The first resident who really reamed me out on the wards was having trouble reading my handwriting. My handwriting became doctor-unreadable well before medical school, but how quaint. It was the beginning of my second month of clinical training, and hers of internship. She couldn’t follow our shared patient’s daily progress note. I didn’t tell the story in the right order. The format was wrong. Instead of noting only pertinent clinical findings, I had listed some normal findings like “good skin turgor” that I had memorized during our second-year bedside examination course. (When was the last time a doctor put that instrument up to your eye, turned out the lights, and magnified your fundi?) There were too many strikethroughs, deletions I did not know to label “error,” initial, and date. I had labeled the strikethroughs I wanted to take back “STET,” journalism jargon, not medical practice. So I inadvertently created extra work for her, a misstep that made me want to STET my free will.
Like most medical students in the same scenario, my immediate reaction to her constructive criticism was a full-bodied blush. There were the palpitations, the paraspinal tension, slumped shoulders. I sought temporary refuge in the summer lemonade purees at the boutique market across the street. Mixed-up heads benefit from juice cleansers. Like the juice I then drank, and the band Orange Juice, I ripped it up, started again, and went back to the hospital to rewrite the note in her image. No trouble for her, me in no further trouble. It was totally fine, and I discarded the previous draft in a special container for patient health information waste management.
Will future medical students shred themselves in quite this way?
A New England Journal of Medicine study reported that less than ten percent of U.S. hospitals and 17% of outpatient clinics had an electronic medical records (EMR) system. Less than two percent of these had fully integrated EMR platforms. These numbers have gone up since the Health Information Technology for Economic and Clinical Health (HITECH) Act (2009), a provision of the federal stimulus bill to encourage health care providers and organizations to adopt EMR. A disproportionate number of the EMR systems were in place in academic hospitals and large urban hospitals—exactly where we train medical students. Around that time, 90% of American medical students had at least read-only access to electronic medical records.
Efforts to ensure medical students universal access to medical records in teaching hospitals continue today: The American Medical Association’s Council on Medical Education published a report encouraging academic hospitals to ensure it, and to date, 130 of 134 accredited U.S. medical schools guarantee students full EMR access. So earlier this year, the AMA announced that it has awarded $11 million in grants to 11 different medical schools as part of an“Accelerating Change in Medical Education” campaign. At least three of these programs include pilot projects to teach medical students how to use EMR from the first days of medical school. Along these lines, my own medical school received one such grant (not my idea):
The proposal will create the “Integrated Care Coordination and Analysis Curriculum,” a flexible three year, individualized, technology-enabled curriculum to improve care coordination and quality improvement. The foundation for the curriculum will be a virtual patient panel containing de-identified patient data from physician network practices to immerse students in a real world clinical setting. Students will also create an ePortfolio with a dashboard for tracking their competence development. The virtual patient panel can be used after students graduate to support a lifelong learning framework in which physicians can input their own patient data.
Confused yet? So are medical students. Why go through all that effort to anonymize real-life patient data from a rich data-mined silt to rebuild a virtual patient for child’s play? What practical information could a medical student learn from a mock-up of an electronic medical record? Should “preclinical” medical students even have to learn clinical decision-making and data analysis yet? From a student’s perspective, the answer to these questions is obvious: Better to misunderstand records for a fake person than a real one. Medical students exist to misinterpret. Do what you’re told, push paper, get better grades. For medical educators, the move is pragmatic: It is simply easier to spend thousands of dollars creating a virtual patient than access to the EMR of an identifiable, billable patient. You can’t expedite the latter except in a simulation experience.
This convoluted logic smacks of bad Kafka unless you’re familiar with how hospitals “transition” to EMR in the flesh. Over my four years of medical school, I have “rotated” (worked and studied for one to two months) at six different teaching hospitals and about twice that number of outpatient clinics. Whenever I begin work at a new out-of-network facility, or begin a new school year, I must complete at least four hours of computer training in order to receive permission to review patient records. For each of the teaching hospitals and/or “affiliates,” these sessions outline institutional variations in medical informatics, mostly in regard to the implementation of patient privacy law (the Health Insurance Portability and Accountability Act of 1996, or HIPAA). If I get 90% or higher on the post-test, the place lets me read charts.
From there, I try to build up to writing patient records myself where I can. It helps the team. Often that mandates an extra four hours of online training away from the team. If I am permitted to place orders as an acting intern, I can expect to be out of commission for another four to eight hours on top of that. Some of these trainings happen in computer classrooms, and others I can do on my own time at home, if they are compatible with my MacBook and Web browser. Inevitably, they are not, which means I have to go back to the medical library or the inpatient floor. In some cases, that time investment means lost time with patients, time I will make up when I am back in a patient care setting by filling out more electronic forms.
To do that, I must find a wayward desktop on the inpatient floors. The PCs are slow from running all the time. Crowd control distracts me from the content of the record. Residents all know the best out-of-way offices, so I feel like I only ever run into nurses and other students at the workstations. There, one group is teaching the other how to use the technology. Once we learn it, we write the longest notes, to tell the residents and attending we are making good use of this learning time, but more because we can’t find the appropriate “within normal limits” autoprompts.
