Cited by 825Electronic Health Records SystemsInformation Systems Theories and ImplementationTechnology and Human Factors in Education and Health

The DOI matches its Crossref record; 61 of the 61 references it cites were found in a registry or an index; 7 of the 26 sources its claims cite were checked for support.

Types of Unintended Consequences Related to Computerized Provider Order Entry

Open access

Campbell, E. M., Sittig, D. F., Ash, J. S., Guappone, K. P., Dykstra, R. H.·2006·Journal of the American Medical Informatics Association

DOI 10.1197/jamia.m2042PMC PMC1561794

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Abstract

OBJECTIVE: To identify types of clinical unintended adverse consequences resulting from computerized provider order entry (CPOE) implementation. DESIGN: An expert panel provided initial examples of adverse unintended consequences of CPOE. The authors, using qualitative methods, gathered and analyzed additional examples from five successful CPOE sites. METHODS: Using a card sort method, the authors developed a categorization scheme for the 79 unintended consequences initially identified and then iteratively modified the scheme to categorize 245 additional adverse consequences resulting from fieldwork. Because the focus centered on consequences requiring prevention or remedial action, the authors did not further analyze reported unintended beneficial (positive) consequences. RESULTS: Unintended adverse consequences (UACs) fell into nine major categories (in order of decreasing frequency): 1) more/new work for clinicians; 2) unfavorable workflow issues; 3) never ending system demands; 4) problems related to paper persistence; 5) untoward changes in communication patterns and practices; 6) negative emotions; 7) generation of new kinds of errors; 8) unexpected changes in the power structure; and 9) overdependence on the technology. Clinical decision support features introduced many of these unintended consequences. CONCLUSION: Identifying and understanding the types and in some instances the causes of unintended adverse consequences associated with CPOE will enable system developers and implementers to better manage implementation and maintenance of future CPOE projects.

Integrity signals

Registry

Crossref · 10.1197/jamia.m2042

Cites

61 of 61 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

7 of 26 cited sources checked · 4 supported · 0 flagged · accuracy not yet measured

