Unanticipated consequences of healthcare information technology

Researchers at the University of Pennsylvania School of Medicine and the Agency for Healthcare Research and Quality (AHRQ) have developed a framework to help hospital managers, physicians, and nurses handle the tough challenges of implementing health information technology (HIT) by directly addressing the unintended consequences that undermine safety and quality.

As documented in a 2005 JAMA article by Penn's Ross Koppel, PhD, computerized physician order entries, CPOE for short, reduce medication errors due to transcription or hand-writing deficiencies but produce many unintended consequences. For example, in some CPOE systems, physicians must enter the patient's weight before ordering some types of medications. Physicians will often insert an estimated weight just to order the desired medication, without being able to indicate it as an estimation. That number is then used by subsequent physicians for medications requiring more careful weight measurements. Koppel is the Principal Investigator of an AHRQ-supported study of hospital workplace culture and medication error at Penn's Center for Clinical Epidemiology and Biostatistics and a faculty member in Penn's Sociology Department.

In this new paper, co-authors Koppel, AHRQ's Michael I. Harrison, PhD, and Shirly Bar-Lev, PhD, from the Ruppin Academic Center, Israel, show managers and clinicians how to avoid or catch unintended consequences before they cause lasting harm. This study appears in the September issue of the Journal of American Medical Informatics Association – JAMIA.

Use of sophisticated HIT in hospitals is increasing dramatically. In addition to CPOE, other examples in which unintended consequences can occur are decision support systems and electronic medical records. Health care facilities are investing millions of dollars in health care information technology as they seek to improve patient care, safety, efficiency, and cost savings. Yet the results are often disappointing, say the researchers.

“Managers and clinicians need to prevent more undesirable side effects and recognize unforeseeable consequences early on,” says lead author Harrison. “Then they can take steps to remedy them before damage mounts.”

The authors demonstrate how new HIT changes workplace processes and how practitioners alter these technologies during use. The authors call their new paradigm “Interactive Sociotechnical Analysis.”

“We are strong proponents of HIT,” say Harrison and Koppel. “But introducing HIT is not like adding a fax machine. HIT involves a whole set of activities and interactions with existing IT, people, the built environment, and with other systems. These interactions generate unpredictable developments. We map these developments to inspire greater awareness of IT implementation problems and increased action to improve new IT systems.”

“Decision makers are taking unnecessary risks if they wait for HIT projects to run for a year or two before doing a post-hoc evaluation,” observes Harrison. “Real time evaluations can reveal unintended consequences as they emerge, allowing remedial action to be taken.”