1. East Carolina University Division of Surgical Education Turning Knowledge into Action Educational Impact of the Electronic Medical Record Paul J. Schenarts, MD, FACS Director, General Surgery Residency Assistant Dean for Clinical Academic Affairs Associate Professor of Surgery Division of Surgical Education Department of Surgery East Carolina University

2. Division of Surgical Education Turning Knowledge into Action Outline  Impact on resident education  Effects on resident work flow  Potential time savings  Impact on medical students (future residents)  Potential education-related opportunities

3. East Carolina University Division of Surgical Education Turning Knowledge into Action Point of clarification Education (noun): 1.The action or process of educating or of being educated 2.The knowledge and development resulting from an educational process Webster’s College Dictionary

4. East Carolina University Division of Surgical Education Turning Knowledge into Action Fact: The EMR is here to stay  Advancements in computer technology and societal attitudes towards technology  Important stakeholders have called for widespread implementation Institute of Medicine US Government Association of American Medical Colleges (AAMC) Accreditation Council for Graduate Medical Education (ACGME) American Recovery & Reinvestment Act of 2009  Justification: improve quality, increase patient satisfaction & reduce medical errors

5. East Carolina University Division of Surgical Education Turning Knowledge into Action Fact: Only minimal literature on the impact of the EMR on the EDUCATION of residents Most are surveys about residents’ perceptions, rather than objective or outcome data

6. East Carolina University Division of Surgical Education Turning Knowledge into Action Impact on Education Potential Benefit: Greater adherence to evidence-based guidelines

7. East Carolina University Division of Surgical Education Turning Knowledge into Action Impact on Education Pull Systems: The learner must actively pull information from a drop box Push Systems: Recommendations are automatically pushed on the learner What effect do these system links have on education?

8. East Carolina University Division of Surgical Education Turning Knowledge into Action Impact on Education University of Calgary Surgery Clerkship Study  3 rd Year Surgery Clerkship Students  Randomized into two groups 1)Computer order entry with on line educational content 2)Traditional paper chart  No difference between groups on the pre-test J Am Med Inform Assoc 11:43-49, 2004

9. East Carolina University Division of Surgical Education Turning Knowledge into Action Impact on Education University of Calgary Surgery Clerkship Study  3 rd Year Surgery Clerkship Students  Randomized into two groups 1)Computer order entry with on line educational content 2)Traditional paper chart  No difference between groups on the pre-test  No difference between groups on the post-test  Templates may prompt learners but does not improve learning and may in fact be detrimental J Am Med Inform Assoc 11:43-49, 2004

10. East Carolina University Division of Surgical Education Turning Knowledge into Action Impact on Education Potential Benefit: Computerized clinical decision support systems: A system that adds information to assist in the decision-making process. The physician can accept or reject the advice

11. East Carolina University Division of Surgical Education Turning Knowledge into Action Impact on Education Systematic review of 100 trials of CDSS:  Overall physician performance improved in 64%  Diagnostic systems, improvement in only 40%  Disease management systems, improvement in 62%  Drug-dosing systems, improvement in 66% JAMA 293:1223-1238, 2005 Computerized EKG reading:  When compared to no computerized read  If correct, resident performance improved  If incorrect, residents treated the incorrect reading J Am Med Inform Assoc 10:478-483, 2003

12. East Carolina University Division of Surgical Education Turning Knowledge into Action Summary Points  CDSS and other educational material linked to the EMR likely does not improve resident education.  While attractive, these systems may not significantly improve patient outcome  The EMR is a data feast but a critical thinking famine

13. East Carolina University Division of Surgical Education Turning Knowledge into Action Resident Work Flow Potential Benefit: Increased resident efficiency, which will leave more time for educational activities

14. East Carolina University Division of Surgical Education Turning Knowledge into Action Resident Work Flow EMR Benefits:  Improved access to records  Easier data review  Improved legibility  Auto-filled problem lists  Auto-filled medication lists  Auto-filled labs, vent settings, x-ray reports

15. East Carolina University Division of Surgical Education Turning Knowledge into Action Resident Work Flow Unforeseen Consequences:  Remote access means notes are frequently written without seeing the patient  Residents research patients extensively before performing an initial H&P, which may induce bias as well as compromise learning Arch Int Med 170:1276, 2010  Notes are so long it is nearly impossible to identify the important points

16. East Carolina University Division of Surgical Education Turning Knowledge into Action More Unforeseen Consequences Copy & Paste:  Major parts of the note are copied and pasted and only minor changes are made.  While saving time this allows little opportunity for education or reflection about a patients course  Ideally old information would be replaced by new but in reality there is only addition  Errors tend to be amplified JAMA 295:2335-2336, 2006 Arch Int Med 170:1276

17. East Carolina University Division of Surgical Education Turning Knowledge into Action Even More Unforeseen Consequences Auto-filled Data:  While accurate, residents loss the opportunity to intellectually process the information The process of writing compels the learner to prioritize, synthesize and integrate clinical information. And then organize their thinking in order to express it.

18. East Carolina University Division of Surgical Education Turning Knowledge into Action Summary Point Notes can be created quickly with minimal cognitive effort, however their impressive length implies diligence and attention to detail.

19. East Carolina University Division of Surgical Education Turning Knowledge into Action Time Savings Potential Benefit: Decrease resident work hours in the era of more stringent duty hour monitoring

20. East Carolina University Division of Surgical Education Turning Knowledge into Action Time savings in the era of duty hour restrictions? One study: Prospective, randomized Reduced patients missed on rounds by 50% Shorted rounds by 90 seconds per patient Residents saved 30-45 min/day or 200 resident work hours over approx 100 days J Am Coll Surg 200:538-545, 2005 Other studies: On average 16 min to document a 15 min encounter 68% report spending > 4 hrs on documentation Bringing the work home Fam Med 33:128-132, 2001 Int J Med Inform 74: 657-662, 2005 Fam Med 42:562566, 2010 Arch Int Med 170:377-380, 2010

21. East Carolina University Division of Surgical Education Turning Knowledge into Action DANGER Recently a non-surgical residency at our institution was cited for a duty hours violation for knowingly having residents work from home.

22. East Carolina University Division of Surgical Education Turning Knowledge into Action The EMR & Medical Students (AKA: our future residents)  39% of academic medical centers never include medical student notes in the EMR  Many others limit access to the EMR Acad Med 84:1698-1704, 2009 Mount Sinai J Med 76:357-364, 2009  How are our future residents going to learn clinical reasoning?  How well prepared will our interns be?  ?? Slippery slope where only senior residents may write in the EMR

23. East Carolina University Division of Surgical Education Turning Knowledge into Action Potential education-related opportunities  Profile a leaner’s clinical experience  Document RRC requirements  Communication skills  Practice based learning  Development of database to measure resident specific outcomes  Substrate for research projects

24. East Carolina University Division of Surgical Education Turning Knowledge into Action Take Home Points  The EMR is here to stay  It is a data feast but a critical thinking famine  Work flow is likely improved but at the cost of learning and education  Resident time may or may not be saved  Your future interns may be significantly disadvantaged.

25. East Carolina University Division of Surgical Education Turning Knowledge into Action MOST Important Take Home Point Nearly all of these negative impacts are easily corrected by reading the notes and engaging the learner.

26. East Carolina University Division of Surgical Education Turning Knowledge into Action