{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,23]],"date-time":"2026-07-23T22:26:29Z","timestamp":1784845589152,"version":"3.55.0"},"reference-count":35,"publisher":"Oxford University Press (OUP)","issue":"9","license":[{"start":{"date-parts":[[2018,7,27]],"date-time":"2018-07-27T00:00:00Z","timestamp":1532649600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/journals\/pages\/about_us\/legal\/notices"}],"funder":[{"DOI":"10.13039\/100000133","name":"Agency for Healthcare Research and Quality","doi-asserted-by":"publisher","award":["T32HS00046"],"award-info":[{"award-number":["T32HS00046"]}],"id":[{"id":"10.13039\/100000133","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000049","name":"National Institute on Aging","doi-asserted-by":"publisher","award":["UL1TR001881"],"award-info":[{"award-number":["UL1TR001881"]}],"id":[{"id":"10.13039\/100000049","id-type":"DOI","asserted-by":"publisher"}]},{"name":"National Center for Advanced Translational Science"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2018,9,1]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Objective<\/jats:title><jats:p>To evaluate provider responses to a narrowly targeted \u201cBest Practice Advisory\u201d (BPA) alert for the intensification of blood pressure medications for persons with diabetes before and after implementation of a \u201cchart closure\u201d hard stop, which is non-interruptive but demands an action or dismissal before the chart can be closed.<\/jats:p><\/jats:sec><jats:sec><jats:title>Materials and Methods<\/jats:title><jats:p>We designed a BPA that fired alerts within an electronic health record (EHR) system during outpatient encounters for patients with diabetes when they had elevated blood pressures and were not on angiotensin receptor blocking medications. The BPA alerts were implemented in eight primary care practices within UCLA Health. We compared data on provider responses to the alerts before and after implementing a \u201cchart closure\u201d hard stop, and we conducted chart reviews to adjudicate each alert\u2019s appropriateness.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Providers responded to alerts more often after the \u201cchart closure\u201d hard stop was implemented (P\u2009&amp;lt;\u2009.001). Among 284 alert firings over 16 months, we judged 107 (37.7%) to be clinically unnecessary or inappropriate based on chart review. Among the remainder, which represent clear opportunities for treatment, providers ordered the indicated medication more often (41% vs 75%) after the \u201cchart closure\u201d hard stop was implemented (P\u2009=\u2009.001).<\/jats:p><\/jats:sec><jats:sec><jats:title>Discussion<\/jats:title><jats:p>The BPA alerts for diabetes and blood pressure control achieved relatively high specificity. The \u201cchart closure\u201d hard stop improved provider attention to the alerts and was effective at getting patients treated when they needed it.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>Targeting specific omitted medication classes can produce relatively specific alerts that may reduce alert fatigue, and using a \u201cchart closure\u201d hard stop may prompt providers to take action without excessively disrupting their workflow.<\/jats:p><\/jats:sec>","DOI":"10.1093\/jamia\/ocy073","type":"journal-article","created":{"date-parts":[[2018,5,18]],"date-time":"2018-05-18T19:14:30Z","timestamp":1526670870000},"page":"1167-1174","source":"Crossref","is-referenced-by-count":24,"title":["Primary care provider adherence to an alert for intensification of diabetes blood pressure medications before and after the addition of a \u201cchart closure\u201d hard stop"],"prefix":"10.1093","volume":"25","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5063-1028","authenticated-orcid":false,"given":"Magaly","family":"Ramirez","sequence":"first","affiliation":[{"name":"Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Richard","family":"Maranon","sequence":"additional","affiliation":[{"name":"Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeffery","family":"Fu","sequence":"additional","affiliation":[{"name":"Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Janet