Transcript Educational Challenges of the Electronic Medical Record

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
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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
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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
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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
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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