Interruptive Electronic Alerts for Choosing Wisely Recommendations: A Cluster Randomized Controlled Trial

J Am Med Inform Assoc. 2022 Oct 7;29(11):1941-1948. doi: 10.1093/jamia/ocac139.


Objective: To assess the efficacy of interruptive electronic alerts in improving adherence to the American Board of Internal Medicine's Choosing Wisely recommendations to reduce unnecessary laboratory testing.

Materials and methods: We administered 5 cluster randomized controlled trials simultaneously, using electronic medical record alerts regarding prostate-specific antigen (PSA) testing, acute sinusitis treatment, vitamin D testing, carotid artery ultrasound screening, and human papillomavirus testing. For each alert, we assigned 5 outpatient clinics to an interruptive alert and 5 were observed as a control. Primary and secondary outcomes were the number of postalert orders per 100 patients at each clinic and number of triggered alerts divided by orders, respectively. Post hoc analysis evaluated whether physicians experiencing interruptive alerts reduced their alert-triggering behaviors.

Results: Median postalert orders per 100 patients did not differ significantly between treatment and control groups; absolute median differences ranging from 0.04 to 0.40 for PSA testing. Median alerts per 100 orders did not differ significantly between treatment and control groups; absolute median differences ranged from 0.004 to 0.03. In post hoc analysis, providers receiving alerts regarding PSA testing in men were significantly less likely to trigger additional PSA alerts than those in the control sites (Incidence Rate Ratio 0.12, 95% CI [0.03-0.52]).

Discussion: Interruptive point-of-care alerts did not yield detectable changes in the overall rate of undesired orders or the order-to-alert ratio between active and silent sites. Complementary behavioral or educational interventions are likely needed to improve efforts to curb medical overuse.

Conclusion: Implementation of interruptive alerts at the time of ordering was not associated with improved adherence to 5 Choosing Wisely guidelines.

Trial registration: NCT02709772.

Keywords: Choosing Wisely; clinical decision support; interruptive alerts; randomized controlled trial.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Decision Support Systems, Clinical*
  • Electronic Health Records
  • Electronics
  • Humans
  • Male
  • Medical Order Entry Systems*
  • Prostate-Specific Antigen
  • Vitamin D


  • Vitamin D
  • Prostate-Specific Antigen

Associated data