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May 2015

An Academic Approach to EHR Training
By Juliann Schaeffer
For The Record
Vol. 27 No. 5 No. 24

A group of professors has examined the benefits and barriers to offering a hands-on experience to medical students.

In every realm of health care, EHRs are becoming more commonplace—some may say the technology is ubiquitous. According to the latest statistics from the Centers for Disease Control and Prevention, almost 80% of office-based physician offices are using some sort of EHR.

If electronic records are indeed now the norm in many settings, why aren't students entering the medical profession being trained on such technologies prior to entering residency? And what are the ramifications when students skip this class, even if it's through no fault of their own?

In the Classroom
An article published in the November/December issue of The Annals of Family Medicine explored the benefits of teaching medical students how to document in an EHR.

"[This article] was designed to stimulate thought and conversation about what is an appropriate role of the student learner in terms of documentation," says Mark Stephens, MD, a professor and chair of the department of family medicine at the Uniformed Services University of the Health Sciences. "It was a nice collaboration between me [working in the federal system] and my colleagues [who are in the civilian system]. There are many different EHRs out there and everybody does things a little differently, so this article was an effort to come to some agreement on what we might look at as shared entrustable professional activities in the context of EMR documentation for students."

While it seems most postgraduate medical programs offer student access to EHRs, it appears to be sporadic, says Christine Matson, MD, appointed chair of the department of family and community medicine at Eastern Virginia Medical School in Norfolk. "The majority of schools would indicate that they do [offer students some type of EHR access], but there's a wide variety," she says. "We did an informal survey of family medicine educators prior to our doing the article and the majority of them [in the 60% range] said that students did have access to EHR."

At the Uniformed Services University of the Health Sciences, which differs from civilian schooling, Stephens says medical students have received a range of EHR exposure. "At the end of students' preclerkship period, we have a week that's a crash course of sorts on how to be a doctor in the hospital," he says. "And that includes a day or so of explicit training on our particular electronic health record [which is unique to the uniformed services]."

Students also receive on-the-job training as well as additional sessions in several clerkships that deal with EHR nuances such as efficiency, templates, and order entry.

John F. Kennedy (JFK) University in the San Francisco Bay area is in the process of rolling out Valant EHR technology, a specialized behavioral health system, at the university's three counseling centers. According to Alvin McLean, Jr, PhD, a professor of clinical psychology and codirector of clinical training at JFK's doctorate in clinical psychology program, all clinical psychology doctoral students, as well as terminal master's students, will be introduced to the EHR through a broad overview, with most of the training taking place at counseling centers.

Training students on the finer points of EHRs can be filled with hurdles. For example, at Eastern Virginia, students initially were able to enter and extract data on a working EHR, developed by Matson and colleagues, at a standardized skills center. But after Eastern Virginia rolled out an Allscripts product in the outpatient setting a few years later, compliance became a concern and students were denied access to the system.

"So that's been a good deal of frustration that goes back nine years now," Matson says, noting that a third system came into the mix when the hospitals with which the medical school is affiliated implemented an Epic EHR. "They immediately went out and recruited about 70 students, who were trained as their superusers, and brought them up to EHR speed, reasoning that these younger generation folks would help with the older physicians in the transition," she says.

Having three different EHR systems has resulted in three different experiences for students, creating an inconsistent academic environment that has frustrated Matson. "[Working with two EHR systems] created a split in our organization," she says. For the hospitals with Epic, students are able to participate in all aspects of the EHR, while those working in the outpatient setting only recently gained read-only access to the EHR.

Matson says all medical students deserve the opportunity to receive EHR training—for their sake and the sake of their future patients. "Currently, some students do have access, whereas others don't," she says. "That's not fair. That's a disparity in training, and the folks that don't are at a disadvantage when they start their graduate or residency training."

Benefits of EHR Training
The Annals of Family Medicine article lists various reasons EHR access and training prior to residency is important, including student efficiency, employability, and patient care. According to Stephens, the biggest gain relates to the knowledge set students bring to residency from day one. "I think probably the biggest benefit is they know what they're doing when they hit residency, and you're not wasting time training them how to use an EHR," he says. "That way, they become immediately efficient in the context of the clinical care team."

McLean knows firsthand what can happen when residents arrive without being exposed to EHRs. For example, he has received reports from community mental health centers and hospitals about students struggling to grasp EHR systems so much that it was impeding their ability to comprehend patient care aspects. "[Learning EHRs is] a major stepping stone for the students as they go into these different hospitals and clinics that can slow up their clinical work as they try to adjust to a system of care that they are not accustomed to," McLean says.

There's a reason students often stumble on these systems, Matson says. Because interviewing patients while using an EHR requires physicians to use both sides of their brain (the right side focused on understanding narrative medicine and the left side zeroed in on checklists and details), it requires time and practice to master the nuances. "It's important to be able to learn in training how to mesh those two types of circuits rather than having one predominate over the other," Matson says, adding that students who enter this environment on the fly may adversely affect patient care.

"My personal feeling as an educator is that the patient-centered and narrative aspects do predominate for most physicians, but we have to be able to use EHR for certain purposes; everything from documentation to billing," she explains. "And if students are not able to use the EHR during the formative months of their medical training, then the concern is that they either will never get to be as good as they might or that they will not develop the understanding of how the two types of data should mesh."

Not only will EHR-trained students enter the workforce better prepared to handle the heavy demands of today's health care system, they also may join the ranks sooner than those without such training. "Students will be more 'employable' if they have been trained on an EHR," says Kristin Walker, a behavioral health EHR consultant and founder of EverythingEHR.com who helped JFK University in their search for an EHR to train their postgraduate mental health students.

