2. Incorporating EMR education into Medical School curriculum Lauri Lopp, MD Theresa Waters, BSN, RN

3. Objectives SIUSOMs history of promoting HIT for medical students National trends/experience SIUSOM Y2-4 experience with EMR documentation Successes and challenges of student EMR implementation Future opportunities to enrich medical student HIT

4. Issues regarding medical student EMR use Mintz et al, 12/2009, found: –Less than 50% of Internal Medicine clerkships using an EMR sampled had policies guiding student EMR use Of those clerkships that had student policies, there were major variations

5. Issues regarding medical student EMR use No clear national standard has been established Effects of EMR use on medical student education is not known Access early in education key to understanding of systems-based practice

6. Positive aspects: student EMR exposure Essential that students learn EMR ability to: Improve quality of care Decrease medical errors Improve patient satisfaction Allow clinical messaging Offer clinical decision support systems (CDSS) Enhance monitoring of drug therapy Improve adherence to evidence-based guidelines

7. Necessary for future clinical survival Exposure to different documentation: templates, drop-down menus –Scherger et al, 8/2008 study Positive aspects: student EMR exposure

8. An EMR can enhance patient-physician communication –Need EMR specific communication skills Introduce EMR into office encounter Form patient-physician triad EMR screen reminders about prolonged use Share data with patient from screen Positive aspects: student EMR exposure

9. An EMR can improve faculty feedback –Written, verbal, synchronous, or asynchronous feedback Students value asynchronous feedback equally to immediate feedback Positive aspects: student EMR exposure

10. An EMR can profile students’ clinical experiences EMRs can be queried and facilitate: –practice-based learning –Quality improvement –Self-reflection Positive aspects: student EMR exposure

11. Students have positive perspective about EMR use –Study of 33 U of Kansas Y3 med students found: 72% reported asking more questions with EMR prompts 70% felt essential pt info was easier to find 69% felt EMR improved their documentation 40% students reported more feedback on notes Positive aspects: student EMR exposure

12. Early student exposure is essential to orient them about how EMR success is dependent upon: –multiple systems –user-based factors –provider education Many practicing physicians, residents and students have received suboptimal training in EMR use Positive aspects: student EMR exposure

13. Negative aspects: student EMR exposure May adversely impact clinical reasoning –Risk of no longer creating notes “de novo” Issues with templates, drop-downs, copy-paste Interference of existing drug, problem, PMHx lists Pre-set orders with computerized physician order entry (CPOE) May adversely impact physician-patient relationship

14. Negative aspects: student EMR exposure Billing issues – major issue –Prohibitive Medicare policies –Medicare documentation policies established in 1998, 2 trends in med education: Emphasis on ambulatory faculty working one-on- one with students Increasing reliance on EMRs

15. Negative aspects: student EMR exposure Legal concerns –Faculty fear of committing fraud –Signature issues Mintz et al, in 12/2009, found that of academic schools that allow student notes in EMR: –40% faculty only signature on student notes –40% required faculty and student to sign –20 % reported “other processes” –NO schools allowed students to sign without co-signature

16. Negative aspects: student EMR exposure Legal concerns –Knight et all, in 2005, found: Students at hospital using CPOE reported placing significantly fewer orders than students at hospitals using paper orders. Those students reported feeling much less a part of the team They felt less adequately ready to be an intern Felt they made resident spend too much time reviewing orders

17. Negative aspects: student EMR exposure Issues with access –User licenses, log-ins, passwords –Poor educational focus in EMR design/structure Institutional issues –Lack of support in education, funding

18. Negative aspects: student EMR exposure Faculty issues –EMR use with students slows them down –Increased production pressure –Variation of IT competency in community and academic faculty –Faster access to diagnostic studies for faculty before meeting with trainee Students have less incentive to think critically –Faculty access to EMR while precepting

19. Negative aspects: student EMR exposure Student issues –Risk of devaluing student involvement if access is limited

20. Keys to enhancing medical education with an EMR Students document electronically from their earliest clinical experiences –Can identify suboptimal keyboarding skills –EMR communication skills can be easily taught –Morrow, et al in 1/2009 found that: 1 st yr students receiving EMR communication skills training performed better than controls in 6 out of 10 EMR communication skills These students did not spontaneously demonstrate EMR skills without instruction

21. Keys to enhancing medical education with an EMR In 2007, Rouf and colleagues reported without early EMR exposure: –33 Y3 students conducting patient EMR encounters felt: 64% satisfied with pt-MD communication 24% EMR improved their ability to build rapport 21% thought patients liked them using EMR 48% reported less time looking at patient because of EMR 34% reported spending less time talking to patient

22. Keys to enhancing medical education with an EMR Emphasize improved communication opportunities –Synchronous and asynchronous care Conduct faculty development around teaching with the EMR

23. EMR Implementation Educational Applications of the Electronic Health Record (EAEHR) Committee Educational Applications of Health Information Technology (eHIT) Committee EMR roll-out in clinics

24. SIUSOM Considerations for student EMR documentation Clinical reasoning skills Legal considerations Licensing issues Forms development Medical records policy for student documentation

25. Year 2 students EMR training ‘Read only’ access in Production Documentation privileges in the Educational EMR Progressive documentation with SP Teaching Cases

