Hiding in plain sight: What Koppel et al. tell us about healthcare IT

Abstract

We agree with the point that Dr. Koppel and coauthors make in their JAMA paper ‘‘The Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors.’’ There really is a problem with healthcare IT and the problem is not an artifact of the particular system that the paper s research covered. It is intriguing that this is considered news. Heeks et al. [1] have contended that ‘‘many—even most—health care information systems are failures.’’ Moll van Charante et al. [2] pointed out similar issues 12 years ago. The research that our lab has conducted over the past decade indicates that this is the way healthcare IT systems work. With no changes to how IT systems are developed, this is the way they will continue to work in the future. That a problem exists is not an issue. What the problem is and why it exists beg more discussion. Safety culture attitude surveys are currently popular, but produce only shifting sands that offer little traction when it comes to making progress in patient safety. The Koppel et al. article offers a firm foothold. But where do we take the next step? The problem is not ‘‘human error.’’ If it exists, error is a consequence of interaction with IT systems rather than a cause of adverse outcomes [3]. The core issue is to understand healthcare work and workers. On the surface, healthcare work seems to flow smoothly. That is because the clinicians who provide healthcare service make it so. Just beneath the apparently smooth-running operations is a complex, poorly bounded, conflicted, highly variable, uncertain, and high-tempo work domain. The technical work [4] that clinicians perform resolves these complex and conflicting elements into a productive work domain. Occa-