Juntos: A Model for Language Congruent Care to Better Serve Spanish-Speaking Patients with COVID-19.

Coronavirus disease 2019 (COVID-19) exacerbated pre-existing health disparities and disproportionately affected the Latino community. Clinicians identified communication barriers as a major challenge in care for COVID-19 Latino patients with limited English proficiency (LEP). To address these challenges, Juntos (Together) consult service was established to promote language-congruent care with cultural sensitivity, identify barriers to safe discharge, and facilitate referral to appropriate resources. Spanish speaking volunteer health care providers worked synergistically with medical teams caring for LEP Latino patients. Volunteers were trained on consultant responsibilities and discharge planning resources. The program was evaluated by a satisfaction survey distributed to providers who requested a Juntos consult and Juntos volunteers. Between May 5 and July 30, 2020, 19 individuals volunteered time to the Juntos consult service, 12 (63%) Latinos, 14 (74%) physicians, and 5 (26%) staff. The service supported 127 patients, 76 (60%) males, mean age 42 (±16), 83 (65%) uninsured, and 91 (72%) without primary care. The most common referral sources were medical units (52, 41%) and intensive care units (47, 37%). The most common services offered were family engagement (55, 43%), goals of care (35, 28%), and mental status assessment (26, 20%). The majority of providers who consulted Juntos were very satisfied (48/59, 81%) with the care delivered. The Juntos service offered critical support tailored to the patients' and primary teams' needs. The experience reinforced the need for cultural-based communication to provide optimal care to LEP patients. The Juntos consult service could be a model for providing language-congruent care even beyond COVID-19, but to do so will require institutional investment and rigorous outcomes evaluation.

The Effect of Eliminating Intermediate Severity Drug-Drug Interaction Alerts on Overall Medication Alert Burden and Acceptance Rate.

OBJECTIVE: This study aimed to determine the effects of reducing the number of drug-drug interaction (DDI) alerts in an order entry system. METHODS: Retrospective pre-post analysis at an urban medical center of the rates of medication alerts and alert acceptance during a 5-month period before and 5-month period after the threshold for firing DDI alerts was changed from "intermediate" to "severe." To ensure that we could determine varying response to each alert type, we took an in-depth look at orders generating single alerts. RESULTS: Before the intervention, 241,915 medication orders were placed, of which 25.6% generated one or more medication alerts; 5.3% of the alerts were accepted. During the postintervention period, 245,757 medication orders were placed of which 16.0% generated one or more medication alerts, a 37.5% relative decrease in alert rate (95% confidence interval [CI]: -38.4 to -36.8%), but only a 9.6% absolute decrease (95% CI: -9.4 to -9.9%). 7.4% of orders generating alerts were accepted postintervention, a 39.6% relative increase in acceptance rate (95% CI: 33.2-47.2%), but only a 2.1% absolute increase (95% CI: 1.8-2.4%). When only orders generating a single medication alert were considered, there was a 69.1% relative decrease in the number of orders generating DDI alerts, and an 85.7% relative increase in the acceptance rate (95% CI: 58.6-126.2%), though only a 1.8% absolute increase (95% CI: 1.3-2.3%). CONCLUSION: Eliminating intermediate severity DDI alerts resulted in a statistically significant decrease in alert burden and increase in the rate of medication alert acceptance, but alert acceptance remained low overall.

Does Use of Electronic Alerts for Systemic Inflammatory Response Syndrome (SIRS) to Identify Patients With Sepsis Improve Mortality?