26. Year 2 students Accessing EMR in exam room during SP Teaching case Required SOAP Notes

27. Year 3 students Privileges in Production changed from ‘read only’ to ‘document’ 4 student encounter forms –Medical Student SOAP Note –Medical Student Comprehensive Note –Medical Student OB/GYN Note –Medical Student Psych SOAP Note

30. Clerkships EMR requirements clerkship specific Student notes housed in separate folder Physician feedback and student signature

31. Year 4 students Documentation as in Year 3 EMR-specific system limitations in allowing order and referral writing Visiting medical students

32. Successes of student EMR implementation Vision of SIUSOM for EAEHR, eHIT, and EMR educational specialist Entire SIUSOM team Teamwork between medical education and SIU Healthcare Info Systems Positive acceptance of clerkship directors

33. Successes of student EMR implementation Positive student experience and involvement Rapid form development Ease of licensing for students with GE Adequate hardware resources for students Minimal technical glitches/smooth rollout

34. Challenges of student EMR implementation Few guidelines/precedents Student involvement Legal considerations Limited resources for students in midst of large multi-specialty roll-out Licensing issues Ensuring feedback from physicians

35. Challenges of student EMR implementation Decision regarding the EMR for year 2 EMR Centricity specific limitations regarding capabilities for students/preceptors Time for student/faculty training for each clerkship

36. Future Directions Consideration of changes to standard clinical note writing early in medical school Increase speed of exposure for Y2 student Expand Y4 student privileges Expand clerkship requirements with note writing/interacting with EMR Querying the EMR to facilitate practice- based learning and quality improvement Educational curriculum for EMR communication skills

37. Research Year 2 medical students EMR perceptions study Educational curriculum for EMR communication skills to preserve patient- physician relationship Current papers, posters and presentations being written regarding SIUSOM unique EMR implementation for Y2 and Y3-Y4

38. Summary Health systems must ensure that EMRs don’t diminish the education within medical student clinical experiences Medical education must expose students early to EMRs Medical educators must train them to use strong critical thinking skills and not let an EMR foster a generic/automatic approach to diagnosis and treatment

39. Summary The computer can not be a barrier between physician and patient Teaching hospitals that use CPOE must ensure that: –the system allows students to place orders, –adequate training for residents and faculty to help students –System allows student day-to-day involvement in care

40. Summary All of the technological value of an EMR will be lost if it jeopardizes medical education SIUSOM very fortunate to have environment that is not restrictive to medical students EMR education

41. Questions and Discussion

42. References Adams, WG, Mann AM, Bauchner H. Use of an EMR improves the quality of urban pediatric primary care. Pediatrics 2003;11:626-632 Gilatto, P, MD, Masters, P, MD, Karani, R, MD. Medical Student Documentation in the Medical Record: A Liability ?. Mount Sinai Journal of Medicine 76:357-364, 2009 Hobbs, J, MD Strothers, H, MD Manyon, A, MD. Impact of Expanding Use of Health Information Technologies on Medical Student Education in Family Medicine. Annals of Family Medicine 7:470-471 (2009), pp 1-4. Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medical safety: a systematic review. Arch Intern Med 2003; 163:1409-1416 Keenan, C, MD, Nguyen H, MD, Srinivasan, M, MD. Electronic Medical Records and Their Impact on Resident and Medical Student Education. Academic Psychiatry, 30:6, Nov-December 2006, pp 522-527. Knight, A, MD, Kravet, S, MD, Harper, M, MD, Leff, B, MD. The Effect of Computerized Provider Order Entry on Medical Student Clerkship Experiences. Journal of the American Medical Informatics Association, Vol 12, Number 5, Sep/October 2005, pp. 554-560.

43. References Hartzband P, MD, Groopman, J, MD. Off the Record – Avoiding the Pitfalls of Going Electronic. N Engl J Med, April 17, 2008, 358, 16. Hunt DL, Haynes RB, Hanna SE, Smith K. Effects of computer based clinical decision support systems on physician performance and patient outcomes: a systematic review. JAMA 1998: 280: 1339-1346. Mintz, M, MD Narvarte, H, MD O’Brien K, MD Papp, K, PhD, Thomas, M, Durning, J, MD. Use of Electronic Medical Records by Physicians and Students in Academic Internal Medicine Settings. Academic Medicine, Vol. 84, No. 12/December 2009, pp1698-1704. Morrow, J, DVM, MS, Dobbie A MD, Jenkins C, MD, Long R, PhD, Mihalic A, MD, Wagner J, MD. First Year Medical Students Can Demonstrate EHR-specific Communication Skills: A Control-group Study. Family Medicine, January 2009, 41 (1): 28-33. Peled, J, Sagher, O, Morrow, J, Dobbie, A. Do Electronic Health Records Help or Hinder Medical Education. PLoS Medicine. May 2009, Vol 6, Issue 5, pp 1-5.

44. References Scherger, J, MD, MPH. First-year Medical Students Document More Pain Characteristics When Using an Electronic Health Record. Family Medicine. Letters to the Editor, Vol 40, No 7, July-August 2008. Sequist TD, Sing S, Periera AG. Use of an electronic medical record to profile the continuity clinic experiences of primary care residents. Acad Med 2005; 80: 390-394.