And the better the technology used in training, the better off students will be—particularly those who desire to open up their own practice, Walker says. "Students not only need to know what to use clinically but these are also future business owners," she says.

"They need to know that the EHR can also sufficiently help them obtain payment for their services," Walker adds, noting that medical billing is often ignored in many academic environments. "What is the point of using a system that may do a fine job of helping you practice medicine but can't handle your revenue? Schools may offer classes on coding, billing, and compliance but unfortunately most are not using an EHR that has this properly programmed into the application."

Overcoming Barriers
According to Walker, a lack of funding, foresight, and resources are the largest hurdles to more schools offering EHR training. Matson agrees that financial and resource constraints can make it difficult for universities to make a large investment in an EHR. "If you don't have a system that supports students being involved and the personnel to train students, sign them on, and monitor their usage, that makes it costly," she says. "So failure to share the cost of the educational endeavor could be a huge barrier."

But above all, Matson believes compliance concerns rank as the top impediment. "I think it's the concern that students would use mechanisms like copying a medical note and then pasting it in at another spot [creating] inaccurate data," she says. "Or the possibility of students—and this is a big one—writing notes in the EHR that would then be discoverable by lawyers that the attending physician hadn't thoroughly reviewed and corrected."

Stephens understands the paranoia attached to compliance concerns. "I think that paranoia stems from a risk-averse culture and includes the possibility that students may misdocument information or that they may not have the same understanding as an attending physician," he says. "I think it's a lack of trust. And some of that stems, unfortunately, from regulatory burden."

While there may not be formal guidelines regarding how schools train medical students on EHRs, Stephens says the RIME (reporter, interpreter, manager, educator) scheme, a topic he and others addressed in a paper, is an accepted framework for undergraduate medical education. "It's a very explicit framework for throughout the four years of medical school, detailing the kinds of activities the students could demonstrate facility with and then progressively earn more rights to documentation, if you will," he says.

Matson is encouraged by the tide of organizations starting to see the value of such training, with more beginning to advocate for its use despite compliance concerns. She refers to a recommendation by the Society of Teachers of Family Medicine, an educational group chaired by Beat Steiner, MD. "[The recommendation] includes that all students should have access to an EHR, that it should be available during their clinical training, and that it should be a requirement as opposed to an elective," Matson says.

The Association of American Medical Colleges (AAMC) recently changed its stance on EHR use by medical students. According to Matson, the organization's 2011 compliance advisory quoted the Centers for Medicare & Medicaid Services' statement describing limitations on student use of EHRs. But as conversations with the AAMC progressed, the language of the advisory was revised to promote EHRs as a teaching tool (making accommodations for confidentiality and privacy), a big win for students, Matson says. She says the next step is to convince university and health care organization compliance officers that the benefits of training students on EHRs outweigh the negatives.

While the compliance advisory has changed, Matson realizes concerns remain about the potential for litigation related to student misuse of EHRs. "It's a realistic threat," she says. "We have always had that threat and in my opinion the role of educators is to supervise the students closely—not only when they have hands on patients but also when they record data, so that it's accurate. But those are the challenges we have right now.

"We have to work to come up with mechanisms so that students' notes will not increase the medical-legal risk of the institutions," Matson adds, emphasizing the importance of supervising students working with an EHR in any capacity.

Steps to EHR Success in Schools
For institutions considering an EHR investment for their medical program, Walker suggests they view it not only as an investment but also as a recruitment tool. "Realize that as an institution you will actually attract more students if you showcase that you offer advanced EHR technology as part of your core curriculum," she says. "Students choosing where to learn are going to take an academic institution seriously that can help them obtain meaningful and gainful employment upon graduation.

"Students are often more technologically advanced than the tools their academic institutions provide them. Why not choose to be ahead of the EHR technology curve by offering students the best tools in the marketplace?" Walker asks, emphasizing the importance of schools finding an EHR product that best fits their needs and those of their students.

Matson says medical program directors must have sufficient people resources before making a large technology purchase. Both IT professionals and clinician educators are needed to sufficiently train students with the necessary supervision, she says.

While IT personnel ensures the technology runs smoothly, the importance of clinician educators teaching students how to collect the right kinds of data—both quantitative and qualitative—can't be underestimated. "It's an important time in this evolution of these new ways to record patient data that we don't just go for what's easy but that we find ways to record and utilize what's most important in the patient's story," Matson says.

"In health care, we're moving in the direction to be able to include not just biologic data but psychosocial data and community determinants of health as well," she continues, referring to a New England Journal of Medicine article. "It's really exciting, but if we don't have students using the EHR as they go through training in an optimal way under the supervision of clinician educators who have their learning at heart, then they'll discover shortcuts and quick and dirty ways to learn it eventually. However, it should be under the watchful eye of mentors to have the optimal outcome."

Whatever system is used in whatever context, Stephens is quick to point out that for medical students, any EHR training is better than none. "I think explicit training in any EHR will teach the students the infrastructure of the electronic system that hopefully then allows them to focus on an accurate and full translation of the patient's medical history," he says. "It's more about foundational knowledge."

The irony, Walker says, is that the end game of any EHR technology isn't at all about the technology but rather the patient. "An EHR is a tool, and it is supposed to make the working life of the medical provider easier while aiding them with compliancy so they can spend quality time on patient care and not on technology issues," she says.

According to Stephens, the sooner students start EHR education, the better. "The EHR, via the computer, has become a third individual in the room that often detracts the provider—be that a student, a resident, or an attending physician—from giving their full attention to the patient," he says. "Teaching people early how to deal with that third individual in the room, I think that's going to become really helpful in improving doctor-patient communication."

— Juliann Schaeffer is a freelance health writer and editor based in Alburtis, Pennsylvania.