Overdependence on technology: an unintended adverse consequence of computerized provider order entry
This is a review of Campbell EM, Sittig DF, Guappone KP, Dykstra RH, Ash JS's 2007 article, Overdependence on technology: an unintended adverse consequence of computerized provider order entry. 
In a recent paper by Campbell et al, Types of unintended consequences related to computerized provider order entry, they looked at the unintended consequences that occur with the implementation of a Computerized Provider Order Entry (CPOE) system. From this study nine unintended consequences of CPOE implementation were found. This paper focuses on the dynamics behind one of those unintended adverse consequences- overdependence on technology.
To answer the question “How does the introduction of CPOE create the potential for overdependence on technology in healthcare organizations?”
The authors selected several sites based on their reputation with CPOE, geography, type of hospital setting and whether they had an in-house CPOE system or a commercial one. They visited each of the sites for 3 days to perform a qualitative study via direct observation in the inpatient and outpatient arena as well as structured interviews with users of the system. The combined 390 hours of observation, 32 user interviews, 1894 pages of field notes and transcripts were analyzed with Quality Analysis software (QSR N6) to identify any unintended consequences of CPOE implementation. Out of this analysis there were nine categories of unintended consequences found. For this paper, the 20 instances categorized as representing overdependence on technology were reviewed in detail.
Amongst the 20 instances of unintended consequences there were three predominate themes: System downtime, data accuracy, and clinician inability to work without automated systems.
When system downtime occurs it causes chaos for providers who depend on that system in that they must find workarounds for their tasks, perform redundant work to re-enter the information when the system is back up or worse, may elect to forgo documenting important information. System downtime in one area can dramatically affect the functions of another area (ie. Data relied on by an ancillary system of the hospital for identification is unavailable due to failure of the Admission, Discharge and Transfer software system). Complete system downtime is disastrous as clinicians no longer have access to historical data and often don’t have the resources or backup plans to complete their work.
Data accuracy is another theme in overdependence on technology. Clinicians had varying views regarding the validity of the data displayed by the CPOE system. Some trusted the data implicitly (“If it is in the computer it must be right”) whereas others were skeptical and did not believe the data unless they confirmed it themselves. When it comes information entered by clinicians there was the mis perception that data, once entered into the computer, was fully accessible and useful for the entire system regardless of how or where it was captured. There was also the tendency to assume that entering and completing the order for an item in the CPOE system was equivalent to the item being completed.
The third theme was inability to work without automated systems. Physicians who come to rely solely on the clinical decision support within a CPOE system, as opposed to their own clinical judgment have an increased potential for error. This theme was emphasized as clinicians who spent all of their training on a CPOE system moved to a health organization that did not have one.
The authors recommend that specific system downtime policy and procedures be instituted and tested. In addition, all outside data should be checked for accuracy and users trained on how to correctly enter data. Providers should be educated regarding the proper role and amount of dependence on technology.
CPOE systems have been shown to have the positive benefits of reducing drug errors and standardizing care. However, there are unintended consequences as well. From the chaos caused during system downtimes, issues of data accuracy, to providers becoming so dependent on the technology that they cannot work without it, overdependence on technology is an unintended consequence that needs to be recognized and prepared for.
- Campbell EM, Sittig DF, Guappone KP, Dykstra RH, Ash JS. Overdependence on Technology: An Unintended Adverse Consequence of Computerized Provider Order Entry. AMIA Annu Symp Proc. 2007. http://www.ncbi.nlm.nih.gov/pubmed/18693805