Some unintended consequences of information technology in health care
Introduction: The IOM report noted that medical errors in the US may cause up to 98,000 hospital deaths and cost $38 billion annually; UK data suggests 850,000 incidents and errors occur in the NHS each year. Although patient care information systems (PCISs) are implemented to improve safety, their complexity can lead to unintended consequences as detailed in this paper.
Methods: Through a literature review and a series of qualitative research studies (ethnographic observation and semi-structured interviews) based on US, Australian and Dutch data, unintended errors of PCISs were elucidated.
Results: I. Errors in the Process of Entering and Retrieving Information: A human-computer interface that is not suitable for a highly interruptive use context results in juxtaposition errors which occur when something is close to something else on the screen and the wrong option is chosen in error. PCISs can also result in errors by causing cognitive overload by overemphasizing “complete” information entry. Overly structured data entry lead to loss of cognitive focus and having to go to too many fields resulted in “loss of overview” (PCIS worked against the ability to acquire, maintain, and refine a mental overview of the case). Fragmentation of data also decreased physician’s ability to review information that they normally would review when it was all in one place on paper. Over completeness was also problematic: too many standard phrases decrease the readability and information value from reports. Also, “cutting and pasting” resulted in wrong content entering a patient’s record.
II. Errors in the Communication and Coordination Process: The use of urgent medication orders relies on a large gray zone of informal management of responsibilities and task between nurses and physicians; such complex interactions cannot be handled by inflexible PCISs and may delay the use of urgent medications. Further, PCISs may not be able to efficiently handle transfers between departments which results in treatment delays as orders cannot be entered until a patient is in the “new bed”. Physicians may develop workarounds to inadequate PCISs which may further undermine patient safety. PCISs may reduce direct interaction among physicians, nurses, and pharmacy with a loss of feedback. As a result of miscommunication, orders or appointments are missed, diagnostic tests are delayed, and medications are not given. Another problem is decision support overload, which results when too many alerts are sent to the user, resulting in the provider disregarding the messages.
Discussion: The subtle nature of these errors requires several means to eliminate them: education; vendors must ensure not only that their systems provide the flexibility to fit real world work practices but also detail the limitations of their products; ensure clinicians are involved in implementation; ensure systems are in place to monitor the safety of the PCIS; utilize qualitative, multidisciplinary research to identify insidious problems and answer the “why” and “how” questions that quantitative research cannot answer.
Comments: The authors provide an overview of unintended consequences occurring when PCISs are implemented. These errors are insidious and may only be identified through and appropriate system of monitoring. Such problems may be prevented through education, system design measures, clinician involvement, and qualitative research.
