{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,11,25]],"date-time":"2025-11-25T20:39:37Z","timestamp":1764103177026},"reference-count":28,"publisher":"Georg Thieme Verlag KG","issue":"01","funder":[{"name":"National Library of Medicine of the National Institutes of Health","award":["R01LM011966"],"award-info":[{"award-number":["R01LM011966"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Appl Clin Inform"],"published-print":{"date-parts":[[2021,1]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:p>\n          Objective\u2003Clinical decision support (CDS) can contribute to quality and safety. Prior work has shown that errors in CDS systems are common and can lead to unintended consequences. Many CDS systems use Boolean logic, which can be difficult for CDS analysts to specify accurately. We set out to determine the prevalence of certain types of Boolean logic errors in CDS statements.<\/jats:p><jats:p>\n          Methods\u2003Nine health care organizations extracted Boolean logic statements from their Epic electronic health record (EHR). We developed an open-source software tool, which implemented the Espresso logic minimization algorithm, to identify three classes of logic errors.<\/jats:p><jats:p>\n          Results\u2003Participating organizations submitted 260,698 logic statements, of which 44,890 were minimized by Espresso. We found errors in 209 of them. Every participating organization had at least two errors, and all organizations reported that they would act on the feedback.<\/jats:p><jats:p>\n          Discussion\u2003An automated algorithm can readily detect specific categories of Boolean CDS logic errors. These errors represent a minority of CDS errors, but very likely require correction to avoid patient safety issues. This process found only a few errors at each site, but the problem appears to be widespread, affecting all participating organizations.<\/jats:p><jats:p>\n          Conclusion\u2003Both CDS implementers and EHR vendors should consider implementing similar algorithms as part of the CDS authoring process to reduce the number of errors in their CDS interventions.<\/jats:p>","DOI":"10.1055\/s-0041-1722918","type":"journal-article","created":{"date-parts":[[2021,3,11]],"date-time":"2021-03-11T01:34:09Z","timestamp":1615426449000},"page":"182-189","source":"Crossref","is-referenced-by-count":4,"title":["Algorithmic Detection of Boolean Logic Errors in Clinical Decision Support Statements"],"prefix":"10.1055","volume":"12","author":[{"given":"Adam","family":"Wright","sequence":"additional","affiliation":[{"name":"Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States"},{"name":"Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States"},{"name":"Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, United States"},{"name":"Partners eCare, Partners HealthCare System, Boston, Massachusetts, United States"}]},{"given":"Skye","family":"Aaron","sequence":"additional","affiliation":[{"name":"Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States"}]},{"given":"Allison B.","family":"McCoy","sequence":"additional","affiliation":[{"name":"Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States"}]},{"given":"Robert","family":"El-Kareh","sequence":"additional","affiliation":[{"name":"Department of Medicine, UC San Diego Health, University of California, San Diego, San Diego, California, United States"}]},{"given":"Daniel","family":"Fort","sequence":"additional","affiliation":[{"name":"Center for Outcomes and Health Services Research, Ochsner Health System, New Orleans, Louisiana, United States"}]},{"given":"Steven Z.","family":"Kassakian","sequence":"additional","affiliation":[{"name":"Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, United States"}]},{"given":"Christopher A.","family":"Longhurst","sequence":"additional","affiliation":[{"name":"Department of Medicine, UC San Diego Health, University of California, San Diego, San Diego, California, United States"}]},{"given":"Sameer","family":"Malhotra","sequence":"additional","affiliation":[{"name":"Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, United States"},{"name":"Department of Internal Medicine, NewYork-Presbyterian Hospital, New York, New York, United States"}]},{"given":"Dustin S.","family":"McEvoy","sequence":"additional","affiliation":[{"name":"Partners eCare, Partners HealthCare System, Boston, Massachusetts, United States"}]},{"given":"Craig B.","family":"Monsen","sequence":"additional","affiliation":[{"name":"Center for Informatics, Atrius Health, Boston, Massachusetts, United