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REGULAR | December 01, 2006

Electronic Medical Records and Their Impact on Resident and Medical Student Education

Craig R. Keenan; Hien H. Nguyen; Malathi Srinivasan

Academic Psychiatry 2006;30:522-527.

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Received February 2, 2006; revised May 4, 2006; accepted June 15, 2006. Drs. Keenan, Ngyuen, and Srinivasan are affiliated with the University of California, Davis, Sacramento, California. Address correspondence to Dr. Keenan, 2315 Stockton Boulevard, Sacramento, CA 95817; craig.keenan@ucdmc.ucdavis.edu (e-mail).

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Abstract

Objective: Electronic medical records (EMRs) are becoming prevalent and integral tools for residents and medical students. EMRs can integrate point-of-service information delivery within the context of patient care. Though it may be an educational tool, little is known about how EMR technology is currently used for medical learners. Method: The authors reviewed the available published literature about the impact of EMRs on learners, including learners’ attitudes about EMRs, educational uses of EMRs, and the potential effects of EMRs on learners’ daily work. Results: Research on EMRs for education is in its infancy. The authors found fewer than 50 articles with evidence on their use in medical education. The applications to education included point-of-care knowledge delivery, computerized clinical decision support systems, profiling of learner experiences, and daily workflow management. The evidence was mainly derived from single institution studies and occasionally across disciplines. Conclusions: EMRs have great potential as an educational tool, but thus far, strong data to support their use for this are lacking. As the usage of EMRs rises, educators must continue to study how best to use technology as an educational tool and as a tool to improve the daily work of residents and medical students.

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Electronic medical records have long been available and are becoming more prevalent in health care in the United States. Recently, the Institute of Medicine strongly urged electronic medical record (EMR) use to improve the quality of care and patient safety (¹). The definition of an EMR varies, but a complete EMR includes clinical documentation (notes), patient data (e.g., labs, radiology results, other test results), and computerized order entry (for tests and medications). Other added features include messaging between providers and staff, decision support systems, and patient access to information. Recent surveys find that 16% of hospitals have computerized order entry (COE), 14.1% of medical group practices use EMRs, and 32.5% of groups are planning to roll out EMRs in the next 2 years (², ³). Academic medical centers and the VA Healthcare system, where much of the nation’s medical education occurs, have been leaders in the use of EMRs. Thus, EMR use will certainly continue to increase and will be an important tool in medical student and resident training.

This article reviews available evidence regarding the use of EMRs as educational tools in all fields of medicine and the potential impact of EMRs on medical education. We were unable to find any articles specifically related to psychiatric education. Thus, we review general attitudes about EMR use, educational uses of the EMR, and the impact of the EMR on the daily work of residents and medical students across all disciplines.

Resident and Student Attitudes and Acceptance of the EMR

Abstract | Resident and Student Attitudes and Acceptance of the EMR | Educational Uses of EMR | Conclusions | References

There have been significant changes in computer technology and societal attitudes toward technology since EMRs were first introduced three decades ago. Unlike the first EMR users from the 1970s, most current students and residents have had extensive exposure to computers. And as our trainees’ familiarity with computers has increased, EMRs have evolved. For example, the Internet, which allows remote access to EMR information systems, has dramatically changed physicians’ workflow (e.g., they can now work from home or from a remote site). As each user’s experience of an EMR varies in response to the specific EMR program they are using, learner attitudes also vary. For this reason, we concentrate on four recent articles, published since 1999, that address medical learner attitudes about EMRs.

Two large studies of residents using EMRs were published in 1999 and 2001. One study surveyed 216 family practice residents at 24 residency programs with an EMR in the ambulatory clinic, while the other surveyed 330 house staff and faculty 1 year after rolling out an EMR at their institution (⁴, ⁵). The family practice residents felt ambivalence toward the EMR. They noted improvements, saying that the EMR improved access to records, eased data review, increased documentation accuracy and legibility, eased their ability to see other physicians’ patients, improved problem lists and medication lists, improved remote access, and improved health maintenance consistency. But they also felt that the EMR decreased time with patients, increased workloads in the clinic, and detracted from physician-patient interactions.

