Example 13: EHR-in-Use Alters Clinical Authority and Oversight

Issues Encountered

A hospital policy at an academic medical center required infectious disease (ID) fellows to review residents' CPOE orders of broad-spectrum antibiotics. However, no restrictions on residents' ordering privileges were implemented in the system. In order to avoid the hassle of dealing with the ID fellows, some residents would resort to "stealth dosing," that is, waiting until the ID fellows went off duty to prescribe the restricted medications. When they came back into work, ID fellows could demand medication changes. But changing antibiotic regimes can be problematic, so ID fellows let many such orders stand even if they were not ideal. Because ID fellows often take no remedial actions and residents can game the system, stealth dosing constrains the ID fellows' authority and weakens the oversight process.

Finding a Solution

Changes in organizational policy facilitated by the introduction of new clinical information systems can be a major source of unintended consequences. As we see in the example above, the unintended consequence of "stealth dosing" was not the result of any limitations or problems with the CPOE system; it was a response to a change in hospital policy. Just as is the case with the implementation of new clinical information systems, careful thought and consideration must be given to implementation of new EHR-related policies. After new policies are implemented, user response should be carefully monitored and user feedback about the policy changes should be regularly solicited.

Lessons Learned

  • Changes in EHR-related organizational policy can lead to unintended consequences.
  • EHR-related policies can motivate users to work around or "game" the system.
  • User responses to policy changes should be carefully monitored.

Source: LaRosa LA, Fishman NO, Lautenbach E, et al. Evaluation of antimicrobial therapy orders circumventing an antimicrobial stewardship program: investigating the strategy of "stealth dosing". Infect Control Hosp Epidemiol. 2007 May; 28(5): 551-6.

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