Categorizing the unintended sociotechnical consequences of computerized provider order entry

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This study attempts to describe the kinds of unintended consequences related to the implementation of computerized provider order entry (CPOE) in the outpatient setting. While in the narrow sense CPOE is defined "as a process in which a provider who has ordering authority uses a computer to enter medical orders directly eliminating the need for an intermediary to respond to written or verbal orders given by a provider", this study uses an expanded definiton of CPOE that includes accompanying processes such as decision support, documentation, and order delivery.[1]


The study defines an innovation as “an idea, practice, or objective perceived as new by an individual, a group, or an organization” and uses Diffusion Of Innovation (DOI) theory as the framework for its conclusion, defined as “the process by which an innovation is communicated through certain channels over time among the members of a social system”


Ethnographic and interview data were collected by an interdisciplinary team over a 7 month period at four clinics, all of which were successfully using CPOE. The institutions varied according to type and geographic location.


A grounded theory approach (using the patient's own words as a starting point) was used to identify emergent themes. Consequences varied greatly in level of severity, granularity, direction (positive and negative), source, and frequency of occurrence. Instances of unintended consequences were categorized using an expanded Diffusion of Innovations theory framework.


There were both desirable and undesirable unintended consequences after implementation of CPOE, and these were felt to be either direct or indirect, but there were also many consequences that are not clearly either desirable or undesirable (interestingly, the authors felt that some consequences may be both, depending on the observer's viewpoint). The undesirable consequences included error and security concerns and issues related to alerts, workflow, ergonomics, interpersonal relations, as well as reimplementation. There is a very interesting thematic hierarchical network model of consequences of CPOE in the article (Figure 2). Two specific examples are described:

  • A positive, or serendipitous, unintended consequence was “collaborative charting” between the physician and the patient. When the physician turned the screen toward the patient, the patient noted errors in the information displayed and together the patient and physician corrected the record.
  • A negative consequence of CPOE was a change in the physicians' workflow and time spent at the computer. The physicians used their lunch hour to catch up on charting resulting in less socialization with the office staff.


Consequences of implementing and reimplementing clinical systems are complex. Not all outcomes can be foreseen! The expanded Diffusion of Innovations theory framework is probably a useful tool for analyzing such consequences.The authors state "Once unintended consequences are better understood, more will be foreseeable and strategies can be outlined for preventing them, mitigating them, or overcoming them completely". When analysed, this statement can, at some levels, be compared to some of the fundamental principles of risk management (in decreasing order of desirability, risk is best avoided, mitigated, or assumed in toto).


  1. Ash, J. S., Sittig, D. F., Dykstra, R. H., Guappone, K., Carpenter, J. D., & Seshadri, V.(2007). doi: 10.1016/j.ijmedinf.2006.05.017.

VM 11/12/06