Categorizing the unintended sociotechnical consequences of computerized provider order entry
Abstract
Objective To describe the kinds of unintended consequences related to the implementation of computerized provider order entry (CPOE) in the outpatient setting.Design Ethnographic and interview data were collected by an interdisciplinary team over a 7 month period at four clinics.Measurements Instances of unintended consequences were categorized using an expanded Diffusion of Innovations theory framework.Results The framework was clarified and expanded. There are both desirable and undesirable unintended consequences, and they can be either direct or indirect, but there are also many consequences that are not clearly either desirable or undesirable or may even be both, depending on one's perspective. The undesirable consequences include error and security concerns and issues related to alerts, workflow, ergonomics, interpersonal relations, and reimplementations.Conclusion Consequences of implementing and reimplementing clinical systems are complex. The expanded Diffusion of Innovations theory framework is a useful tool for analyzing such consequences.
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Multiple organizations working together have found and recorded thousands of possible EHR safety defects.
“Beyond these published reports, several organizations have collectively identified and documented thousands of potential EHR-related safety flaws.34”
From EHR Safety: The Way Forward to Safe and Effective Systems (2008) · cites this paper as [34]
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Ensuring the Safety of Health Information Systems: Using Heuristics for Patient Safety
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Computerized Provider Order Entry and Patient Safety
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Usability Flaws in Medication Alerting Systems: Impact on Usage and Work System
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Exploring the unintended consequences of computerized physician order entry.
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Self-citationWhat is the safety case for health IT? A study of assurance practices in England
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- Authors
- Ash, J. S., Sittig, D. F., Dykstra, R. H., Guappone, K., Carpenter, J. D., & Seshadri, V.
- Affiliations
- Oregon Health & Science University (US)
- Corresponding author
- Ash, Joan S.
- Venue
- International Journal of Medical Informatics
- Publisher
- Elsevier BV
- Published
- 2007-06
- Volume
- 76
- Pages
- S21-S27
- ISSN
- 1386-5056 (ISSN-L)
- OpenAlex
- W2004091813
- Cited by
- 267
- References
- 19
- Citations by year
- 2026: 4 · 2025: 4 · 2024: 8 · 2023: 8 · 2022: 8 · 2021: 4 · 2020: 6 · 2019: 15 · 2018: 9 · 2017: 18 · 2016: 17 · 2015: 17 · 2014: 18 · 2013: 22 · 2012: 22
- FWCI
- 33.61
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- International Journal of Medical Informatics (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institutes of Health
- U.S. National Library of Medicine (LM06942)
- Topics
- Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
- Social Sciences › Sociology and Political Science › Information Systems Theories and Implementation
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Technology and Human Factors in Education and Health
- Keywords
- computerized physician order entry, unintended consequences, diffusion of innovations, outpatient clinics, clinical workflow, clinical alerts, medical errors, patient safety, human factors, interpersonal relationships, health information technology
- MeSH terms
- Ambulatory Care, Diffusion of Innovation, Humans, Interviews as Topic, Oregon, Sociology, Medical, Interdisciplinary Communication, Medical Order Entry Systems
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