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The Curse of Unexpected Consequences

August 3, 2009
by James Feldbaum
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In a recent post Charlene Marietti discussed the People Problem. There are so many reasons for “resistance” from all quarters involved in the implementation process that I would need a white-paper just to scratch the surface.

While so much of the push-back is obvious and overt there can be behavioral work-arounds that add a dangerous but avoidable element to patient care. Work-arounds in the paper world usually represent strategies for circumventing “policy,” sometimes as an improvement to flawed or outdated policy, but dangerously often as a convenience that has insinuated itself into routine care. All processes need to be evaluated and corrected as needed as part of the creation of an electronic work flow. It is a squandered opportunity to assume that there is no need for process re-evaluation as part of an implementation.

In addition, there are unexpected consequences to process re-design as new work-arounds are substituted for old, often to the detriment of good patient care. We evaluated the use of IV anti-anxiety medications in the pre-op area of a hospital that had just mandated anesthesiologists to enter their own orders. The medication use was way way down. It seems that it was perceived as just too much work for the physician to enter the order as part of their workflow - so patients went to the OR minus one drug. We did solve the problem by creating a pre-op protocol that included indications and orders for the medication (solutions are very culture dependant).

The lesson learned is that it is not enough to create an electronic order. There needs to be a re-evaluation of process following implementation to look for unintended consequences.

What we think, or what we know, or what we believe is, in the end, of little consequence. The only consequence is what we do.

John Ruskin (1819 - 1900)



For a great framework, study the work of Dr. Joan Ash, and Dr. Dean Sittig, they have great articles on these issues, I used there framework and was able to anticipate problems and address them before an issue happen. CPOE does increase physician workload, We have to find ways to help.

The curse of unexpected consequences is oftentimes a blessing in disguise.

I was just having the same discussion with a CIO over dinner tonight. We were discussing the practice of having order from physician new to CPOE print out for automatic review by a medical officer. The practice clearly turned up unexpected opportunities for improvement and feedback.