The cited sources support only part of this claim — read each source’s verdict below.
In the paper
“If their patient loads are not decreased temporarily during training periods, clinicians work longer hours to complete their combined electronic and clinical work.13”
§ Types of Unintended Consequences Related to Computerized Provider Order Entry > Introduction
What the sources say
- Partly supported
  In “Adaptation of the organisation to the new electronic medical record environment” (p. 1314), clinicians report an additional 30–75 minutes of electronic-record work per day, and the implementation provided extra clinicians to help with the initial workload. The paper does not establish the claimed condition that patient loads were not temporarily reduced during training, or that this caused clinicians to work longer hours. (LLM, conf=0.84)
  cites [13] 13. Scott JT, Rundall TG, Vogt TM, Hsu J. Kaiser Permanente's experience of implementing an electronic medical record: a qualitative study. Br Med J 2005;331(7528):1313-6. sourceExperimental — accuracy not yet measured
Strength:plain· not yet calibratedCausal:direct· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passes
Every source the paper cites for this claim was checked and supports it.
In the paper
“This loss of efficiency often recovers over time.12”
§ Types of Unintended Consequences Related to Computerized Provider Order Entry > Introduction
What the sources say
- Supported
  The Discussion reports that order-entry time fell with experience and says other studies found that the initial time difference from paper-based ordering disappeared after 4 to 8 weeks. The paper therefore supports the general claim that an initial loss of efficiency often recovers over time. (LLM, conf=0.91)
  cites [12] 12. Overhage JM, Perkins S, Tierney WM, McDonald CJ. Controlled trial of direct physician order entry: effects on physicians' time utilization in ambulatory primary care internal medicine prac- tices. J Am Med Inform Assoc 2001;8(4):361-71. source
Strength:plain· not yet calibratedCausal:direct· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passes
The sources with a verdict support this claim; the rest weren’t checked yet, have no full text we could read, or their verdicts aren’t rated yet.
In the paper
“Studies have indicated that CPOE adoption can generate new kinds of health care-practice related errors, while others have described roles for CPOE in both preventing and causing medication errors.(4,20 -25 )”
§ Types of Unintended Consequences Related to Computerized Provider Order Entry > Type 7: Generation of New Kinds of Errors
What the sources say
- Not checked — no full text of the sourcecites [4] 4. Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. J Am Med Inform Assoc 2005;293(10):1197-203. source
- Not checked — no full text of the sourcecites [20] 20. Bates DW, Kuperman GJ, Rittenberg E, et al. A randomized trial of a computer-based intervention to reduce utilization of redun- dant laboratory tests. Am J Med 1999;106(2):144 -50. source
- Not checked — no full text of the sourcecites [21] 21. Bates DW, Teich JM, Lee J, et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc 1999;6(4):313-21. source
- Not checked — no full text of the sourcecites [22] 22. Bobb A, Gleason K, Husch M, Feinglass J, Yarnold PR, Noskin GA. The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry. Arch Intern Med 2004;164(7):785-92. source
- Supported
  The introduction (p. 1) explicitly says that CPOE’s prescribing-safety benefits can be compromised by new kinds of error arising from human–computer interaction. The case analysis (p. 2) also describes how faults involving clinicians and information systems can produce a medication error. (LLM, conf=0.93)
  cites [23] 23. Horsky J, Kuperman GJ, Patel VL. Comprehensive analysis of a medication dosing error related to CPOE. J Am Med Inform Assoc 2005;12(4):377-82. source
- Not checked — no full text of the sourcecites [24] 24. Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. [see comment]. Arch Intern Med 2003;163(12):1409 -16. source
- Not checked — no full text of the sourcecites [25] 25. Oren E, Shaffer ER, Guglielmo BJ. Impact of emerging technol- ogies on medication errors and adverse drug events. Am J Health-System Pharm 2003;60(14):1447-58. source
Load-bearingStrength:hedged· not yet calibratedCausal:conditional· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
In the paper
“Despite an explicit directive on CPOE printouts not to do so, and counter to current recommendations by the American Hospital Information Management Association, 17 clinicians placed annotated printouts in the patient's chart as formal documentation.”
§ Types of Unintended Consequences Related to Computerized Provider Order Entry > Type 4: Problems Related to Paper Persistence
What the sources say
- Not matched
  Couldn’t be matched to a paper in Crossref, so it can’t be checked.
  cites [17] 17. AHIMA e-HIM Work Group on Health Information in a Hybrid Environment. The Complete Medical Record in a Hybrid EHR Environment. Part III. Authorship of and Printing the Health Record (AHIMA Practice Brief). Available at: http://library. ahima.org/xpedio/groups/public/documents/ahima/bok1_ 021583.hcsp?dDocNameϭbok1_021583. Accessed Apr 29, 2006.
Load-bearingStrength:plain· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
In the paper
“Many CPOE systems slow the speed at which clinicians can carry out the clinical documentation and ordering processes.11”
§ Types of Unintended Consequences Related to Computerized Provider Order Entry > Introduction
What the sources say
- Not checked — no full text of the sourcecites [11] 11. Poissant L, Pereira J, Tamblyn R, Kawasumi Y. The impact of electronic health records on time efficiency of physicians and nurses: a systematic review. J Am Med Inform Assoc 2005;12(5): 505-16. source
Strength:plain· not yet calibratedCausal:direct· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passes
In the paper
“However, in actual clinical practice the process is much more adaptable, and includes a variety of checks, balances, interventions, and exceptions.14”
§ Types of Unintended Consequences Related to Computerized Provider Order Entry > Type 2: Unfavorable Workflow Issues
What the sources say
- Not checked — no full text of the sourcecites [14] 14. Hazlehurst B, McMullen C, Gorman PN, Sittig DF. How the ICU follows orders: Care delivery as a complex activity system. AMIA Ann Symp. 2003:284 -88.
Load-bearingStrength:plain· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“As CPOE technology diffuses and becomes entrenched within organizations, clinical care delivery becomes inextricably dependent upon it.”
§ Types of Unintended Consequences Related to Computerized Provider Order Entry > Type 9: Overdependence on Technology
Load-bearingStrength:plain· not yet calibratedCausal:direct· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
- Rests on an assumption: Health care is increasingly dependent on technology and this is unlikely to change.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Thus, clinicians must learn to navigate serially through CPOE interface screens to perform their work.”
§ Types of Unintended Consequences Related to Computerized Provider Order Entry > Type 7: Generation of New Kinds of Errors
Load-bearingStrength:plain· not yet calibratedCausal:direct· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
- Rests on an assumption: CPOE workstation screens cannot display large amounts of clinical data simultaneously.

