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Discussion
This study highlights several factors influencing physicians’ perspectives of CDSS alerts, especially the role of perceived ease of use in shaping perceived usefulness, user satisfaction and behavioural intention. Physicians with high patient volumes found CDSS alerts less useful and harder to use, likely due to cognitive load and alert fatigue. Older physicians also reported lower ease of use and usefulness, while those with greater clinical experience viewed alerts more positively, possibly due to familiarity with integrating them into workflows. Meanwhile, ease of use and usefulness were strongly associated with positive attitudes and satisfaction; user satisfaction alone did not significantly predict behavioural intention to use the system. Most physicians agreed that pop-up alerts were effective reminders and expressed a willingness to use them during clinical decision-making; however, they also suggested that adopting context-aware alerts, which optimise triggering rules based on specific situations, could enhance relevance. These findings provide hospitals with a holistic understanding of the factors influencing physicians’ behavioural intention to use CDSS alerts, offering guidance for CDSS alert improvements to enhance clinical workflow.
Our study aligns with previous research underscoring the importance of perceived usefulness and ease of use in the acceptance of CDSS alerts, with particular emphasis on alert frequency and context-specific features as key factors in user acceptance. For example, Van de Sijpe et al found that integrating patient-specific factors into CDSS alerts improved relevance, reduced alert fatigue and increased acceptance.23 Similarly, Hussain et al showed that tailoring alerts to specific clinical roles and refining interaction design helped minimise alert fatigue and enhance acceptance.5 Ancker et al further demonstrated that reducing the frequency of non-informative alerts can alleviate alert fatigue and increase user engagement.4 However, our findings suggested that physicians with high patient loads and older age tend to reduce acceptance. Additionally, unlike some studies that emphasise user satisfaction as a key driver of sustained system use, our research did not find a significant correlation between satisfaction and behavioural intention to use. This indicates that in high-pressure settings, practical factors like perceived usefulness and ease of use may play a more decisive role than satisfaction in influencing continued usage.
The implications of this study are substantial for clinical practice and policy-making, underscoring the importance of context-driven customisation in CDSS alerts. Our findings highlight the strong impact of perceived ease of use and usefulness on physicians’ behavioural intention to use CDSS alerts, suggesting that CDSS developers should prioritise user-friendly designs that minimise disruption and cognitive load, especially for clinicians with high patient volumes. Aligned with the ‘CDS Five Rights’ framework—delivering the right information to the right person, in the right format, through the right channel and at the right time—CDSS alerts would benefit from AI-based context-sensitive systems rather than traditional rule-based designs.24 An AI-driven approach could dynamically adjust alert timing, frequency and content based on real-time clinical context, sending notifications only at critical workflow points, such as the start of a visit, rather than repetitively.25 Policymakers can leverage these insights to develop evidence-based guidelines and visual prioritisation strategies for alert frequency and customisation, fostering efficient and clinician-centred CDSS use.26
Building on these insights, future research should examine additional factors that may influence behavioural intention to use CDSS alerts beyond perceived usefulness, ease of use and user satisfaction. As our findings suggest that context and workload play a pivotal role in how alerts are perceived, further exploration of adaptive, context-sensitive alert systems could be valuable. For hospitals aiming to optimise CDSS alerts, we recommend focusing on several practical strategies: reducing alert frequency through regular system maintenance,5 27 ensuring alerts are highly relevant to clinical processes and tailoring alert presentations based on clinical importance. Clinical alerts presented as pop-up notifications were generally preferred by physicians, whereas administrative alerts, often seen as less valuable, might benefit from alternative notification formats, such as color-coded text or soft-stop warnings.28 Engaging high-volume clinicians in feedback loops for system improvements can further enhance CDSS acceptance, ultimately contributing to improved patient safety and more efficient clinical workflows.
Limitations
This study has several limitations that should be considered. First, factors such as changes in hospital policies, the implementation of new alerts and Public Health Emergencies of International Concern may impact the findings over time, highlighting the need for regular surveys to capture longitudinal data and provide deeper insights. To address this, regular surveys should be conducted to gather longitudinal data and provide deeper insights. Second, the study focused on outpatient settings, where the context of alerts may differ significantly from inpatient environments. Therefore, our findings may not fully apply to inpatient settings, where alert needs and workflows could vary substantially. Meanwhile, this study had a relatively low response rate, which may affect the representativeness of our results and could introduce response bias. Future studies with larger sample sizes across different settings could help validate these findings. Additionally, the data for this study were collected from a single academic medical centre in Taiwan. This may not accurately reflect the clinical workflow of other hospitals, thereby limiting the generalisability of our findings. Furthermore, while behavioural intention to use can predict actual usage of alerts, it does not equate to actual alert usage. This distinction should be considered when interpreting the findings, and future studies should aim to examine real-world alert usage in addition to behavioural intentions. Lastly, the quantitative analysis method used in this study has its limitations, as the results are subjective and heavily influenced by the characteristics of the respondents. To address this, future studies should include quantitative metrics such as alert burden, alert overridden rate, and alert dwell time.
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