represented institutions. In addition, we review limitations on the ability to evaluate alerts in the current state and identify opportunities for further scholarship. Conclusion Ultimately, alert management programs must strive to meet common goals of improving patient care, while at the same time decreasing the alert burden on clinicians. In so doing, organizations have an opportunity to promote the wellness of patients, clinicians, and EHRs themselves.

Key Points Question Can text messaging with behavioral insights increase participation in COVID-19 vaccine outreach? Findings In this randomized clinical trial comprising 16 045 participants, text messaging did not result in a higher response rate than outbound telephone calls. Behaviorally informed messaging did not result in a significantly higher response than usual content. Meaning Text messaging offers a low-cost alternative to outbound telephone calls, but additional efforts are needed to increase vaccine uptake.

IMPORTANCE Hepatitis C virus (HCV) screening has been recommended for patients born between 1945 and 1965, but rates remain low.OBJECTIVE To evaluate whether a default order within the admission order set increases HCV screening compared with a preexisting alert within the electronic health record. DESIGN, SETTING, AND PARTICIPANTSThis stepped-wedge randomized clinical trial was conducted from June 23, 2020, to April 10, 2021, at 2 hospitals within an academic medical center.Hospitalized patients born between 1945 and 1965 with no history of screening were included in the analysis. INTERVENTIONSDuring wedge 1 (a preintervention period), both hospital sites had an electronic alert prompting clinicians to consider HCV screening. During wedge 2, the first intervention wedge, the hospital site randomized to intervention (hospital B) had a default order for HCV screening implemented within the admission order set. During wedge 3, the second intervention wedge, the hospital site randomized to control (hospital A) had the default order set implemented. MAIN OUTCOMES AND MEASURES Percentage of eligible patients who received HCV screeningduring the hospital stay. RESULTSThe study included 7634 patients (4405 in the control group and 3229 in the intervention group). The mean (SD) age was 65.4 (5.8) years; 4246 patients (55.6%) were men; 2142 (28.1%) were Black and 4625 (60.6%) were White; and 2885 (37.8%) had commercial insurance and 3950 (51.7%) had Medicare. The baseline rate of HCV screening in wedge 1 was 585 of 1560 patients (37.5% [95% CI, 35.1%-40.0%]) in hospital A and 309 of 1003 patients (30.8% [95% CI, 27.9%-33.7%]) in hospital B. The main adjusted model showed an increase of 31.8 (95% CI, 29.7-33.8) percentage points in test completion in the intervention group compared with the control group (P <. 001). CONCLUSIONS AND RELEVANCEThis stepped-wedge randomized clinical trial found that embedding HCV screening as a default order in the electronic health record substantially increased ordering and completion of testing in the hospital compared with a conventional interruptive alert. TRIAL REGISTRATION Clinicaltrials.gov: NCT04525690

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