Abstract
Background 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.
Objective 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.
Methods 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.
Results 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.
Discussion Advanced customization of EHRs for the purpose of CDS can present significant risks
to clinical workflow.
Conclusion 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.
Keywords
clinical decision support - electronic health records and systems - clinical information
systems - safety - error management