PURPOSE: The objective of this study was to assess whether earlier antibiotic administration in patients with systemic inflammatory response syndrome (SIRS) and evidence of organ dysfunction identified through electronic alerts improves patient mortality. METHODS: This is a retrospective observational cohort study of adult patients admitted across 5 acute-care hospitals. Mortality, Premier CareScienceTM Analytics Expected Mortality Score, and clinical and demographic variables were obtained through the electronic medical record and Premier (Premier Healthcare Solutions, Inc, Charlotte NC) reports. Patients with 2 SIRS criteria and organ dysfunction were identified through an automated alert. Univariate and multivariate logistic regression was performed. RESULTS: Of those with SIRS and organ dysfunction, 8146 patients were identified through the electronic Best Practice Alert (BPA). Overall 30-day mortality rate was 8.7%. There was no significant association between time to antibiotic administration from BPA alert and mortality (P = 0.21) after adjusting for factors that could influence mortality, including age, heart rate, blood pressure, plasma lactate levels, creatinine, bilirubin levels, and the CareScienceTM Predicted Mortality Risk Score. Female gender (odds ratio [OR] 1.31, 95% confidence interval [CI] 1.06-1.63) and facility were also independently associated with mortality. CONCLUSION: The use of alerts in the electronic medical record may misclassify patients with SIRS as having sepsis. Time to antibiotic administration in patients meeting SIRS criteria and evidence of end-organ dysfunction through BPA alerts did not affect 30-day mortality rates across a health system. Patient severity of illness, gender, and facility also independently predicted mortality. There were higher rates of antibiotic use and Clostridioides difficile infection in patients with BPA alerts.

Relative impact of a patient blood management program on utilization of all three major blood components.

BACKGROUND: Although patient blood management (PBM) programs clearly reduce transfusion overuse, the relative impact on red blood cell (RBC), plasma, and platelet (PLT) utilization is unclear. STUDY DESIGN AND METHODS: A retrospective analysis of electronic records was conducted at a medium-sized academic hospital to assess blood utilization for all inpatients admitted during 1-year periods before (n = 20,531) and after (n = 19,477) PBM efforts began in September 2014. Transfusion guideline compliance and overall utilization were assessed for RBCs, plasma, and PLTs. The primary PBM efforts included education on evidence-based transfusion guidelines, decision support in the computerized provider order entry system, and distribution of provider-specific reports showing comparison to peers for guideline compliance. Cost avoidance was determined by two methods (acquisition cost and activity-based cost), and clinical outcomes were compared during the two periods. RESULTS: For RBCs, orders outside hospital guidelines decreased (from 23.9% to 17.1%, p < 0.001), and utilization decreased by 12% (p < 0.035). For plasma and PLTs, both orders outside guidelines and utilization changed minimally. Overall cost avoidance was $181,887/year by acquisition cost (and from $582,039 to $873,058/year by activity-based cost), 93% of which was attributed to reduction in RBC utilization. Length of stay, morbidity, and mortality were unchanged. CONCLUSIONS: Our findings demonstrate a greater opportunity for reducing RBC compared to plasma and PLT utilization. A properly implemented PBM program has potential to reduce unnecessary transfusions and their associated risk and costs, without compromising clinical outcomes.

Impact of an educational intervention on the frequency of daily blood test orders for hospitalized patients.

OBJECTIVES: During hospitalizations, blood is drawn for diagnostic laboratory tests to help guide patient care. Often, blood tests continue to be ordered even in the face of clinical and laboratory stability. Blood draws are painful and costly, and they may be associated with anemia. We hypothesized that provider education could reduce the frequency of daily blood tests ordered for hospitalized patients. METHODS: During a 2-month intervention period, internal medicine providers were educated through flyers displayed in providers' offices and periodic email communications reminding them to order daily blood tests only if the results would change patient care. Two-month preintervention data from 982 patients and 2-month postintervention data from 988 patients were analyzed. The primary outcome measured was the number of daily blood tests ordered per patient per day. RESULTS: Mean orders of CBC decreased from 1.46 to 1.37 tests per patient per day (P < .05) after the intervention. Basic metabolic panel orders were reduced from 0.91 to 0.83 tests per patient per day (P < .05). Cost analyses showed a reduction of $6.33 per patient day based on the decrease in the number of daily laboratory tests ordered. CONCLUSIONS: Provider education and reminders can reduce the frequency of daily blood tests ordered by providers for hospitalized patients. This can decrease health care costs and may reduce the risk of complications such as anemia.

