"e-Iatrogenesis": The Most Critical Unintended Consequence of CPOE and other HIT
Open accessAbstract
In the September/October 2006 issues of JAMIA, Campbell et al.'s article “Types of Unintended Consequences Related to Computerized Provider Order Entry”1 lays out an innovative and comprehensive framework for categorizing the things that can go wrong when CPOE systems are implemented. We commend the authors for helping to move forward our collective understanding of this important area. As CPOE and other components of health information technology (HIT) logarithmically diffuse across the U.S. health care system, it is clear they will eventually become the standard all-encompassing platform for the delivery of medical care. As has been the case for all previous medical and non-medical technologies, HIT dissemination carries with it both positive and negative consequences. All nine types of “unintended consequences” outlined by Campbell et al. in their article should be of concern to health informaticists and others in involved in health care. We would like to suggest to the authors and your readers that one of the many unintended consequences they identified lurks as the most serious of all. Within Campbell et al.'s so-called “Type-7” category (new kinds of errors) is arguably the ultimate of unintended consequences: what we term “e-iatrogenesis.” We define e-iatrogenesis as patient harm caused at least in part by the application of health information technology. Our team has coined this new term as part of an ongoing Commonwealth Fund/Robert Wood Johnson Foundation supported project to develop new frameworks for measuring and promoting ambulatory care quality and safety within the HIT context. Using different labels, most scholarly discussion of actual or potential (i.e., “near-miss”) e-iatrogenic events have surrounded CPOE ordering errors, particularly relating to drugs or diagnostic tests.2–4 But we believe this is only the tip of the iceberg. An e-iatrogenic event can be associated with just about any aspect of a comprehensive HIT system and it may involve errors of commission or omission. These unintended adverse events may fall into technical, human-machine interface or organizational domains. Some e-iatrogenic events will represent the electronic version of “traditional” errors, such as a patient receiving the wrong drug dosage due to a human click-error. But other HIT precipitated or enabled errors may have no exact analog in the non-electronic context. For example, a clinical decision support system (CDSS) embedded within an electronic health record might contribute to a clinician's incorrect diagnosis or treatment plan; this could represent either a “type-one” or “two” error (e.g., making a diagnosis that was not present or missing one that was). Furthermore, while the focus of our discussion is human errors and technical design flaws, some e-iatrogenic events will not be due to errors, per se. Just as a properly used traditional medical intervention (e.g., a drug or procedure) may cause patient harm, it is inevitable that a well-designed HIT module used appropriately may also contribute to an undesirable outcome. As part of our ongoing development effort (known as the “e-indicator” quality measurement project) we are working with a consortium of five advanced HIT enabled integrated delivery systems, and we have also interviewed numerous early HIT adopters across the nation. Universally, we are hearing reports that e-iatrogenesis, and the broader area of unintended consequences, is of concern at all of these top-notch organizations. What will happen as HIT is rolled out at organizations further down the diffusion curve? By coining the term e-iatrogenesis and writing this letter our intent is to draw attention to this critical issue. We believe that both the health informatics and patient safety/quality communities must urgently collaborate to addresses this emerging problem. It is understandable that developers and vendors continue to promote the many ways that HIT can improve quality and reduce safety hazards. But we also believe it is imperative that all parties acknowledge that even with all its promise, CPOE and other types of health information technology represent a new 21st century vector for medical care-system induced harm—something we must all work to understand, measure, and mitigate.
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- Findingown data§ 'e-Iatrogenesis': The Most Critical Unintended Consequence of CPOE and other HIT · p. 1
Reports from a consortium of five advanced HIT-enabled integrated delivery systems and numerous early HIT adopters uniformly indicated concern about e-iatrogenesis and the broader area of unintended consequences at those organizations.
“Universally, we are hearing reports that e-iatrogenesis, and the broader area of unintended consequences, is of concern at all of these top-notch organizations.”
Quote in the paperSubstantial claim - Interpretationreasoning§ 'e-Iatrogenesis': The Most Critical Unintended Consequence of CPOE and other HIT · p. 1
Some e-iatrogenic events are not caused by errors as such.