It may state two separate claims as one. 26
Probably not a substantial claim. 12
The quote only partly states this claim. 1

The cited sources support only part of this claim — read each source’s verdict below.
In the paper
“Although limited experience exists, embedding clinical decision support (CDS) within CPOE systems may increase clinician-users' access to educational material 30,31 and may affect learning and retention.32”
§ Types of Unintended Consequences Related to Computerized Provider Order Entry > Type 9: Overdependence on Technology
What the sources say
- Supported
  The Results (p. 1) and Conclusion (p. 9) report that visible, context-sensitive links in CPOE increased clinicians’ access to educational decision-support materials, although absolute access rates remained low. The separate claim about learning and retention is attached to citation 32, not to this source. (LLM, conf=0.92)
  cites [30] 30. Rosenbloom S, Geissbuhler A, Dupont W, et al. Effect of CPOE user interface design on user-initiated access to educational and patient information during clinical care. J Am Med Inform Assoc 2005;12(4):458 -73. source
- Not checked — no full text of the sourcecites [31] 31. Bochicchio GV, Smit PA, Moore R, et al. Pilot Study of a Web-Based Antibiotic Decision Management Guide. J Am Coll Surg 2006;202(3):459 -67. source
- Partly supported
  Citation 32 is attached to the claim that CPOE may affect learning and retention, not to the preceding claim about access to educational material. The Discussion reports that CPOE may affect medical students’ learning experiences, but the paper does not address retention or establish the effect for clinician-users generally. No page number is available in our copy. (LLM, conf=0.84)
  cites [32] 32. Knight A, Kravet S, Harper G, Leff B. The effect of computerized provider order entry on medical student clerkship experiences. J Am Med Inform Assoc 2005;12(5):554 -60. sourceExperimental — accuracy not yet measured
Load-bearingStrength:hedged· not yet calibratedCausal:conditional· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
It may state two separate claims as one.
The cited sources support only part of this claim — read each source’s verdict below.
In the paper
“CPOE systems prevent some types of errors while creating or propagating new ones.4,5,21,22,24,25,33,54 -61”
§ Types of Unintended Consequences Related to Computerized Provider Order Entry > Changes in communication patterns
What the sources say
- Not checked — no full text of the sourcecites [4] 4. Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. J Am Med Inform Assoc 2005;293(10):1197-203. source
- Supported
  The introduction (p. 1) says CPOE systems can reduce errors through order checks, reminders, and improved communication. It also says patient care information systems can generate new errors; the “Catching Errors” section (p. 6) specifically describes how CPOE order entry can be prone to errors. (LLM, conf=0.92)
  cites [5] 5. Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc 2004;11(2):104 -12. source
- Not checked — no full text of the sourcecites [21] 21. Bates DW, Teich JM, Lee J, et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc 1999;6(4):313-21. source
- Not checked — no full text of the sourcecites [22] 22. Bobb A, Gleason K, Husch M, Feinglass J, Yarnold PR, Noskin GA. The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry. Arch Intern Med 2004;164(7):785-92. source
- Not checked — no full text of the sourcecites [24] 24. Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. [see comment]. Arch Intern Med 2003;163(12):1409 -16. source
- Not checked — no full text of the sourcecites [25] 25. Oren E, Shaffer ER, Guglielmo BJ. Impact of emerging technol- ogies on medication errors and adverse drug events. Am J Health-System Pharm 2003;60(14):1447-58. source
- Partly supported
  The Abstract (page unavailable) says CPOE combined with basic clinical decision support decreases the likelihood of serious medication errors. Neither that passage nor the Discussion (page unavailable) says CPOE creates or propagates new errors; the Discussion addresses alerts that clinicians may ignore, not errors caused by CPOE. (LLM, conf=0.88)