The house staff from the second study felt that the EMR increased availability of information, the ability to communicate, legibility, and completeness of information while easing data review and making their workflow more efficient. Fifty-two percent felt that the EMR saved time documenting details of care and prevented medical errors. Barriers to their use of the EMR included slow speed and lack of computers. Forty-six percent of the family practice residents and 88% of the mixed house staff from the second study preferred the EMR over paper records. Interestingly, residents’ technological background did not affect their perception of the EMR; perceived adequacy of training was associated with perceived EMR benefits. A third, smaller survey from 2002 of 85 pediatrics and internal medicine residents at Yale found that 91% were "satisfied" with the EMR, 99% felt that the benefits of EMR outweighed any inconveniences, and 91% felt that the use of an EMR can improve care delivery (⁶). Thus, although there were several areas of complaint, the majority of residents surveyed preferred EMRs and felt they had significant benefits for patient care.

Medical students are also affected by the use of EMRs. A study of 137 Johns Hopkins students on their internal medicine clerkship found that those who worked at hospitals with a computerized order entry (COE) system placed significantly fewer orders than those with paper-based orders (⁷). Residents did not want the students to enter orders, which may have affected their education. Health systems must work to ensure that EMRs do not diminish the educational component of medical student clinical experiences.

Educational Uses of EMR

Abstract | Resident and Student Attitudes and Acceptance of the EMR | Educational Uses of EMR | Conclusions | References

Point of Care Education

A key principle of adult education is that new knowledge is best assimilated when learned in context. In medicine, having access to information at the point of patient contact provides just this opportunity. The EMR can provide knowledge to help physicians as they write orders and document the care plan. This knowledge can be provided through links that the learner must actively "pull" information from or can be automatically "pushed" to the learner in the form of pop-up screens, alerts, or recommendations.

Researchers at the University of Calgary took 45 medical students starting their surgery clerkship and non-randomly split them between a hospital with COE plus online educational content and a hospital with traditional paper-based orders (⁸). Educational information and recommended orders for common surgical concepts and clinical problems were linked to 50 order sets that the students used to write orders at the COE hospital. The students clicked on a hyperlink to pull up the educational materials. Despite frequent accessing of the online educational materials, there was no difference between the two groups of students when compared by pre- and post-rotation examinations that assessed the basic knowledge covered in the educational materials.

Electronic order sets and templated care notes used in EMRs for common conditions have also been touted as potential educational tools for residents and students. Order sets put usual treatment orders in context with the diagnosis, reminding the learner of important concepts. Templates can prompt learners to ask pertinent historical questions and perform key portions of the physical exam. Internal medicine and pediatric residents surveyed felt that templates taught about recommended preventive practices, and 81% felt that they reminded them about anticipatory guidance (⁶). Clearly, more study is required to determine whether templates and order sets can be used to teach medicine.

Using COE may teach medical students how to write orders. Ninety-nine medical students on an emergency medicine clerkship who trained at hospitals with COE or with paper-based orders were tested on their order-writing skills using pre- and post-rotation tests (⁹). Students using COE improved compared to those with paper-based orders. This study may have significant bias, as factors other than the lack of COE at the paper-based hospitals may have limited their order-writing skills.

Educators at the University of Minnesota created a fully simulated EMR where students follow virtual patients in a primary care clinic on a weekly basis over a prolonged time period (¹⁰). The virtual patients are used to illustrate and supplement information taught in the courses and clerkships and to promote early integration of the basic science and clinical concepts. No information has been published on the educational impact of their program. Another small report from the University of Texas used simulated patients in an EMR for teaching medical students clinical problem solving, as opposed to other methods of simulation (e.g., paper or actors) (¹¹). Student performance with EMR simulation was identical to the traditional simulation. Both of these programs show great promise for more context-specific education, and may help prepare students for future work using information technology in patient care.

Computerized Clinical Decision Support Systems

A computerized clinical decision support system (CDSS) is any system that adds information to assist in a clinician’s decision-making process. A clinician reviews the information provided by the system and then accepts or rejects the advice given by the computer. Common examples of CDSS are illustrated in Appendix 1. Information can be "pushed" to the clinician, or the clinician may have to actively "pull" information from links or menus. Once the information is available, it can be acted on immediately (e.g., you can order the test from that screen) or the clinician may take additional steps (e.g., open order entry screen, select test, order and sign).

A recent systematic review evaluated 100 trials of CDSS (¹²). It found that CDSS improved practitioner performance in 64% of the studies, including 40% of diagnostic systems, 76% of reminder systems, 62% of disease management systems, and 66% of drug-dosing or prescribing systems. Systems that were integrated into the practitioner workflow and which automatically prompted users (i.e., pushed information to the user) did better than systems that required the clinician to access the CDSS (i.e., clinician must pull information).

