THE GUIDE OFFERS multiple case studies of known unintended consequences, raising awareness of the issues and illustrating a process and approach to resolving them. The following example describes the unintended consequences of the
continued use of paper after an EHR implementation.
Paper Persistence after EHR Implementation
The Computerized Patient Record System (CPRS) is imple-
mented throughout the Veterans Affairs medical system. A
recent study indicated that clinicians in the VA system consis-
tently use paper to work around the limitations of CPRS. Some
examples of the workarounds they identified include:
An emergency department physician feels that a paper form
is more efficient than CPOE. He passes his paper-based or-
ders to the nurse, who passes them off to the clerk, who then
enters the order into the computer.
A pharmacist makes handwritten notes on printouts from
Finding a Solution
the EHR and then enters the handwritten data back into the
system later in the day. The pharmacist said, “The hand notes
help me remember. I do this for discharges and inpatients.
There can be 6 to 12 discharges per day. It is not possible to
make these types of notes in CPRS [in real time]. I don’t know
how you would do this in the computer... We need paper to do
A nurse uses a notebook to track patient lab values: “I add
important footnotes—anytime the [international normalized ra-
tio] INR is too high... The primary care provider will think the
INR was too high only this one time but I have the data in my
notebook to show that it was too high three times.”
An EHR has many advantages over the paper record, including
improved legibility, remote access, and the ability to integrate
The guide contains real-world experiences from a variety of
settings. One example involves the Veterans Health Administration’s (VHA) implementation of its prospective risk analysis system, Health Care Failure Mode and Effect Analysis (HFMEA).
This five-step process uses an interdisciplinary team to evaluate
a healthcare process proactively. HFMEA is an example of root
cause analysis, which the guide recommends as a systematic
approach for identifying risks introduced by an EHR.
The guide describes a case study of employing HFMEA in a
pediatric oncology department, which used the model to evaluate its processes related to chemotherapy. The department used
HFMEA to guide implementation of a computerized physician
order entry (CPOE) system, with three essential functionalities
identified: limiting choices (thereby emphasizing menus instead of free text); enforcing entry of required data so that users
across information systems. However, don’t be surprised if
the EHR does not replace paper use entirely. Paper use may
continue to the extent that clinicians perceive that it is more
efficient than using the EHR.
How to best deal with the persistence of the paper record
is still an open problem. However, the VA is carefully studying when, where, and why clinical users would develop these
paper-based information tools to supplement or work around
the EHR. They then use their observations to determine how
the EHR applications could be altered to better suit the clinical
In some instances, paper-based solutions may be more efficient than a difficult-to-use EHR. However, these workarounds
can create unanticipated risks or negate many of the benefits
of having an EHR. If modifying the EHR to better suit the clinicians’ work processes is not feasible, it might be most effective to develop standardized paper-based tools that can be
used throughout your organization to supplement the EHR.
While this solution may not be ideal, it is likely preferable to
several different ad-hoc approaches floating around.
Paper-based supplementation and workarounds are very
Administrators should seek to find out why clinicians find
paper records desirable and try to determine how the EHR
could be modified to better suit clinical work so as to reduce
the need for paper.
In some instances, user preference for paper may be very
strong. In these circumstances, it may be preferable to use
both paper and electronic systems; approved paper systems
should be standardized to avoid inconsistencies across the
cannot navigate from a page until all required fields are entered;
and alerting users to abnormal values.
ISTA and More
Another model for understanding how and why unintended
consequences occur and developing solutions for them is Interactive Sociotechnical Analysis (ISTA), a method Koppel co-developed.
“In thinking of the role of technology, there are these recursive
feedback loops that not only affect the way technology is used
but also change the social code of the organization,” he says.
An example occurred in an intensive care unit Koppel visited.
“This ICU had state-of-the-art everything, but it turned out that
the wireless connectivity didn’t work throughout the unit. The
plan was to have computers on wheels, but they didn’t work in