{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T19:04:26Z","timestamp":1789585466745,"version":"build-2803163510"},"reference-count":47,"publisher":"Oxford University Press (OUP)","issue":"9","license":[{"start":{"date-parts":[[2026,6,26]],"date-time":"2026-06-26T00:00:00Z","timestamp":1782432000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/pages\/standard-publication-reuse-rights"}],"funder":[{"name":"National Cancer Institute of the National Institutes of Health","award":["R01CA245145"],"award-info":[{"award-number":["R01CA245145"]}]},{"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":[[2026,9,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Clinical decision support (CDS) is increasingly delivered through distributed architectures that connect electronic health record (EHR) workflows to external services and community partners. While these designs enable rapid deployment and interoperability, they also introduce new failure modes that can silently disrupt time\u2011sensitive care processes. Practical, real\u2011world descriptions of these distributed CDS malfunctions remain limited.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Case Report<\/jats:title>\n                    <jats:p>We describe 3 malfunctions in a distributed CDS system used to support smoking cessation referrals. The issues reflected common distributed\u2011system failure modes, including clock drift, timing\u2011related data availability problems, and asynchronous processing across partner systems.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion and Recommendations<\/jats:title>\n                    <jats:p>Given the implications software architecture can have on distributed systems, it is critical to expand the definition of what constitutes the CDS system to include components outside the EHR, including those of third-party partners system. Further, monitoring techniques for distributed systems may also require multiple methods to account for differences in how each component can fail.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/jamia\/ocag114","type":"journal-article","created":{"date-parts":[[2026,6,16]],"date-time":"2026-06-16T12:37:27Z","timestamp":1781613447000},"page":"1790-1797","source":"Crossref","is-referenced-by-count":0,"title":["Malfunctions in distributed clinical decision support: 3 cases from a multi\u2011component clinical decision support system"],"prefix":"10.1093","volume":"33","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9202-539X","authenticated-orcid":false,"given":"Jeritt G","family":"Thayer","sequence":"first","affiliation":[{"name":"Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania , Philadelphia, PA 19146,","place":["United States"]},{"name":"Clinical Futures, Children\u2019s Hospital of Philadelphia , Philadelphia, PA 19146,","place":["United States"]},{"name":"Department of Biomedical and Health Informatics, Children\u2019s Hospital of Philadelphia , Philadelphia, PA 19146,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gerald P","family":"Shaeffer","sequence":"additional","affiliation":[{"name":"Clinical Futures, Children\u2019s Hospital of Philadelphia , Philadelphia, PA 19146,","place":["United States"]},{"name":"Department of Biomedical and Health Informatics, Children\u2019s Hospital of Philadelphia , Philadelphia, PA 19146,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexander G","family":"Fiks","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania , Philadelphia, PA 19146,","place":["United States"]},{"name":"Clinical Futures, Children\u2019s Hospital of Philadelphia , Philadelphia, PA 19146,","place":["United States"]},{"name":"Department of Biomedical and Health Informatics, Children\u2019s Hospital of Philadelphia , Philadelphia, PA 19146,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6082-4931","authenticated-orcid":false,"given":"Brian P","family":"Jenssen","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania , Philadelphia, PA 19146,","place":["United States"]},{"name":"Clinical Futures, Children\u2019s Hospital of Philadelphia , Philadelphia, PA 19146,","place":["United States"]},{"name":"Department of Biomedical and Health Informatics, Children\u2019s Hospital of Philadelphia , Philadelphia, PA 19146,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Janani","family":"Ramachandran","sequence":"additional","affiliation":[{"name":"Clinical Futures, Children\u2019s Hospital of Philadelphia , Philadelphia, PA 19146,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dean","family":"Karavite","sequence":"additional","affiliation":[{"name":"Department of Biomedical and Health Informatics, Children\u2019s Hospital of Philadelphia , Philadelphia, PA 19146,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3910-1824","authenticated-orcid":false,"given":"Emara","family":"Nabi-Burza","sequence":"additional","affiliation":[{"name":"Division of General Academic Pediatrics, Tobacco Research and Treatment Center, Massachusetts General Hospital for Children , Boston, MA 02115,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jonathan P","family":"Winickoff","sequence":"additional","affiliation":[{"name":"Division of General Academic Pediatrics, Tobacco Research and Treatment Center, Massachusetts General Hospital for Children , Boston, MA 02115,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert W","family":"Grundmeier","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania , Philadelphia, PA 19146,","place":["United States"]},{"name":"Clinical Futures, Children\u2019s Hospital of Philadelphia , Philadelphia, PA 19146,","place":["United States"]},{"name":"Department of Biomedical and Health Informatics, Children\u2019s Hospital of Philadelphia , Philadelphia, PA 19146,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,6,26]]},"reference":[{"key":"2026091614314326100_ocag114-B1","doi-asserted-by":"crossref","first-page":"371","DOI":"10.1007\/978-3-031-69947-4_15","volume-title":"Human Computer Interaction in Healthcare","author":"Franklin","year":"2024"},{"key":"2026091614314326100_ocag114-B2","author":"Index - 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