Educational Challenges of the
Electronic Medical Record
Jeremy 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 2009
Jha N Engl J Med. 2009
Chaudhry 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. 2009
AAMC.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. 2009
AAMC.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
• MyCode TM
– 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