Unintended Consequences of Nationwide Electronic Health Record Adoption: Challenges and Opportunities in the Post-Meaningful Use Era

This follow-on article moves the discussion forward by adding further dimension to the issue of unintended consequences from the perspective of the United States health system.


When humans created the cities to enable surplus food, labor division, and trade, the city itself generated new modalities of problems such as disease and violence. The American sociologist Robert K. Merton (1910-2013) coined the term unintended consequences (UCs) to describe these antagonistic elements inherent in any human endeavor. The health care industry, which in the United States has reached near universal adoption of electronic health record (EHR) systems, is no exception.

Calls for nationwide adoption of EHRs finally came to fruition when the US Congress passed the Health Information Technology for Economic and Clinical Health (HITECH) Act into law in 2009, establishing the Meaningful Use (MU) program. As a result of MU, EHR adoption among US hospitals increased an impressive 8-fold in 6 years, and today, 9 in 10 hospitals use a government-certified EHR, and adoption among office-based physicians is above 80%. However, although successful in promoting its intended consequences (EHR adoption and use), the program, and other contributing factors, also produced important UCs, with effects that range from the health system level all the way to the point of care level. Many recent publications have criticized MU and particularly EHRs; however, little attention has been dedicated to promoting effective solutions. Although previous articles have elicited emerging health information technology (HIT) UCs such as decreased patient-provider interaction, security breaches, and overdependence on technology and proposed a research agenda to fixing the EHR, such reports were produced during the MU implementation, and therefore, their conclusions were made before the US health system had been exposed to the effects of nationwide EHR adoption. On the basis of our own experiences from large-scale HIT adoption projects and a collection of key studies in HIT evaluation, we discuss the most prominent UCs of MU and provide recommendations for future research to empower the broader medical and informatics communities to realize the full potential of a now digitized health system.

Unintended consequences of Meaningful Use, their contributing factors, and opportunities for future research from the broadesttothe most specific level. ARRA: American Recovery and Reinvestment Act; EHR: electronic health record; HIT: health informationtechnology; UC: unintended consequence.