The Electronic Medical Record: A Tool for Teaching Nancy B. Clark, M.Ed. Director of Medical Informatics Education, FSU College of Medicine For the Graylyn Conference, 9/13/05

Hot topics and the Better Question How do we train students to use hospital and outpatient systems? How should students use these systems? What are the barriers? How can we use this as a tool for teaching? –What skills/knowledge? –What level is appropriate?

Historic Perspective “A complete medical record is essential to reliable continuity of medical care….It would seem most logical to have the physician enter the problem statements directly into the computer.” Weed, L. (1968) Medical Records that Guide and Teach. NEJM (278);11

AAMC MSOP Medical School Objectives Project Medical informatics’ use in five major roles played by physicians— –Life-long Learner –Clinician –Educator/Communicator –Researcher –Manager (June 1998)

Role of Clinician Retrieve patient-specific information from a clinical information system, demonstrating the ability to display selected subsets of the information available about a given patient

Role of Clinician Make critical use of decision support, demonstrating knowledge of the available sources of decision support which range from textbooks to diagnostic expert systems to advisories issued from a computer-based patient record.

Role of Clinician Document and share patient-specific information, demonstrating the ability to record in information systems specific findings about a patient and orders directing the further care of the patient. Use security-directed features of an information system

Current Level of Adoption Urban hospitals in Florida- 52.2% Rural hospitals in Florida- 51.9% Physicians in Florida- 23.7% Brooks RG. Menachemi N. Burke D. Clawson A. Patient safety-related information technology utilization in urban and rural hospitals. Journal of Medical Systems. 29(2):103-9, 2005 Apr.

Strategies Simulated EMR –Minnesota –Connecticut –MedCases –DxR Commercial EMRs –FSU

FSU’s First Strategy No clinical activity – no real patients Clinical Learning Center - simulated patients –History Taking –Physical Exam –Documentation Electronic Medical Record System

Practice Partner Donated 40 user licenses Established in doctors using 30+ residency programs Practice based research network Decision Support –Drug interactions –Drug allergy –Knowledge base links

Strategy 2002 Use in CLC Populate with simulated patient case information Students access record before examining patient Students document S & O parts of progress notes in records

Problems Encountered Faculty time to build patient records Simultaneous access to one patient’s record –Created 6 copies of same patient Faculty time to review progress notes ( ed) Templates were above students level Abandoned 2003

EMR

Implementation in 3 rd Year Doctoring 3 (2003) –Longitudinal Experience –One half day per week – all year –Primary care physician –Each regional campus dean is coordinator for his students

Objectives of D3 Longitudinal Demonstrate knowledge of –the natural history of common chronic diseases. –the factors that contribute to compliance with chronic disease care including psychological, social, and behavioral. Apply the principles of prevention and chronic disease management to patients, families, and populations. (2004) Demonstrate the ability to use an EMR to document patient care.

“Physicians have for years been preoccupied with episodic illness, with problems only when they erupt into symptoms and only with patients who can get themselves to the doctor…. One must learn how to move easily from a single-minded focus on one problem to attention to the total list and interrelations of multiple problems.” L. Weed (1968)

Implementation Summer Assigned a panel of Pts with chronic problems Build a complete patient chart in Practice Partner to include –Problems list, medications list, PMHx, SHx, FHx, Health Maintenance, Labs and Vital signs for last year –Progress notes for each visit with patient

HIPAA Compliance No real names –Use student’s last name No real DOB –Use Jan 1 of year closest to DOB No SSN, address, phone #, etc. No mention of real physician System userIDs and Passwords

Software Configuration Student laptops loaded with two versions of software: Portable and Client Portable Version Practice Partner –Does not need a connection –Allows you to add information to charts –Limitations: can not edit saved items At clinics, students enter data into patient record on portable

On Campus Server Patient Database Wireless node Client Laptop Students synchronize portable to Server Use client to edit charts Print any part of chart

Supervision Regional campus deans and longitudinal faculty –Monitor student records –Provide feedback on documentation, progress notes

Longitudinal Faculty Help the student – I dentify appropriate health maintenance issues –Discuss recommendations literature: guidelines and articles on the topic –Identify appropriate screening tests and lab work –Discuss lab results –Appreciate psychological, social and behavioral issues that affect patients with chronic disease and help plan ways to deal with these –Determine which items (health maintenance, counseling, labs, physical exam, and vital signs) should be included in flow sheet

Challenges Technical problems –Syncing portable over distance –Initial transfer to portable Longitudinal faculty buy-in Paper records incomplete

Chart Transition Form Mine paper or EMR Labs Vitals HM Demographics

Typical Chronic Patient Record Margaret Smith 62 yr old White Female Patient for 5 yrs

Practice Partner

Chart Summary

“Data involving physical findings, vital signs, laboratory values, medications, intakes and outputs can lead to sound interpretations and decisions only if they are organized by means of a flow sheet to reveal clearly temporal relations.” L. Weed (1968)

Vital Sign Flow Sheet

Lab Tables

“One major goal of clinical teaching should be to designate the problems that should have a flow sheet, the variables that should be included and the frequency with which they should be followed.” L. Weed (1968)

Flow Sheets

Health Maintenance

Adding Disease Specific HM

HM Templates

Progress Note Templates Potential 200 templates Use point-and-click quick text Populate other parts of medical record Import from other parts of medical record Include links to patient education materials Include links to practice guidelines, research

Controversy To allow or not to allow students to use templates Some think yes—they teach the students the proper things to document Course director things no—students don’t learn the “words” We currently are not using them

Demonstration of Progress Notes If time

Teaching Opportunity Develop one template –Follow-up visit –Appropriate S, O, A and P –All of your patient’s chronic diseases –Includes link-outs to appropriate clinical practice guidelines

EMR Educational Objectives Access patient information Documentation of Progress Chronic Disease Management Coding Communication- Dr/Pt/Computer Triad Decision Support Patient Education Handouts Prevention/Health Maintenance Security and Privacy