Educational Challenges of the Electronic Medical

RecordJeremy Lipman, MD

Case Western Reserve University

No disclosures

Health Record, 1790’s

Siegler Ann Intern Med. 2010

EHR Is Here to Stay

• More efficient care• Lower cost care• Better quality care• Medicare / Medicaid incentive

American Recovery and Reinvestment Act 2009Jha N Engl J Med. 2009Chaudhry Ann Intern Med 2006

AAMC

• Communicate effectively, both orally and in writing, with patients, patients’ families, colleagues, and others with whom physicians must exchange information in carrying out their responsibilities

aamc.org/initiatives/msop/Learning Objectives for Medical Student Education

LCME

• ED-23• Medical students receive instruction in … communication

skills before engaging in patient care activities.• ED-19• The curriculum of a medical education program must

include specific instruction in communication skills as they relate to physician responsibilities, including communication with patients and their families, colleagues, and other health professionals

https://www.lcme.org/publications/2015-16-functions-and-structure-with-appendix.pdf

Alliance for Clinical Education

• Document• Write orders• Use decision aids (UpToDate)• Schools should set EHR competencies

Hammoud, Teach Learn Med. 2012

Background

• Students must learn to use EHR• Few curricula specifically address EHR

– Pre-clinical or clinical

• Many institutions limit student access to EHR

Legal Challenges

• Medical Student notes are discoverable• Nothing can be deleted• “Safest” approach is no med student access

Gliatto, Mt Sinai J Med. 2009AAMC.ORG

Billing Challenges

• Medicare accepts students’:– ROS, PMH, PSH, FH, Social

• All other info must be re-documented• Role as “scribes” is controversial

Gliatto, Mt Sinai J Med. 2009AAMC.ORG

Educational Challenges

• EHR alters traditional learning model– Students participate in less data synthesis

• Attendings rapidly obtain info– Less reliance on residents and students– Deprives students hearing attending questions

Schenarts, J Surg Educ. 2012

Educational Challenges

• Radiology reports readily available• Auto-fill decreases individual item review• Order sets

Schenarts, J Surg Educ. 2012

Educational Challenges• Miss out on patient interactions and exam

– Overly reliant on EHR

• Rounds conducted at serial computers– Group discussions limited

Verghese, N Engl J Med. 2008

Educational Challenges

• Distracted from teaching (65.1%)

• Teaching less (62.3%)

• Most enthusiastic teachers most affected

Spencer, Teach Learn Med. 2012

Student Perspective

• Easier to find information• Ask questions based on prompts

– Otherwise would not

• More feedback on notes• Less time looking at patients

Rouf BMC Med Educ. 2008

Student Perspective

• 95% (113/119) copy their own notes• 90%: copying from others’ notes unacceptable• 43% documented signed in under attending

Heiman, Teach Learn Med. 2014

Frontiers

• Electronic patient interactions• Creating effective templates• Link to on-line educational resources

– Self-directed just-in-time learning

Frontiers

• Best-practices and guidelines• Risk modeling• Pharmacy resources• Clinical calculators

Frontiers

• MyCodeTM

– 50,000 enrolled since October, 2013– Applied wherever possible– “Actionable” mutations

Community Health Initiative of Geisinger Health System

Pre-Clinical Training

• Familiarize with common facets

• Get beyond “document and communicate”

– Optimize linked resources

– Create and expand order sets

– Create next generation EHR

Simulated Medical Record

• Can create patients of varying complexities• Students confront the challenges of the EHR• Safe environment• “Epic Train”

Milano, Academic Medicine 2014

Simulated Medical Record

• Create scenarios for management– Provide ED notes– Import CT scans– Labs– History

Simulated Medical Record

• Independent exploration of record– Some data can be hidden (scanned EKG)

• Students then write H&P• Activate appropriate order sets

– Can intentionally leave gaps for them to fill

Milano, Academic Medicine 2014

Simulated Medical Record

• Targeted learning– Patients created to meet specific goals

• System based practice• Practice based learning

Simulated Medical Record

• Improve retention and participation• Preserves clinical time

Consorti, Comput Educ. 2012

Simulated Medical Record

• Can be time consuming to create– Average 16 months in one study

• Costly, in some settings– Up to $10,000

Bloice BMC Med Inform Decis Mak. 2013

Recommendations

• Select patients not to review before rounds• Guide students to access EHR adjuncts• Collaborate with other departments to create

simulated patients

Recommendations

• Computers in OSCE• Dedicated EHR curriculum• Meet with your CIO

Questions