Algorithmic Detection of Boolean Logic Errors in Clinical Decision Support Statements

Adam Wright, Skye Aaron, Allison B. McCoy, Robert El-Kareh, Daniel Fort, Steven Z. Kassakian, Christopher A. Longhurst, Sameer Malhotra, Dustin S. McEvoy, Craig B. Monsen, Richard Schreiber, Asli O. Weitkamp, Duwayne L. Willett, Dean F. Sittig

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


Objective Clinical 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. Methods Nine 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. Results Participating 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. Discussion An 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. Conclusion Both 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.

Original languageEnglish (US)
Pages (from-to)182-189
Number of pages8
JournalApplied Clinical Informatics
Issue number1
StatePublished - Jan 1 2021


  • alerting
  • clinical decision support
  • decision support algorithm
  • efficiency improvement
  • electronic health records and systems

ASJC Scopus subject areas

  • Health Informatics
  • Computer Science Applications
  • Health Information Management


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