The goal of this pragmatic randomized clinical trial is to determine whether an Epic-based clinician notification increases initiation of guideline-directed cardio-kidney-metabolic (CKM) therapies in adults with type 2 diabetes and confirmed albuminuria.

The main question it aims to answer is:

• Does an Epic clinician notification improve initiation of guideline-directed CKM therapies compared with usual care?

Researchers will compare an Epic in-basket clinician notification strategy with usual care.

In the intervention arm, the treating clinician will receive an Epic notification identifying confirmed albuminuria and potential eligibility for guideline-directed CKM therapies using existing electronic health record (EHR) data. Participants in the usual care arm will receive standard clinical care without notification.

This study is a pragmatic, randomized, EHR-embedded implementation trial designed to evaluate whether an Epic-based clinician notification improves initiation of guideline-directed CKM therapies in adults with type 2 diabetes and confirmed albuminuria.

Despite contemporary guideline recommendations, substantial gaps remain in urine albumin-to-creatinine ratio (UACR) screening, confirmatory testing, and initiation of evidence-based CKM therapies, including renin-angiotensin system inhibitors (RASi), sodium-glucose cotransporter-2 inhibitors (SGLT2i), non-steroidal mineralocorticoid receptor antagonists (ns-MRA), and glucagon-like peptide-1 receptor agonists (GLP-1RA). Health-system workflows frequently fail to translate identification of albuminuria-associated CKM risk into timely initiation of disease-modifying therapy.

Eligible participants will be randomized in a 1:1 ratio to either usual care or an Epic-based clinician notification strategy.

In the intervention arm, the treating clinician will receive an Epic in-basket message identifying confirmed albuminuria and potential eligibility for guideline-directed CKM therapies using existing EHR data. All treatment decisions will remain at the discretion of the treating clinician.

The primary endpoint is initiation of one or more eligible guideline-directed CKM therapies within 3 months of randomization.

This study will provide important implementation data regarding whether low-burden EHR-based clinician notifications can improve evidence-based CKM care in real-world clinical practice settings.

Inclusion Criteria

• Adults aged ≥18 years
• Diagnosis of type 2 diabetes mellitus
• Receiving outpatient care within Baylor Scott & White Health
• At least 1 outpatient encounter within the preceding 12 months
• Confirmed albuminuria (UACR >30 mg/g)
• Eligible for one or more guideline-directed CKM therapies based on - prespecified clinical criteria and EHR review

Exclusion Criteria:

• Type 1 diabetes mellitus
• Contraindication or documented intolerance to all eligible guideline-directed CKM therapies
• Advanced kidney dysfunction below recommended initiation thresholds for SGLT2i or finerenone
• Hyperkalemia or elevated baseline serum potassium precluding safe therapy initiation
• Contraindicated drug interactions (e.g., strong CYP3A inhibitors with finerenone)
• Other guideline- or labeling-based contraindications to therapy initiation

Deidentified individual participant data (IPD) underlying the reported study results will be shared, including demographic, clinical, laboratory, prescribing, and implementation-related variables collected through the electronic health record (EHR). A data dictionary and analytic code may also be shared to support interpretation and reproducibility.

Data will become available following publication of the primary study results and will remain available for at least 5 years after publication.

Access will be provided to qualified researchers upon reasonable request following review and approval by the study investigators and Baylor Scott & White Research Institute. Shared data will be deidentified and made available in accordance with institutional policies, applicable regulations, and data use agreements.