“Furthermore, while the focus of our discussion is human errors and technical design flaws, some e-iatrogenic events will not be due to errors, per se.”
Quote in the paperSubstantial claim - Interpretationreasoning§ 'e-Iatrogenesis': The Most Critical Unintended Consequence of CPOE and other HIT · p. 1
Other errors caused or enabled by HIT may lack an exact equivalent in the non-electronic setting.
“But other HIT precipitated or enabled errors may have no exact analog in the non-electronic context.”
Quote in the paperNot a substantial claim - Interpretationnone given§ 'e-Iatrogenesis': The Most Critical Unintended Consequence of CPOE and other HIT · p. 1
Certain e-iatrogenic events are electronic counterparts of traditional errors, for instance a patient getting an incorrect drug dose from a human click error.
“Some e-iatrogenic events will represent the electronic version of 'traditional' errors, such as a patient receiving the wrong drug dosage due to a human click-error.”
Quote in the paperNot a substantial claim - Interpretationreasoning§ 'e-Iatrogenesis': The Most Critical Unintended Consequence of CPOE and other HIT · p. 1
CPOE and other health information technologies constitute a new twenty-first-century pathway for harm induced by the medical care system.
“But we also believe it is imperative that all parties acknowledge that even with all its promise, CPOE and other types of health information technology represent a new 21st century vector for medical care-system induced harm-something we must all work to understand, measure, and mitigate.”
Quote in the paperSubstantial claim- Rests on an assumption: HIT dissemination carries both positive and negative consequences, as previous medical and non-medical technologies have done.
- Rests on an assumption: CPOE and other HIT will eventually become the standard all-encompassing platform for medical care delivery.
- Classified as probably not a substantial claim. 4
- May combine two claims. 3
Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.
Interpretationreasoning§ 'e-Iatrogenesis': The Most Critical Unintended Consequence of CPOE and other HIT · p. 1A well-designed HIT module used appropriately may inevitably contribute to an undesirable outcome, just as a properly used traditional medical intervention may cause patient harm.
“Just as a properly used traditional medical intervention (e.g., a drug or procedure) may cause patient harm, it is inevitable that a well-designed HIT module used appropriately may also contribute to an undesirable outcome.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S2 (checkable), S4 (based).
Interpretationreasoning§ 'e-Iatrogenesis': The Most Critical Unintended Consequence of CPOE and other HIT · p. 1Known e-iatrogenic events are only a small part of the problem.
“But we believe this is only the tip of the iceberg.”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim.
Interpretationnone given§ 'e-Iatrogenesis': The Most Critical Unintended Consequence of CPOE and other HIT · p. 1HIT-related unintended adverse events can be grouped into technical, human-machine interface, and organizational domains.
“These unintended adverse events may fall into technical, human-machine interface or organizational domains.”
Quote in the paperSubstantial claimMay combine two claims.
Interpretationnone given§ 'e-Iatrogenesis': The Most Critical Unintended Consequence of CPOE and other HIT · p. 1A clinical decision support system embedded in an electronic health record may lead a clinician to an incorrect diagnosis or treatment plan, which could be a type-one or type-two error.
“For example, a clinical decision support system (CDSS) embedded within an electronic health record might contribute to a clinician's incorrect diagnosis or treatment plan; this could represent either a 'type-one' or 'two' error (e.g., making a diagnosis that was not present or missing one that was).”
Quote in the paperNot a substantial claimMay combine two claims.
Interpretationreasoning§ 'e-Iatrogenesis': The Most Critical Unintended Consequence of CPOE and other HIT · p. 1An e-iatrogenic event can be linked to nearly any component of a comprehensive HIT system and can involve either commission or omission errors.
“An e-iatrogenic event can be associated with just about any aspect of a comprehensive HIT system and it may involve errors of commission or omission.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Premisecitation§ 'e-Iatrogenesis': The Most Critical Unintended Consequence of CPOE and other HIT · p. 1Prior scholarly discussion of actual or potential e-iatrogenic events has centered on CPOE ordering errors, especially those involving drugs or diagnostic tests.
