Joan S. Ash

Some Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System-related Errors

Medical error reduction is an international issue, as is the implementation of patient care information systems (PCISs) as a potential means to achieving it. As researchers conducting separate studies in the United States, The Netherlands, and Australia, using similar qualitative methods to investigate implementing PCISs, the authors have encountered many instances in which PCIS applications seem to foster errors rather than reduce their likelihood. The authors describe the kinds of silent errors they have witnessed and, from their different social science perspectives (information science, sociology, and cognitive science), they interpret the nature of these errors. The errors fall into two main categories: those in the process of entering and retrieving information, and those in the communication and coordination process that the PCIS is supposed to support. The authors believe that with a heightened awareness of these issues, informaticians can educate, design systems, implement, and conduct research in such a way that they might be able to avoid the unintended consequences of these subtle silent errors.

Personal Health Records: Definitions, Benefits, and Strategies for Overcoming Barriers to Adoption

Recently there has been a remarkable upsurge in activity surrounding the adoption of personal health record (PHR) systems for patients and consumers. The biomedical literature does not yet adequately describe the potential capabilities and utility of PHR systems. In addition, the lack of a proven business case for widespread deployment hinders PHR adoption. In a 2005 working symposium, the American Medical Informatics Associations College of Medical Informatics discussed the issues surrounding personal health record systems and developed recommendations for PHR-promoting activities. Personal health record systems are more than just static repositories for patient data; they combine data, knowledge, and software tools, which help patients to become active participants in their own care. When PHRs are integrated with electronic health record systems, they provide greater benefits than would stand-alone systems for consumers. This paper summarizes the College Symposium discussions on PHR systems and provides definitions, system characteristics, technical architectures, benefits, barriers to adoption, and strategies for increasing adoption.

Types of Unintended Consequences Related to Computerized Provider Order Entry

OBJECTIVE To identify types of clinical unintended adverse consequences resulting from computerized provider order entry (CPOE) implementation. DESIGN An expert panel provided initial examples of adverse unintended consequences of CPOE. The authors, using qualitative methods, gathered and analyzed additional examples from five successful CPOE sites. METHODS Using a card sort method, the authors developed a categorization scheme for the 79 unintended consequences initially identified and then iteratively modified the scheme to categorize 245 additional adverse consequences resulting from fieldwork. Because the focus centered on consequences requiring prevention or remedial action, the authors did not further analyze reported unintended beneficial (positive) consequences. RESULTS Unintended adverse consequences (UACs) fell into nine major categories (in order of decreasing frequency): 1) more/new work for clinicians; 2) unfavorable workflow issues; 3) never ending system demands; 4) problems related to paper persistence; 5) untoward changes in communication patterns and practices; 6) negative emotions; 7) generation of new kinds of errors; 8) unexpected changes in the power structure; and 9) overdependence on the technology. Clinical decision support features introduced many of these unintended consequences. CONCLUSION Identifying and understanding the types and in some instances the causes of unintended adverse consequences associated with CPOE will enable system developers and implementers to better manage implementation and maintenance of future CPOE projects.

Grand challenges in clinical decision support

There is a pressing need for high-quality, effective means of designing, developing, presenting, implementing, evaluating, and maintaining all types of clinical decision support capabilities for clinicians, patients and consumers. Using an iterative, consensus-building process we identified a rank-ordered list of the top 10 grand challenges in clinical decision support. This list was created to educate and inspire researchers, developers, funders, and policy-makers. The list of challenges in order of importance that they be solved if patients and organizations are to begin realizing the fullest benefits possible of these systems consists of: improve the human-computer interface; disseminate best practices in CDS design, development, and implementation; summarize patient-level information; prioritize and filter recommendations to the user; create an architecture for sharing executable CDS modules and services; combine recommendations for patients with co-morbidities; prioritize CDS content development and implementation; create internet-accessible clinical decision support repositories; use freetext information to drive clinical decision support; mine large clinical databases to create new CDS. Identification of solutions to these challenges is critical if clinical decision support is to achieve its potential and improve the quality, safety and efficiency of healthcare.

Factors and Forces Affecting EHR System Adoption: Report of a 2004 ACMI Discussion

After the first session of the American College of Medical Informatics 2004 retreat, during which the history of electronic health records was reviewed, the second session served as a forum for discussion about the state of the art of EHR adoption. Adoption and diffusion rates for both inpatient and outpatient EHRs are low for a myriad of reasons ranging from personal physician concerns about workflow to broad environmental issues. Initial recommendations for addressing these issues include providing communication and education to both providers and consumers and alignment of incentives for clinicians.