S","family":"Chon","sequence":"additional","affiliation":[{"name":"Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kimberly","family":"Chen","sequence":"additional","affiliation":[{"name":"Medical Informatics, University of California, Los Angeles Health System, Los Angeles, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carol M","family":"Mangione","sequence":"additional","affiliation":[{"name":"Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA"},{"name":"Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gerardo","family":"Moreno","sequence":"additional","affiliation":[{"name":"Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Douglas S","family":"Bell","sequence":"additional","affiliation":[{"name":"Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2018,7,27]]},"reference":[{"issue":"7160","key":"2020110612225874900_ocy073-B1","doi-asserted-by":"crossref","first-page":"703","DOI":"10.1136\/bmj.317.7160.703","article-title":"Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group","volume":"317","author":"Group UPDS","year":"1998","journal-title":"BMJ"},{"issue":"3","key":"2020110612225874900_ocy073-B2","doi-asserted-by":"crossref","first-page":"335","DOI":"10.1001\/jama.291.3.335","article-title":"Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes","volume":"291","author":"Saydah","year":"2004","journal-title":"JAMA"},{"key":"2020110612225874900_ocy073-B3"},{"issue":"5","key":"2020110612225874900_ocy073-B4","doi-asserted-by":"crossref","first-page":"543","DOI":"10.1007\/s11606-008-0507-2","article-title":"Failure to intensify antihypertensive treatment by primary care providers: a cohort study in adults with diabetes mellitus and hypertension","volume":"23","author":"Bolen","year":"2008","journal-title":"J Gen Intern Med"},{"issue":"2","key":"2020110612225874900_ocy073-B5","doi-asserted-by":"crossref","first-page":"337","DOI":"10.2337\/diacare.28.2.337","article-title":"Quality of diabetes care in U.S. academic medical centers: low rates of medical regimen change","volume":"28","author":"Grant","year":"2005","journal-title":"Diabetes Care"},{"issue":"2","key":"2020110612225874900_ocy073-B6","doi-asserted-by":"crossref","first-page":"355.","DOI":"10.2337\/diacare.26.2.355","article-title":"Hypertension management in patients with diabetes","volume":"26","author":"Berlowitz","year":"2003","journal-title":"Diabetes Care"},{"issue":"1","key":"2020110612225874900_ocy073-B7","doi-asserted-by":"crossref","first-page":"95","DOI":"10.1186\/1745-6215-11-95","article-title":"Study protocol: the Adherence and Intensification of Medications (AIM) study\u2013a cluster randomized controlled effectiveness study","volume":"11","author":"Heisler","year":"2010","journal-title":"Trials"},{"issue":"1","key":"2020110612225874900_ocy073-B8","doi-asserted-by":"crossref","first-page":"186","DOI":"10.1186\/1472-6920-14-186","article-title":"The use of clinical guidelines highlights ongoing educational gaps in physicians\u2019 knowledge and decision making related to diabetes","volume":"14","author":"Corriere","year":"2014","journal-title":"BMC Med Educ"},{"issue":"1","key":"2020110612225874900_ocy073-B9","doi-asserted-by":"crossref","first-page":"e84238","DOI":"10.1371\/journal.pone.0084238","article-title":"Patient and healthcare provider barriers to hypertension awareness, treatment and follow up: a systematic review and meta-analysis of qualitative and quantitative studies","volume":"9","author":"Khatib","year":"2014","journal-title":"PLoS One"},{"key":"2020110612225874900_ocy073-B10","doi-asserted-by":"crossref","first-page":"91","DOI":"10.1016\/j.ijmedinf.2015.12.017","article-title":"A review of randomized controlled trials of medical record powered clinical decision support system to improve quality of diabetes care","volume":"87","author":"Ali","year":"2016","journal-title":"Int J Med Inform"},{"issue":"12","key":"2020110612225874900_ocy073-B11","doi-asserted-by":"crossref","first-page":"2310","DOI":"10.1377\/hlthaff.2010.1111","article-title":"Clinical decision support systems could be modified to reduce \u201calert fatigue\u201d while still minimizing the risk of litigation","volume":"30","author":"Kesselheim","year":"2011","journal-title":"Health Aff (Millwood)"},{"issue":"3","key":"2020110612225874900_ocy073-B12","doi-asserted-by":"crossref","first-page":"487","DOI":"10.1136\/amiajnl-2013-001813","article-title":"Overrides