{"doi":"10.1055/s-0042-1756366","title":"A Qualitative Description of Clinician Free-Text Rationales Entered within Accountable Justification Interventions","abstract":"<jats:title>Abstract</jats:title><jats:p>\n          Background Requiring accountable justifications—visible, clinician-recorded explanations for not following a clinical decision support (CDS) alert—has been used to steer clinicians away from potentially guideline-discordant decisions. Understanding themes from justifications across clinical content areas may reveal how clinicians rationalize decisions and could help inform CDS alerts.</jats:p><jats:p>\n          Methods We conducted a qualitative evaluation of the free-text justifications entered by primary care physicians from three pilot interventions designed to reduce opioid prescribing and, in older adults, high-risk polypharmacy and overtesting. Clinicians encountered alerts when triggering conditions were met within the chart. Clinicians were asked to change their course of action or enter a justification for the action that would be displayed in the chart. We extracted all justifications and grouped justifications with common themes. Two authors independently coded each justification and resolved differences via discussion. Three physicians used a modified Delphi technique to rate the clinical appropriateness of the justifications.</jats:p><jats:p>\n          Results There were 560 justifications from 50 unique clinicians. We grouped these into three main themes used to justify an action: (1) report of a particular diagnosis or symptom (e.g., for “anxiety” or “acute pain”); (2) provision of further contextual details about the clinical case (e.g., tried and failed alternatives, short-term supply, or chronic medication); and (3) noting communication between clinician and patient (e.g., “risks and benefits discussed”). Most accountable justifications (65%) were of uncertain clinical appropriateness.</jats:p><jats:p>\n          Conclusion Most justifications clinicians entered across three separate clinical content areas fit within a small number of themes, and these common rationales may aid in the design of effective accountable justification interventions. Justifications varied in terms of level of clinical detail. On their own, most justifications did not clearly represent appropriate clinical decision making.</jats:p>","journal":"Applied Clinical Informatics","year":2022,"id":627407,"datarank":0.32958368660043297,"base_score":2.1972245773362196,"endowment":2.1972245773362196,"self_citation_contribution":0.32958368660043297,"citation_network_contribution":0.0,"self_endowment_contribution":0.32958368660043297,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":8,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":null,"is_data_producer":false,"deposit_databanks":null,"is_oa":false,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":null,"fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":1623868,"name":"Brittany Zelch","orcid":null,"position":1,"is_corresponding":false},{"id":329611,"name":"Ji Young Lee","orcid":"0000-0002-6102-0510","position":2,"is_corresponding":false},{"id":446990,"name":"Jason N. Doctor","orcid":"0000-0003-3661-8745","position":3,"is_corresponding":false},{"id":110294,"name":"Jeffrey A. Linder","orcid":"0000-0003-2217-184X","position":4,"is_corresponding":false},{"id":259941,"name":"Mark D. Sullivan","orcid":"0000-0002-4396-6038","position":5,"is_corresponding":false},{"id":448053,"name":"Noah J. Goldstein","orcid":null,"position":6,"is_corresponding":false},{"id":110293,"name":"Theresa A. Rowe","orcid":"0000-0003-0659-1094","position":7,"is_corresponding":false},{"id":341928,"name":"Daniella Meeker","orcid":"0000-0002-1034-7628","position":8,"is_corresponding":false},{"id":1623874,"name":"Tara Knight","orcid":null,"position":9,"is_corresponding":false},{"id":446989,"name":"Mark W. Friedberg","orcid":"0000-0002-7907-8358","position":10,"is_corresponding":false},{"id":110292,"name":"Stephen D. Persell","orcid":"0000-0003-2462-1314","position":11,"is_corresponding":false},{"id":695382,"name":"Tiffany Brown","orcid":"0000-0002-5399-3953","position":0,"is_corresponding":false}],"reference_count":0,"raw_metadata":{"has_enrichment":true,"resolved":true,"title":"A Qualitative Description of Clinician Free-Text Rationales Entered within Accountable Justification Interventions","abstract":"<jats:title>Abstract</jats:title><jats:p>\n          Background Requiring accountable justifications—visible, clinician-recorded explanations for not following a clinical decision support (CDS) alert—has been used to steer clinicians away from potentially guideline-discordant decisions. Understanding themes from justifications across clinical content areas may reveal how clinicians rationalize decisions and could help inform CDS alerts.