Factors associated with medication warning acceptance for hospitalized adults.

BACKGROUND: Computerized provider order entry (CPOE) systems can warn clinicians ordering medications about potential allergic or adverse reactions, duplicate therapy, and interactions with other medications. Clinicians frequently override these warnings. Understanding the factors associated with warning acceptance should guide revisions to these systems. OBJECTIVE: Increase understanding of the factors associated with medication warning acceptance. DESIGN: Retrospective study of all single-medication warnings generated in a CPOE system from October 2009 through April 2010. SETTING: Academic medical center. PATIENTS: All adult non-intensive care unit patients hospitalized during the study period. RESULTS: A total of 40,391 medication orders generated a single-medication warning during the 7-month study period. Of these warnings, 47% were duplicate warnings, 47% interaction warnings, 6% allergy warnings, 0.1% adverse reaction warnings, and 9.8% were repeated for the same patient, medication, and provider. Only 4% of warnings were accepted. In multivariate analysis, warning acceptance was positively associated with male patient gender, admission to a service other than internal medicine, caregiver status other than resident, parenteral medications, lower numbers of warnings, and allergy or adverse reaction warning types. Older patient age, longer length of stay, inclusion on the Institute for Safe Medication Practice's List of High Alert Medications, and interaction warning type were all negatively associated with warning acceptance. CONCLUSIONS: Medication warnings are rarely accepted. Acceptance is more likely when the warning is infrequently encountered, and least likely when it is potentially most important. Warning systems should be redesigned to increase their effectiveness for the sickest patients, the least experienced physicians, and the medications with the greatest potential to cause harm.

Reducing excess cardiac biomarker testing at an academic medical center.

BACKGROUND: Elimination of wasteful diagnostic testing will improve value for the United States health care system. OBJECTIVE: Design and implement a multimodal intervention to improve evidence-based ordering of cardiac biomarkers for the diagnosis of acute coronary syndrome (ACS). DESIGN: Interrupted times series. SUBJECTS: A total of 60,494 adult inpatient admissions from January 2009 through July 2011 (pre-intervention) and 24,341 admissions from November 2011 through October 2012 (post-intervention) at an academic medical center in Baltimore, Maryland. INTERVENTION: Multimodal intervention introduced August through October 2011 that included dissemination of an institutional guideline and changes to the computerized provider order entry system. MAIN MEASURES: The primary outcome was percentage of patients with guideline-concordant ordering of cardiac biomarkers, defined as three or fewer troponin tests and zero CK-MB tests in patients without a diagnosis of ACS. Secondary outcomes included counts of tests ordered per patient, incidence of diagnosis of ACS, and estimated change in charges for cardiac biomarker tests in the post-intervention period. KEY RESULTS: Twelve months following the intervention, we estimated that guideline-concordant ordering of cardiac biomarkers increased from 57.1 % to 95.5 %, an absolute increase of 38.4 % (95 % CI, 36.4 % to 40.4 %). We estimated that the intervention led to a 66 % reduction in the number of tests ordered, and a $1.25 million decrease in charges over the first year. At 12 months, there was an estimated absolute increase in incidence of primary diagnosis of ACS of 0.3 % (95 % CI, 0.0 % to 0.5 %) compared with the expected baseline rate. CONCLUSIONS: We implemented a multimodal intervention that significantly increased guideline-concordant ordering of cardiac biomarker testing, leading to substantial reductions in tests ordered without impacting diagnostic yield. A trial of this approach at other institutions and for other diagnostic tests is warranted and if successful, would represent a framework for eliminating wasteful diagnostic testing.

The hybrid progress note: semiautomating daily progress notes to achieve high-quality documentation and improve provider efficiency.

