Clinical decision support alert malfunctions: Analysis and empirically derived taxonomy

Adam Wright, Angela Ai, Joan Ash, Jane FWiesen, Thu Trang T. Hickman, Skye Aaron, Dustin McEvoy, Shane Borkowsky, Pavithra I. Dissanayake, Peter Embi, William Galanter, Jeremy Harper, Steve Z. Kassakian, Rachel Ramoni, Richard Schreiber, Anwar Sirajuddin, David WBates, Dean F. Sittig

Research output: Contribution to journalArticlepeer-review

47 Scopus citations


Objective: To develop an empirically derived taxonomy of clinical decision support (CDS) alert malfunctions. Materials and Methods: We identified CDS alert malfunctions using a mix of qualitative and quantitative methods: (1) site visits with interviews of chief medical informatics officers, CDS developers, clinical leaders, and CDS end users; (2) surveys of chief medical informatics officers; (3) analysis of CDS firing rates; and (4) analysis of CDS overrides. We used a multi-round, manual, iterative card sort to develop a multi-axial, empirically derived taxonomy of CDS malfunctions. Results: We analyzed 68 CDS alert malfunction cases from 14 sites across the United States with diverse electronic health record systems. Four primary axes emerged: the cause of the malfunction, its mode of discovery, when it began, and how it affected rule firing. Build errors, conceptualization errors, and the introduction of new concepts or terms were the most frequent causes. User reports were the predominant mode of discovery. Many malfunctions within our database caused rules to fire for patients for whom they should not have (false positives), but the reverse (false negatives) was also common. Discussion: Across organizations and electronic health record systems, similar malfunction patterns recurred. Challenges included updates to code sets and values, software issues at the time of system upgrades, difficulties with migration of CDS content between computing environments, and the challenge of correctly conceptualizing and building CDS. Conclusion: CDS alert malfunctions are frequent. The empirically derived taxonomy formalizes the common recurring issues that cause these malfunctions, helping CDS developers anticipate and prevent CDS malfunctions before they occur or detect and resolve them expediently.

Original languageEnglish (US)
Pages (from-to)496-506
Number of pages11
JournalJournal of the American Medical Informatics Association
Issue number5
StatePublished - 2018


  • Anomaly detection
  • Clinical decision support
  • Electronic health records
  • Safety

ASJC Scopus subject areas

  • Health Informatics


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