Computerized Physician Order Entry in U.S. Hospitals: Results of a 2002 Survey

OBJECTIVE To determine the availability of inpatient computerized physician order entry in U.S. hospitals and the degree to which physicians are using it. DESIGN Combined mail and telephone survey of 964 randomly selected hospitals, contrasting 2002 data and results of a survey conducted in 1997. MEASUREMENTS AVAILABILITY computerized order entry has been installed and is available for use by physicians; inducement: the degree to which use of computers to enter orders is required of physicians; participation: the proportion of physicians at an institution who enter orders by computer; and saturation: the proportion of total orders at an institution entered by a physician using a computer. RESULTS The response rate was 65%. Computerized order entry was not available to physicians at 524 (83.7%) of 626 hospitals responding, whereas 60 (9.6%) reported complete availability and 41 (6.5%) reported partial availability. Of 91 hospitals providing data about inducement/requirement to use the system, it was optional at 31 (34.1%), encouraged at 18 (19.8%), and required at 42 (46.2%). At 36 hospitals (45.6%), more than 90% of physicians on staff use the system, whereas six (7.6%) reported 51-90% participation and 37 (46.8%) reported participation by fewer than half of physicians. Saturation was bimodal, with 25 (35%) hospitals reporting that more than 90% of all orders are entered by physicians using a computer and 20 (28.2%) reporting that less than 10% of all orders are entered this way. CONCLUSION Despite increasing consensus about the desirability of computerized physician order entry (CPOE) use, these data indicate that only 9.6% of U.S. hospitals presently have CPOE completely available. In those hospitals that have CPOE, its use is frequently required. In approximately half of those hospitals, more than 90% of physicians use CPOE; in one-third of them, more than 90% of orders are entered via CPOE.

A Consensus Statement on Considerations for a Successful CPOE Implementation

In May of 2001, thirteen experts on computerized provider order entry (CPOE) from around the world gathered at a 2-day conference to develop a consensus statement on successful CPOE implementation. A qualitative research approach was used to generate and validate a list of categories and considerations to guide CPOE implementation.

A Cross-site Qualitative Study of Physician Order Entry

OBJECTIVE To describe the perceptions of diverse professionals involved in computerized physician order entry (POE) at sites where POE has been successfully implemented and to identify differences between teaching and nonteaching hospitals. DESIGN A multidisciplinary team used observation, focus groups, and interviews with clinical, administrative, and information technology staff to gather data at three sites. Field notes and transcripts were coded using an inductive approach to identify patterns and themes in the data. MEASUREMENTS Patterns and themes concerning perceptions of POE were identified. RESULTS Four high-level themes were identified: (1) organizational issues such as collaboration, pride, culture, power, politics, and control; (2) clinical and professional issues involving adaptation to local practices, preferences, and policies; (3) technical/implementation issues, including usability, time, training and support; and (4) issues related to the organization of information and knowledge, such as system rigidity and integration. Relevant differences between teaching and nonteaching hospitals include extent of collaboration, staff longevity, and organizational missions. CONCLUSION An organizational culture characterized by collaboration and trust and an ongoing process that includes active clinician engagement in adaptation of the technology were important elements in successful implementation of physician order entry at the institutions that we studied.

The unintended consequences of computerized provider order entry: findings from a mixed methods exploration.

OBJECTIVE To describe the foci, activities, methods, and results of a 4-year research project identifying the unintended consequences of computerized provider order entry (CPOE). METHODS Using a mixed methods approach, we identified and categorized into nine types 380 examples of the unintended consequences of CPOE gleaned from fieldwork data and a conference of experts. We then conducted a national survey in the U.S.A. to discover how hospitals with varying levels of infusion, a measure of CPOE sophistication, recognize and deal with unintended consequences. The research team, with assistance from experts, identified strategies for managing the nine types of unintended adverse consequences and developed and disseminated tools for CPOE implementers to help in addressing these consequences. RESULTS Hospitals reported that levels of infusion are quite high and that these types of unintended consequences are common. Strategies for avoiding or managing the unintended consequences are similar to best practices for CPOE success published in the literature. CONCLUSION Development of a taxonomy of types of unintended adverse consequences of CPOE using qualitative methods allowed us to craft a national survey and discover how widespread these consequences are. Using mixed methods, we were able to structure an approach for addressing the skillful management of unintended consequences as well.

Organizational Factors that Influence Information Technology Diffusion in Academic Health Sciences Centers

OBJECTIVE To identify the organizational factors which influence the diffusion of end user online literature searching, the computer-based patient record, and electronic mail systems in academic health sciences centers in the United States. DESIGN A total of 1335 individuals working in informatics and library areas at 67 academic health sciences centers in the U.S. were surveyed. Multivariate techniques were used to evaluate the relationship between the set of six organizational factors and two measures of innovation diffusion. MEASUREMENTS A Guttman-like scale was developed to measure infusion, or depth or sophistication, of each of the three innovations at each institution. Diffusion was measured by a question previously developed for another study. Six independent variables were measured via five formerly developed scales and one new one. RESULTS The overall response rate was 41%. The set of organizational variables produced significant results in the diffusion of each of the three innovations, with individual variables influencing diffusion to varying degrees. The same set produced significant results in relation to infusion only for online searching. There was little or no correlation between infusion and diffusion for each innovation. CONCLUSION Organizational attributes are important predictors for diffusion of information technology innovations. Individual variables differ in their effect on each innovation. The set of attributes seems less able to predict infusion. It is recommended that both infusion and diffusion be measured in future studies because there is little relation between them. It is further recommended that individuals charged with implementing information technology in the health sciences receive training in managing organizational issues.