Health care institutions are moving toward fully functional electronic medical records (EMRs) that promise improved documentation, safety, and quality of care. However, many hospitals do not yet use electronic documentation. Paper charting, including writing daily progress notes, is time-consuming and error prone. To improve the quality of documentation at their hospital, the authors introduced a highly formatted paper note template (hybrid note) that is prepopulated with data from the EMR. Inclusion of vital signs and active medications improved from 75.5% and 60% to 100% (P < .001), respectively. The use of unapproved abbreviations in the medication list decreased from 13.3% to 0% (P < .001). Prepopulating data enhances provider efficiency. Interviews of key clinician leaders also suggest that the initiative is well accepted and that documentation quality is enhanced. The hybrid progress note improves documentation and provider efficiency, promotes quality care, and initiates the development of the forthcoming electronic progress note.

Peer assessment of professional performance by hospitalist physicians.

BACKGROUND: The clinical collaborations among hospitalist physicians create opportunities for peer evaluation. We conducted this study to generate validity evidence for a scale that allows for peer assessment of professional performance. METHODS: All of the hospitalist physicians working for >1 year at our hospital were asked to assess each of their physician colleagues along eight domains and name three colleagues whom they would choose to care for a loved one needing hospitalization. A mean composite clinical performance score was generated for each provider. Statistical analyses using the Pearson coefficient were performed. RESULTS: The 22 hospitalist physician participants were confident in their ability to assess their peers' clinical skills. There were strong correlations between the domains of clinical excellence (r > 0.5, P < 0.05). Being selected as a doctor whom colleagues would choose to take care of their loved ones was highly correlated with high scores in the domains of humanism, diagnostic acumen, signouts/handoffs, and passion for clinical medicine, and higher composite clinical performance scores (all r > 0.5, P < 0.05). High scores on the Press Ganey questions correlated with peer assessment of humanism (r = .78, P = 0.06). CONCLUSIONS: The correlation among scale items, the composite clinical performance score, and the variable "a doctor whom you would choose to care for a loved one" provides validity evidence to our assessment scale. Such measurements may allow hospitalist groups to identify top performers who could be recognized, rewarded, and held up as role models and weaker performers who may need focused training or remediation.

The effect of computerized provider order entry on medical students' ability to write orders.

BACKGROUND: Computerized provider order entry (CPOE) is being implemented at increasing numbers of U.S. hospitals, yet the effects of CPOE on medical student education are largely unstudied. PURPOSE: The objective is to investigate the effects of CPOE on medical students' ability to write orders for patients. METHODS: One hundred forty-three medical students who began their Basic Medicine clerkship between March 2003 and April 2004 were asked to write mock admission orders for a patient with pneumonia after the 1st month of their clerkship. Students had spent the month at 1 of 3 hospitals: 1 using CPOE, 1 paper orders, and 1 that began using CPOE midway through this study. Admission orders were scored for the presence of specific orders and features. RESULTS: One hundred twenty students attempted to write admission orders. Students who trained at hospitals using CPOE and those who trained at hospitals using paper orders included expected basic, lifesaving, and higher level orders at similar rates. No significant differences in order clarity or inclusion of unnecessary orders were found for the 2 groups. No significant differences were found when controlling for school year and 4 modifiable rotation features. CONCLUSIONS: When admission order completeness and quality for medical students who trained at hospitals using CPOE were compared to those who trained using handwritten orders, no important differences were found.

Physician-teacher characteristics associated with learner-centered teaching skills.

