1. TEACHING and the Electronic Medical Record: THREATS AND OPPORTUNITIES Nicole Appelle, MD Peter Chin-Hong, MD Lindsay Mazotti, MD

2. Objectives Recognize the paucity of literature and therefore the opportunity in the field Develop EMR education around content and strategies for: Communication and professionalism Learner and patient Learner and preceptor/attending Learner and other health professionals Documentation and professionalism Practice-based learning and improvement/practice management Clinical reasoning Identify a framework to guide using the EMR in the evaluation and feedback of a learner

3. Timeline Until 9:25Intros, Goals 9:25-9:45Literature, Framework 9:45-10:25Small Group Activity #1 10:25-10:35BREAK 10:35-11:15Small Group Activity #2 11:15-11:30Summarize, Evaluations

6. Flowchart, nicole

7. EMR: Ready or Not, They Have Come IOM, MD’s, residents, stakeholders called for widespread implementation Goals to: Improve quality of care Improve patient satisfaction Reduce errors In 2009, only 12-23% of practices had EMRs. Likely more EMRs in academic teaching hospitals

9. The Educator’s Challenges: Communication Documentation Practice Based Learning/ Practice Management Clinical Reasoning/ Professionalism Responsibility/ Liability

10. Literature, or lack thereof: Perceptions of EMR Existing, or lack of existing, policies on documentation Discussion of threats and opportunities Evaluation methods of EMR use

11. Perceptions of the EMR 1. Rouf et al. BMC Med Educ. 2008. 2. O’Malley et al. JGIM. 2010. 3. Stephens et al. Med Sci Educ, 2011. 4. Knight et al. Acad Med. 1994. PositivesNegatives Students reported the EMR improved 1 : o History taking (Prompts helped) o Order writing (options given, preventative services ordered) o Documentation MD’s perceive negative effects on doctor-patient relationship 2 Students perceive multiple downfalls 3,4 : o Frequent use to be proficient o Computer issues o Lack of availability to students o Barriers to placing orders o Significant dissatisfaction with patient communication

12. EMR Policies for Medical Students Study surveyed clerkship directors, 82/110 (75% responded) 58% respondents reported using an EMR in ambulatory settings Of those who used an EMR, only 44% had policies regarding medical student documentation Policies varied at different sites within single institutions Some policies strictly prohibited EMR documentation, others suggested how to properly document Mintz et al. Acad Med. 2009.

13. Threat… or Opportunity?

14. How can we teach using the EMR? How can we make the EMR our friend? Leave here with one way to evaluate students on their EMR skills

15. Small Groups Scenarios 1 and 2 Break into your small groups One person per group read directions on front of envelope Prepare to report back ONE pearl to share

16. BREAK

17. Small Groups Scenarios 3,4,5 Break back into your small groups Discuss AT LEAST 2 of the 3 scenarios on the handout Prepare to report back ONE pearl to share

18. Objectives Recognize the paucity of literature and therefore the opportunity in the field Develop EMR education around content and strategies for: Communication and professionalism Learner and patient Learner and preceptor/attending Learner and other health professionals Documentation and professionalism Practice-based learning and improvement/practice management Clinical reasoning Identify a framework to guide using the EMR in the evaluation and feedback of a learner

19. Evaluation:The RIME EMR Scheme LevelSkill SetEMR-specific skills ReporterClinical Data Entry Records complete history & exam Reliably completes S/O portion of SOAP note Records own findings rather than cut & paste Reviews medical history in EMR InterpreterData Assessment Reliably completes “A” portion of SOAP note Interprets new data (labs, radiology, consults) Independently constructs patient problem list Discusses clinical assessment & diagnostic possibilities. ManagerData Assimilation Constructs “P” portion of SOAP note Requests appropriate services and consults Articulates competent therapeutic plan Decides on appropriate follow up and arranges it EducatorClinical Decision Support Uses embedded support tools to access current evidence related to patient care Uses tools for patient-centered education Modifies care plan in accordance with evidence Stephens et al. Acad Med. 2011.

21. The Future’s So Bright…

22. References 1. O’Malley AS, Grossman JM, Cohen GR, Kemper NM, Pham HH. Are electronic medical records helpful for care coordination? Experiences of physician practices. J Gen Intern Med. 2010; 25(3): 177–185. 2. Stephens MB, Corcoran TS, Motsinger C. Clinical Documentation in Electronic Medical Records: The Student Perspective. Med Sci Educ. 2011; 21(1): 3-6. 3. Rouf E, Chumley HS, Dobbie AE. Electronic health records in outpatient clinics: Perspectives of third year medical students. BMC Med Educ. 2008; 8(13). 4. Mitnz M, Navarte HJ, O’Brien KE, Papp KK, Thomas M, Durning SJ. Use of electronic medical records by physicians and students in academic internal medicine settings. Acad Med. 2009; 84(12): 1698-1704. 5. Knight AM, Kravet SJ, Harper GM, Leff B. The effect of computerized provider order entry on medical student clerkship experiences. J Am Med Inform Assoc. 2005;12: 554-560. 6. Morrow JB, Dobbie AE, Jenkins C, Long R, Mihalic A, Wagner J. First-year medical students can demonstrate HER-specific communication skills: A control-group study. Fam Med. 2009:41(1):28-33. 7. Peled JU, Sagher O, Morrow JB, Dobbie AE. Do electronic medical records help or hinder medical education? PLoS Medicine. 2009; 6(5): e10000069. 8. Stephens MB, Gimbel RW, Pangaro L. The RIME/EMR Scheme: An educational approach to cilnical documentaion in electronic medical records. Acad Med. 2011; 86(1): 11-14.