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The Law of Unintended Consequences - Will the Stimulus Topple the House of Cards?

February 23, 2009
by Pam Arlotto
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While the healthcare industry contemplates the positive impact of the stimulus, it is also important to pause and consider the “unintended consequences” of incenting IT adoption. According to Robert Norton in the Concise Encyclopedia of Economics, “The law of unintended consequences, often cited but rarely defined, is that actions of people—and especially of government—always have effects that are unanticipated or unintended. Economists and other social scientists have heeded its power for centuries; for just as long, politicians and popular opinion have largely ignored it”. While unintended consequences can result in a positive unexpected benefit, the reverse or negative effect is typically the one highlighted. Stated in simple terms, each cause has more than one effect; and typically at least one unforeseen effect.

Researchers at Oregon Health & Science University have identified nine specific unintended consequences associated with CPOE. On a regular basis I see unintended consequences earlier stage applications such as clinical documentation, medication administration and departmental systems. Examples include nurses who continue document at shift change versus when the intervention/medication occurred –not realizing that today’s systems will track timing and record this as a potential medical error; automated assessments requiring extensive time to complete; and workarounds to compensate for awkward or inconvenient applications of bar code technologies. Will the HIT stimulus just layer on to an already shaky house of cards?

Any time you try to change something as complex as healthcare, there will be unintended consequences. Lessons can be learned from Massachusetts’s recent experimentation with healthcare reform. An unintended consequence of giving everyone healthcare insurance, has created a shortage of primary care physicians link. Another example, the recent CMS focus “never events” had two goals – improve patient safety and reduce costs. An unintended consequence is that providers are spending a great deal of time on unnecessary patient care and creating the perfect chart.

Providers should not wait until all of the details of the stimulus are defined to prepare for both the intended and unintended consequences of IT adoption. There are three steps you can take today to be ready:

  • Assess the value and effectiveness of your investment in information technology and electronic medical records today, including unintended consequences that are specific to your organization
  • Understand specific midcourse corrections you can make to address the consequences you already know about and can predict based on the lessons of those who have gone before you
  • Develop and begin to implement an action plan
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Comments

Pam,
Thanks for this post. I appreciate the prescriptive 'three steps' to mitigate this inevitable outcome.

I especially appreciate the reference to Joan Ash and associates in the link you provided.  Their site starts with this graphic, with the words "Think before you leap."  I've attended her conference presentations for years.  Brilliant work that informs all of HCIT, spanning multiple provider organizations, vendors, and issues.




The Advisory Board's research is also helpful in this space.  They found 4 highly common lessons, or unintended and avoidable roads to failure.  The observation that
"a good clinical project starts with go-live, it shouldn't end with go-live"
is one of those lessons. I rarely see staffing for post-go-live assessment. I'm not talking about a month or year after go-live. More like days.  The majority of organizations don't build in these end-user tune-ups, into their project and on-going system management plans.

I've routinely seen (across multiple vendors) evidence that users aren't using the products adequately, relative to the products strengths. Often, users are rarely observed and coached. And, one consequence of that is that unintended consequences are detected late, if at all.

One such unintended consequence that I find particularly understandable is related to your 'end-of-shift charting' example. Several CIOs have shared privately that clinicians, faced with a demanding task list, often forget to stop and think about required care needs that aren't on that list.

Having the computerized list has the initial effect of distracting doctors and nurses from 'stopping and thinking.' The bigger the list, the stronger the likelihood of degrading ad hoc care that is sometimes critical.

Thanks again for articulating and giving voice to this important issue.

Pam,
Thanks for asking.  I meant to be succinct, not telegraphic.  From the article, Homework First:


... the next level of failure is what the Advisory Board calls “perceiving go-live as an end-state.” (“Unlocking the Value of Clinical Information Technology — Best Practices for Designing, Deploying, and Managing Clinical Systems,” The Advisory Board, Washington, D.C.) It's only after a system is live that the technology-enabling changes can be vetted and stabilized in the real world. And yet, according to their extensive review, this failure to recognize and invest in the Fairness phase is one of the four most common, reasons for failure. The other three, by the way, are

failure to establish metrics of success,

failure to design for optimal end-user workflows, and

settling for partial adoption and co-existence of multiple platforms.

Sound familiar?

Joe:
Can you share TAB's other 3 lessons or avoidable roads to failure....that might be helpful for our readers...Thx!

Pam Arlotto

President and CEO, Maestro Strategies

Pam Arlotto’s blog focuses on the business and clinical value of the healthcare industry’s...