Lessons From “Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System”

Abstract

We are writing in response to the article “Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System” by Han et al.1 The authors are to be congratulated for their courage in bringing their compelling account of computerized physician order entry (CPOE) implementation problems to the medical literature as they tried to interpret their results concerning mortality. Their article is as much a search for answers as it is a recitation of the shortfalls in their implementation process and computer systems. It is critically important to understand that the types of problems described by Han et al are not limited to their institution. In fact, setbacks and failures in the implementation of clinical information systems (CISs) and CPOE systems are all too common (eg, see refs 2–4). Although it is tempting to focus solely on the role of new technology in the problems highlighted by this example, there are also important lessons to be learned about related organizational and workflow factors that affect the potential for danger associated with CPOE implementation. There are many previous publications about troubled or failed implementations. The account by Han et al is unique in that an adverse change in mortality rate was associated in time with CIS and CPOE implementation. We may question the study's methodology and conclude that causality was not proven, yet the assignment of CPOE to a severity-adjusted odds ratio of 3.71 for patient death simply cannot be ignored. Regardless of what was or was not proven, if only one unnecessary death were caused by the implementation process or CIS and CPOE modules, that is one too many. The question that must be asked is how can intelligent and well-intentioned leaders at all levels of an institution make the kind of implementation … Address correspondence to Dean F. Sittig, PhD, Kaiser Permanente Center for Health Research, 3800 N Interstate Ave, Portland, OR 97227. E-mail: dean.f.sittig{at}kp.org