The integration of CDSSs into the workflow of students and residents is an intriguing way to provide "learning in context." Other than that described above, the use of CDSSs integrated into EMRs has not been studied as an educational tool for students and residents. But CDSSs have improved depression treatment performance when used by practicing physicians for psychiatric conditions, so they do show promise for younger learners (¹³). A few studies have looked at CDSSs as stand-alone programs or on personal digital assistants (PDAs), but these are beyond the scope of this article.

When a clinician must accept or reject the recommendations of the computer, the potential for error exists if the wrong choice is made. This may be more likely in younger, less experienced practitioners. CDSSs and COE could also potentially reduce learning, as the learners do not need to think through each order or decision. Although these potential negative effects have not been thoroughly studied, one study found a negative impact of CDSS use on resident performance specific to the task of reading electrocardiograms (ECGs) (¹⁴). Most ECG machines print a computer interpretation at the top of the ECG, which physicians can use to assist in their interpretation. But computer interpretation is not always correct. This study found that internal medicine residents’ performance significantly improved when the computer interpretation was correct, as opposed to the residends reading the ECG without any computer interpretation. But residents’ performance trended downward compared with their own unaided reading when the computer interpretation was incorrect—the residents followed the incorrect advice of the computer.

Clearly, more research must be done to outline the potential of CDSS for educating students and residents as well as explore the potential downsides. Creative ways to deliver educational content in the context of providing patient care may prove to be very powerful tools.

Profiling Clinical Experiences

Profiling learners’ clinical experiences to verify that they meet learning goals is now commonplace. Using PDAs or stand-alone programs for logging procedures is time and resource intensive, and may not be reliable (¹⁵). An EMR is a large database that can automate profiling of clinical experiences, which may improve the reliability and reduce the time required for data entry.

One internal medicine residency used their ambulatory EMR to profile the clinical experiences of eight primary care residents over a 1-year period (¹⁶). The EMR database was searched for information on gender, age, and visit diagnoses for all of the provider’s patient visits for the year. Individual residents’ profiles were compared with data for all residents. This could easily be done for psychiatry residents’ clinical encounters as well. The researchers found significant variations in the residents’ experiences for numbers and types of clinical diagnoses, age, and gender of patients. Another group used the EMR to provide frequent reports on student experiences during a family practice clerkship (¹⁷). Such data can be used to monitor residents and students in a timely manner for adequate exposure to specific conditions. Clerkship and residency directors can use profiles to identify educational gaps and make targeted curricular changes for rotations or for individual learners. In addition, using an EMR to profile residents’ procedures is a natural use of its database capabilities.

Research, Quality Improvement Education, and Core Competencies

EMR databases can also be mined for quality improvement measures and can make teaching quality improvement an easier task. As an example, in our own internal medicine residency clinic, we regularly create a report of each resident’s diabetic patients with the values for quality measures (e.g., last hemoglobin A1C, last LDL cholesterol, and last urine microalbumin). The same could be done with patients on atypical antipsychotics with regard to metabolic syndrome. Residents are taught how to use these reports to improve the care of their diabetic patients. The ease of the data access, compared with paper chart reviews, makes it feasible to do this on a regular basis. Some training programs have residents routinely develop and implement their own quality improvement programs, and an EMR makes this a much simpler proposition. A logical extension is that the EMR database provides ripe opportunities for residents to develop and perform their own clinical research projects (¹⁸).

The ease of access to clinical information in the EMR also has promise in helping medical schools and residency programs meet the needs of measuring the Accreditation Council for Graduate Medical Education (ACGME) and Association of American Medical Colleges (AAMC) Core Competencies. As mentioned above, profiling experiences and logging procedures can assist in reporting of outcomes for the Patient Care Competency. Residents’ performance on quality improvement projects, with the EMR as a tool, can be used as outcomes for the Practice-Based Learning and Improvement and Systems-Based Practice Competencies. An example is our own residency clinic’s quality improvement project to increase problem list utilization. We went from 19% utilization of a paper-based problem list to 81% use of an electronic problem list (unpublished data). Individual residents’ performance was included in their training file as an outcome measure of these competencies.

Impact on Daily Work of Residents and Students

A learner’s use of an EMR can significantly change how he or she spends time. The impact is not well studied, particularly in medical students. Here we will review several areas where data exist.

Resident sign-out policies are a universal feature of residency training programs. Cross-coverage by residents, resulting in poor communication or lack of knowledge about the patients, is associated with preventable adverse events (¹⁹). One study showed that implementing a computerized sign-out system eliminated this association of cross-coverage with preventable adverse events (²⁰).