</jats:p><jats:p>\n          Methods We conducted a qualitative evaluation of the free-text justifications entered by primary care physicians from three pilot interventions designed to reduce opioid prescribing and, in older adults, high-risk polypharmacy and overtesting. Clinicians encountered alerts when triggering conditions were met within the chart. Clinicians were asked to change their course of action or enter a justification for the action that would be displayed in the chart. We extracted all justifications and grouped justifications with common themes. Two authors independently coded each justification and resolved differences via discussion. Three physicians used a modified Delphi technique to rate the clinical appropriateness of the justifications.</jats:p><jats:p>\n          Results There were 560 justifications from 50 unique clinicians. We grouped these into three main themes used to justify an action: (1) report of a particular diagnosis or symptom (e.g., for “anxiety” or “acute pain”); (2) provision of further contextual details about the clinical case (e.g., tried and failed alternatives, short-term supply, or chronic medication); and (3) noting communication between clinician and patient (e.g., “risks and benefits discussed”). Most accountable justifications (65%) were of uncertain clinical appropriateness.</jats:p><jats:p>\n          Conclusion Most justifications clinicians entered across three separate clinical content areas fit within a small number of themes, and these common rationales may aid in the design of effective accountable justification interventions. Justifications varied in terms of level of clinical detail. On their own, most justifications did not clearly represent appropriate clinical decision making.</jats:p>","is_dataset_classified":null,"base_score":2.1972245773362196,"endowment":2.1972245773362196,"datacite_reuse_total":0,"file_count":0,"downloads":0,"views":0,"has_version_chain":false,"is_dataset":false,"is_oa":false,"pmid":"36070799","pmcid":"PMC9451951","openalex_id":"https://openalex.org/W4294991687","authors":[],"funders":[{"funder_name":"NIA NIH HHS","grant_id":"R33 AG057383","title":null},{"funder_name":"NCATS NIH HHS","grant_id":"UL1 TR001422","title":null},{"funder_name":"NIA NIH HHS","grant_id":"R21 AG057396","title":null},{"funder_name":"NIA NIH HHS","grant_id":"R33 AG057395","title":null},{"funder_name":"NCATS NIH HHS","grant_id":"UL1 TR001855","title":null},{"funder_name":"NIA NIH HHS","grant_id":"R21 AG057383","title":null},{"funder_name":"NIA NIH HHS","grant_id":"P30 AG059988","title":null},{"funder_name":"NIA NIH HHS","grant_id":"R21 AG057395","title":null},{"funder_name":"National Institutes of Health","grant_id":"5R21AG057383-02","title":"Behavioral Economics Applications to Geriatrics Leveraging EHRs (BEAGLE)"},{"funder_name":"National Institutes of Health","grant_id":"1R21AG057396-01","title":"Reducing High-Risk Geriatric Polypharmacy via EHR Nudges"},{"funder_name":"National Institutes of Health","grant_id":"1RC4AG039115-01","title":"Use of Behavioral Economics to Improve Treatment of Acute Respiratory Infections"},{"funder_name":"National Institutes of Health","grant_id":"1P30AG059988-01A1","title":"The Claude D. Pepper Older Americans Independence Center (OAIC) at Northwestern University"},{"funder_name":"National Institutes of Health","grant_id":"5R21AG057395-02","title":"Application of Economics & Social psychology to improve Opioid Prescribing Safety (AESOPS) Trial"}],"total_grants":13,"fwci":1.5857,"citation_percentile":0.81630864,"influential_citations":0,"citation_trend":[{"year":2024,"count":6},{"year":2025,"count":2}],"oa_status":"hybrid","license":"cc-by-nc-nd","oa_locations":[{"url":"http://www.thieme-connect.de/products/ejournals/pdf/10.1055/s-0042-1756366.pdf","host_type":"journal"},{"url":"http://www.thieme-connect.de/products/ejournals/pdf/10.1055/s-0042-1756366.pdf","host_type":"publisher"},{"url":"https://doi.org/10.1055/s-0042-1756366","host_type":"journal"},{"url":"https://pubmed.ncbi.nlm.nih.gov/36070799","host_type":"repository"},{"url":"https://www.ncbi.nlm.nih.gov/pmc/articles/9451951","host_type":"repository"},{"url":"https://europepmc.org/articles/PMC9451951","host_type":"Europe_PMC"},{"url":"https://europepmc.org/articles/PMC9451951?pdf=render","host_type":"Europe_PMC"},{"url":"http://dx.doi.org/10.1055/s-0042-1756366","host_type":""}],"fields_of_study":["Clinical Reasoning and Diagnostic Skills","Patient-Provider Communication in Healthcare","Palliative Care and End-of-Life Issues","03 medical and health sciences","0302 clinical medicine"],"mesh_terms":["Aged","Analgesics, Opioid","Humans","Practice Patterns, Physicians'","Physicians","Social Responsibility","Decision Support Systems, Clinical"],"keywords":["Psychological intervention","Medicine","Action (physics)","Qualitative research","Anxiety","Nursing","Psychology","Psychiatry","Analgesics, Opioid","Social Responsibility","Physicians","Humans","Practice Patterns, Physicians'","Decision Support Systems, Clinical","Aged"],"sdg_mappings":[{"sdg_number":3,"sdg_label":"3. Good health"},{"sdg_number":0,"sdg_label":"Peace, Justice and strong institutions"}],"linked_datasets":[],"clinical_trials":[],"software_tools":[],"database_accessions":[],"source":"live","citation_network_status":"fetched"},"created_at":"2026-08-04T17:25:18.645561Z","pmid":null,"pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}