BACKGROUND: Academic institutions do not have a way to identify physician-teachers who are proficient in learner-centered teaching. AIM: To identify physician characteristics associated with being highly learner-centered. METHODS: A cohort of 363 physicians was surveyed. Measured items included personal characteristics, professional characteristics, teaching activities, self-assessed teaching proficiencies and behaviors, and scholarly activities. A learner-centeredness scale was developed using factor analysis. Logistic regression models were used to determine which characteristics were independently associated with scoring highly on the learner-centeredness scale. RESULTS: Two hundred and ninety-nine physicians responded (82%) of whom 262 (88%) had taught medical learners in the prior 12 months. Six variables combined to form the learner-centeredness scale and the Cronbach Alpha of the scale was 0.73. The eight characteristics independently associated with high learner-centered scores for physician teachers were (i) proficiency in giving lectures or presentations (OR ;= ;5.1, 95% CI: 1.3-19.6), (ii) frequently helping learners identify resources to meet their own needs (OR ;= ;3.7, 95% CI: 1.3-10.3), (iii) proficiency in eliciting feedback from learners (OR ;= ;3.7, 95% CI: 1.7-8.5), (iv) frequently attempting to detect and discuss emotional responses of the learners (OR ;= ;2.9, 95% CI: 1.2-6.9), (v) frequently reflecting on the validity of feedback from the learners (OR ;= ;2.8, 95% CI: 1.1-7.4), (vi) frequently identifying available resources to meet the teacher's learning needs (OR ;= ;2.8, 95% CI: 1.1-7.2), (vii) having given an oral presentation related to education at a national/regional meeting (OR ;= ;2.6, 95% CI: 1.1-6.0), and (viii) frequently letting learners know how different situations affect the teacher (OR ;= ;2.5, 95% CI: 1.1-5.5). CONCLUSIONS: The clinical competence and professional growth of medical learners can be most effectively facilitated by learner-centered educational methods. It may now be possible to identify medical educators who are more learner-centered in their teaching.

Long-term follow-up of a 10-month programme in curriculum development for medical educators: a cohort study.

CONTEXT: There is an ongoing need for curriculum development (CD) in medical education. However, only a minority of medical teaching institutions provide faculty development in CD. This study evaluates the long-term impact of a longitudinal programme in curriculum development. METHODS: We surveyed eight cohorts of participants (n = 64) and non-participants (n = 64) from 1988 to 1996 at baseline and at 6-13 years after completion of a 10-month, one half-day per week programme offered annually, which included a mentored CD project, workshops on CD steps, a final paper and a presentation. RESULTS: Fifty-eight participants (91%) and 50 non-participants (78%) returned completed follow-up surveys. In analyses, controlling for background characteristics and baseline self-rated proficiencies, participants were more likely than non-participants at follow-up to report having developed and implemented curricula in the past 5 years (65.5% versus 43.7%; odds ratio [OR] 2.41, 95% confidence interval [CI] 1.03-5.66), to report having performed needs assessment when planning a curriculum (86.1% versus 58.8%; OR 5.59, 95% CI 1.20-25.92), and to rate themselves highly in developing (OR 3.57, 95% CI 1.36-9.39), implementing (OR 3.04, 95% CI 1.16-7.93) and evaluating (OR 2.74, 95% CI 1.10-6.84) curricula. At follow-up, 86.2% of participants reported that the CD programme had made a moderate or great impact on their professional careers. Responses to an open-ended question on the impact confirmed continued involvement in CD work, confidence in CD skills, application of CD skills and knowledge beyond CD, improved time management, and lasting relationships formed because of the programme. CONCLUSIONS: Our results suggest that a longitudinal faculty development programme that engages and supports faculty in real CD work can have long-lasting impact.

Qualitative assessment of the long-term impact of a faculty development programme in teaching skills.

CONTEXT: The long-term impact of faculty development programmes (FDPs) is poorly understood, and most assessments of them have been quantitative in nature. OBJECTIVE: This study aimed to use qualitative methods to better understand the long-term impact of an FDP in teaching skills (FDP/TS). METHODS: A survey was carried out in July 2002 of the 242 faculty members and fellows who had participated in a 9-month FDP/TS at any time from 1987 through 2000. The survey included 2 quantitative questions and an open-ended qualitative question about the impact of the programme on the participants' professional and personal lives. RESULTS: A total of 200 past participants (83%) responded to the survey. Participants from early and recent cohorts were similarly represented. In all, 82% of respondents said programme participation had had 'a moderate' or 'a lot' of impact on their professional life, and 49% said their personal life had been affected to this degree. Four major domains, each containing at least 3 subcategories, emerged from qualitative analysis. The domain intrapersonal development included changes participants reported in themselves and in their approach to self-management. Interpersonal development contained subcategories relating to how participants interact with others. Subcategories in the domain development as a teacher related to increased teaching ability and enjoyment. The domain career development included professional growth and career opportunities attributed to programme participation. CONCLUSIONS: Longitudinal FDPs can have broad and sustained positive effects on the professional and personal lives of participants. Qualitative evaluation methods may result in a richer and deeper understanding of the impact of these programmes.