  cites [33] 33. Galanter WL, Polikaitis A, DiDomenico RJ. A trial of automated safety alerts for inpatient digoxin use with computerized phy- sician order entry. J Am Med Inform Assoc 2004;11(4):270 -7. sourceExperimental — accuracy not yet measured
- Not checked — no full text of the sourcecites [54] 54. Berger RG, Kichak JP. Computerized physician order entry: helpful or harmful? J Am Med Inform Assoc 2004;11(2):100 -3. source
- Not matched
  Couldn’t be matched to a paper in Crossref, so it can’t be checked.
  cites [55] 55. Hagland M. Safe ways. Hospitals looking to improve patient safety are turning to CPOE, bar coding and e-prescribing. Healthcare Inform 2004;21(8):20 -5.
- Not checked — no full text of the sourcecites [56] 56. King WJ, Paice N, Rangrej J, Forestell GJ, Swartz R. The effect of computerized physician order entry on medication errors and adverse drug events in pediatric inpatients. Pediatrics 2003; 112(3 Pt 1):506 -9. source
Load-bearingStrength:plain· not yet calibratedCausal:direct· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Unintended adverse consequences (UACs) fell into nine major categories (in order of decreasing frequency): 1) more/new work for clinicians; 2) unfavorable workflow issues; 3) never ending system demands; 4) problems related to paper persistence; 5) untoward changes in communication patterns and practices; 6) negative emotions; 7) generation of new kinds of errors; 8) unexpected changes in the”
§ Types of Unintended Consequences Related to Computerized Provider Order Entry > Abstract
Load-bearingStrength:plain· not yet calibratedCausal:direct· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
It may state two separate claims as one. The quote only partly states this claim.
- Rests on an assumption: The five selected hospitals are representative of successful CPOE implementations, so the UACs observed there generalize to other successful CPOE sites.
- Rests on an assumption: The frequency of occurrence of UAC types in the data (Table 2) accurately reflects their relative frequency in CPOE implementations.
- Rests on an assumption: The UACs observed are caused by CPOE rather than other organizational changes or site-specific factors.
- Rests on an assumption: The perspectives of clinical end-users, IT staff, and administrators are sufficient to identify the major types of UACs.
In the paper
“Accordingly, CPOE-based CDS is not consistently useful for clinicians, is impractical to maintain, and is less than fully reliable in complex situations.19,24,[33][34][35][36][37][38]”
§ Types of Unintended Consequences Related to Computerized Provider Order Entry > Decision Support Systems
What the sources say
- Not matched
  Couldn’t be matched to a paper in Crossref, so it can’t be checked.
  cites 19,24,[33][34][35][36][37][38]
Load-bearingStrength:plain· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Paper-based clinical record storage will become obsolete, but use of paper in the clinical setting will not.”
§ Types of Unintended Consequences Related to Computerized Provider Order Entry > Type 4: Problems Related to Paper Persistence
Load-bearingStrength:plain· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
It may state two separate claims as one.
- Rests on an assumption: Paper remains the most malleable, flexible, and easily transportable data medium available.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“While order standardization may benefit the organization, it may confuse clinicians.”
- Also stated in: § CPOE system configurations control who may do what (and when) through the use of clinical, role-based authorizations. · hedged
  “Such terminology not only disrupts clinicians' workflows, but might also compromise patient care.”
§ Types of Unintended Consequences Related to Computerized Provider Order Entry > CPOE system configurations control who may do what (and when) through the use of clinical, role-based authorizations.
Load-bearingStrength:hedged· not yet calibratedCausal:conditional· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
It may state two separate claims as one.