of medication-related clinical decision support alerts in outpatients","volume":"21","author":"Nanji","year":"2014","journal-title":"J Am Med Inform Assoc"},{"issue":"2","key":"2020110612225874900_ocy073-B13","doi-asserted-by":"crossref","first-page":"138","DOI":"10.1197\/jamia.M1809","article-title":"Overriding of drug safety alerts in computerized physician order entry","volume":"13","author":"van der Sijs","year":"2006","journal-title":"J Am Med Inform Assoc"},{"issue":"2","key":"2020110612225874900_ocy073-B14","doi-asserted-by":"crossref","first-page":"432","DOI":"10.1093\/jamia\/ocw119","article-title":"A systematic review of the types and causes of prescribing errors generated from using computerized provider order entry systems in primary and secondary care","volume":"24","author":"Brown","year":"2016","journal-title":"J Am Med Informatics Assoc"},{"issue":"4","key":"2020110612225874900_ocy073-B15","doi-asserted-by":"crossref","first-page":"431","DOI":"10.1197\/jamia.M1788","article-title":"A randomized trial of electronic clinical reminders to improve quality of care for diabetes and coronary artery disease","volume":"12","author":"Sequist","year":"2005","journal-title":"J Am Med Inform Assoc"},{"issue":"2","key":"2020110612225874900_ocy073-B16","doi-asserted-by":"crossref","first-page":"399","DOI":"10.4338\/ACI-2015-12-RA-0169","article-title":"Clinical decision support tool for parental tobacco treatment in hospitalized children","volume":"7","author":"Jenssen","year":"2016","journal-title":"Appl Clin Inform"},{"issue":"10","key":"2020110612225874900_ocy073-B17","doi-asserted-by":"crossref","first-page":"e949","DOI":"10.1200\/JOP.2016.013540","article-title":"Electronic intervention to improve structured cancer stage data capture","volume":"12","author":"Cecchini","year":"2016","journal-title":"J Oncol Pract"},{"issue":"5","key":"2020110612225874900_ocy073-B18","doi-asserted-by":"crossref","first-page":"404","DOI":"10.2500\/aap.2016.37.3970","article-title":"Effect of educational and electronic medical record interventions on food allergy management","volume":"37","author":"Zelig","year":"2016","journal-title":"Allergy Asthma Proc"},{"issue":"6","key":"2020110612225874900_ocy073-B19","doi-asserted-by":"crossref","first-page":"1109","DOI":"10.1136\/amiajnl-2014-002777","article-title":"Don\u2019t fuel the fire: decreasing intravenous haloperidol use in high risk patients via a customized electronic alert","volume":"21","author":"Pell","year":"2014","journal-title":"J Am Med Inform Assoc"},{"issue":"3","key":"2020110612225874900_ocy073-B20","doi-asserted-by":"crossref","first-page":"324","DOI":"10.1007\/s13142-014-0259-y","article-title":"Using the electronic health record to connect primary care patients to evidence-based telephonic tobacco quitline services: a closed-loop demonstration project","volume":"4","author":"Adsit","year":"2014","journal-title":"Behav Med Pract Policy Res"},{"issue":"6","key":"2020110612225874900_ocy073-B21","doi-asserted-by":"crossref","first-page":"686","DOI":"10.1016\/j.japh.2017.06.018","article-title":"Physician experiences with clinical pharmacists in primary care teams","volume":"57","author":"Moreno","year":"2017","journal-title":"J Am Pharm Assoc"},{"key":"2020110612225874900_ocy073-B22","volume-title":"Clinical Decision Support Systems: State of the Art","author":"Berner","year":"2009"},{"issue":"2","key":"2020110612225874900_ocy073-B23","first-page":"195","article-title":"Clinical decision support alert appropriateness: a review and proposal for improvement","volume":"14","author":"McCoy","year":"2014","journal-title":"Ochsner J"},{"issue":"5","key":"2020110612225874900_ocy073-B24","doi-asserted-by":"crossref","first-page":"493","DOI":"10.1136\/jamia.2010.005264","article-title":"A review of human factors principles for the design and implementation of medication safety alerts in clinical information systems","volume":"17","author":"Phansalkar","year":"2010","journal-title":"J Am Med Inform Assoc"},{"issue":"4","key":"2020110612225874900_ocy073-B25","doi-asserted-by":"crossref","first-page":"187","DOI":"10.1093\/intqhc\/mzm015","article-title":"Monitoring patients using