Should medical students learn how to use an EHR in medical school?

Outside a patient’s room in the cardiac intensive care unit (CICU), a senior doctor, a nurse, and several residents in various stages of wakefulness cluster for morning rounds. Each resident mans a computer-on-wheels (once called a C.O.W., the acronym was formally abandoned at MGH, legend has it, after a patient thought it was directed at her and took offense).

One of the residents reads off laboratory test results from the patient’s electronic record. Another resident uses her mouse to toggle through the patient’s medications and share them with the group. The nurse reads aloud blood pressures and heart rates from a handwritten hourly log. As scribe for the day, I type these numbers to update a progress note that we’ll later print and place in the patient’s paper chart. Someday, these records will be completely digital, finally matching the wonderland of medical technology that is the CICU.

As the Electronic Health Record (EHR) slowly but inexorably assumes its rightful place in modern health care, obviating the ridiculous cultural norm of physicians with illegible handwriting, reducing medical errors, and making care (usually) more efficient, educators are asking the question: are we teaching this in medical school?

Not consistently, it turns out.

Anywhere from 34 to 57% of doctors’ offices and 19% of hospitals now use an EHR. While they are more often found in academic hospitals and clinics (where training occurs) than in other American health care settings, a recent survey finds that this tool doesn’t always trickle down to medical students. Only 64% of medical schools let their students use the EHR, and only about a third of those let students enter patient orders or write notes within the record, according to the survey of 338 educators nationwide that appeared in last month’s Teaching and Learning in Medicine.

Respondents blamed lack of computers, faculty who are naïve to EHRs themselves, and limited ability to oversee students’ use (the last one, to be fair, isn’t unique to electronic records). The researchers, part of the Alliance for Clinical Education (ACE), used these findings to suggest that medical schools have students practice entering orders for real or simulated patients and evaluate students on their use of the EHR.

It’s unfortunate that some medical students don’t have access to an EHR since trainees learn best by involving ourselves in every aspect of care for our patients. As a medical student, I felt more useful and took more responsibility for my patients when I could help my team by looking up a test result or posting a note (co-signed by a real doctor). Just as importantly, EHR access gives medical students the chance to grapple with how electronic records are changing the practice of medicine. But these lessons don’t come from a session in a computer lab – they require real experience.

After all, the question is not whether medical trainees will be able to navigate an EHR. Raised in the era of laptops and iPhones, we aren’t afraid of adopting new information technology.  Instead, we get frustrated by the inefficiencies and the clunky features of health IT that fail to meet the standards set by the non-medical, more user-friendly technologies in our lives (for example, and I’m not joking: auto-save).

By the same token, medical schools shouldn’t use precious classroom time to teach EHR skills, especially when systems still vary so widely from hospital to hospital. My residency class started out our intern year with handwritten progress notes and switched to computerized notes halfway through. It was a well-designed system, and we got the hang of it in a matter of days.

There are more critical, and more interesting, issues for medical educators to address:

How will doctors learn to incorporate EHR without corroding the patient-doctor relationship? We are a generation unphased by Blackberries at the dinner table, and my co-residents and I will often use a C.O.W. to take notes as we interview a newly hospitalized patient. How does this affect the stories we are able to elicit from our patients and their ability to trust us?

How will doctors resist the temptation of copy-and-paste medicine? It’s common practice for doctors to lift entire paragraphs from prior patient documents. In the medical world, this does not get you suspended from Time or The New Yorker, but it does lead to the well-documented hazards of precluding an open mind in clinical reasoning and propagating misinformation. In the ACE survey, 24% of respondents noted issues with unattributed copy-and-pastes, and the transition to fully computerized records will only make this easier.

Ishani Ganguli is a journalist and an internal medicine-primary care resident who blogs at The Boston Globe’s Short White Coat, where this article originally appeared. 

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  • http://twitter.com/Nomo312 ftrflyr29

