Recognizing that health information technology is the wave of the future -- if not the present -- family medicine educators say that medical students should be exposed to all aspects of health IT, including electronic health records, or EHRs, as early as possible in their academic careers. That way, these educators contend, students will be well prepared when they encounter EHRs in their residencies and future clinical practices -- especially if they will be practicing primary care.
Medical students from The Commonwealth Medical College in Northeastern Pennsylvania gather around a computer as part of their introduction to health information technology.
Presently, there are no standardized ways for medical schools to present this technology to students. As a result, wide variation exists in how students learn about EHRs; enter their own medical notes; and determine how the computerized data can be used to improve patient care, advance patient safety, and help the finances of a practice.
In fact, according to a study published in(journals.lww.com) Academic Medicine in 2009, slightly less than one-half of the academic medical centers that reported using an EHR in ambulatory settings had policies that required or allowed students to document in the EHR; the remainder flatly prohibited students from doing so.
Such inconsistent policies seem to reflect divisiveness among educators regarding the appropriate use of EHRs by students, said the study authors, and may be due to a number of factors, such as
- lack of faculty experience in the use of EHRs;
- lack of comfort with EHR use, even if experienced;
- lack of guidance regarding the role of EHRs in student education; and
- lack of data on how to best integrate EHRs into medical education.
Additional challenges study participants cited included cost, access and variability among EHRs used at different clinical sites.
"Despite the challenges and barriers, students should practice with (EHRs); if they do not learn to use them appropriately, or if they learn to use them inappropriately, they will be poorly equipped after their training to practice medicine in settings in which (EHRs) are becoming more commonplace," the study said.
Medical student members of the AAFP Commission on Education say they support more standardized training and access to electronic health records, or EHRs, as a way to enhance the primary care patients receive.
"I believe the EHR is crucial for improvements to patient care, but we still have a long way to go in broadly implementing ideal systems," said Jessica Johnson, a fourth-year student at the University of Connecticut School of Medicine in Farmington.
According to Johnson, medical students' use of EHRs varies greatly among clinical training sites. Students often can't write notes, she explained, although more advanced records allow students to enter notes that can be edited and signed by residents and physicians.
Johnson said she appreciates EHRs' ability to allow quick access to important information, display trends clearly and serve as a tool for patient engagement and education. When properly used, EHRs improve the efficiency of the visit and allow more face-to-face time with each patient, she said.
Courtney Huhn, a fourth-year student at the University of Kansas School of Medicine in Kansas City, said students usually have access to EHRs in area family medicine practices, although a few practices haven't yet converted to an EHR system or they restrict student access.
Huhn cited a number of tasks that can be enhanced by using an EHR. Writing patient notes, for example, is more efficient and legible and, therefore, possibly more complete, she said.
"I feel electronic prescriptions and orders help to avoid errors with handwriting and lack of attention," Huhn added. "I feel having access to a patient's complete medical record is helpful in communicating with them, and it helps the patient feel that you have invested time into learning about their condition to date."
Johnson and Huhn both noted that EHR training should be more standardized and have carefully considered learning objectives.
Others, apparently, agree. In fact, at the interim meeting of the AMA House of Delegates in November 2010, delegates adopted a resolution -- introduced by the medical student section -- that called on the AMA to
- encourage teaching hospitals and clinical training sites to permit medical student access to EHRs,
- study current barriers to student access, and
- help facilitate that access.
Many family medicine educators agree that educating students about EHRs and other health information technology needs to change.
"We should be training people and consciously making decisions about the curriculum -- the good, the bad and the ugly -- and developing a thoughtful curriculum about caring for patients in a complex health care environment," said family physician Thomas Agresta, M.D., M.B.I.
Agresta is the former director of medical education in the department of family medicine at the University of Connecticut, or UConn, School of Medicine in Farmington. He now is associate professor and director of medical informatics in the school's family medicine department and co-director of biomedical informatics at the university's Connecticut Institute for Clinical and Translational Science.
UConn medical students start learning about health IT right from the beginning of their training, said Agresta. For example, they are required to use their cell phones, laptop computers and/or personal digital assistants to retrieve diagnostic and other information when they visit private practices and community health centers in the opening weeks of their first year, Agresta said.
At the UConn-St. Francis Hospital family medicine residency's clinical practice site in Hartford, students can log in to the practice's EHR, view patient histories and medications, and write portions of the medical note under the supervision of faculty physicians. According to Agresta, some students actually write better notes than their faculty supervisors because they gather more information for medical and social histories and spend more time with patients.
In other clinical settings, however, exposure to EHR training is a little dodgier, said Agresta.
