Computerized order entry sites could suffer unintended consequences

Fear of adverse unintended consequences has impeded wider adoption of computerized provider order entry systems, according to a new study. As a result, fewer than 10% of U.S. hospitals report installation of these systems. The paper attempted to identify the extent and importance of unintended adverse CPOE consequences by surveying domestic hospitals using the systems (J Am Med Inform Assoc 2007;14:415-423)."Unintended consequences are going to happen, and we need to accept that as a given and work hard to manage them as they arise," said Joan S. Ash, Ph.D., of the department of medical informatics and clinical epidemiology at Oregon Health & Science University. "Aggressive detection and management of adverse unintended consequences is vital for CPOE success."

The paper defined several types of unintended consequences:

• workflow changes
• system support demands
• alteration in communication patterns
• new kinds of errors
• dependence on CPOE

Ash said her goal was to identify the types of unintended consequences so they can be monitored and managed.

"Once unintended consequences are predicted or detected, hospitals can work to either try to avoid them or accept them as trade-offs," Ash said.CPOE can have a negative impact on clinical workflow, for example, because it takes more time for a physician to enter orders than in the conventional manual way. But this might be accepted as a trade-off for the added patient safety benefits of CPOE, she said. Ash recommends that developers and implementors consider each unintended consequence carefully during planning. The ability to maintain control over consequences may give hospital administrators more confidence when deciding on CPOE implementation."Consequences like workflow issues are immense and affect nearly every staff member of the hospital," she said. Implementors must also take steps to offset altered communications created by electronic systems.There appears to be no correlation between the importance of each type of consequence and the length of time that a CPOE system had been in place, according to Ash."Despite the recent timing of many implementations, these CPOE systems are highly infused, deeply embedded into workflow, and heavily used," she said.Previous studies have reported taxonomies of CPOE errors and hierarchical models of unintended consequences, but the Ash paper is the first to provide a description of the extent and importance of unintended CPOE consequences in U.S. hospitals.