    Completely agree with this article. As a 4th year medical student, I have rotated in places that have strictly paper charts, that are half EHR and half paper (which always overlap), and places that are 100% EHR, to include places that are currently in the midst of switching from paper to EHR. The EHR programs at the different hospitals and clinics are all different–EPIC, OCW, Powerchart, others whose names I can’t remember. From “my experience” (please note the quotations and sarcasm contained within–actually N = merely med school clerkships = no experience), the different brands of EHR all seem to be variations on the same theme. The only difference is the marketing and self-importance they have assigned. Which program ends up at a hospital? The one that markets itself the best, or the one that promises a seamless transition, or the one that is in cahoots with medicare/BCBS/Aetna–whoever reimburses the highest at the hospital, or my favorite–the one that “Mr XXX, member-of-the-board-of-directors, MBA, JD, MS, MA, MSW, MS Ed, etc, etc (notice there is not one MD, DO, BSN, RN, etc)” wants for the hospital, but forgot to mention that it is his son’s wife’s father’s company OR it’s the one that promises to increase hospital profits, that in reality will not, but he has never seen a patient or spoken to a Healthcare worker to actually know what will help make things more efficient and improve patient safety. But, I digress…… In the rotations with varying degrees of EHR, I have been given no access at all, limited access with my own log-in, and full access. Even as a non-traditional student (one who took typing and home-ec in HS and did not own a computer until 4 years after completing undergrad–a Pentium processor no less–top of the line at the time), it only takes me a few hours of playing around on the system to be able to navigate as well, if not better than most of the attendings. That’s not to say all the attendings are old and inflexible, but many of them have simply spent so much time with paper charts, their routine has become reflex and learning this new system, not to mention transferring 20 years of a patient’s history into a system that only goes back 3 years (even though the “seamless transition” powerpoint promised all history would appear) makes their work day that much longer–at a time when they are having to squeeze more and more patients into their day to make up for decreases in compensation. AND they are required to attend 3 FULL (8 hrs) days of training to even be allowed to see patients with the new EHR. As a medical student, I spent 1.5 hours as a first year receiving my First Aid/CPR certification, but I was required to sit through 1 full day of training for one of the systems that had yet to be implemented–what a colossal waste of time and a completely misguided sense of direction. I looked around to see many an EHR company worker/trainer (suddenly thrust into a position of power) wandering around the room more worried about controlling the minute-by-minute activities of the students present and threatening to keep us longer or not give us credit for attending if we didn’t actually pay attention–appeared to me to be a lot of people trying to seem important to validate their existence. The training session itself was death-by-powerpoint. No one seemed to realize that once we are instructed on 3 things, the remainder of what came out of the mouths of whoever-it-was at the lectern sounded a lot like Charlie Brown’s teacher. What would have been a better use of my time (and probably most residents’/attendings’/nurses’ time)– give me my log-in and a quick down and dirty of how to get to the basic things and then let me point and click through the screens at my leisure through the remainder of training with previously trained med students/physicians/nurses (those persons applicable to my current situation) wandering around to assist with questions or provide helpful hints. Even better–give that medical student full access in the clinic and watch what helpful things they can discover to assist you in the future. Not only will I have the time to discover new exciting things on the program, when I see 80y/o Mr. Smith, who’s been coming to you for 30 years, I can look through his old notes and check the appropriate boxes to fill in his history–a win-win for all, I get to see the patient as the human he is, I take care of some of the EHR hurdles (for free) and I may be able to help you become more comfortable with your new system. If we are able to experience EHR in medical school, even better if it is different systems, we will be able to hit the ground running on day 1 of internship.

    • southerndoc1

      You seem to have a very good grasp of how our medical system works. Keep up the critical thinking: it’s in short supply these days.

  • http://www.thehappymd.com/ Dike Drummond MD

    The doctor’s method of documentation is always the #1 stress they will quote when you ask about burnout. Documentation is the devil and my answer to your article headline is “YES” … you must learn something other than a paper chart in your training.

    You must learn how you will incorporate documentation into your patient encounters without it interfering with your relationship. And here is what the real world looks like.

    You will most likely be simultaneously dealing with up to 3 different EMR interfaces at the same time. You will have one system in the office, one at the hospital and one in the student health clinic you man on fridays … or something like that. It is never just one EMR after you graduate.

    Since documentation is mandatory the only intelligent option is to become an expert in the program your practice uses. Most doctors will go in the opposite direction and vilify and complain about the EMR … which only increases stress and burnout levels.

    Embrace your EMR – become a power user and do it NOW.

    My two cents,

    Dike
    Dike Drummond MD
    http://www.thehappymd.com

  • glandsone

    I hope that med students will learn to enjoy the extra hours of documentation work that EHR use will mean in their practices as well as learning how to pay for its upkeep on their own. I hope they will also learn how to speed read the pages of boilerplate documentation their peers include in all notes in order to upcode insurance claims. I also hope they will learn how to function in their practices when the electronic system goes down, as it will sometimes do, unlike paper records, and how they will safeguard the privacy of those records when they misplace whatever tablet or smartphone they can use to access the system. That’s a lot to learn, on top of learning to be a physician. You always wanted to have a second (unpaid) career as a data entry clerk, didn’t you?

  • SaraJMD

    Just another example of why we need to completely rethink medical training, I believe. In our current system, how can we purport to provide a meaningful clinical experience to medical students without giving them any real degree of access to the chart? I think there are other approaches we could use to make a similar access situation work, but these approaches require more dedicated didactic staff and time than I have seen in medical training. In the usual system of sticking med students on a clinical team to learn by exposure, minimal or no access to the chart can really render a potentially wonderful experience nearly pointless, if students don’t have the tools they need to even follow clinical management. Thanks for bringing up the topic.

  • http://www.facebook.com/jonathan.marcus.ca Jonathan Marcus

    I’m a physician from Toronto. The entire current generation of EHRs are a cumbersome waste of time. We need a simplification revolution with this technology, without which we will see the quality of medical care and the morale of healthcare staff decrease. All other conversations about this are about as useful as trying to shoehorn an elephant’s foot into a dress loafer.

  • Harold Lehmann

    There’s also the cognitive issue that EHRs fragment physicians’ view of a patient—if only because they can’t (as the NYT article today pointed out) lay out 6 pieces of paper on the table. It may be that the multiplicity of apps only aggravates the fracturing. How can we measure this cognitive effect? How do we ameliorate it?