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