Tweaking Medical Education to Leverage EHRs

Tweaking Medical Education to Leverage EHRs



Author’s Note:The purpose of this 5-part series is to make the case for implementing a widespread, systematic approach to HIT education in medical schools and continuing medical education programs for physicians. Previous posts reviewed challenges posed by the HIT Deluge and the Impact of EHRs on Medical Education.

EHRs have begun an inevitable march into the lives of all physicians. The US government has established an ambitious plan for their deployment, and providers seem both eager to comply and anxious to avoid financial penalties associated with not doing so.

But as described in Part II of this series, EHRs can have deleterious effects on the education of medical students and residents. These include disrupting interactive sessions involving educators and trainees and complicating patient-physician communication.

Jay Morrow and Alison Dobbie of Texas Southwestern Medical Center argue that much of this negative impact derives from a mistaken perception that EHRs are a health care delivery method rather than a medium through which physicians deliver care. It follows from this argument that the quality-improving, cost-reducing benefits of EHRs can only be realized if multiple systems and user-based factors are aligned to optimize utilization of the new medium.

Medical educators can begin the alignment process by developing answers these 3 questions:

When Should EHR Education Begin?
Arguably, the process should begin as early as possible. Since the 1970s, medical curricula have included non-science oriented courses such as “Introduction to the Patient,” “Communication Skills” and the like. These courses present ideal opportunities to introduce the new medium.

Students in such courses should be taught to navigate through and use basic EHR functions such as order entry, lab look-up, messaging and charting. Ideally, this exposure should occur outside the clinical setting so trainees can focus on mastering the EHR interface itself. At this time, it should be possible to identify those in need of extra help with keyboard skills, and to provide assistance as necessary.

Keyboarding skills should not be assumed, even for the current generation of physician-trainees. In a 2007 focus group of first-year students at Texas Southwestern for example, 62% of the participants expressed concerns about such skills, and many claimed to have better texting than typing abilities.

If students master keyboarding and EHR navigation skills before starting their clinical rotations, they can focus the latter time on traditional learning exercises, such as clinical reasoning, diagnosis, acquiring medical procedure skills and interacting with ancillary caregivers and patients.

What Should and Should Not be Taught?
First off, medical students and residents should not be permitted to copy and paste the notes of other physicians while using an EHR. If this means disabling the relevant EHR functionality for trainees, then so be it. Cutting and pasting presents a tempting short-cut that risks short circuiting a critical aspect of medical education, which is learning how to integrate disparate pieces of clinical information into a thoughtful patient care assessment plan.

The most important skill that should be taught is physician–patient communication in the presence of an EHR. The results of cross-sectional survey of patients and clinicians by Emran Rouf and colleagues emphasized the need for such training. The study revealed that senior staff physicians and their patients “were more comfortable incorporating the EHR into clinical encounters than were residents and their patients. Thus, EHR-specific skills may increase with physician seniority.”

EHR-specific communication skills that can be imparted to trainees include:

– adjusting the spacing between patient, physician and computer to generate a triad that enables the patient to see what the physician is doing on the computer,

– encouraging the physician to walk-through data on the screen with patients,

– spending no more than 30 seconds at a time typing into the computer,

– making frequent eye contact with the patient, and frequent assessments of the patient’s emotional status and understanding of the information being provided, and

– communicating effectively on an asynchronous basis with physicians and patients (for example, when interaction is required before the results of a test are known).

Kaiser Permanente and other providers have used videotaping with great success in their efforts to teach patient-physician communication in the presence of an EHR.

What About the Faculty?
The majority of medical school teaching faculty has received little or no training in the use of EHRs. Yet it stands to reason that until faculty become expert EHR users, they are not going to be good role models for physicians in training.

Faculty development should include introductions to several computer platforms like laptops and tablets, and to the general challenges and possibilities presented by EHRs (as covered previously). In particular, faculty should refrain from using EHRs to look-up patient information before or during clinical presentations by students and residents. This practice drains color from the time-honored interaction between teacher and student and will impede the trainee’s abilities to synthesize clinical information into a meaningful whole.

Faculty members that cannot master the new environment may find their effectiveness as teachers to be diminished in the modern era.

In addition to establishing these basic curricular requirements, it is imperative that leaders in the field of medical education begin developing a research agenda designed to determine best practices in the field.

The few studies that have so far been published on the matter have relied on surveys of medical students and residents. This isn’t a bad place to begin, but such studies can be augmented by actual trials designed to:

1) assess how EHRs impact knowledge and skills acquisition and practice behavior,
2) identify optimal physician-patient communication strategies in an EHR-enriched environment and,
3) identify teaching strategies that assure such strategies are implemented.

Thankfully, innovation has begun in this area. In the last post of this series (to be published this Friday), we introduce some of the leading thinkers and their contributions to date.

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 frequent writer for EHR Bloggers, where this post first appeared.