DISCUSSION
Our results demonstrate that the IQ-MAPLE intervention for problem list improvement had limited effectiveness at increasing problem list documentation, across conditions and at multiple sites. The overall acceptance rate (22.1%) is higher than those reported in many other published studies of CDSThe overall impact of the alert on problem documentation was strong—leading to a 4.6-fold increase in the number of problems added in the intervention arm. This increase is statistically significant; however, it is likely that there are still many patients who have the problems of interest missing from their problem list, again suggesting a need for alternative strategies for problem list addition.Our findings confirmed our hypothesis that the IQ-MAPLE intervention would lead to an increase in problem list additions. However, we further hypothesized that the intervention would also lead to an increase in measurable clinical quality. Unfortunately, our analysis of the HEDIS data suggests that, at least as measured by HEDIS, our intervention did not yield an increase in quality. There are several possible explanations for this. First, even after the intervention, many patients still had problem list gaps. Second, HEDIS measures may not be an accurate reflection of the true quality of care provided.