Developing a Guide to Identifying and Remediating Unintended Consequences of Implementing Health Information Technology (California)

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Summary:

While there are many benefits to the use of electronic health records (EHRs), implementing them can have unanticipated and undesirable consequences, referred to as "unintended consequences." Because health care environments are highly complex, the technologies used within them are also by necessity complex. This intersection of complex environments and technologies creates subtle unintended consequences when EHRs are implemented. These result from interactions between the EHR and the health care work environment and between the EHR and the technical and physical infrastructure. Because unintended consequences can undermine provider acceptance, increase costs, lead to failed implementations, and even result in harm to patients, it is important that they are understood and mitigated. This project developed a guide on how to avoid, understand, identify, and remediate unintended consequences of implementing health information technology.

Content for the guide was based on the literature, practice-oriented guides for EHR implementation and use, research conducted by the project team, and interviews with organizations that recently implemented EHRs. Content was targeted to the full range of health care organizations, from solo physician practices to large hospital systems. Users of the guide are expected to be EHR implementers including chief information officers, directors of clinical informatics, EHR champions or "super users," administrators, information technology specialists, and clinicians involved in EHR implementation. Users of EHRs, such as physicians and nurses, may also find the guide useful.

The main objectives of the project were to:

  • Synthesize the existing knowledge on types and causes of unintended consequences and strategies to avoid or address undesired consequences.
  • Develop the draft version of the guide and instructions for its use.
  • Pilot test the guide at three additional sites to assess its usability and usefulness.
  • Revise the guide and disseminate final version in a Web-accessible format through several methods.

The guide is organized in three primary sections: Avoid Unintended Consequences; Understand and Identify Unintended Consequences; and Remediate Unintended Consequences. Case examples and tools are presented throughout the guide to aid users in understanding the issues, and having access to the tools to avoid, identify, and remediate the unintended consequences within their own organizations. 

Developing a Guide to Identifying and Remediating Unintended Consequences of Implementing Health IT - 2011

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Contract Number: 
    290-06-0017-5
  • Project Period: 
    May 2009 - June 2011
  • AHRQ Funding Amount: 
    $399,894
  • PDF Version: 
    (PDF, 189.01 KB)

Summary: The use of new health information technology (IT) has been shown to enhance the quality, safety, and effectiveness of medical care. However, there are also unanticipated and undesired effects of health IT implementation-often called unintended consequences-that can be difficult to identify during a technical analysis or pilot test of the new technology. The RAND Corporation, in partnership with Kaiser Permanente of Colorado and the American Health Information Management Association (AHIMA), have developed, conducted user testing of, and disseminated the empirically-grounded Web accessible Guide to Reducing Unintended Consequences of Electronic Health Records. This guide synthesizes the existing knowledge on types and causes of unintended consequences and presents strategies to avoid or address them.

The project was a collaboration of six major health care settings and groups representing a geographically diverse group of provider organizations that included inpatient and outpatient care delivered in academic and community settings. These organizations were either in the process of implementing a variety of health IT components from several vendors or were planning to do so in the near future. Depending on health IT implementation status and preferences, participants served either as laboratory sites to help develop the guide or as pilot sites to test it. The laboratory and pilot tests sites differed in settings (rural/ urban), size (academic centers and solo physician practices), and scope of practice (inpatient/ambulatory), and therefore offered a range of perspectives and helpful feedback.

The guide will help organization leaders understand sociotechnical sources of unintended consequences and may help them avoid undesirable effects of health IT implementation. This knowledge will allow organizations to develop a process to diagnose and cope with emergent consequences. This process may even help prevent undesirable outcomes and provide opportunities for learning about and improving health care delivery. Examples of the target audience for the guide include regional extension centers, chief information officers, directors of clinical informatics, practitioners serving as champions of health IT, hospital and clinic administrators, and implementation oversight teams. Front-line health IT users, including physicians and nurses, should also find the guide useful.

