What happens when an Electronic Medical/Health Records system (EHR) is first installed in a large clinic or hospital? We must always expect the emergence of unintended outcomes, the consequences of enterprise level automation of deeply-routinized social and technical tasks. These unintended outcomes may include:

• 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

Perhaps you have witnessed these effects in your own organizational experience, and wondered "why didn't the vendor tell us this would happen?"

Freshly launched is this valuable guide for developers, designers, and IT administrators authored by the team of Ross Koppel and Michael Harrison (who brought us Unintended consequences of information technologies in health care) with Spencer Jones, Susan Ridgely, Ted Palen, and Shinyi Wu. Published online by AHRQ, the Guide would have comprised up to 100 pages of print, but instead is a nicely navigable site organized into sections for:

• How to Avoid Unintended Consequences(For Current and Future EHR Users)

• Understand and Identify Unintended Consequences

• Remediate Unintended Consequences

Based on the earlier article cited above, the team advocates the sociotechnical systems analysis process known as ISTA - Interactive Sociotechnical Analysis, a process that examines the sociotechnical practices in the healthcare work domain, using ethnographic or in-depth interviews and observations to assess EHR practices as designed and as-used. Employed by researchers familiar with social sciences research, the ISTA process helps an institution identify potential breakdowns in EHR use based on the reality of the work environment and clinical needs.The online guide gives a helpful overview of the salient issues and problems a research team will face in an internal research project to critique and recommend improvements to design or practices to optimize (or mediate) the fit of a complex EHR system to complex work situations.

One of the most valuable complements to the Guide as the Appendixes, including case studies and resources that would never have been included in a print document or article. The case examples include:

1. Staff Readiness for EHR Implementation
2. Conflicting Priorities: Regulatory Compliance vs. Clinical Workflow
3. Choose Your EHR Vendor Carefully
4. Redesigning Hospital Workflow
5. Managing Expectations About How EHR Implementation Will Affect Workflow
6. FMEA + CPOE = Fewer Medication Errors
7. Paper Persistence After EHR Implementation
8. User Frustration With Frequent EHR Updates
9. Despite Testing, Unintended Consequences Can Still Occur
10. Post-EHR Changes in Communication
11. Conflicts Between Technology and the Physical Environment
12. EHR Safety Check Results in a Potentially Dangerous Workaround
13. EHR-in-Use Alters Clinical Authority and Oversight
14. System Integration Problems
15. Responding to Alert Fatigue

As Design for Care is nearly done, its great to see these types of resources showing up - as I'm able to cite this valuable reference and include it before the final publication. Along with Fred Trotter's recent O'Reilly book Meaningful Use and Beyond (and my own Chapter 7) there is a full out assault on the heedless IT and organizational practices that lead to ineffective EHR implementation.