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Order on the wards! The Effect of Computerized Provider Orders Entry on Medical Students' Ability to Write Orders. Knight AM et al. Teaching and Learning in Medicine 2012;24(1):63-70

Reviewed by Virginia Randall

What was the study question?
Is there a difference between students' ability to write admission orders for a mock patient if they have trained entering orders into a computer or writing them on paper?

How was the study done?
One hundred thirty seven third-year medical students from Johns Hopkins performed their internal medicine clerkship at one of three hospitals: one using exclusively computer-provider order entry (CPOE), one that transitioned from paper orders to CPOE, and one that used paper orders only. Each group received classroom training in writing orders on their first day of the clerkship. Students' ability to write appropriate orders for a mock patient (elderly woman with pneumonia, hypoxia, uncontrolled diabetes, mild renal failure, and dehydration) was tested and scored by two raters (Interrater agreement of 0.96). Orders were scored for their structure, legibility, and clarity.

What were the results?
There were no significant differences among the students in their ability to write correct and appropriate orders.

What are the implications of these findings?

  1. The use of computerized patient orders in a basic medicine clerkship did not impede medical students' ability to learn how to write admission orders. This study examined one aspect of the effect of computerized patient records on medical student learning.
  2. Important teaching that occurred for students who were at all hospitals in this study included: classroom orientation, encouragement to write orders at every opportunity, and preceptor awareness of the importance of reviewing orders with students. The provision of this teaching may mitigate the lack of experience in writing de novo orders. This teaching is an important component of a clinical clerkship when either CPOE or paper records are used.

Editor's note: While this study did not show a significant difference between the study groups, there did emerge some note-worthy trends: that students who had trained using paper orders were less likely than their COPE–peers to use illegible words, nonstandard abbreviations, unnecessary orders, or include historical data in their orders. What proved to be more important that practicing writing orders, though, was being directly involved in patient care - students who were more involved in discussions about patients were more likely to write higher level orders than those who were less involved. That writing orders well is tied more to an understanding of patient care than to practicing writing orders is a fascinating discovery. (What is not well explained in this study is the extent to which students had practiced writing orders in previous clerkship rotations.)

A few weeks ago, when I was on service, our hospital computer server shut down for days, resulting in an inability to enter orders or retrieve data on our computers. What a joy it was to put pen to paper and scroll out orders by hand! (SLB)

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