States"}]},{"given":"Richard","family":"Schreiber","sequence":"additional","affiliation":[{"name":"Physician Informatics and Department of Internal Medicine, Geisinger Holy Spirit, Camp Hill, Pennsylvania, United States"}]},{"given":"Asli O.","family":"Weitkamp","sequence":"additional","affiliation":[{"name":"Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States"}]},{"given":"DuWayne L.","family":"Willett","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, United States"}]},{"given":"Dean F.","family":"Sittig","sequence":"additional","affiliation":[{"name":"School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, Texas, United States"}]}],"member":"194","published-online":{"date-parts":[[2021,3,10]]},"reference":[{"issue":"12","key":"ref1","doi-asserted-by":"crossref","first-page":"1409","DOI":"10.1001\/archinte.163.12.1409","article-title":"Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review","volume":"163","author":"R Kaushal","year":"2003","journal-title":"Arch Intern Med"},{"issue":"10","key":"ref2","doi-asserted-by":"crossref","first-page":"1223","DOI":"10.1001\/jama.293.10.1223","article-title":"Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review","volume":"293","author":"A X Garg","year":"2005","journal-title":"JAMA"},{"issue":"10","key":"ref3","first-page":"e445","article-title":"Using electronic health record clinical decision support is associated with improved quality of care","volume":"20","author":"R G Mishuris","year":"2014","journal-title":"Am J Manag Care"},{"key":"ref4","doi-asserted-by":"crossref","first-page":"56","DOI":"10.1186\/2046-4053-3-56","article-title":"The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systematic review and meta-analysis","volume":"3","author":"T K Nuckols","year":"2014","journal-title":"Syst Rev"},{"key":"ref5","doi-asserted-by":"crossref","first-page":"1178222617697975","DOI":"10.1177\/1178222617697975","article-title":"Systematic review of medical informatics-supported medication decision making","volume":"9","author":"B L Melton","year":"2017","journal-title":"Biomed Inform Insights"},{"key":"ref6","doi-asserted-by":"crossref","first-page":"78","DOI":"10.1016\/j.ijmedinf.2018.08.001","article-title":"Best practices for preventing malfunctions in rule-based clinical decision support alerts and reminders: results of a Delphi study","volume":"118","author":"A Wright","year":"2018","journal-title":"Int J Med Inform"},{"issue":"11","key":"ref7","doi-asserted-by":"crossref","first-page":"1552","DOI":"10.1093\/jamia\/ocy091","article-title":"Smashing the strict hierarchy: three cases of clinical decision support malfunctions involving carvedilol","volume":"25","author":"A Wright","year":"2018","journal-title":"J Am Med Inform Assoc"},{"key":"ref8","first-page":"1385","article-title":"Methods for detecting malfunctions in clinical decision support systems","volume":"245","author":"A Wright","year":"2017","journal-title":"Stud Health Technol Inform"},{"issue":"05","key":"ref9","doi-asserted-by":"crossref","first-page":"496","DOI":"10.1093\/jamia\/ocx106","article-title":"Clinical decision support alert malfunctions: analysis and empirically derived taxonomy","volume":"25","author":"A Wright","year":"2018","journal-title":"J Am Med Inform Assoc"},{"issue":"06","key":"ref10","doi-asserted-by":"crossref","first-page":"1068","DOI":"10.1093\/jamia\/ocw005","article-title":"Analysis of clinical decision support system malfunctions: a case series and survey","volume":"23","author":"A Wright","year":"2016","journal-title":"J Am Med Inform Assoc"},{"issue":"05","key":"ref11","doi-asserted-by":"crossref","first-page":"1081","DOI":"10.1093\/jamia\/ocv073","article-title":"Cross-vendor evaluation of key user-defined clinical decision support capabilities: a scenario-based assessment of certified electronic health records with guidelines for future development","volume":"22","author":"A B McCoy","year":"2015","journal-title":"J Am Med Inform Assoc"},{"issue":"02","key":"ref12","first-page":"159","article-title":"Clinical decision support systems: a review on knowledge representation and inference under uncertainties","volume":"1","author":"G Kong","year":"2008","journal-title":"Intl J Comput Intel Syst"},{"issue":"03","key":"ref13","doi-asserted-by":"crossref","first-page":"1","DOI":"10.15585\/mmwr.rr6703a1","article-title":"Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices-United States, 2018-19 Influenza Season","volume":"67","author":"L A Grohskopf","year":"2018","journal-title":"MMWR Recomm Rep"},{"key":"ref14","volume-title":"Boolean Algebra and Its Applications","author":"J E