{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,11,25]],"date-time":"2025-11-25T20:35:59Z","timestamp":1764102959678,"version":"3.37.3"},"reference-count":16,"publisher":"Oxford University Press (OUP)","issue":"11","license":[{"start":{"date-parts":[[2018,7,27]],"date-time":"2018-07-27T00:00:00Z","timestamp":1532649600000},"content-version":"vor","delay-in-days":1,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"name":"National Library of Medicine of the National Institutes of Health","award":["R01LM011966"],"award-info":[{"award-number":["R01LM011966"]}]},{"DOI":"10.13039\/100000002","name":"National Institutes of Health","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2018,11,1]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:p>Clinical vocabularies allow for standard representation of clinical concepts, and can also contain knowledge structures, such as hierarchy, that facilitate the creation of maintainable and accurate clinical decision support (CDS). A key architectural feature of clinical hierarchies is how they handle parent-child relationships \u2014 specifically whether hierarchies are strict hierarchies (allowing a single parent per concept) or polyhierarchies (allowing multiple parents per concept). These structures handle subsumption relationships (ie, ancestor and descendant relationships) differently. In this paper, we describe three real-world malfunctions of clinical decision support related to incorrect assumptions about subsumption checking for \u03b2-blocker, specifically carvedilol, a non-selective \u03b2-blocker that also has \u03b1-blocker activity. We recommend that 1) CDS implementers should learn about the limitations of terminologies, hierarchies, and classification, 2) CDS implementers should thoroughly test CDS, with a focus on special or unusual cases, 3) CDS implementers should monitor feedback from users, and 4) electronic health record (EHR) and clinical content developers should offer and support polyhierarchical clinical terminologies, especially for medications.<\/jats:p>","DOI":"10.1093\/jamia\/ocy091","type":"journal-article","created":{"date-parts":[[2018,6,27]],"date-time":"2018-06-27T07:16:53Z","timestamp":1530083813000},"page":"1552-1555","source":"Crossref","is-referenced-by-count":8,"title":["Smashing the strict hierarchy: three cases of clinical decision support malfunctions involving carvedilol"],"prefix":"10.1093","volume":"25","author":[{"given":"Adam","family":"Wright","sequence":"first","affiliation":[{"name":"Department of Medicine, Brigham and Women\u2019s Hospital, Boston, Massachusetts, USA"},{"name":"Departments of Medicine and Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA"},{"name":"Partners eCare, Partners Healthcare, Boston, Massachusetts, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Aileen P","family":"Wright","sequence":"additional","affiliation":[{"name":"Department of Medicine, Brigham and Women\u2019s Hospital, Boston, Massachusetts, USA"},{"name":"Departments of Medicine and Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Skye","family":"Aaron","sequence":"additional","affiliation":[{"name":"Department of Medicine, Brigham and Women\u2019s Hospital, Boston, Massachusetts, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5811-8915","authenticated-orcid":false,"given":"Dean F","family":"Sittig","sequence":"additional","affiliation":[{"name":"Department of Biomedical Informatics, UTHealth \u2013 Memorial Hermann Center for Healthcare Quality and Safety, School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, Texas, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"286","published-online":{"date-parts":[[2018,7,26]]},"reference":[{"year":"2018","author":"Centers for Disease Control and Prevention","key":"2020110612232877500_ocy091-B1"},{"issue":"4\u20135","key":"2020110612232877500_ocy091-B2","first-page":"394","article-title":"Desiderata for controlled medical vocabularies in the twenty-first century","volume":"37","author":"Cimino","year":"1998","journal-title":"Methods Inf Med"},{"author":"SNOMED International","key":"2020110612232877500_ocy091-B3"},{"issue":"7","key":"2020110612232877500_ocy091-B4","doi-asserted-by":"crossref","first-page":"862","DOI":"10.1093\/jamia\/ocy041","article-title":"Using statistical anomaly detection models to find clinical decision support 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