The good news about CPOE and medical student ordering ability.

When the quality of orders written by medical students was compared for those who trained at hospitals using computerized provider order entry (CPOE) to those who trained using handwritten orders, no significant differences were found.

Antiretroviral medication errors among hospitalized patients with HIV infection.

BACKGROUND: Highly active antiretroviral therapy (HAART) has improved survival for persons living with human immunodeficiency virus (HIV) infection. However, effective therapy requires high levels of adherence over extended periods of time. Previous studies suggest that patients receiving long-term medication are at risk for unintended medication discrepancies at the time of hospital admission. METHODS: We retrospectively identified every HIV-infected patient admitted to our hospital over a 1-year period who received an antiretroviral agent. We collected information on medications and renal function from the hospital computerized provider order entry system. We reviewed the medical records for those admissions for which a potential error was identified. We defined errors using Department of Health and Human Services guidelines and included only those errors that were not corrected within 24 h after initial entry. RESULTS: There were a total of 209 admissions during a 1-year period in which an HIV-infected patient received antiretroviral therapy. After review of the medical records for 77 admissions with a potential error, 61 uncorrected errors from 54 admissions were identified (percentage of total admissions, 25.8%; 95% confidence interval, 20.1%-32.3%). The most common type of error was an error with respect to the amount or frequency of dosage, which occurred in 34 (16.3%) of the admissions; 18 of these errors were attributable to failure to appropriately adjust dosage for renal insufficiency. The next most common error was combining antiretroviral drugs with a contraindicated medication; this occurred in 12 (5.2%) of the admissions. Patients erroneously received

Physician characteristics associated with proficiency in feedback skills.

BACKGROUND: Providing and eliciting high-quality feedback is valuable in medical education. Medical learners' attainment of clinical competence and professional growth can be facilitated by reliable feedback. This study's primary objective was to identify characteristics that are associated with physician teachers' proficiency with feedback. METHODS: A cohort of 363 physicians, who were either past participants of the Johns Hopkins Faculty Development Program or members of a comparison group, were surveyed by mail in July 2002. Survey questions focused on personal characteristics, professional characteristics, teaching activities, self-assessed teaching proficiencies and behaviors, and scholarly activity. The feedback scale, a composite feedback variable, was developed using factor analysis. Logistic regression models were then used to determine which faculty characteristics were independently associated with scoring highly on a dichotomized version of the feedback scale. RESULTS: Two hundred and ninety-nine physicians responded (82%) of whom 262 (88%) had taught medical learners in the prior 12 months. Factor analysis revealed that the 7 questions from the survey addressing feedback clustered together to form the "feedback scale" (Cronbach's alpha: 0.76). Six items, representing discrete faculty responses to survey questions, were independently associated with high feedback scores: (i) frequently attempting to detect and discuss the emotional responses of learners (odds ratio [OR]=4.6, 95% confidence interval [CI] 2.2 to 9.6), (ii) proficiency in handling conflict (OR=3.7, 95% CI 1.5 to 9.3), (iii) frequently asking learners what they desire from the teaching interaction (OR=3.5, 95% CI 1.7 to 7.2), (iv) having written down or reviewed professional goals in the prior year (OR=3.2, 95% CI 1.6 to 6.4), (v) frequently working with learners to establish mutually agreed upon goals, objectives, and ground rules (OR=2.2, 95% CI 1.1 to 4.7), and (vi) frequently letting learners figure things out themselves, even if they struggle (OR=2.1, 95% CI 1.1 to 3.9). CONCLUSIONS: Beyond providing training in specific feedback skills, programs that want to improve feedback performance among their faculty may wish to promote the teaching behaviors and proficiencies that are associated with high feedback scores identified in this study.

