Understanding Stakeholder Perspectives, Medical Student Metacognition and Reflections on Learning Order Entry in the Electronic Health Record

Background: Accurate and complete order entry is an essential skill expected of all medical graduates. However, medical students report limited confidence performing this task. This study employed a convergent mixed methods design to examine stakeholder perspectives, medical student performance, and metacognition during simulated electronic health record order entry, with the goal of identifying educational gaps and informing curriculum development. Methods: The study was conducted in two phases. Phase 1 included qualitative analysis of semi-structured interviews of interprofessional stakeholders: nurses, pharmacists, interns, and supervising physicians using open inductive coding. Phase 2 included quantitative and qualitative analysis of fourth-year medical student performance and metacognition on two simulated admission order entry cases using a think-aloud protocol with screen capture followed by self-reflection and exit interviews. Results: Eight themes emerged from qualitative analysis of 17 stakeholder interviews in Phase 1: Education and Training, Contextual Awareness, Collaboration in Care, Oversight and Accountability, Optimizing Order Systems, Special Populations and Vulnerable Moments, Informed Decision Making, and Precision in Practice. In Phase 2, 36 students completed the recorded order entry simulation. Student confidence significantly improved. Use of order sets was associated with significant differences in required order elements including vital signs, diet order, activity order, and venous thromboembolism prophylaxis. Qualitative analysis revealed six core themes: Oversight and Accountability, Cognitive Load and Uncertainty, Experiential Learning Through Iteration, External Resources and Decision Support, Informed Decision Making, and Navigational Challenges in the Electronic Health Record Interface. Qualitative analysis of participant self-reflections and exit interviews revealed four key themes: Evolving Confidence Through Practice, Uncertainty in Task Expectations, Desire for Feedback and Comparative Reference Points, and System Navigation and Interface Literacy. Conclusions: This study revealed critical gaps in order entry education. Stakeholder perspectives emphasized complexity of order entry, contextual awareness, oversight, and system optimization. Simulation fostered experiential learning and increased confidence, though safe and complete performance remained inconsistent. These findings support longitudinal simulation, interdisciplinary collaboration, and instruction in metacognition. Enhancing students' metacognitive skill development may reduce risk of patient harm and better prepare them for independent practice. These methods may also be applied to other entrustable professional activities requiring high cognitive integration and digital competence.