Electronic Health Records In the Classroom?

Outside a patient’s room in the cardiac intensive care unit (CICU), a senior doctor, a nurse, and several residents in various stages of wakefulness cluster for morning rounds. Each resident mans a computer-on-wheels (once called a C.O.W., the acronym was formally abandoned at MGH, legend has it, after a patient thought it was directed at her and took offense).

One of the residents reads off laboratory test results from the patient’s electronic record. Another resident uses her mouse to toggle through the patient’s medications and share them with the group. The nurse reads aloud blood pressures and heart rates from a handwritten hourly log. As scribe for the day, I type these numbers to update a progress note that we’ll later print and place in the patient’s paper chart. Someday, these records will be completely digital, finally matching the wonderland of medical technology that is the CICU.

As the Electronic Health Record (EHR) slowly but inexorably assumes its rightful place in modern health care, obviating the ridiculous cultural norm of physicians with illegible handwriting, reducing medical errors, and making care (usually) more efficient, educators are asking the question: are we teaching this in medical school?

Not consistently, it turns out.

Anywhere from 34 to 57% of doctors’ offices and 19% of hospitals now use an EHR. While they are more often found in academic hospitals and clinics (where training occurs) than in other American health care settings, a recent survey finds that this tool doesn’t always trickle down to medical students. Only 64% of medical schools let their students use the EHR, and only about a third of those let students enter patient orders or write notes within the record, according to the survey of 338 educators nationwide that appeared in last month’s Teaching and Learning in Medicine.
Respondents blamed lack of computers, faculty who are naïve to EHRs themselves, and limited ability to oversee students’ use (the last one, to be fair, isn’t unique to electronic records). The researchers, part of the Alliance for Clinical Education (ACE), used these findings to suggest that medical schools have students practice entering orders for real or simulated patients and evaluate students on their use of the EHR.

It’s unfortunate that some medical students don’t have access to an EHR since trainees learn best by involving ourselves in every aspect of care for our patients. As a medical student, I felt more useful and took more responsibility for my patients when I could help my team by looking up a test result or posting a note (co-signed by a real doctor). Just as importantly, EHR access gives medical students the chance to grapple with how electronic records are changing the practice of medicine. But these lessons don’t come from a session in a computer lab – they require real experience.

After all, the question is not whether medical trainees will be able to navigate an EHR. Raised in the era of laptops and iPhones, we aren’t afraid of adopting new information technology.  Instead, we get frustrated by the inefficiencies and the clunky features of health IT that fail to meet the standards set by the non-medical, more user-friendly technologies in our lives (for example, and I’m not joking: auto-save).

By the same token, medical schools shouldn’t use precious classroom time to teach EHR skills, especially when systems still vary so widely from hospital to hospital. My residency class started out our intern year with handwritten progress notes and switched to computerized notes halfway through. It was a well-designed system, and we got the hang of it in a matter of days.

There are more critical, and more interesting, issues for medical educators to address:

How will doctors learn to incorporate EHR without corroding the patient-doctor relationship? We are a generation un-phased by Blackberries at the dinner table, and my co-residents and I will often use a C.O.W. to take notes as we interview a newly hospitalized patient. How does this affect the stories we are able to elicit from our patients and their ability to trust us?

How will doctors resist the temptation of copy-and-paste medicine? It’s common practice for doctors to lift entire paragraphs from prior patient documents. In the medical world, this does not get you suspended from Time or The New Yorker, but it does lead to the well-documented hazards of precluding an open mind in clinical reasoning and propagating misinformation. In the ACE survey, 24% of respondents noted issues with unattributed copy-and-pastes, and the transition to fully computerized records will only make this easier.

Finally, how will doctors organize and make sense of the over-abundance of information now offered by EHR? More on this in an upcoming post.

Ishani Ganguli, MD, is a journalist and a second-year resident physician in internal medicine/primary care at Massachusetts General Hospital. She blogs regularly at  Short White Coat.

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  1. While not a medical school, my Medical Admin Specialist (secretary) students are learning about the EHR and getting practice entering both demographic and clinical data then evaluating the accuracy and validity of the automatic coding.