By GLENN LAFFEL

Author’s Note: This the second of a 5-part series whose purpose it is to make the case for implementing a widespread, systematic approach to HIT education in medical schools and continuing medical education programs for physicians. A previous post reviewed challenges posed by the HIT Deluge.

Countries around the world are racing to digitize patient medical records. In the US for example, the American Recovery and Reinvestment Act allocated $21 billion to an incentive program designed to encourage the “meaningful use” of such systems.

The Federal government’s largesse is based on the premise that EHRs will improve the quality of care and reduce its costs, but the move will impact the health care system in many other ways as well. One area sure to be impacted is the education and training process for new physicians.

What kind of impact can we expect? In some ways, EHRs appear to enhance medical education, but there are as many or more instances in which the impact appears to be negative. Thankfully, careful planning can mitigate most of the collateral damage, a topic to be covered in this series’ next installment. For now, we’ll settle for a review of the good, the bad and the ugly.

Jay Morrow and Alison Dobbie of Texas Southwestern Medical Center suggest several ways in which EHRs can improve physician training.

They assert for example, that EHRs enhance history-taking and physical exam skills and cite their own work by way of support for this claim. They found that first-year students who used an EHR to document a medical history recorded more features of pain than those using paper charting.

In a separate survey of third-year students, Rouf and Chumley showed that 72% reported asking more history questions when prompted by an EHR, and 39% said they ordered more preventive services (BMC Med. Ed. 8:13). 69% of the students in this survey said that the EHR improved their documentation overall.

In focus groups associated with the latter survey, many students said they valued the prompts and would “go through the electronic screens in their mind’s eye” in deciding which questions to pose to patients.

Beyond this, EHRs give educators and medical students real-time access to patient-related health information. This saves time that can be better spent discussing nuances of the case in question. EHRs also speed access to texts and scientific articles, a luxury likely to facilitate learning and encourage students to rely on medical evidence.

In addition, by facilitating access to performance reports and care outcomes, EHRs help establish a culture of continuous improvement and lifetime learning among young physicians.

According to Rouf and Chumley, EHRs also increase the amount of faculty feedback to students and enable both parties to track the number of procedures that have been performed by students and residents.

Some EHRs even permit educators to store the records of particularly interesting cases in a “teaching file” for use as they see fit at a later date. Presumably students and residents can create files of their own for use in future didactic session with educators.

Nevertheless, many educators believe EHRs can negatively impact learning for medical students and residents. The perceived effect is large enough to have prompted Jonathan Peled of the Albert Einstein College of Medicine and Oren Sagher of the University of Michigan Health System to warn that EHRs “could erode the education of an entire generation of physicians.”

The concerns are that:
1) EHRs can adversely impact the clinical learning environment itself, and
2) Insinuating an EHR into patient encounters can negatively impact patient-physician communication.

One way EHRs might disrupt learning environment is by creating shortcuts that threaten the time-honored process by which trainees synthesize patient’s symptoms, signs, and lab results into a coherent story and present them to senior clinicians for feedback and discussion.

In the presence of EHRs, attending physicians are tempted peruse patient information before or during the trainee’s presentation. With such information in hand, they might ignore gaps in the trainee’s presentation, which robs trainees of the opportunity to engage in dialogue and hear the thought process that goes through the mind of the more experienced physician.

In addition EHRs can, some say, deleteriously impact the very geography of the teaching environment. Before EHRs became available, trainees and educators often sat side-by-side at a table pouring over charts together. This arrangement promoted spontaneous engagement and dialogue. Such learning opportunities are lost in a wired conference room, in which teachers and students sit before their own screens positioned along the walls, clicking away in silence.

An equally pervasive risk–referred to pejoratively by Peled and Sagher as “copy and waste”–is the tendency of EHR-empowered trainees to copy and paste chart notes and other information, and send them electronically to supervisors for feedback. This can perpetuate errors and discourage critical thinking on the part of the trainee.

Many times for example, a trainee will forward an assessment compiled by another physician, allowing him or her to forego his own clinical thinking altogether.

With respect to the negative impact EHRs might have on physician-patient communication, Kaiser Permanente pediatrician and EHR expert Michael McNamara recently told the Oregonian, “there’s a general fear that you put something new like this in an exam room with me and it’s going to ruin my interaction with the patient. It’s a super-powerful tool, and if you let it, it can become the focus of the conversation.”

The challenge is significant for seasoned physicians, and even more so for medical students and residents who are just finding their voice as professionals. The insertion of a computer terminal into the middle of a young physician’s session with a patient adds complexity to the interaction, might reduce eye contact and stilt the conversation, and prevent her from learning how her words and body language impacts her patients.

In conclusion, given the near certainty that EHRs will soon disseminate throughout the health care system, there is an overwhelming need to assess the impact of such systems on the educational processes of medical students and physicians of all ages, really. And despite the smattering of references given here, the field is littered with more questions than answers.

How and when should specialized training in EHR utilization be integrated into medical curricula? What should the curricula look like?

We don’t have good answers to these questions yet. In the next post in this series, we’ll suggest some preliminary approaches that have gained traction, but a lot more work remains to be done.

Glenn Laffel is a physician with a PhD in Health Policy from MIT and serves as Practice Fusion’s Senior VP, Clinical Affairs.  He is a regular writer for EHR Bloggers, where this post first appeared.