35 of 35

The paper relies on this without support.
The five selected hospitals are representative of successful CPOE implementations, so the UACs observed there generalize to other successful CPOE sites.
“The initial expert panel helped the authors to identify five hospitals in three different organizations where successful CPOE implementation occurred (See Table 1).To study a range of successful CPOE implementations, the project selected both academic and non-academic hospitals of differing sizes and geographic locations.”
The paper relies on this without support.
The frequency of occurrence of UAC types in the data (Table 2) accurately reflects their relative frequency in CPOE implementations.
“Table 2 lists the UACs and their frequencies of occurrence.”
The paper relies on this without support.
The UACs observed are caused by CPOE rather than other organizational changes or site-specific factors.
“To identify types of clinical unintended adverse consequences resulting from computerized provider order entry (CPOE) implementation.”
The paper relies on this without support.
The perspectives of clinical end-users, IT staff, and administrators are sufficient to identify the major types of UACs.
“Specifically, we gathered perspectives regarding CPOE from three groups: clinical end-users, IT staff, and administrators.”
The paper relies on this without support.
Paper remains the most malleable, flexible, and easily transportable data medium available.
“Furthermore, paper remains the most malleable, flexible, and easily transportable data medium available.”
The paper relies on this without support.
CPOE workstation screens cannot display large amounts of clinical data simultaneously.
“However, CPOE workstation screens cannot display large amounts of data simultaneously.”
The paper relies on this without support.
Health care is increasingly dependent on technology and this is unlikely to change.
“Health care is increasingly dependent on technology and this is unlikely to change.”
The paper relies on this without support.
Emotional responses to change are inevitable.
“Emotional responses to change are inevitable.”
The paper relies on this without support.
Currently, CPOE technology is immature and rapidly evolving.
“Currently, CPOE technology is immature and rapidly evolving.”

9 of 9

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Naturalistic inquiry
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Authors: Campbell, E. M., Sittig, D. F., Ash, J. S., Guappone, K. P., & Dykstra, R. H.
Affiliations: Oregon Health & Science University (US)
Corresponding author: Campbell, E. M.
ORCID: Sittig, D. F.
Ash, J. S.
Venue: Journal of the American Medical Informatics Association
Publisher: Oxford University Press (OUP)
Published: 2006-09-01
Volume: 13
Issue: 5
Pages: 547-556
ISSN: 1067-5027 (ISSN-L)
1527-974X
DOI: 10.1197/jamia.m2042
PMC: PMC1561794
OpenAlex: W2160382101
Semantic Scholar: 90391845572d1d2d9424cddcbdfdb4867be5e69c
Cited by: 823
References: 61
Citations by year: 2026: 9 · 2025: 18 · 2024: 24 · 2023: 29 · 2022: 29 · 2021: 27 · 2020: 27 · 2019: 59 · 2018: 32 · 2017: 44 · 2016: 48 · 2015: 48 · 2014: 52 · 2013: 80 · 2012: 46
FWCI: 86.07
Type: journal article
Language: en
Open access: bronze
doi.org
Locations: Journal of the American Medical Informatics Association (publishedVersion)
PubMed Central (publishedVersion)
PubMed (publishedVersion)
Funders: National Institutes of Health
U.S. Public Health Service (ASMM10031)
U.S. National Library of Medicine (R01LM006942, LM06942, R56LM006942)
Topics: Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
Social Sciences › Business, Management and Accounting › Management Information Systems › 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, clinical workflow, clinical decision support, clinician workload, communication patterns, medical errors, health information technology implementation
MeSH terms: Communication, Humans, Organizational Innovation, Organizational Culture, Workload, Medical Errors, Medical Order Entry Systems

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Types of Unintended Consequences Related to Computerized Provider Order Entry

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