Nine Unintended Consequences of Health IT

An article on Monday 16th December in the Oregon Business titled The promise and pitfalls of eHealth interviewed a staff member, Assoc Prof Aaron Cohen, from the the Oregon Health & Science University, which recently formed a partnership with Epic Systems Corporation — the first such affiliation by Epic with an academic institution.

A very interesting sidebar in the article is the description of a set of 9 unintended consequences of health IT. This is the list verbatim.

SIDEBAR: Nine unintended consequences of eHealth

Joan Ash, a medical informatics professor at Oregon Health & Science University, and her colleagues have identified nine types of harmful, unintended consequences that can arise when health systems implement computerized order entry. It’s an eye-opening catalog:

More/New Work Issues: Physicians find that CPOE adds to their workload by forcing them to enter required information, respond to alerts, deal with multiple passwords, and expend extra time.

Workflow Issues: Many unintended consequences result from mismatches between the clinical information system (CIS) and workflow and include workflow process issues, workflow and policy/procedure issues, workflow and human computer interaction issues, workflow and clinical personnel issues, and workflow and situation awareness issues.

Never Ending Demands: Because CPOE requires hardware technically advanced enough to support the clinical software, there is a continuous need for new hardware, more space in which to put this hardware, and more space on the screen to display information. In addition, maintenance of the knowledge base for decision support and training demands are ongoing.

Paper Persistence: It has long been hoped that CIS will reduce the amount of paper used to communicate and store information, but we found that this is not necessarily the case since it is useful as a temporary display interface.

Communication Issues: The CIS changes communication patterns among care providers and departments, creating an “illusion of communication,” meaning that people think that just because the information went into the computer the right person will see it and act on it appropriately.

Emotions: These systems cause intense emotions in users. Unfortunately, many of these emotions are negative and often result in reduced efficacy of system use, at least in the beginning.

New Kinds of Errors: CPOE tends to generate new kinds of errors such as juxtaposition errors, in which clinicians click on the adjacent patient name or medication from a list and inadvertently enter the wrong order.

Changes in the Power Structure: The presence of a system that enforces specific clinical practices through mandatory data entry fields changes the power structure of organizations. Often the power or autonomy of physicians is reduced, while the power of the nursing staff, information technology specialists, and administration is increased.

Overdependence on Technology: As hospitals become more dependent on these systems, system failures can wreak havoc when paper backup systems are not readily available.

Source: The Extent and Importance of Unintended Consequences Related to Computerized Provider Order Entry by Joan S. Ash, Dean F. Sittig, Eric G. Poon, Kenneth Guappone, Emily Campbell, and Richard H Dykstra; Journal of the American Medical Informatics Association (2007).

We would expect that our technology would mitigate most of these items. Emergent Clinical Information Systems (ECIS) technology along with Clinical Team-Led Design (CTLD) enables the clinical team to design their own system without the need for any intervening programming. The system designed will present full clinical workflows of all roles in the team, paper forms are reproduced electronically and fully integrated into the system, and there is no dependency on a superuser or IT staff.

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