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Appl Clin Inform. 2019 Mar;10(2):237-246. doi: 10.1055/s-0039-1683985. Epub 2019 Apr 3.

Assessing the Safety of Custom Web-Based Clinical Decision Support Systems in Electronic Health Records: A Case Study.

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Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States.
Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States.
Department of Information Services, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States.



With the widespread adoption of vendor-supplied electronic health record (EHR) systems, clinical decision support (CDS) customization efforts beyond those anticipated by the vendor may require the use of technologies external to the EHR such as web services. Pursuing such customizations, however, is not without risk. Validating the expected behavior of a customized CDS system in the high-volume, complex environment of the live EHR is a challenging problem.


This article identifies technology failures that impacted clinical care related to web service-based advanced custom CDS systems embedded in the complex sociotechnical context of a production EHR.


In an academic health system's primary care network, we performed an inventory of incidents between January 1, 2008 and December 31, 2016 related to a customized CDS system and performed a targeted review of changes in the CDS source code. Additional feedback on the root cause of individual incidents was obtained through interviews with members of the CDS project teams.


We identified five CDS malfunctions that impaired clinical workflow. The mechanisms for these failures are mapped to four characteristics of well-behaved applications: (1) system integrity; (2) data integrity; (3) reliability; and (4) scalability. Over the 9-year period, two malfunctions of the customized CDS significantly impaired clinical workflow for a total of 5 hours. Lesser impacts-loss of individual features with straightforward workarounds-arose from three malfunctions, which affected users on 53 days.


Advanced customization of EHRs for the purpose of CDS can present significant risks to clinical workflow.


This case study highlights that advanced customization of CDS within a commercial EHR may support care for complex patient populations, but ongoing monitoring and support is required to ensure its safe use.

[Available on 2020-03-01]

Conflict of interest statement

Drs. Fiks and Grundmeier are coinventors of the “Care Assistant” software that was evaluated in this study. Mr. Miller is a coinventor of “Project SHARE” which is a Care Assistant module to support the care of children with attention deficit disorder. They hold no patent on the software and have earned no money from this invention. No licensing agreement exists. Dr. Fiks has also received an Independent Research Grant from Pfizer from which he personally drew no support. The other authors have indicated they have no potential conflicts of interest to disclose.

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