Smashing the strict hierarchy: three cases of clinical decision support malfunctions involving carvedilol

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 — 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 β-blocker, specifically carvedilol, a non-selective β-blocker that also has α-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.