Unintended Consequence of Electronic Health Records (also EMR) – USA

Technology is not a silver bullet

Technology by its very nature is seductive and therefore no wonder it is thought to be a silver bullet to solve complex problems.

EHR/EMR – Silver Bullet

In U.S medical costs have been shooting up, creating a fear that individuals and even the nation can go bankrupt, if no urgent action is to control costs. Insertion of EMR technology, where the current fragmented paper-based system is consolidated and integrated in an electronic platform, has been considered as an essential solution.

Law of Unintended Consequences

However, Health Care crisis in USA is so complex, it is unrealistic to expect that insertion of any technology without re-engineering of work process along with human change management will bring positive change that is not degraded by the inevitable forces of Law of Unintended Consequences.

Though the technology may exist, its implementation, requiring the medical staff to change their work approach, after a lifetime of following the paper-based system is exceedingly problematic.

To study problem in detail and suggest ways to alleviate the unintended consequences, RAND Corporation, a highly respected think tank was tasked by Agency for Healthcare Research and Quality.  They identified the following unintended consequences (full report is here http://ucguide.org/). The suggested suggestions are by the author – Avi Dear.

A. Unintended Consequences – More work for clinicians: 

Example: After the introduction of an EHR, physicians often have to spend more time on documentation because they are required to (and facilitated to) provide more and more detailed information than with a paper chart. While this information may be helpful, the process of entering the information may be time consuming, especially at first.

A. Suggested Solutions to overcome Unintended Consequences 

  1. Use of tablets like iPad with special-purpose Apps can reduce the data-entry overhead for physicians
  2. These should be designed in consultations with physician in the age group of late 50’s, since we want them to co-opt this technology.

B. Unintended Consequences – Unfavorable workflow changes:

Example: Computerized physician order entry (CPOE) automates the medication and test ordering process by reducing the number of clinicians and clerical staff involved, but by doing so it also eliminates checks and counterchecks in the manual ordering process. That is, with the older system, nurses or clerks may have noticed errors, whereas now the order goes directly from the physician to the pharmacy or lab.

B. Suggested Solutions to overcome Unintended Consequences

  1. Use of Artificial Intelligence-based Expert System encoded with human heuristics that will wet the order, based on prior defined rules.
  2. The means that these Expert Systems will be inserted between Ordering by Physician and Execution by lab or pharmacy and flag any potential errors, for review by a human

C. Unintended Consequences – Never-ending demands for system changes: 

Example: As EHRs evolve, users rely more heavily on the software, and demand more sophisticated functionality and new features (e.g., custom order sets). The addition of new functionalities necessitates that more resources be devoted to EHR implementation and maintenance.

C. Suggested Solutions to overcome Unintended Consequences

  • This is a typical problem with a roll-out of a new technology that is still not fully developed.  Premature roll-out of technology with all the bugs and challenges can at time doom it.
  • It will be better that user trials are conducted at a specific test facilities with additional costs  build-in for user feedback, rather than rolling out to  a large number of facilities and users.  In the test facility the challenges to technology adoption concurrent with human dynamics can be close observed and feedback used for improvements.

D. Unintended Consequences – Conflicts between electronic and paper-based systems: 

Example: Physicians who prefer paper records annotate printouts and place these in patient charts as formal documentation, thus creating two distinct and sometimes conflicting medical records.

D. Suggested Solutions to overcome Unintended Consequences

  1. New tablet based Apps can be developed to allow for handwriting to be captured and converted, bridging the gap between paper-based and electronic systems,

E. Unintended Consequences – Unfavorable changes in communication patterns and practices: 

Example: EHRs create an “illusion of communication,” (i.e., a belief that simply entering an order ensures that others will see it and act upon it.) For example, a physician fails to speak with a nurse about administering a medication, assuming that the nurse will see the note in the EHR and act upon it.

E. Suggested Solutions to overcome Unintended Consequences

  1. Two-way electronic communications should be programmed, so that when the nurse “sees” the physician order, the physician can electronically monitor it. Therefore, if sees no response within a specific time, he can personally reach out and talk to the nurse.

F. Unintended Consequences – Negative user emotions: 

Example: Physicians become frustrated with hard-to-use software.

F. Suggested Solutions to overcome Unintended Consequences

  1. Again, premature roll-out of new technology with is challenging to physicians should be fully tested before large-scale roll-out.

G. Unintended Consequences – Generation of new kinds of errors: 

Example: Busy physicians enter data in a miscellaneous section, rather than in the intended location. Improper placement can cause confusion, duplication, and even medical error

G. Suggested Solutions to overcome Unintended Consequences

  1. The software application should be properly designed so that only relevant sections are visible/available, thereby reducing mistakes.
  2. User training and re-training should be integral part of any roll-out.

H. Unintended Consequences – Unexpected and unintended changes in institutional power structure: 

Example: IT, quality assurance departments, and the administration gain power by requiring physicians to comply with EHR-based directives (e.g., clinical decision support alerts).

H. Suggested Solutions to overcome Unintended Consequences

  1. Younger physicians with computer background/interest should be incorporated into IT so they provide the physician perpective and become bridge between the old and the new.

I. Unintended Consequences – Over-dependence on technology: 

Example: Physicians dependent on clinical decision support may have trouble remembering standard dosages, formulary recommendations, and medication contraindications during system downtimes.

I. Suggested Solutions to overcome Unintended Consequences

  1. As mentioned development before, development of expert systems capturing the  physician heuristics should be a component of EMR/EHR. This way part of the vast knowledge base is captured and provides guidance and sanity checks.

Liked this post? Subscribe to my RSS feed and get loads more!


If you want to learn more about The Law of Unintended Consequences and this blog, please see


If you want to add your expertise to subject of The Law of Unintended Consequences, please see





Tags: , , , , ,