Information Technology: A Double-Edged Sword in Health Care
MedSun: Newsletter #2, March 2006

Clinical information technology (IT) is rapidly being added to virtually all health care facilities, yet such “progress” often generates new forms of failure and error. Robust health care computer systems need to be user-centered rather than technology-centered and to support successful human-computer interaction. In a well-documented case study analysis appearing in the AHRQ WebM&M, Dr. Richard I. Cook of the University of Chicago (who spoke at our MedSun annual conference in October in CA) illustrates how reliance on IT can confound patient care and delay appropriate treatment.

A 70-year-old woman admitted to a community hospital was shown by a CT scan of her brain to have an acute subdural hematoma. Transferred to a large referral center for urgent neurosurgical evaluation, the woman was subsequently misdiagnosed as having had a stroke, based on a CD containing relevant but outdated images that had been sent with her to the larger facility. A consulting neurologist later found more recent images that demonstrated the acute subdural hematoma, which was then urgently evacuated. The patient improved after a prolonged period of rehabilitation.

Dr. Cook uses this case study to explore the challenges inherent in introducing clinical IT to health care settings. Adding IT does not eliminate failure, he states, but instead changes the type, frequency, and severity of failures, often in unpredictable and surprising ways. Such failures are often regarded as human (operator) error but actually arise from poor human-computer interaction.

Additional Information:

The complete text of Dr. Cook’s analysis is available at

MedSun Newsletters are available at