In “outpatient settings”—clinics, doctor’s offices—I have more solitary time to review the software. However hard I try to follow instructions to read the tabs left to right, I read all the subfolders and view options scattershot, so I get patient summary from an outside consult or an imaging report pop-up when I want chart review or past meds. When I forget to mention a screening guideline, say telling a woman over 35 that she shouldn’t smoke and use birth control at the same time, the computer will remind me, and so I will remind the computer instead of her. All those physical findings I actively forgot after the encounter with the paper record resident come back to me, pings and arrows up, if I forget to fill them in for my supervising doctor (or fill them in accidentally if I did not observe them as part of my physical exam if irrelevant) If I forgot to put them in the chart, I certainly won’t forget to put them in the billing, except I don’t get to do the billing codes. One of the reasons it’s so hard to get medical students into medical records is because they’re legally prohibited from getting reimbursed.
My classmates and I joke that we save our residents’ work. Thanks to EMR, they are bogged down in more record-keeping, and have fewer work hours in which to complete them. If we offer to help, we often create more work, and we certainly aren’t allowed to dictate the notes, as many physicians are doing.Medical students are used to feeling extraneous to their teams, but perhaps never as much as when they are completing EMRs as a learning exercise. While that has been my personal experience, it is also a paraphrase of official testimony by Ivy Baer, senior director of the regulatory and policy group of the American Association of Medical Colleges, to the Centers for Medicare and Medicaid Services, in May 2013. If the criticism has reached them, it suggests to me that the inefficiency is a universal experience—and a bad harbinger for future successes in EMR implementation.
Sometimes I wonder if the architects of EMR were hoping my generation of “digital natives” would go into the new system pure. When I was the student at the beginning of this essay creating the messy paper trail, the hospital where I was rotating was transitioning to EMR, meaning I did both at once. I reviewed lab values at computer stations, overnight vital signs from a paper chart at the bedside, and synthesized them onto paper. Does such synthesis help patients or hurt them? One of the best academic evaluations I ever got was from a resident at a separate hospital who was impressed I knew how to call a hospital’s microbiology lab and to use a fax machine to transfer the results of a blood culture from one urban public hospital to another in the same health care network. Of course I put in all that effort to determine, as the team suspected, that the results were normal, and we all had a good laugh.
And yet I almost longed for the old-fashioned bureaucracy. It was the enemy I knew from public school teaching, from the classroom, from the womb. As a physician who got postbaccalaureate premedical training, geezer M.D. me remembers my parents getting a snail mail from an office down the street in Reston recommending I try out their AOL/Prodigy CD-ROM. As a patient, handwritten medical records have an emotional valence that EMRs does not provide: My pediatrician plotted my growth chart with me, and I loved watching my orthodontist fill out his dental diagrams. As a student, I have a positive transference: I got much better grades when I was still submitting work on paper, and when I didn’t I still got a kick out of learning how to design 3D structures for organic chemistry synthesis reactions. And in this case with the resident and the progress note, I liked how the editing process forced me to outline the case again. The activity felt novel, so it didn’t feel like being a paperpusher. Their clinical decision-making process became clearer. I fantasized I was the journalist John McPhee snipping sections of his reporting and rearranging his paragraphs them like a puzzle.
I have no insight into EMR as a business, nor as an economist, but as a student I have concerns about “meaningful use.” We spend much of our medical education reviewing national screening guidelines and evidence-based medical management. EMR implementation is supposed to alert doctors to them to increase compliance. It is supposed to decrease medical error. If we have to go through so many hoops to learn both systems, should we reasonably expect to be able to meet these high expectations? We are doing our best, but it’s hard. When I think of medical records now, I think of people complaining about EMR. A health systems research team at the University of Central Florida provider described institutional case studies of resistance to change, bu many other studies point out that it is still unclear if EMR are beginning to cut health care costs or improve clinical efficacy .
Yet this essay is not a plea for a return to paper. I feel like I’m on my phone every 5 seconds, and I played a large role in founding a Web start-up. Though I receive neither salary nor other financial support or benefits from this site, the text annotation social network Rap Genius, somebody else over there is coincidentally about to launch Health Genius to demystify medicolegal documents and biomedical jargon.
Here I seek to do much the same, to demystify the EMR “disruption” as what it is for the students learning: An object of fascination. As such, they are also often a distraction. I read a lot of narrative essays by idealistic medical students who really, really connected with a patient, or really messed up with one, but I almost never read anybody who writes about our failure to connect with computers. Online we squint our eyes, redirect eye level. In our confusion about where to look, or to whom, we begin to avoid eye contact with each other and with the people in front of us. Our supervisors are starting to make jokes that our fleeting moments with fake patients may be the last times we get to spend significant minutes on patient interviews, owing to our inexperience at efficacious medical interviewing with EMR. Once we’re distracted by electronic billing code set-ups, our attention will go even further toward the wastebins.
Electronic platforms will not placate technology-hungry students and patients just because they are there. Efficient platforms might help. EMRs aren’t there yet. In the meantime, I still clutch file folders to my chest in a fetal curl like a freshman girl getting asked to the sockhop by her lab partner for the first time. I hope we pass this science experiment.
Maureen Miller is a medical student who blogs at doctor writer maureen miller.