Whitesitt","year":"1961"},{"issue":"01","key":"ref15","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1145\/2133797.2133800","article-title":"Describing the what and why of students' difficulties in Boolean logic","volume":"12","author":"G L Herman","year":"2012","journal-title":"ACM Trans Comput Edu"},{"key":"ref17","first-page":"131","volume-title":"Investigating student difficulties with mathematical logic","author":"V L Almstrum","year":"1996"},{"key":"ref18","volume-title":"Lattice Theory: First Concepts and Distributive Lattices","author":"G Gr\u00e4tzer","year":"1971"},{"key":"ref19","first-page":"1730","article-title":"Multi-institutional, large-scale, international applied clinical informatics research through the Clinical Informatics Research Collaborative (CIRCLE)","volume":"264","author":"A B McCoy","year":"2019","journal-title":"Stud Health Technol Inform"},{"issue":"01","key":"ref20","doi-asserted-by":"crossref","first-page":"188","DOI":"10.1093\/jamia\/ocw039","article-title":"Testing electronic health records in the \u201cproduction\u201d environment: an essential step in the journey to a safe and effective health care system","volume":"24","author":"A Wright","year":"2017","journal-title":"J Am Med Inform Assoc"},{"key":"ref22","doi-asserted-by":"crossref","DOI":"10.1007\/978-1-4613-2821-6","volume-title":"Logic Minimization Algorithms for VLSI Synthesis","author":"R K Brayton","year":"1984"},{"issue":"05","key":"ref23","doi-asserted-by":"crossref","first-page":"727","DOI":"10.1109\/TCAD.1987.1270318","article-title":"Multiple-valued minimization for PLA optimization","volume":"6","author":"R L Rudell","year":"1987","journal-title":"IEEE Trans Comput Aided Des Integrated Circ Syst"},{"issue":"05","key":"ref24","doi-asserted-by":"crossref","first-page":"564","DOI":"10.1093\/jamia\/ocx096","article-title":"Unintended adverse consequences of a clinical decision support system: two cases","volume":"25","author":"E G Stone","year":"2018","journal-title":"J Am Med Inform Assoc"},{"issue":"01","key":"ref25","doi-asserted-by":"crossref","first-page":"46","DOI":"10.1055\/s-0039-3402757","article-title":"Reducing interruptive alert burden using quality improvement methodology","volume":"11","author":"J D Chaparro","year":"2020","journal-title":"Appl Clin Inform"},{"issue":"01","key":"ref26","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1055\/s-0039-3402715","article-title":"Reducing alert burden in electronic health records: state of the art recommendations from four health systems","volume":"11","author":"J D McGreevey III","year":"2020","journal-title":"Appl Clin Inform"},{"issue":"01","key":"ref28","doi-asserted-by":"crossref","first-page":"112","DOI":"10.1055\/s-0040-1701253","article-title":"To Share is Human! Advancing evidence into practice through a national repository of interoperable clinical decision support","volume":"11","author":"E A Lomotan","year":"2020","journal-title":"Appl Clin Inform"},{"issue":"01","key":"ref29","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1145\/2363.2366","article-title":"Information-flow and data-flow analysis of while-programs","volume":"7","author":"J-F Bergeretti","year":"1985","journal-title":"ACM Trans Prog Lang Syst"},{"key":"ref30","first-page":"532","article-title":"Modeling and executing electronic health records driven phenotyping algorithms using the NQF Quality Data Model and JBoss\u00ae Drools Engine","volume":"2012","author":"D Li","year":"2012","journal-title":"AMIA Annu Symp Proc"},{"key":"ref32","doi-asserted-by":"crossref","first-page":"285","DOI":"10.1016\/j.ijmedinf.2019.06.024","article-title":"Prescriber perceptions of medication-related computerized decision support systems in hospitals: a synthesis of qualitative research","volume":"129","author":"B A Van Dort","year":"2019","journal-title":"Int J Med Inform"}],"container-title":["Applied Clinical Informatics"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/www.thieme-connect.de\/products\/ejournals\/pdf\/10.1055\/s-0041-1722918.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,3,11]],"date-time":"2021-03-11T01:35:36Z","timestamp":1615426536000},"score":1,"resource":{"primary":{"URL":"http:\/\/www.thieme-connect.de\/DOI\/DOI?10.1055\/s-0041-1722918"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,1]]},"references-count":28,"journal-issue":{"issue":"01","published-online":{"date-parts":[[2021,1,6]]},"published-print":{"date-parts":[[2021,1]]}},"URL":"https:\/\/doi.org\/10.1055\/s-0041-1722918","relation":{},"ISSN":["1869-0327"],"issn-type":[{"value":"1869-0327","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,1]]}}}