Recent advancements in assessment have introduced alternative item types (AITs) that extend beyond traditional multiple-choice items, including interactive simulations, clinical decision-making cases, and enhanced matching. These innovations aim to better assess complex skills. However, challenges persist in psychometric properties and operational feasibility. In this session we will share presentations, focusing on AIT design, implementation, and impact. The first presentation explores clinical decision-making cases in medical exams, discussing challenges and insights from developing multiple-choice and short-answer items, comparing them to traditional multiple-choice items, and addressing scoring considerations. The second presentation examines a lab-based assessment for cloud computing challenges, sharing findings to inform exam improvements. The third presentation analyzes AIT performance across STEM programs, offering practical recommendations for integrating AITs into testing.