The Unintended Consequences of Uncaring Automation

Peter Jones Design for Care, Design for Practice

I’m completing the final sections of the manuscript for the two-year project researching and writing the Rosenfeld Media book Design for Care.   A central theme weaving together the 8 chapters is systemic design, the adoption of a whole system (social cybernetic) approach to the complex design situations in healthcare.  Variations in this thinking range from the medical competency of systems-based practice to the “whole human” perspective recently promoted by the emeritus U London professor BM Hegde. Where we must insist on systemic design is in the design of systems, specifically in the integration of enterprise level IT in clinical practice.

One of the more heavy-handed systems problems clinics and healthcare professionals face is the introduction and integration of electronic medical records (EMR) systems. While some of these systems are better than others, they can significantly divert clinical organizations from a patient-centered care model. They are a quite a boon to IT shops, as they are deploying everywhere due to the stimulus push for large institutions to capitalize on the 2009 HITECH Act incentive funding. HITECH pushes institutions to deploy EMRs for “Meaningful Use” requirements, which are fuzzy enough to include almost any uses of EMRs.

From a systemic design perspective, two thick issues emerge in this emerging automation landscape.

  • One, what are the unforeseen consequences of enterprise-level automation of deeply-routinized social and technical tasks?
  • Two, what are the human and social impacts of Meaningful Use?

In other words, how will EMRs affect the way patients are engaged in institutional care practices, given the way automation tends to separate human activity into transactions?

Overall, interaction and systems designers need to point out the answer to “what could possibly go wrong” – and we ought to have better options to promote when these systems arrive at a clinic near you and your work.

If you’re on the clinical side of healthcare design, you already know this is a wicked problem. If you’re on the consumer or vendor side, it may not yet be on your radar, but it should be. Two recent publications deserve your attention in this regard. I have posted about both of these on Design for Care, but these “communities” require the occasional reminder and prompt – which this newsletter is about.

Fred Trotter’s new O’Reilly book – Meaningful Use and Beyond – is a well-researched discussion of the IT, process and clincial practice issues involved in achieving meaningful use of EMRs. Fred is a well-rounded expert with consistent depth, but best of all his book is readable and sustains interest. The O’Reilly book can be bought as print and PDF/eBook together, so if you need to quote for a Monday meeting, you can get started immediately, like I did.

My most recent post covers Ross Koppel and Michael Harrison’s new online practice guide for evaluating potential problems with EMRs – Reducing Unintended Consequences of Electronic Health Records

AHRQ sponsored the development of the online guide which evaluates unintended consequences (such as)

  • Unfavorable workflow changes
  • Never-ending demands for system changes
  • Conflicts between electronic and paper-based systems
  • Generation of new kinds of errors
  • Unexpected and unintended changes in institutional power structure

Koppel and Harrison developed the ISTA ( Interactive Sociotechnical Analysis) methodology, combining ethnographic observation and interview with sociotechnical analysis – detailed in the online guide.  The framework is described in four dimensions:


ISTA combines a systems perspective with the empirical reality of on-the-ground research to formulate high quality observations.  Their original research article on the process was published in JAMIA and this is their excellent formulation of the process otherwise locked up in the publisher’s article.  We haven’t adopted the process in our Research Methodologies course at OCAD University yet, but the Winter term course may see this and related sociotechnical methods as toolkits for systemic design and foresight practice.