Types of Unintended Consequences of CPOE

1.  More/New Work for Clinicians

CPOE systems can significantly increase clinician workload. This can happen, for instance, by requiring that clinicians enter more information than was previously necessary or having them respond to an excessive number of alerts that may or may not contain useful information. Although improved system design may limit the amount of added work, the lesson here is that more work for the clinician is inevitable, and must be addressed in the planning process. Successful implementations balance required new work with system-based improvements in old work processes (e.g., providing integrated real time results reporting) to make use of the systems by clinicians tolerable.

2.  Workflow Issues

Clinical information systems (CIS) in general, and some CPOE systems in particular, can dramatically highlight mismatches between intended and actual work processes in real-world clinical settings. CPOE designers and implementers must considered the appropriate range of workflow perspectives (e.g., those of the nursing staff, clerical staff and pharmacists, as well as of physicians) for the resulting technological system to accommodate comprehensive, fully integrated clinical workflows. But the fact remains, no CPOE system fits all workflows of a given hospital perfectly. Even if a system initially did so, it would not eliminate the need for constant system adaptation to changing workflows in the future.

3.  Never Ending System Demands

As CPOE systems evolve (i.e., are reconfigured, enhanced, or replaced) users must be retrained and quality assurance measures must be reassessed. With each change, implementers should expect unintended consequences. Planning must allocate adequate resources for ongoing improvements.

4.  Problems Related to Paper Persistence

Many CPOE vendors advertise products as helping an organization to "go paperless." But a key distinction must be made. Paper-based clinical record storage will become obsolete, but use of paper in the clinical setting will not. Paper remains the most malleable, flexible, and easily transportable data medium available, and clinicians often rely on it as a necessary, sometimes superior, cognitive memory aid during patient care. Organizations are understandably hard pressed to limit paper use. The key issue is to decrease or eliminate the dependency on ineffective, paper-based processes that form barriers to optimal health care delivery (such as illegible written orders).

5.  Changes in Communication Patterns and Practices

CPOE implementation changes clinical communication patterns. Some describe CPOE as providing an "illusion of communication" because it promotes the belief that entry of an order into the system ensures that the proper people will see it and act upon it. Doctors, nurses and other providers consistently report that clinical systems like CPOE can cause unsatisfactory reductions in face-to-face communication regarding patient care, which in turn may increase the likelihood of errors being made. Improvements in system interface design must pay special attention to the communication needs of health care providers. In addition, a comprehensive communication plan that reaches all levels of the organization must be part of any CPOE project management plan.

6.  Negative Emotions

Emotional responses to change are inevitable. Shifting from paper-based order generation to CPOE is bound to evoke strong emotional responses as users struggle to adapt to the new technology. These responses can point out significant problems with the system design, and can lead to solutions. Training and open communication can help to promote better understanding, which may reduce the negative emotional responses to CPOE.

7.  Generation of New Kinds of Errors

CPOE systems prevent some types of errors while creating or propagating new ones. New CPOE-related errors result from: problematic electronic data presentations; confusing order option presentations and selection methods; inappropriate text entries; misunderstandings related to test, training, and production versions of the system; and workflow process mismatches. Recognizing current unintended consequences should encourage system designers to optimize human computer interface design, and to exert caution when implementing new alerts.

8.  Unexpected and Unintended Changes in Institutional Power Structure

As CPOE systems enforce specific clinical practice patterns, while also monitoring clinicians behaviors, they may induce changes in the power structure and culture of an organization. Because CPOE-related power changes affect organizational and personal autonomy, they often cause significant unintended adverse consequences for end-users. Most often it is the physician who loses power: this must be recognized and dealt with explicitly during the CPOE planning process.

9.  Overdependence on Technology

Health care is increasingly dependent on technology, and this is unlikely to change. The more widely and deeply diffused the technology, the more difficult it becomes to work without it. But dependence on technology must never become so great that basic medical care cannot be provided in its absence. Prolonged CPOE system failures (lasting hours) have the potential to dramatically halt the flow of clinical information to such an extent that outpatient activities may be curtailed or canceled and emergency rooms at trauma centers may divert admissions until vital systems are restored. Planning for management of unexpected downtime is critical.

Furthermore, users of CPOE should maintain a healthy skepticism about the information provided by such systems (e.g., not blindly trusting all information in the system without considering that it might be incorrect, or without seeking verification).

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