Long-term follow-up of a longitudinal faculty development program in teaching skills.

BACKGROUND: The long-term impact of longitudinal faculty development programs (FDPs) is not well understood. OBJECTIVE: To follow up past participants in the Johns Hopkins Faculty Development Program in Teaching Skills and members of a comparison group in an effort to describe the long-term impact of the program. DESIGN AND PARTICIPANTS: In July 2002, we surveyed all 242 participants in the program from 1987 through 2000, and 121 members of a comparison group selected by participants as they entered the program from 1988 through 1995. MEASUREMENTS: Professional characteristics, scholarly activity, teaching activity, teaching proficiency, and teaching behaviors. RESULTS: Two hundred participants (83%) and 99 nonparticipants (82%) responded. When participants and nonparticipants from 1988 to 1995 were compared, participants were more likely to have taught medical students and house officers in the last year (both P<.05). Participants rated their proficiency for giving feedback more highly (P<.05). Participants scored higher than nonparticipants for 14 out of 15 behaviors related to being learner centered, building a supportive learning environment, giving and receiving feedback, and being effective leaders, half of which were statistically significant (P<.05). When remote and recent participants from 1987 through 2000 were compared with each other, few differences were found. CONCLUSIONS: Participation in the longitudinal FDP was associated with continued teaching activities, desirable teaching behaviors, and higher self-assessments related to giving feedback and learner centeredness. Institutions should consider supporting faculty wishing to participate in FDPs in teaching skills.

The effect of computerized provider order entry on medical student clerkship experiences.

OBJECTIVE: To describe medical students' attitudes toward placing orders during training, and the effect of computerized provider order entry (CPOE) on their learning experiences. DESIGN: Prospective, controlled study of all 143 Johns Hopkins University School of Medicine students who began the Basic Medicine clerkship between March 2003 and April 2004 at one of three teaching hospitals: one using CPOE, one paper orders, and one that began using CPOE midway through this study. MEASUREMENTS: Survey of students at the start and after the first month of the clerkship. RESULTS: Ninety-six percent of students responded. Students expressed a desire to place 100% of orders for their patients. Ninety-five percent of students believed that placing orders helps students learn what tests and treatments patients need. Eighty-four percent reported that being unavailable due to conferences and teaching sessions was a significant barrier to participating in the ordering process. Students at hospitals using CPOE reported placing significantly fewer of their patients' follow-up orders compared to students at hospitals using paper orders (25% vs. 50%, p < 0.01) and were more likely to report that their resident or intern did not want them to enter orders (40% vs. 16%, p < 0.01). Comparisons of students at hospitals using CPOE to each other showed that these differences were attributable to one of the hospitals. Thirty-two percent of students at both hospitals using CPOE reported that the extra length of time required for housestaff to review their orders in the computer was a significant barrier. CONCLUSION: Hospitals need to ensure that the educational potential of medical students' clinical experiences is maximized when implementing CPOE.

Clinician-teachers' self-assessments versus learners' perceptions.

Understanding how clinician-teachers' self-assessments compare to learners' impressions can serve to help educators place each of these evaluations in the appropriate context. Past participants of the Johns Hopkins Faculty Development Program and other physician-teachers were surveyed in 2002 regarding their teaching skills and behaviors. We surveyed their learners to compare teacher and learner assessments of teaching proficiency, behaviors, enjoyment, and career satisfaction. In each area, learners' ratings were statistically significantly higher than their teachers' self-ratings. Though it is unclear whether teachers' or learners' assessments are a more accurate reflection of the truth, the more positive learner ratings should promote self-confidence in clinician-educators regarding their teaching abilities.