control charts: a systematic review","volume":"19","author":"Tennant","year":"2007","journal-title":"Int J Qual Heal Care"},{"key":"2020110612225874900_ocy073-B26","first-page":"179","volume-title":"Introduction to statistical Quality Control","author":"Montgomery","year":"2009"},{"issue":"8","key":"2020110612225874900_ocy073-B27","first-page":"AS13","article-title":"Patients as partners in clinical research: a proposal for applying quality improvement methods to patient care","volume":"36","author":"Solodky","year":"1998","journal-title":"Med Care"},{"issue":"3","key":"2020110612225874900_ocy073-B28","doi-asserted-by":"crossref","first-page":"174","DOI":"10.1097\/00019514-200407000-00004","article-title":"Improving hypertension care with patient-generated run chart: physician, patient, and management perspectives","volume":"13","author":"Hebert","year":"2004","journal-title":"Q Manag Heal Care"},{"issue":"1","key":"2020110612225874900_ocy073-B29","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1370\/afm.1196","article-title":"Impact of electronic health record clinical decision support on diabetes care: a randomized trial","volume":"9","author":"O\u2019Connor","year":"2011","journal-title":"Ann Fam Med"},{"issue":"1","key":"2020110612225874900_ocy073-B30","doi-asserted-by":"crossref","first-page":"66","DOI":"10.1197\/jamia.M2687","article-title":"Impact of non-interruptive medication laboratory monitoring alerts in ambulatory care","volume":"16","author":"Lo","year":"2009","journal-title":"J Am Med Informatics Assoc"},{"issue":"17","key":"2020110612225874900_ocy073-B31","doi-asserted-by":"crossref","first-page":"1578","DOI":"10.1001\/archinternmed.2010.324","article-title":"Unintended effects of a computerized physician order entry nearly hard-stop alert to prevent a drug interaction","volume":"170","author":"Strom","year":"2010","journal-title":"Arch Intern Med"},{"issue":"6","key":"2020110612225874900_ocy073-B32","doi-asserted-by":"crossref","first-page":"789","DOI":"10.1136\/amiajnl-2011-000199","article-title":"Making electronic prescribing alerts more effective: scenario-based experimental study in junior doctors","volume":"18","author":"Scott","year":"2011","journal-title":"J Am Med Inform Assoc"},{"issue":"1","key":"2020110612225874900_ocy073-B33","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1136\/jamia.2010.006130","article-title":"A randomized-controlled trial of computerized alerts to reduce unapproved medication abbreviation use","volume":"18","author":"Myers","year":"2011","journal-title":"J Am Med Inform Assoc"},{"issue":"12","key":"2020110612225874900_ocy073-B34","first-page":"3279","article-title":"The effect of an electronic \u201chard-stop\u201d alert on hiv testing rates in the emergency department","volume":"86","author":"Schnall","year":"2008","journal-title":"Nurs Res Pract"},{"issue":"04","key":"2020110612225874900_ocy073-B35","doi-asserted-by":"crossref","first-page":"569","DOI":"10.4338\/ACI-2013-04-RA-0021","article-title":"A retrospective analysis of interruptive versus non-interruptive clinical decision support for identification of patients needing contact isolation","volume":"04","author":"Pevnick","year":"2013","journal-title":"Appl Clin Inform"}],"container-title":["Journal of the American Medical Informatics Association"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/academic.oup.com\/jamia\/article-pdf\/25\/9\/1167\/34150303\/ocy073.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"http:\/\/academic.oup.com\/jamia\/article-pdf\/25\/9\/1167\/34150303\/ocy073.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,8,23]],"date-time":"2022-08-23T22:35:01Z","timestamp":1661294101000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/jamia\/article\/25\/9\/1167\/5060849"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2018,7,27]]},"references-count":35,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2018,7,27]]},"published-print":{"date-parts":[[2018,9,1]]}},"URL":"https:\/\/doi.org\/10.1093\/jamia\/ocy073","relation":{},"ISSN":["1067-5027","1527-974X"],"issn-type":[{"value":"1067-5027","type":"print"},{"value":"1527-974X","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2018,9]]},"published":{"date-parts":[[2018,7,27]]}}}