“rounded CPOE ordering errors, particularly relating to drugs or diagnostic tests. 2-4”
Quote in the paperNot a substantial claim0 of 3 sources checked- cites [2] 2. Ash JS, Sittig DS, Dykstra RH, Guappone, K, Carpenter, JD, Seshadri V. Categorizing the unintended societal consequences of computerized order entry. Int J Med Inform, (e-pub ahead of print) June 20, 2006. DOI 10.1016/ijmedinf.2006.05.017. Available at: http://intl.elsevierhealth.com/journals/ijmi/.
Not checked in the free run.
- cites [3] 3. Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA 2005;293(10):1197-1203. source
Not checked in the free run.
- cites [4] 4. McDonald CJ, Computerization can create safety hazards: A bar-coding near miss. Ann Int Med. 2006;144(7):510-516. source
Not checked in the free run.
The paper relies on this without support.
HIT dissemination carries both positive and negative consequences, as previous medical and non-medical technologies have done.
“As has been the case for all previous medical and non-medical technologies, HIT dissemination carries with it both positive and negative consequences.”
The paper relies on this without support.
CPOE and other HIT will eventually become the standard all-encompassing platform for medical care delivery.
“As CPOE and other components of health information technology (HIT) logarithmically diffuse across the U.S. health care system, it is clear they will eventually become the standard all-encompassing platform for the delivery of medical care.”
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Rapid adoption of electronic health records has revealed potential safety concerns related to EHR design, implementation, and use.
“In particular, rapid adoption of electronic health records (EHRs) has revealed potential safety concerns related to EHR design, implementation, and use.12 17–21”
From An analysis of electronic health record-related patient safety concerns (2014) · cites this paper as [19]
Increasing adoption of electronic health records has revealed potential safety implications related to EHR design, implementation, and use.
“the increasing adoption of electronic health records (EHR) has revealed potential safety implications related to EHR design, implementation, and use.”
From Exploring the sociotechnical intersection of patient safety and electronic health record implementation (2014) · cites this paper as [13]
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“Even more importantly, they raise safety concerns, which must be seen as an important component of e-iatrogenesis [28].”
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“12 The term ‘ e-iatrogenesis ’ 13 has even been coined to refer to harm introduced as a result of conversion to electronic records.”
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“” [5] e-Iatrogenesis can result from a variety of factors involving any type of HIT.”
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- Authors
- Weiner, J. P., Kfuri, T., Chan, K., & Fowles, J. B.
- Affiliations
- Johns Hopkins University (US)
- Corresponding author
- Weiner, J. P.
- Venue
- Journal of the American Medical Informatics Association
- Publisher
- Oxford University Press (OUP)
- Published
- 2007-05-01
- Volume
- 14
- Issue
- 3
- Pages
- 387-388
- ISSN
- 1067-5027 (ISSN-L)
- 1527-974X
- PMC
- PMC2244888
- OpenAlex
- W2112033800
- Semantic Scholar
- ec32cd67f6ff2f654fd40bd38d08cc267dfc7d97
- Cited by
- 189
- References
- 4
- Citations by year
- 2026: 1 · 2025: 3 · 2024: 4 · 2023: 5 · 2022: 5 · 2021: 6 · 2020: 5 · 2019: 12 · 2018: 5 · 2017: 7 · 2016: 19 · 2015: 16 · 2014: 15 · 2013: 17 · 2012: 18
- FWCI
- 25.55
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Journal of the American Medical Informatics Association (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Health Sciences › Health Professions › Health Information Management › Medical Coding and Health Information
- Keywords
- computerized physician order entry, patient harm, clinical decision support systems, electronic health records, medical errors, human-machine interaction, outpatient care, near misses, medication errors
- MeSH terms
- Humans, Iatrogenic Disease, Quality of Health Care, Medical Errors, Medical Order Entry Systems
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