Computerized physician order entry (CPOE) has been promoted as an important component of patient safety, quality improvement, and modernization of medical practice. In practice, however, CPOE affects health care delivery in complex ways, with benefits as well as risks. Every implementation of CPOE is associated with both generally recognized and unique local factors that can facilitate or confound its rollout, and neurohospitalists will often be at the forefront of such rollouts. In this article, we review the literature on CPOE, beginning with definitions and proceeding to comparisons to the standard of care. We then proceed to discuss clinical decision support systems, negative aspects of CPOE, and cultural context of CPOE implementation. Before concluding, we follow the experiences of a Chief Medical Information Officer and neurohospitalist who rolled out a CPOE system at his own health care organization and managed the resulting workflow changes and setbacks.

The widespread implementation of electronic health records (EHRs) was predicated on hopes that they would rapidly improve care, but initial experiences have been disappointing and thought to be a key part of physician dissatisfaction and burnout. The crisis created by EHR implementation is only in part due to EHRs themselves, and might also be viewed as a crisis that has served to surface longstanding problems in healthcare-ones that if grappled with, will lead to more rapidly effective digital transformation.

The widespread implementation of electronic health records (EHRs) was predicated on hopes that they would rapidly improve care, but initial experiences have been disappointing and thought to be a key part of physician dissatisfaction and burnout. The crisis created by EHR implementation is only in part due to EHRs themselves, and might also be viewed as a crisis that has served to surface longstanding problems in healthcare-ones that if grappled with, will lead to more rapidly effective digital transformation.

Objective

Subspecialty consultation in the emergency department (ED) is a vital, albeit time consuming, part of modern medicine. Traditional consultation requires manual paging to initiate communication. Although consult orders through the electronic health record (EHR) may help, they do not facilitate 2-way communication. However, the impact of combining these systems within the EHR is unknown. We estimated the effect of implementing an integrated paging system on ED workflow efficiency and user attitudes.

Methods

We integrated a messaging system into order entry at our tertiary care academic ED, such that placing a consult order simultaneously paged the consultant. We measured ED workflow efficiency metrics (length of stay [LOS], consult initiation time) and MD/nurse practitioner (NP)/physician assistant (PA) attitudes (perceived mis-pages, efficiency, and workflow preference) 3 months before and 6 months after the implementation.

Results

Six months after implementation, there was 25% use of the new workflow. During the pre-implementation phase, the median time to consult initiation and ED LOS were 150 and 621 minutes, respectively. Implementation of the order was associated with a 15-minute reduction in median time to consult initiation (P < 0.001), and a 52-minute reduction in median ED LOS (P < 0.001). ED MDs/NPs/PAs perceived a reduction in the rate of mis-pages, improved efficiency, and overall preferred the new workflow.

Conclusions

We consolidated steps in the ED consult workflow using an integrated consult order, which improved user satisfaction, and reduced consult initiation time and ED LOS for patients requiring a consult at an urban tertiary care ED.

Background

Though patient census has been used to describe resident physician workload, this fails to account for variations in patient complexity. Changes in clinical orders captured through electronic health records may provide a complementary window into workload. We aimed to determine whether electronic order volume correlated with measures of patient complexity and whether higher order volume was associated with quality metrics.

Methods

In this retrospective study of admissions to the internal medicine teaching service of an academic medical center in a 13-month period, we tested the relationship between electronic order volume and patient level of care and severity of illness category. We used multivariable logistic regression to examine the association between daily team orders and two discharge-related quality metrics (receipt of a high-quality patient after-visit summary (AVS) and timely discharge summary), adjusted for team census, patient severity of illness, and patient demographics.

Results

Our study included 5,032 inpatient admissions for whom 929,153 orders were entered. Mean daily order volume was significantly higher for patients in the intensive care unit than in step-down units and general medical wards (40 vs. 24 vs. 19, P < .001). Order volume was also significantly correlated with severity of illness (P < .001). Patients were 12% less likely to receive a timely discharge summary for every 100 additional team orders placed on the day prior to discharge (OR 0.88; 95% CI 0.82-0.95).

Conclusions

Electronic order volume is significantly associated with patient complexity and may provide valuable additional information in measuring resident physician workload.

BACKGROUND: In varied educational settings, narrative evaluations have revealed systematic and deleterious differences in language describing women and those underrepresented in their fields. In medicine, limited qualitative studies show differences in narrative language by gender and under-represented minority (URM) status. OBJECTIVE: To identify and enumerate text descriptors in a database of medical student evaluations using natural language processing, and identify differences by gender and URM status in descriptions. DESIGN: An observational study of core clerkship evaluations of third-year medical students, including data on student gender, URM status, clerkship grade, and specialty. PARTICIPANTS: A total of 87,922 clerkship evaluations from core clinical rotations at two medical schools in different geographic areas. MAIN MEASURES: We employed natural language processing to identify differences in the text of evaluations for women compared to men and for URM compared to non-URM students. KEY RESULTS: We found that of the ten most common words, such as energetic and dependable, none differed by gender or URM status. Of the 37 words that differed by gender, 62% represented personal attributes, such as lovely appearing more frequently in evaluations of women (p < 0.001), while 19% represented competency-related behaviors, such as scientific appearing more frequently in evaluations of men (p < 0.001). Of the 53 words that differed by URM status, 30% represented personal attributes, such as pleasant appearing more frequently in evaluations of URM students (p < 0.001), and 28% represented competency-related behaviors, such as knowledgeable appearing more frequently in evaluations of non-URM students (p < 0.001). CONCLUSIONS: Many words and phrases reflected students personal attributes rather than competency-related behaviors, suggesting a gap in implementing competency-based evaluation of students. We observed a significant difference in narrative evaluations associated with gender and URM status, even among students receiving the same grade. This finding raises concern for implicit bias in narrative evaluation, consistent with prior studies, and suggests opportunities for improvement.