One academic center looked more closely at the impact of such a sign-out system on resident work. It created a Web-based computerized rounding and sign-out system for their internal medicine and general surgery residents at two hospitals (²¹, ²²). The system interfaces with hospital electronic records to download vital signs and test results to augment the problem lists, medication lists, and to-do lists that residents enter themselves. The system creates reports for sign-outs, daily rounding, and templated progress notes. In a prospective, randomized crossover study, the majority of residents felt that the system significantly improved sign-out quality and continuity of care (²¹). The program reduced the number of patients missed on resident rounds by half and shortened rounds by 1.5 minutes per patient. The authors estimated that residents saved 200 hours on rounds that took place over 103 days of the study. Residents felt that the tool saved time as well, with 82% reporting they finished their work sooner, saving an average of 30 to 45 minutes per day. Psychiatry residents could also use such a system to facilitate coverage and transfer of care of patients on psychiatry consultation or inpatient rotations.

Another study of computerized order entry and an electronic medication administration record (MAR) implementation (²³) found improvements in the following areas that could affect residents’ daily work and patient care: 1) medication turn-around times fell from 5:28 hours to 1:51 hours; 2) radiology procedure completion times fell from 7:37 hours to 4:21 hours; and 3) lab results reporting times fell from 31:3 minutes to 23:4 minutes. At the same time, transcribing errors for orders were eliminated and length of stay decreased. The COE and MAR improved the timeliness of several areas of patient care, allowing for more rapid completion of common tasks and an increase in speed for physician work time.

At our facility, the transition to a digital, computerized radiology system from printed films showed dramatic effects on resident physician workflow (M. Srinivasan, personal communication). Using real-time reporting, the average time residents spent searching for an X-ray image fell from 16 minutes to 1.9 minutes with the digital system. A potential educational downside was that residents looked at the films with the radiologists less frequently.

Other components of EMRs are likely to have positive effects on resident satisfaction and workflow but have not been specifically studied. Examples include: 1) online vital signs, medication administration records, consultation reports, and test results to reduce time searching for the paper versions of this information; 2) remote access to patient information from home or at other facilities to allow residents to care for their patients without coming into the hospital or clinic; 3) rounding, transfer, and discharge "navigators" in EMRs to pull key information needed for these intensive and frequent functions to increase residents’ thoroughness and efficiency; 4) patient lists that can be shared with all members of the treating team, whether inpatient or outpatient, to facilitate care and reduce recopying of information; 5) CDSSs may decrease the time residents need to find information to make the next decision.

One barrier to EMR implementation is concern about the time necessary to enter data and orders. Few studies actually report data involved with EMRs. One study of COE in the ambulatory primary care setting found that non-house staff physicians spent 0.43 minutes more per patient when using COE (²⁴). Studies in the inpatient setting have found that COE increases interns’ time placing orders from 2.1% of their time to 9.0%. But with other downstream savings in time created by the data entry, the overall effect was an increase from 2.1% to 5.0% of their time (²⁵).

Clearly, further research must be performed to assess the impact of order sets, templated notes, CDSSs, and other point of care information within the EMR on learners’ education and day-to-day activities.

Conclusions

Abstract | Resident and Student Attitudes and Acceptance of the EMR | Educational Uses of EMR | Conclusions | References

EMRs are powerful patient care tools that are gaining acceptance, and will be more prevalent in medicine, and hence, medical education. There are very few reports on psychiatric utilization of EMRs, EMR use for psychiatric education, or the use of EMRs to improve psychiatric care, and much research is needed to determine the potential impact of EMRs on all of these areas. The ability of EMRs to deliver information in context offers great potential as an educational tool, but thus far, strong data to support this are lacking. CDSSs improve providers’ performance in patient care, but it is not clear if they affect learning. The EMR has promise for creating detailed profiles of resident and student patient experiences, which can be used to individually tailor a curriculum to their needs over time. EMRs can be used to teach about quality improvement and can be used for resident research projects. Educators can use EMRs to document outcomes in the Core Competencies of the AAMC and ACGME. Lastly, EMRs significantly alter the daily work of residents. Further research is needed to clarify the impact of EMRs on education and the optimal methods of using them as a teaching tool.

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APPENDIX 1. Common Computerized Clinical Decision Support Systems

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Abstract | Resident and Student Attitudes and Acceptance of the EMR | Educational Uses of EMR | Conclusions | References

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