Module I: Introduction to Unintended Consequences

EHRs offer many advantages, but even the most experienced implementers can face unexpected difficulties. This module provides an overview of the kinds of issues that might arise during implementation.

Question 1: What are unintended consequences?

EHRs can offer many benefits to health care providers and their patients, including better quality of medical care, greater efficiencies, and improved patient safety. However, even if these benefits are achieved, you will almost certainly face some unanticipated and undesirable consequences from implementing an EHR. Such consequences are often referred to as unintended consequences.

Unintended consequences can undermine provider acceptance, increase costs, sometimes lead to failed implementation, and even result in harm to patients. However, if you learn to anticipate and identify unintended consequences, you will be in a better position to make effective decisions, clarify tradeoffs, and address problems as they arise.

Question 2: What are some examples of unintended consequences?

Here are some examples of common unintended consequences:
 1.   More work for clinicians
Example: After the introduction of an EHR, physicians often have to spend more time on documentation because they are required to (and facilitated to) provide more and more detailed information than with a paper chart. While this information may be helpful, the process of entering the information may be time consuming, especially at first.

2.    Unfavorable workflow changes
Example: Computerized physician order entry (CPOE) automates the medication and test ordering process by reducing the number of clinicians and clerical staff involved, but by doing so it also eliminates checks and counterchecks in the manual ordering process. That is, with the older system, nurses or clerks may have noticed errors, whereas now the order goes directly from the physician to the pharmacy or lab.

3.    Never-ending demands for system changes
Example: As EHRs evolve, users rely more heavily on the software, and demand more sophisticated functionality and new features (e.g., custom order sets). The addition of new functionalities necessitates that more resources be devoted to EHR implementation and maintenance.

4.    Conflicts between electronic and paper-based systems
Example: Physicians who prefer paper records annotate printouts and place these in patient charts as formal documentation, thus creating two distinct and sometimes conflicting medical records.

5.    Unfavorable changes in communication patterns and practices
Example: EHRs create an "illusion of communication," (i.e., a belief that simply entering an order ensures that others will see it and act upon it.) For example, a physician fails to speak with a nurse about administering a medication, assuming that the nurse will see the note in the EHR and act upon it.

6.    Negative user emotions
Example: Physicians become frustrated with hard-to-use software.

7.    Generation of new kinds of errors
Example: Busy physicians enter data in a miscellaneous section, rather than in the intended location. Improper placement can cause confusion, duplication, and even medical error.

8.    Unexpected and unintended changes in institutional power structure
Example: IT, quality assurance departments, and the administration gain power by requiring physicians to comply with EHR-based directives (e.g., clinical decision support alerts).

9.    Overdependence on technology
Example: Physicians dependent on clinical decision support may have trouble remembering standard dosages, formulary recommendations, and medication contraindications during system downtimes.