The impact of real-time alerting on appropriate prescribing in kidney disease: a cluster randomized controlled trial

March 17, 2016
Free for AMIA members and students of Academic Forum member institutions; Others: $50
Linda Awdishu, PharmD, MAS; Carrie R. Coates, PharmD; Robert El-Kareh, MD, MS, MPH

The impact of real-time alerting on appropriate prescribing in kidney disease: a cluster randomized controlled trial 

Awdishu L, Coates CR, Lyddane A, et al. The impact of real-time alerting on appropriate prescribing in kidney disease: a cluster randomized controlled trial. J Am Med Inform Assoc. 2015 Nov 27. pii: ocv159. doi: 10.1093/jamia/ocv159. [Epub ahead of print]


Linda Awdishu, PharmD, MAS is an Associate Clinical Professor of Pharmacy and Medicine at the University of California, San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences whose clinical practice is in the Chronic Kidney Disease Program.  Her research program involves pharmacokinetics of drugs and dosing in kidney disease. Currently, Dr. Awdishu is co-directing The International Drug Induced Renal Injury Consortium (DIRECT) which will investigate the genetic basis of serious drug-induced renal injury, through a collaborative network comprised of leading clinical research centers from around the world. 

Carrie R. Coates, PharmD, is a Willow Certified Informatics Pharmacist at UCSD Medical Center with extensive experience in the design, build, testing and analysis of electronic clinical decision support tools.  Additionally, Dr. Coates and her team are responsible for end-to-end medication use processes in the enterprise electronic health record at UCSD.

Robert El-Kareh, MD, MS, MPH, has a joint appointment between the divisions of Biomedical Informatics and Hospital Medicine in the UC San Diego Department of Medicine. He is a hospitalist and conducts research in clinical informatics and quality improvement focusing on the use of health information technology to improve the accuracy, speed and efficiency of the diagnostic process.His work also includes efforts to improve medication reconciliation, communication and test result management.


  • 40-minute discussion between the authors and the JAMIA Student Editorial Board moderators including salient features of the published study and its potential impact on practice.
  • 20-minute discussion of questions submitted by listeners via the webinar tools.


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JAMIA Journal Club managers are JAMIA Student Editorial Board members:

Mary Regina Boland, MA, Department of Biomedical Informatics, Columbia University

Matthew K. Breitenstein, PhD, Department of Health Sciences Research, Mayo Clinic


The PubMed citation for the paper under discussion is:

Awdishu L, Coates CR, Lyddane A, et al. The impact of real-time alerting on appropriate prescribing in kidney disease: a cluster randomized controlled trial. J Am Med Inform Assoc. 2015 Nov 27. pii: ocv159. doi: 10.1093/jamia/ocv159. [Epub ahead of print]

The abstract is available here.

Fee Statement

Students who are not AMIA members, but whose academic institutions are members of the Academic Forum, are eligible for a complimentary JAMIA Journal Club registration. Please contact Susanne Arnold at for the discount code. In the email, please include: full name, Academic Department, and the primary Academic Forum representative of that Academic Department. Note that AMIA Student memberships are $45, which allow access to JAMIA, all JAMIA Journal Clubs, and other webinars of interest to the biomedical informatics community. 

Statement of Purpose

Patients with kidney disease are at risk for adverse events due to improper medication prescribing. There have been few publications of randomized controlled trials of clinical decision support (CDS) utilizing dynamic assessment of patients' kidney function to improve prescribing for patients with kidney disease.

Awdishu et al developed a CDS tool for 20 medications within a commercial electronic health record. This customized system detected scenarios in which drug discontinuation or dosage adjustment was recommended for adult patients with impaired renal function in the ambulatory and acute settings. The primary endpoint was the proportion of study prescriptions that were appropriately adjusted for patients' kidney function at the time that patients' conditions warranted a change according to initial prescription and “look-back” alert logic.
This study’s results suggest that CDS improves drug prescribing, particularly when providing guidance on new prescriptions.

Health care professionals with an interest in effective use of CDS to improve appropriate treatment for patients will want to consider how to incorporate the methods of this study into their own research and practice. 

Target Audience

The target audience for this activity is professionals and students interested in biomedical and health informatics.

Learning Objective

After this live activity, the participant should be better able to:

  • Assess how a customized CDS tool may contribute to a reduction in the number of inappropriate medication orders for patients with acute or chronic kidney disease
  • Consider how to customize commercially available CDS tools to reduce inappropriate medication orders in patients with other disease states
  • Consider how to conduct randomized, prospective clinical trials to assess CDS effectiveness.


Linda Awdishu, PharmD, MAS
Health Sciences Associate Clinical Professor of Pharmacy
Skaggs School of Pharmacy and Pharmaceutical Sciences
University of California, San Diego
San Diego, CA

Carrie R. Coates, PharmD
Willow Certified Informatics Pharmacist
UCSD Medical Center
University of California, San Diego
San Diego, CA

Robert El-Kareh, MD, MS, MPH
Health Sciences Assistant Clinical Professor
Division of Hospital Medicine, Department of Medicine
University of California, San Diego
San Diego, CA

Accreditation Statement

The American Medical Informatics Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation Statement

The American Medical Informatics Association designates this live activity for a maximum of 1 AMA PRA Category 1 Credit(s). Physicians should claim only the credit commensurate with the extent of their participation in the activity. 

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The physician participant will be able to generate a CME certificate through the AMIA automated system. 
For a certificate of completion, contact

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No commercial support was received for this activity.

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Disclosures for this Activity

These faculty, planners, and staff who are in a position to control the content of this activity disclose that they and their life partners have no relevant financial relationships with commercial interests: 

Faculty: Linda Awdishu, Carrie R. Coates, Robert El-Kareh
JAMIA Journal Club planners: Mary Regina Boland, Matthew Breitenstein
AMIA staff: Susanne Arnold, Pesha Rubinstein

JAMIA Journal Club planner Michael Chiang discloses the following:

  • Received Grant/Research support from the National Institutes of Health
  • Is an unpaid member of the Scientific Advisory Board of Clarity Medical Systems

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