The Parable of the Broken Window

Despite our best efforts to the contrary, we all know, expect and often dread unintended consequences associated with Health Information Technology (HIT). The French economist Frédéric Bastiat offers a classic example of our experience with these consequences in his “broken window” parable that goes like this:

A shopkeeper’s son accidentally breaks his father’s store window. A bystander suggests the broken window is worth celebrating because a glazier will earn money fixing it and benefit others spending his earnings at local shops. For Bastiat, the problem arises if we go no further than this surface understanding. He writes, “Your theory stops at what is seen. It does not take account of what is not seen.” Yes, the glazier benefits, but we miss the shopkeeper’s loss – the new shoes he planned to buy his wife but now cannot afford. We also fail to recognize the wife’s loss of no new shoes, and the struggling shoemaker’s loss of business he did not even realize was coming. On the surface, we do not see, appreciate or anticipate these deeper consequences. 1

While we may think no one would really celebrate a broken window, similar situations actually happen frequently. In a recent presentation, a colleague related his organization’s experience with a Computerized Physician Order Entry (CPOE) system implementation. This institution, a tertiary care academic medical center, serves highly complex pediatric patients whose care is often equally complex. Over several years they developed integrated CPOE functionality with their Electronic Health Record (EHR). The system included extensive use of iteratively designed and tested order sets. The institution showed that by standardizing clinical decision-making, they reduced medication errors and patient care costs without adversely affecting physician satisfaction. What they did not intend was the effect on physician thinking.

At an academic medical center, physicians in training (medical students, residents and fellows), with oversight from attending physicians, entered most patient orders into the CPOE system. Before CPOE, trainees recorded individual orders manually. Through years of repetition trainee orders became second nature, engrained into their thinking. The advent of automated order sets, however, created an unseen consequence. The presenter related a conversation with a trainee about to complete her three-year residency. This young physician observed the CPOE system made a positive difference in care delivery and quality. She could simply click an order set, and she was done. The only problem was she never really learned the specifics of individual orders within each set. She wondered how she would practice at another hospital without a CPOE system.

Another example is the widely observed electronic, template-driven progress note “copy-paste” phenomenon. 2 In the same way that physicians in training may fail to internalize the details of order writing, they may lose (or never fully develop) the ability to create meaningful and useful progress notes, operative reports and discharge summaries.

There are numerous other unseen consequences like these. For example, in 2013 Montague and Asan examined how HIT (in the form of an EHR in an exam room) altered physician-patient relationships. The investigators found “…physician–patient eye-gaze patterns are different during a visit in which electronic health records versus a paper-chart visit are used. Not only does the doctor spend less time looking at the patient, the patient also almost always looks at the computer screen, whether or not the patient can see or understand what is on the screen.” The authors concluded, the “way EHRs are currently used in the exam room affects physicians’ communication quality, cognitive functioning and the ability of patients and physicians to build rapport and establish emotional common ground.” 3

In short, these effects illustrate unseen HIT consequences – including a failure to truly understand the data, a loss of knowledge gained in the traditional data capture process, and a significant shift in how physicians interact with patients. This is all due to evolving interaction with HIT and its inherently large, overwhelming, new and different data.


  1. Bastiat, Frédéric. Selected Essays on Political Economy. Seymour Cain, trans. 1995. Library of Economics and Liberty. Retrieved April 9, 2015 from
  2. McCann, Erin (October 2013). EHR copy and paste? Better think twice. Healthcare IT News. Retrieved from:
  3. Montague, Enid (December 2013). Dynamic modeling of patient and physician eye gaze to understand the effects of electronic health records on doctor-patient communication and attention, International Journal of Medical Informatics, March 2014, Vol. 83, Issue 3, pp. 225-234, retrieved from
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Posted on November 25th, 2015 in Innovating Health Care IT
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