J Am Med Inform Assoc 21:e55-e62 doi:10.1136/amiajnl-2013-001990
  • Research and applications

A highly scalable, interoperable clinical decision support service

  1. Blackford Middleton4
  1. 1Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
  2. 2Harvard Medical School, Boston, Massachusetts, USA
  3. 3Information Systems, Partners HealthCare, Boston, Massachusetts, USA
  4. 4Department of Biomedical Informatics and the Informatics Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
  1. Correspondence to
    Dr Howard S Goldberg, Partners HealthCare System, 93 Worcester Street, Wellesley, MA 02481, USA; hgoldberg{at}
  • Received 6 May 2013
  • Revised 12 June 2013
  • Accepted 14 June 2013
  • Published Online First 4 July 2013


Objective To create a clinical decision support (CDS) system that is shareable across healthcare delivery systems and settings over large geographic regions.

Materials and methods The enterprise clinical rules service (ECRS) realizes nine design principles through a series of enterprise java beans and leverages off-the-shelf rules management systems in order to provide consistent, maintainable, and scalable decision support in a variety of settings.

Results The ECRS is deployed at Partners HealthCare System (PHS) and is in use for a series of trials by members of the CDS consortium, including internally developed systems at PHS, the Regenstrief Institute, and vendor-based systems deployed at locations in Oregon and New Jersey. Performance measures indicate that the ECRS provides sub-second response time when measured apart from services required to retrieve data and assemble the continuity of care document used as input.

Discussion We consider related work, design decisions, comparisons with emerging national standards, and discuss uses and limitations of the ECRS.

Conclusions ECRS design, implementation, and use in CDS consortium trials indicate that it provides the flexibility and modularity needed for broad use and performs adequately. Future work will investigate additional CDS patterns, alternative methods of data passing, and further optimizations in ECRS performance.

Related Article

Free Sample

This recent issue is free to all users to allow everyone the opportunity to see the full scope and typical content of JAMIA.
View free sample issue >>

Access policy for JAMIA

All content published in JAMIA is deposited with PubMed Central by the publisher with a 12 month embargo. Authors/funders may pay an Open Access fee of $2,000 to make the article free on the JAMIA website and PMC immediately on publication.

All content older than 12 months is freely available on this website.

AMIA members can log in with their JAMIA user name (email address) and password or via the AMIA website.

Navigate This Article