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Dr. Nosey reports that his hospital’s computer physician order entry (CPOE) is now online, three years late and more than $50M over budget. Apparently there are a few problems. One physician noted that the order entry system rounds up fractional morphine doses — a dose of one-half milligram can be entered but the computer renders this internally as a full milligram. When doses are in the tens of milligrams such imprecision might be acceptable but when the provider actually writes for a half-milligram and the nurse sees an order for one milligram you really do have to wonder. Dr. Nosey was told that a fix for this problem is going to be put in place “very soon”.  That’s good, he says, but what does this say about the development of the system itself?

The same people that assumed a fractional milligram should be a full one have surely made a lot of other assumptions.  The physician who discovered this one was astonished; he did not imagine that any system would behave this way. And this is an important problem with clinical healthcare information technology. <i>It can easily be configured to do things no one would anticipate. Because they are not anticipated, no one looks for them & they are discovered only by accident.</i>