Harrison, Michael I; Koppel, Ross; Bar-Lev, Shirly

Table 1

Unintended Consequences by ISTA Type

ISTA Type	Unintended Consequences*
1. New HIT changes social system	*More/New Work for Clinicians*14 Physicians spend more time on documentation & justification.
	*Changes in Communication Patterns & Practices* Introduction of IT leads to decline of vital interaction among care providers, ancillary services, & units.† IT system eliminates informal interactions & redundant checks that help catch errors.‡
	*Workflow* CPOE undermines informal gatekeeping by clerk who decided whether patients really needed daily x-rays.
2. Technical & physical infrastructures mediate HIT use	*Paper Persistence*14 Paper used to solve problems of lack of integration of CPOE & other clinical information systems.
3. Social system mediates HIT use	*New Types of Errors14 Busy physicians enter CPOE data in miscellaneous section, rather than scrolling for optimal location. Improper placement can impede use by other physicians & by CPOE system. Causing Cognitive Overload by Overemphasizing Structured & “Complete” Information Entry or Retrieval11 Fragmentation* Distribution of information over several screens sometimes leads busy physicians to miss key parts of record, such as interpretations or reports by other types of physicians. Structure; Overcompleteness. Extensive reporting requirements lead physicians to cut & paste whole reports, rather than extracting pertinent facts. *Paper Persistence14 Counter to hospital directives & recommended IT practice, MDs who prefer paper records annotate CPOE printouts & place these in patient charts as formal documentation. Misrepresenting Collective, Interactive Work as Linear, Clearcut, Predictable Workflow11 Inflexibility; Transfers* Inflexible EHR reporting requirements generate failures to record clinically appropriate drug administration & cause difficulties in managing patient transfers. Urgency Nurses & physicians refuse to follow data-entry rules requiring physician pre-authorization for urgent care. Workarounds Physicians and nurses provide urgent care by working around cumbersome procedures. *Misrepresenting Communication as Information Transfer11 Decision support overload* Alert fatigue: physicians ignore warnings & reminders. Loss of communication Urgent requests & some test results from accident & emergency, admissions are never viewed on ward terminal. “… orders … are missed, … tests are delayed, & medication is not given.” Loss of feedback Nurses initial orders on receipt, rather than administration, so physicians cannot tell if orders have been carried out. *Human-Computer Interface Unsuitable for Highly Interruptive Context11 Juxtaposition errors* Entry of orders for or on behalf of the wrong person
4. HIT-in-use changes social system	*Changes in the Power Structure*14 Narrow, role-based authorizations redistribute work—requiring physicians to enter orders directly. Remote monitoring by the organizations undermines physicians’ autonomy. IT, quality assurance departments, administration gain power by requiring physician to comply with CPOE-based directives. In decentralized systems, internal variations in CPOE uses & configurations increase interdepartmental conflicts & competition.
	*Overdependence on Technology*14 Care delivery becomes inextricably dependent on IT; system failures wreak havoc when paper backup systems are eliminated. Physicians dependent on CPOE sometimes rely on decision support for real-time information & error prevention. When they transfer to settings without CPOE, they may have trouble remembering standard dosages, formulary recommendations, & medication contraindications.
	*Changes in Communication* …14 IT system creates “illusion of communication,” a belief that entry of an order assures that people will see it & act upon it.
5. HIT-social system interactions engender HIT redesign	*Never-Ending System Demands*14 As implemented CPOE systems evolve, users rely more on the software, demand more sophisticated functionality, & customize software (e.g., physicians create their own order sets). New features must be added to original software. Interactions among multiple variations of the software in use make CPOE system unmanageable & require replacement with newer versions.

↵* The headings for the types of unintended, negative consequences cited by Campbell and colleagues14 are the short forms that appear in the Discussion section of their paper. A subsequent paper27 uses the same headings with minor variations.
↵† Also treated in Ash and colleagues11(Misrepresenting Communication as Information Transfer—loss of communication). The italicized and bold type headings from the paper by Ash and colleagues are abbreviated versions of headings appearing in italics in the body of their paper. Their subtypes appear in Table 1 in italics but without bold and are shown as modifiers to the main headings.
↵‡ Also treated in Ash and colleagues11 under Misrepresenting communication … catching errors.

Unintended Consequences of Information Technologies in Health Care—An Interactive Sociotechnical Analysis

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