1. “Meaningful” Medical Student Use of the Outpatient EHR: How Did We Get There? Christine Jerpbak M.D. Jefferson Medical College Aaron Michelfelder, M.D. Loyola University Chicago Stritch School of Medicine David Power, M.D., M.P.H. University of Minnesota Medical School Frances Biagioli, M.D. Oregon Health and Science University

2. Objectives By the end of this presentation, participants will be able to… – Cite CMS’s guidelines for teaching physicians – Cite the recommendations from the AAMC Compliance Officer’s Forum in regards to medical student documentation in the EHR – Recognize the practice guidelines from the ACE (Alliance for Clinical Education) statement on electronic health records – Hear 3 institutions’ policies and practices on medical student EHR documentation – Identify institutional barriers to student use of EHR – Discuss ideas and solutions to optimize student use of EHR

3. CMS guidelines AAMC Compliance Officer’s Forum recommendations ACE recommendations Oregon Health & Science University Policy University of Minnesota Medical School Policy Loyola University Chicago Policy Discussion Presentation Road Map

4. CMS (Medicare/Medicaid) guidelines Students may document services in the medical record To Bill : Teaching physicians – May refer to the student documentation of the ROS and / or PFSH (Not history of present illness) (Not physical examination) (Not medical decision making) – Must verify and re-document HPI,PE, and A/P Fact Sheet: Guidelines for Teaching Physicians, Interns, and Residents. Dec 2011. Medicare Learning Network, Center for Medicare and Medicaid Services. Department of Health and Human Services http://www.cms.gov/Outreach-and-Education/Medicare-Learning- Network-MLN/MLNProducts/downloads//gdelinesteachgresfctsht.pdf

5. Compliance Advisory: Electronic Health Records in Academic Health Centers Topic 1: Medical Student Documentation June 11, 2011 https://www.aamc.org/download/253812/data/appropriatedocumentationinanehr.pdf AAMC Compliance Officer’s Forum (COF)

6. Summary: – Only Med Student documentation of ROS and PFSH should become a part of the actual patient chart – Scribing needs to be clearly designated as such in the chart – No Copy and Paste (Except for ROS, PFSH) – EHR system should automatically recognize med student documentation to apply limits AAMC COF Advisory

7. Medical Student Documentation in Electronic Health Records: A Collaborative Statement From the Alliance for Clinical Education, Teaching and Learning in Medicine: An International Journal, 24:3, 257-266 8/12/12 http//dx.doi.org/10.1080/10401334.2012.692284 ACE Statement on Electronic Health Records

8. Students must document in the patient’s chart; their notes should be reviewed for content and format Students must have the opportunity to practice order entry in an EHR-in actual or simulated patient cases-prior to graduation ACE Guidelines

9. Students should be exposed to the utilization of the decision aides that typically accompany EHRs Schools must develop a set of medical student competencies related to charting in the EHR and state how they would evaluate it. This should include specific competencies to be documented at each stage, and by time of graduation ACE Guidelines

10. Student EHR Use Year 1, 2, 3 and 4. (Trained week 1). At OHSU Students ‘medical assistant’-level access – Update History (PMH, Surgical History, Family History, social history) – Review and reconcile medications – Pend orders – Write notes Most OR hospitals on the same EHR (EPIC) – Hospital systems have differing student EHR use policy Students have remote access – Simulated-EHR modules are feasible with remote capability Simulated EHR use with OSCEs and PBL/TBL cases Oregon Health & Science University

11. Mixed interpretation depending on department / system affiliation and location attached to a hospital or not Scribing by a medical student in clinic is acceptable (also in ER rotations) Medical student can create an order that needs to be signed but not prescribe University of Minnesota

12. Mixed interpretation depending on department / system affiliation and whether location attached to a hospital or not – Eg. Required EMR training Scribing by a clerkship medical student in clinic is acceptable (also in EM clerkship) University of Minnesota

13. University of Minnesota Medical School Policy

14. Student has unique login Student documents the note as if they are transcribing for the physician – “I did” not “we did” etc. – “This note is scribed by Medical Student, MS4 on behalf of Attending Physician, MD” – Attending reviews and edits the note – “I confirm that I personally formed the clinical encounter documented in this note.” Clerkship scribing

15. If student works with licensed resident in a non-hospital linked clinic, above is OK Compliance Officer LOVES exam-room precepting (TIPP) Billing by time does not require documentation Other caveats:

16. How Student Documentation Helped Us Students Have Full Access to Charts Student Work Clearly Identified Write Notes, Enter and Pend Orders, Update Meds Problem List Attending Only How We Got Here Query About Medical Students Writing Orders – Illinois Department of Public Health – CMS Loyola University Chicago

17. What is the situation at your institution? Is there information here that will help you? Are there lessons to be learned from our colleagues? What are the next steps? Reflection and Discussion

18. Survey clerkship directors about current med school policies Experienced programs act as consultants or mentors Create an EHR toolkit Formulate a response to AAMC COF Next Steps

19. Christine Jerpbak M.D. Jefferson Medical College Aaron Michelfelder, M.D. Loyola University Chicago Stritch School of Medicine David Power, M.B., M.P.H. University of Minnesota Medical School Frances Biagioli, M.D., Oregon Health and Science University Thanks!