EMR Benefits: Medical education

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Medical Education

While clinical and operational benefits of EMRs are obvious, their effect on medical education and trainees are not well documented. The few studies that have analyzed such effects have shown that there are advantages inherent in EMRs that can be leveraged and disadvantages in the current EMRs to education that need to be addressed in the future [22]. Implementation of EMRs in academic environments can benefit education of trainees by:

  1. Increased accessibility to relevant and up-to-date literature for diagnosis and management plans via clinical decision support (CDS) systems within the EMR
  2. Training the students to follow accepted clinical guidelines (best practices) using CDS
  3. Monitoring clinical experience of trainees more efficiently in real time to optimize workflow for trainees and training programs. Use of EMRs to track patient care milestones achieved by trainees will identify that can be then addressed more efficiently in a prospective manner.
  4. EMRs have been used to help physicians improve the quality of their clinical skills. An example of this has been in Radiology. Radiologists do not routinely receive information on clinical outcomes of patients for whom they provide radio-diagnoses. Alkasab et.al created an automated outcome tracking system for radiologists which allows them to review clinical outcomes of the patients whose images they reported on. Such a system can allow radiologists to improve self-assessment, accuracy and relevance of their reporting, and study interventions in their processes to improve outcomes [47].

The disadvantages of EMRs to education were noted by the following issues:

  1. Problems with student access into the facilities systems such as obtaining log-ins and passwords
  2. Concern that students will not learn skills of independently recognizing items that need to be documented, but rather the students would only choose from drop down boxes and pick lists.
  3. Instructor's concern that EMRs allow portions or entire sections of notes to be copied and pasted, which in turn leads to ethical concerns with plagiarism and documenting procedures that were never performed.
  4. Trainees overly attentive to patient’s EMR data versus gaining information from physical examination and patient interactions
  5. Focus on engagement with computer terminal disrupts patient-physician relationship in exam room
  6. Automation bias - too much trust in decision support systems without consideration of their limitations

As EMR use becomes standard fare in medical practice, the benefits of using EMR need to be harnessed by adapting the training curriculum of medical students and graduate medical education trainees to incorporate EMR-related sub-competencies [1] [2] In fact a study describes the opinion of residents who were making transition from a paper-based system to computerized physician order entry (CPOE) in the hospital. The study indicated that during the initial six months or the transition period, residents expressed discontent. However, with progressive use, many residents preferred CPOE to paper based ordering. Not surprisingly, EMR resources in the future employers site was a very big positive for many of the residents. In addition, this study mainly indicates that including use of EMR as a curriculum helps to remove resistance and fosters appreciation for the new technology. Therefore helps to facilitate the transition from a paper based records to electronic records [3].

Improving Interpersonal and Communication Skills

Patients receive care from multiple providers/healthcare givers in the course of their illness. Effective communication is a must to provide optimal care. Interpersonal and Communication Skills is one of the six competencies domain of the Accreditation Council for Graduate Medical Education (ACGME) in which medical trainees are assessed. In addition to medico-legal purposes both effective written and oral communication are needed to allow continuity of care and provide effective patient care. This communication is not only with the other healthcare providers but is also with patients and their families. This allows them to become a partner in their own care. EMRs can improve written communication skills of the trainees if designed appropriately and allow a mechanism of free expression. However EMRs have negative effects on the communication skills as EMRS can reduce face to face time between the trainees and the patients, due to the ability of medical students and residents to access patient information remotely. This may result in spending less time with the patients, and poor development of bedside skills. In an article by Tierney et. al [1] the authors also highlight that the use of pre-developed templates for documentation may impair critical thinking by limiting the trainees to set form of documentation. As they now feel a need to fill the template and not critically think through the clinical scenario. The authors suggest that perhaps this can be mitigated by not allowing medical students to use a template. EMRs are also beneficial as the review of the historical data allows the trainees to learn from the medical records.

Medical Knowledge and Practice Based Learning and Improvement

Medical Knowledge and Practice Based Learning and Improvement is one of the six competencies domains of the Accreditation Council for Graduate Medical Education (ACGME) in which medical trainees are assessed. Medical trainees, that include residents and medical students, are expected to learn from their daily patient care activities by reviewing the appropriate literature. Well-designed EMRs can provide links to a repository of appropriate preselected medical articles based upon patients’ medical diagnoses. This may not be practical as the new information is discovered and it is almost impossible to keep such a data repository current without a mechanism of active review and active involvement of the medical staff. However, EMRs can provide easy links to the online resources and allow the trainees to search these resources in a timely manner. In an article by Tierney et. [1] the authors also point that the Clinical Decision Support Systems can either have beneficial effect on training or can impede the training of the trainees. Too many inconsequential alerts can cause alert fatigue and promote a culture of alert override resulting in medical error, in addition to frustration of the trainees due to frequent stoppages. However, thoughtful alerts will allow the residents to pause and think about their clinical care resulting in indirect education of the trainees.

Law and Ethics

Law and ethics in medicine is an important topic that needs to be considered for the safety of patients and providers. Is it ethical to track patients in the Electronic Health Records EHR? According to (Brisson,2015) the law permits the use of EHR for the purpose of education. However, will this be a violation of the patient's privacy? Arguments have been made on supporting and opposing the tracking of patients in the EHR. [4]

Argument on Ethics Supporting Tracking

An argument done by Brisson, et al 2015, is that tracking can support the education and advance the training of the students in medical school. This will allow them to start early training on EHR and learn from trial and error in their future encounters with patients. Tracking could also be supported by the ethical principle of distributive justice, which describes a duty to advance the fair, equitable, and appropriate distribution of benefits and burdens within a community—acknowledging that such a commitment may conflict with autonomy. Briton, 2015 [4] Therefore, any student should access EHR of the patient in an appropriate ethical manner considering the benefits and the potential to harm. Overall, tracking will improve and promote the patients welfare. Thus training will empower the student to learn from experience.


Enhancing professionalism

Detailed data provided by EMR can help doctors or other medical workers to convince patients more easily. EMR documentation can enhance professionalism among medical personnel by increasing accountability on the part of the healthcare provider to offer quality healthcare to patients.

Access to knowledge resource

Today, clinicians can get access to medical literature on the internet while making clinical decisions or reviewing patient charts. EHRs can provide links in a patient record to internet resources like PubMed, NLM, and OVID to show clinicians the most up-to-dated information and knowledge in medicine.

References

  1. 1.0 1.1 1.2 Medical Education in the Electronic Medical Record (EMR) Era: Benefits, Challenges, and Future DirectionsMichael J. Tierney, MD, Natalie M. Pageler, MD, Madelyn Kahana, MD, Julie L. Pantaleoni, MD, and Christopher A. Longhurst, MD, MS Acad Med. 2013 Jun;88(6):748-52. http://www.ncbi.nlm.nih.gov/pubmed/23619078
  2. Refocusing Medical Education in the EMR Era. Natalie M. Pageler; Charles P. Friedman; Christopher A. Longhurst. JAMA. 2013;310(21):2249-2250. http://jama.jamanetwork.com/article.aspx?articleid=1787416
  3. Attitudes and Perceptions of Pediatric Residents on Transitioning to CPOE, Shriner and Webber, Appl Clin Inform 2014; 5: 721–730
  4. 4.0 4.1 Should Medical Students Track Former Patients in the Electronic Health Record? An Emerging Ethical Conflict,http://www-ncbi-nlm-nih-gov.ezproxyhost.library.tmc.edu/pubmed/25565261,Brisson, G. E., Neely, K. J., Tyler, P. D., & Barnard, C. (2015). . Academic medicine: journal of the Association of American Medical Colleges.