Specific Aims:

  • Synthesize the existing knowledge on types and causes of unintended consequences and strategies to avoid or address undesired consequences. (Achieved)
  • Develop the draft version of the guide, and instructions for its use. (Achieved)
  • Pilot test the guide at three additional sites to assess its usability and usefulness. (Achieved)
  • Revise the guide and disseminate final version in a Web-accessible format through several methods. (Achieved)

2011 Activities: The focus of activity was on completing and disseminating the final version of the guide. The guide had been pilot-tested at four sites in 2010 to assess its usability and usefulness. Revisions were made in 2011 in response to the feedback received. The project was completed in June 2011. The guide was prepared in a Web-based format and is now available at http://www.healthit.gov/unintended-consequences. It represents a compilation of the known best practices for anticipating, avoiding, and addressing electronic health record-related unintended consequences. Because this area of research is still in its infancy, the guide is considered to be a work in progress.

Impact and Findings: Unintended consequences can undermine provider acceptance, increase costs, sometimes lead to failed implementation, and even result in harm to patients. Examples of unintended consequences include but are not limited to: more work for clinicians, unfavorable workflow changes, conflicts between electronic and paper-based systems, and overdependence on technology. If organizations learn to anticipate and identify unintended consequences, they will be in a better position to make effective decisions, clarify tradeoffs, and address problems as they arise.

Target Population: General 

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Synthesis and Dissemination

Developing a Guide to Identifying and Remediating Unintended Consequences of Implementing Health IT - 2010

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Contract Number: 
    290-06-0017-5
  • Project Period: 
    May 2009 – June 2011
  • AHRQ Funding Amount: 
    $399,894
  • PDF Version: 
    (PDF, 281.39 KB)


Target Population: General

Summary: The use of new health information technology (IT) has been shown to enhance the quality, safety, and effectiveness of medical care. However, there are also unanticipated and undesired effects of health IT implementations, often called unintended consequences, which can be difficult to identify during a technical analysis or pilot test of the new technology. The RAND Corporation, in partnership with Kaiser Permanente of Colorado and the American Health Information Management Association (AHIMA), is developing, conducting user testing, and disseminating an empirically grounded, practical, Web-accessible Guide to Identifying and Remediating Unintended Consequences of Implementing Health IT. This guide synthesizes the existing knowledge on types and causes of unintended consequences and strategies to avoid or address them.

The project is a collaboration of six major health care settings and groups representing a geographically diverse group of provider organizations that includes inpatient and outpatient care delivered in academic and community settings. These organizations are either in the process of implementing a variety of health IT components from several vendors or are planning to do so in the near future. Depending on health IT implementation status and preferences, participants serve either as laboratory sites to help develop the Guide or as pilot sites to test the Guide. Since these organizations include large numbers of locations and practices, they represent a wide range of perspectives and will facilitate pre-post comparisons of the Guide’s pilot-test assessment.

The Guide will help organization leaders understand sociotechnical sources of unintended consequences and may help them avoid undesirable effects in health IT implementations. This knowledge will allow organizations to develop a process to diagnose and cope with emergent consequences. This process may even help prevent undesirable outcomes and provide opportunities for learning about and improving health care delivery. Examples of the target audience for the Guide include regional extension centers, chief information officers, directors of clinical informatics, practitioners serving as champions of health IT, hospital and clinic administrators, and implementation oversight teams. The front-line health IT users, including physicians and nurses, should also find the Guide useful.

Project Objectives:
  • Synthesize the existing knowledge on types and causes of unintended consequences and strategies to avoid or address undesired consequences. (Achieved)
  • Develop the draft version of the Guide, and instructions for its use. (Achieved)
  • Pilot test the Guide at three additional sites to assess its usability and usefulness. (Achieved)
  • Revise the Guide and disseminate final version in a Web-accessible format through several methods. (Ongoing)

2010 Activities: The focus of activity was on completing the draft version of the Guide and presenting the draft at several meetings, including: the HMO Research Network Conference in March 2010, the Agency for Healthcare Research and Quality’s (AHRQ’s) Annual Health IT Grantee and Contractor Meeting in June 2010, the AHIMA Convention and Exhibit in September 2010, the EPIC Systems Users Conference in September 2010, and AHRQ’s Annual Conference in September 2010.

The Guide was pilot-tested at three sites to assess its usability and usefulness. Revisions have begun in response to the feedback received in the pilot testing phase.

Preliminary Impact and Findings: The project has no findings to date.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Synthesis and Dissemination

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