Despite Mounting Role in Medical Student Education, Barriers to EHR Use Remain

As more medical students gain access during clinical clerkships to electronic health records (EHRs), the educational benefits and challenges of using this technology are coming into ever-sharper focus.

"Wherever there is an EHR ... it helps me to be a more proactive about my learning," said Diana Tucci, a fourth-year medical student at the University of Pittsburgh. On inpatient rotations, she accesses the EHR each day to see what's on the schedule, what new lab information is available and what she needs to review before rounds.

By logging into his clinic's EHR, third-year medical student Tate Hinkle is able to use the system's student functions to review patient history, write notes and enter pending orders.

"It allows us to participate in the care of the patient and not just watch," said Hinkle, who attends the University of Alabama, Birmingham. "It will give us a leg up going into residency ... the learning curve won't be as steep."

At times, however, Hinkle and Tucci, along with many other medical students, lack access to hospital and practice EHRs because of budget or liability concerns, leaving students to rely on busy attending physicians and residents for lab results and other critical information.

Theo Hensley, a fourth-year medical student at East Tennessee University, Johnson City, did a six-week hospital rotation without use of the hospital's EHR. "When you don't have any kind of access at all, it really makes it difficult both to learn and take care of patients," Hensley said.

That's the primary reason the AAFP Commission on Education's Subcommittee on Resident and Student Issues (SRSI), to which Hinkle, Hensley and Tucci belong, pushed for an AAFP policy encouraging medical student access to EHRs. The policy, published in spring 2012, states: "Adequate medical student training depends on a student's ability to access relevant information available to other members of the care team, to document findings, to communicate with other providers and to reflect independent clinical reasoning."

"There were instances of students not being able to get access, and we thought that they couldn't provide care and learn without that access," said Brooke Sciuto, M.D., a former SRSI member and a third-year resident at Travis Air Force Base, Calif. "We're so reliant on it now -- even to be able to look up previous encounters. People come in, and we ask what medications they took, and they say, 'Well, it's in the computer.'"

Almost all --130 out of 134 -- medical schools accredited by the Liaison Committee on Medical Education (LCME) allow student access to EHRs, according to the 2011-12 LCME Annual Medical School Questionnaire. However, access varies widely by clinical setting, and different EHR programs offer levels of student interaction that range from read-only access to access that allows student documentation and creation of pending orders.

Student usage of EHRs was a hot topic during SRSI's Feb. 7 meeting in Kansas City, Mo., said Gary LeRoy, M.D., chair of the subcommittee. SRSI has been tasked with acting on a resolution adopted by the National Congress of Student Members that calls on the AAFP to "advocate to the Liaison Committee on Medical Education to recommend the inclusion of EMR (electronic medical record) training into current educational standards." To date, no such LCME standards exist.

According to LeRoy, who is associate dean of student affairs and admissions at Wright State University's Boonshoft School of Medicine in Dayton, Ohio, determining educational standards is difficult, mostly because the technology is rapidly evolving and maturing. However, he said, teaching students how to use an EHR is just as important as teaching students how to use a stethoscope, and the subcommittee is planning to ask the LCME to address EHRs.

EHR training -- particularly how to make notes in an EHR -- should begin as early as possible, said Alexander Chessman, M.D., professor of family medicine at the Medical University of South Carolina, Charleston.

"We don't tell students to wait to do physical exams of patients until they are interns. They start at day one," Chessman said. "Documentation is one of those essential medical skills."

But as students learn these documentation skills, it's important to ensure that they learn how to write a complete note in the EHR and do not simply become dependent on templates, Sciuto said. "Sometimes the best notes are ones that are documented in the EHR but are free text," she explained.

It's also worth noting that when students have access to EHRs, those students have unique opportunities to learn components of the patient-centered medical home.

"A number of clerkships involve some sort of quality care improvements. One must understand the population and the system of care," Chessman said. Access to patient data helps students participate in systemic changes that can improve care for a subset of patients.

Although Chessman sees more preceptors switching from paper charts to EHRs, it can be challenging for community-based practices to be able to afford granting students access to an EHR when they themselves are acting as volunteer mentors.

Many affiliated hospitals and clinics also have not invested in student modules for their EHRs, LeRoy said. When there is no "safe" avenue for students to interact with the EHR, health care organizations, citing medical-legal issues and concerns about Health Insurance Portability and Accountability Act regulations, often restrict access completely or allow read-only access to certain portions of the records.

"Hospitals have varying priorities, and giving students access to their EHR is not one of their higher priorities," LeRoy said.

The potential for Medicare fraud also is a concern, Chessman said. Physicians cannot use medical student notes for anything other than review of systems, medical history, family history and social history, he said.

Chessman has lobbied the federal Office of the National Coordinator for Health Information Technology (ONC) to mandate that a learner module be incorporated into EHR products, but no such requirement has been outlined to date.

"Some EHR systems have not been engineered to accommodate the needs of educational institutions to provide an EHR with appropriate rights and user profiles for medical students," explained Jacob Reider, M.D., chief medical officer of the ONC and a family physician. "There are currently no ONC certification criteria that require EHR vendors to create such functionality, but the need for these functions has been brought to our attention.

"Even though something may not be required explicitly today, there remains an opportunity for EHR vendors to meet these market expectations without the burden of federal regulation," Reider added. The ONC is working with the Association of American Medical Colleges to identify best practices related to EHR use by students, he said.

Jessica Johnson, M.D., a first-year resident in family medicine at Oregon Health and Science University, Portland, was a member of SRSI when the EHR policy was created and understands the concerns that hospitals and clinics have about sharing access to EHRs with medical students. However, she hopes these challenges will be overcome.

"The cons that come up are things that are worth battling over," she said, listing limited space and resources and a lack of trained faculty as additional reasons medical students may not have access to EHRs. "I think those are all worthwhile things (to take on) if we're trying to train good doctors. I don't see any of the cons as insurmountable."