Educational Challenges of the Electronic Medical Record Jeremy Lipman, MD Case Western Reserve University

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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 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

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 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 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