Like most other segments of the health care community, family medicine residencies are reading the writing on the wall when it comes to implementing health information technology. Almost all of the nation's 451 family medicine residencies use an electronic health record, or EHR, system and are preparing their residents to be savvy users of EHRs, registries and other health IT tools.
As a result, today's family medicine residents are likely to graduate with advanced health IT skills and seek practices with high-functioning EHRs. And that, according to William Warning II, M.D., program director of the Crozer-Keystone Family Medicine Residency in Springfield, Pa., "makes them sought after because the health systems want people to know the EHR. They don't want them to go through all the training."
When the Crozer-Keystone residency installed its EHR in 2005, faculty members spent a lot of time teaching the basics to residents. Now the nuts and bolts are at a minimum, and residents learn how to prepare reports on clinical outcomes and solve practice improvement problems.
"The new generation is pretty savvy about electronics," Warning said. "We have to spend more time on our faculty than on our residents."
The residency piloted the EHR system throughout the Crozer-Keystone Health System, which includes five hospitals. First-year residents throughout the system complete an orientation together, learning how to order, sign off on charts and use the EHR templates.
The residents then move on to a rotation in which they learn about practice management topics and how to use the EHR to complete related tasks. They also embark on quality assurance or practice evaluation projects as part of fulfilling Accreditation Council on Graduate Medical Education competency requirements.
"We couldn't do it without the EHR," said Warning, noting that Crozer-Keystone has achieved recognition from the National Committee for Quality Assurance, or NCQA, as a Level 3 patient-centered medical home. "You have to run reports and look at data. Before, we would just pull charts and thumb through them. Now you can do it in the back room and look at the data and look at metrics. It's an essential tool for any quality assurance, for critically looking at your practice and for patient safety."
The third year of residency is devoted to higher-level problem-solving with the EHR for patient care and practice management.
"'How do you get through 25 patients in a day?' 'How do you handle this data quickly?'" are just some of the questions residents are faced with at this point, said Warning. "For a lot of residents, you can do all the orientation you want, but when they start using the EHR, they come up with a lot more questions."
The residents learn some of the key ways the EHR can improve patient care, including its ability to build a registry of patients with diabetes, alert clinicians about patients' allergies to medications and immediately record tests.
Second-year residents Jason DelCollo, D.O., and Christina Hector, D.O., standing, second and third from left, at the Crozer-Keystone Family Medicine Residency receive "hands-on" training in EHRs. Also pictured are faculty and medical assistant staff members in the Crozer-Keystone Center for Family Health in Springfield, Pa.
Nathan Holmes, M.D., chief resident at the Crozer-Keystone residency, said he particularly likes the EHR features that allow physicians to address missing immunizations and tests.
For example, if a 55-year-old patient is seeking acute treatment for knee pain, Holmes said he can click on a button of the EHR and it will alert him that the patient hasn't had an annual flu shot or scheduled a colonoscopy.
Another key feature is the EHR's ability to facilitate e-prescribing.
"It's fantastic," Warning said. "That's a huge thing for the patient and a safety issue. It's typed and not written. It forces you to get the right drug. That's one of the things that really helps us."
Hendersonville Family Medicine Residency at the Hendersonville Family Health Center in Hendersonville, N.C., is another program that has a well-integrated EHR system. According to FP Natascha Lautenschlaeger, M.D., M.S.P.H., medical director of the family health center, the center's EHR functions as a teaching, practice enhancement and patient care tool.
Faculty and residents use the EHR to e-mail patients, schedule appointments, receive laboratory results, prescribe medications, check flow sheets on blood pressure or hemoglobin A1c levels, run reports on overdue orders, and submit copies of referrals.
The EHR also has been customized with a geriatrics template that includes the recent "Welcome to Medicare" physical. For patients with diabetes, a special template with reminders about clinical issues that should be addressed periodically in these patients -- such as A1c levels, lipids, blood pressure, and eye and foot exams -- has been linked to the EHR's regular visit template.
In addition, the EHR can run disease-specific registries and display patient panels by age, gender and, most recently, diagnosis. Hendersonville also has achieved recognition from the NCQA as a Level 3 patient-centered medical home.
Justin Price, M.D., the program's chief resident, said the residency's EHR is key to managing patients' chronic diseases. Residents can look at data for their patients with diabetes, go through indicators of disease management and make a plan for each patient.
"It improves care by improving accessibility to historical information and facilitating discussions among providers," said Price.
And now that he's worked with an EHR and has seen the advantages it has to offer, Price isn't willing to go back to paper records. "I am definitely pro-electronic and would prefer to be in a location that's electronic. I feel you're much more likely to let issues fall through the cracks when you're relying on paper," he said.
Third-year Hendersonville resident Daniel Yoder, M.D., agrees.
The Accreditation Council on Graduate Medical Education, or ACGME, currently counts knowledge about electronic health records, or EHRs, as falling under its systems-based practice competency area, although each residency program is allowed to decide what skills it will teach.
The ACGME has launched a "milestone" development project, however, that aims to describe specific performance levels residents must demonstrate in each of the six general competency domains, including systems-based practice. Milestone development already is under way in eight specialties and will begin in family medicine in May.
To date, EHR proficiency has not been included as a milestone, said the ACGME, but an expert panel created as part of the milestone development project now will consider doing so.
"There have been countless times that I have been able to avoid ordering tests for my patients because I am easily able to access data about the patient in front of me," he said.
"Today I saw a child for a well-visit and was easily able to go through preventive issues with the mother, order vaccines and print handouts, all while staying in the room and continuing to observe the infant and talk with the mother."
Lautenschlaeger said two features of the EHR that both she and patients especially like are its ability to e-mail a prescription immediately and the after-visit summaries it can produce.
"You click on a button, print out and write instructions for the patient," she said. "Patients love seeing their vital signs. There's a clear list of their medications. If their vital signs are great, I draw a smiley face. It's instant feedback, in a user-friendly way."
Moreover, the EHR is particularly important for rural family physicians, said Lautenschlaeger. "It's all about having at your fingertips all the information about your patients. If you're in a rural area, there might not be a nearby hospital. If you're the only doctor in a small town, you want to know all the information about your patients."
That's good news for Yoder, who said he plans to set up a practice in a rural area of Tennessee that implemented an EHR just in the last year.
According to program director Michael Tuggy, M.D., residents at the Swedish Family Medicine Residency in Seattle are introduced to the residency program's EHR system during a two-day orientation, and, within just a couple of weeks, are comfortable with the core functions and use them every day.
Data from the EHR related to patient care, quality improvement and care management are discussed in meetings with residents, attending physicians and other members of the care team, said Tuggy.
"With that information, we are able to intelligently decide which patient needs more attention or whether providers can do better with their care," he said.
Tuggy added that the residency is diving into using the EHR's communications features, including e-mail and a patient portal, and is implementing the appointment system. The program also is beginning to use the imaging features of the EHR, including viewing X-rays and importing images that then are entered into a patient's record, as well as its ability to record a patient's waiting time to see a provider or receive an e-mail response
Third-year resident Kendra Wiggins, M.D., said the features she especially likes about the Swedish program's EHR include being able to share information among providers, update health care maintenance notes, run reports on her patient panel and e-mail patients.
"I am sure that I spend more time writing notes and probably document more than I would with a paper note, and it is legible," Wiggins said, explaining that paper charts frequently are difficult to decipher.
And, after just returning from an international rotation in Kenya, Wiggins added, she found out how much she relies on the EHR for certain data, such as medication doses.