Lessons from "unexpected increased mortality after implementation of a commercially sold computerized physician order entry system"

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.