At some small practices that students rotate through during their clinical years, there might be "work-arounds," in which students receive the password of a resident, faculty member or private practitioner so they can use the EHR. At some sites, though, students may not get any access to the computer system.
"Because the EHR is going to smaller and smaller doctors' offices, the challenges are surfacing earlier and they are more widespread and complex," Agresta said. That's why it's important, he added, for medical schools to develop a common training methodology
The Commonwealth Medical College, or TCMC, in Scranton, Pa., also is in the forefront of integrating education and training in EHRs and other health IT throughout its four-year program.
TCMC, which opened its doors in 2009, is the first U.S. medical school to adopt a four-year curriculum in medical informatics, said Linda Hogan, Ph.D., professor of medicine and assistant dean for medical informatics at the school.
"Most medical schools do not have any teaching in medical informatics. We said ours will be longitudinal, and we'll introduce students to it in the first year. They're actually introduced to the EHR in the first weeks of medical school," Hogan said.
According to Hogan, among key features of TCMC's integrated curriculum are the following:
- In their first year, students discuss many tools that have the potential to transform clinical practice, including the EHR and e-prescribing. They are challenged to ask the right questions to develop a value proposition for each: Is it innovative? Does it improve the patient care outcome? Does it improve the bottom line?
- Because students are out in the community beginning in their first year, they receive early exposure to the current EHR climate. The Scranton campus and two other regional campuses in Williamsport and Wilkes-Barre are located in areas in which physician practices have different levels of EHR implementation and use a total of 40 different EHRs, with no two regions sharing the same predominant EHR.
- Just before their third year, students are introduced to an EHR simulator that allows them to suggest and enter medications, look at laboratory results and X-rays, make patient care decisions, and receive feedback -- all with no harm to anyone. When they later rotate through their clinical training sites, they learn more about the many different types of EHRs.
- In their fourth year, students can take a medical informatics elective to learn about higher-level health IT applications, such as telemedicine and robotics.
"Since we have a community-based model of care, serving 16 counties throughout northeastern and north-central Pennsylvania, the EHR is important to use, but we don't substitute bells and whistles for good patient care," Hogan said.
Hogan, who is a commissioner with the nonprofit Certification Commission for Health Information Technology, said she thinks the many functions and uses of EHRs actually can encourage students to practice in primary care specialties.
"If students have been reluctant to go into primary care because of the volume of patient data, I think an EHR can instill confidence through the tracking and aggregation of clinically relevant information," Hogan said, explaining that with an EHR, individually tailored treatments can be established and monitored for complex patients, with integrated lab reports, drug alerts and other patient data in one place.
The Liaison Committee on Medical Education, or LCME, the accrediting authority for medical education programs leading to the M.D. degree in U.S. and Canadian medical schools, is working to incorporate language about electronic health records, or EHRs, into its standards.
"This is an important topic," said Dan Hunt, M.D., M.B.A., senior director for accreditation services and co-secretary of the LCME. Although modifying the standards is a lengthy process, he noted, the committee has made a start by working with David Blumenthal, M.D., national coordinator of health information technology, to include items related to EHR training into questions the LCME already asks schools regarding their use of information resources.
Two questions may be added, said Hunt:
- Do students have an opportunity to learn to use an EHR?
- Where do they learn about the use of EHRs for quality improvements?
The latter point is especially relevant for students, Hunt said. "They need to see the use of (the EHR) tool for their future practice."
The Florida State University, or FSU, College of Medicine in Tallahassee is primary care-focused and community-based, and it also has an integrated medical informatics curriculum. According to Nancy Clark, M.Ed., the college's director of medical informatics education, highlights include:
- In the clinical skills and simulation center, paper records are being replaced with an EHR so first- and second-year students can learn how to use it during simulated patient and smart mannequin cases.
- During their third year, students spend one-half day a week in a primary care physician's office at one of 120 sites, where they use the EHR to manage a panel of patients with a chronic disease. In a special activity, students build the records of six patients in an EHR that's loaded onto their own laptops and that runs offline. The students describe patients' problems and medications, enter laboratory results and vital signs, and use chronic disease flow sheets and health maintenance reminder systems. They also write encounter notes for each visit.
- Fourth-year students complete a one-month clerkship in geriatrics, during which they follow patients across multiple sites of care -- for example, from the hospital to a rehabilitation center or to home. Using an EHR customized with geriatric templates, students can export and e-mail their charts to their clerkship director for review.
Still, say these educators, their institutions are grappling with how to introduce EHRs and other technical concepts earlier and in a more structured way.
"It's critical to teach our medical students that this is where we're headed and this is what it will be like to be a primary care physician in the future," Agresta said. "In many ways, it will make primary care a better type of job -- more enjoyable, more manageable. Right now, we're at the 'perfect storm' stage."