Unintended consequences of clinical automation and EMRs

One of my favorite new blogs is healthsystemCIO.com. There is some terrific reporting and more importantly unique and value-added coversations going on between healthcare CIOs. I ran across the recent “Dissecting Physician Resistance to CPOE” posting and thought it was worth sharing. Timothy Hartzog, M.D., Medical Director of IT, Medical University of South Carolina said the following about how implementing Computerized Physician/Provider Order Entry has unintended consequences but all the lessons are applicable to any clinical automation. Here’s a flavor of what he said:

Implementation of clinical informatics creates emotional aspects and unintended consequences, such as the following:

  • More/New Work for Clinicians – work unit secretaries use to do, now requires physician time to complete
  • Unfavorable Workflow – hard stops in CPOE are just a bad idea and lead to angry physicians.
  • Never Ending Demands for System Changes – physician hate when the user interface changes too often, so have an educational plan for when changes are made.
  • Problems Related to Paper Persistence – many complex items like TPN, CHEMO, etc., must be ordered on paper.
  • Untoward Change In Communication Patterns and Practices – with CPOE, physicians can enter orders from anywhere in the hospital and the nurses never know.
  • Negative Emotions – when Computers do not work at stressful moments, physician get angry.
  • Generation of New Kinds of Errors – computers can change how meds are ordered, and confusing interfaces can lead to mistakes.
  • Unexpected and Unintended Changes in Institutional Power Structure – physicians have always prided themselves on being able to treat patients their way. With CPOE, physicians are forced to use certain meds and protocol restrictions.
  • Over-Dependence on Technology – one of my rules to all clinicans is: “IF the medication dose does not look right, it is NOT right until to prove otherwise.” Just because it is on a computer screen does not mean it is always correct.
  • Shifts in Power Control and Autonomy – power shifts to committees like Pharmacy and Therapeutics, Medical Directors etc. Physicians loose the freedom a blank sheet of paper provides.

It’s a great posting and worth reading.

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21 thoughts on “Unintended consequences of clinical automation and EMRs

  1. So true, so true. This was just being implemented in one of the CCF Community Hospitals and the physicians are very resistant for the vary reasons sited above.

  2. Having worked at a hospital w/CPOE:
    There was work nurses used to do that doctors had to do-put in orders was the big thing. They were used to ordering verbally and signing off on papers later.
    Our clerks don't take orders from doctors-usually the orders are nurse driven and now CPOE driven. Clerks see their orders on their own CPOE clerk screen.

    You need to limit hard stops but need lots of alerts which doctors still hate. A hard stop for us was allergy and chemo; others could be acknowledged and ignored (but they are not suppose to ignore.) As for unfavorable workflow, that's why we worked so closely with the endusers to mimic their workflow as much as possible. But a lot of that is also orderset driven. If the doctor wrote the orderset w/out consulting the nurses in the dept, then we'd run into issues with the orderset. Nurses had to stop and say where was their part.

    Our updates were either backend to system or would be front end user changes, usually better for users and required more communication not end user training.

    Our system had paper issues built in so to speak-there were sentences for instruction for next steps built in that instructed user to get the necessary paper. But that was rare and disappeared once the rest of the hospital was on CPOE.

    If there's an order and the nurse doesn't know, then it's because the doctor to nurse alert system isn't built in to that hospital's CPOE. All doctor orders should create orders and flags on the nursing screen view of CPOE. That's how nurses are notified and that view is crucial to nursing care. It's here that they mark off what's done and acknowledge changes. If it's emergent, the doctors were told to call in and alert nurse. But if it were that urgent, the nurse would have already called or had the doc paged and they would be expecting an answer and then calling another doctor if no answer was given in a timely manner.

    Everyone's angry when computers are slow or down. Hard to get around. That's why system updates should be in the middle of the night.

    There should be no interface mistakes. A 3 mg order for a med should go to pharm and back as 3 mg. You can have different versions of the same drug in CPOE and the doctor and nurse must know which correct version to order. Our ordersets allow for certain drugs in a situation (if that's how the dept. created it) but then you can pull up other meds and order what is needed. But our system also has built in what is allowed for given situations. There was an issue over adult versions being ordered for peds-it won't let adult versions be ordered for peds and a workaround had to be created because once in awhile you might want an adult dose for peds. It's all again, how was the system built; why weren't interfaces perfected; and can updates be done after implementation.

    Doctors have more to do on the computer and can't bark out orders and must now work more with nurses but still have plenty of autonomy. If a doctor feels restricted by a use of a med or protocol with CPOE then it is because CPOE was built without reflecting the workflow of the physician and ordersets were built by someone not in that dept. If a doc can't complain and get an orderset changed then it might be because there is no one to complain to, that a package was given to the hospital to use as is which is a huge mistake.

    Nurses especially had to have it reiterated that just because the computer says so doesn't make it right. They were told to think about what would you do on paper; what is the non-tech process (which of course only applies to the current generation of nurses who grew up on paper. You can't use this methodology with future generations who will rely more heavily on how it is in the computer must be how it is in real practice.)

    Any hospital that doesn't have committees working on things is a hospital that was a dictatorship. The older doctors might feel more left out but the younger ones will actually have more autonomy with a computer.

  3. Hi Shahid,
    In case you'd like to take a look at my view of similar issues, you can find it here:
    http://www.serefarikan.com/?p=88
    I've chosen the title for the topic as antipatterns in EHR implementation, but you'll find more detail of similar issues.
    Regards
    Seref

  4. Paper charting and orders have its drawbacks as well. Once while administering a pain killer, the doctor wrote a new order that I was unaware of. Ten minutes later, I was disciplined for giving the pain medication according to the new order. Now we have CPOE but the doctor has to print the new MAR reflecting the change and the order only takes place when the nurse is handed the new MAR

    1. If a hospital still has paper, then they've made a huge mistake. The MAR should be within CPOE and should be the screen that nurses see first when looking at a computer. Flags should alert nurses to updates and changes. The first med ordered should have been canceled by the doctor and reordered as a new med. Then the nurse should have checked her MAR and noticed the change.

      1. Thanks, Since our units only have one computer, the nurse doesnt have constant access. There does need to be an alert to the doctor that there is an old order that he has to cancel before adding a new one. I have taken your suggestions to our IT department

        1. That seems like a huge problem in itself- having CPOE and only one computer. It seems that there is no possible way nurses would be able to access the necessary information with the minimal equipment.

  5. Although there appears to be a significant amount of disadvantages of using EMRs in a health care setting, there are positive feedback that should not be missed such as streamlining the processes for paper orders. What is a big issue is helping those in the medical profession to be more receptive to the changes in technology. Training and support are essential in making users more willing to accept the changes as well as being able to understand its importance in providing the appropriate care to their patients.

  6. That seems like a huge problem in itself- having CPOE and only one computer. It seems that there is no possible way nurses would be able to access the necessary information with the minimal equipment…

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