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Bridging the Gap: Integrating Electronic Health Records into Medical Education

AAMC Reporter: January 2014

—By Stephen G. Pelletier, special to the Reporter

The electronic medical record (EMR) and electronic health record (EHR) are becoming essential tools in patient care. As the use of these tools has increased, many medical schools have incorporated the use of EMRs and EHRs into their curricula. While some medical schools have had success using simulation to train students on EMRs and EHRs, there are barriers. Bridging that gap—integrating student practice on EMRs and EHRs into medical education—has been challenging for many medical schools.

Several factors impede medical students’ use of EMRs and EHRs. Foremost are concerns about protecting patient privacy. Technical firewalls and institutional policies designed to prevent abuse of patient data often keep students at arm’s length from medical records. Many schools deny students full access to EMRs or EHRs, or significantly restrict that access.

Security issues around the EHR—coupled with the reality that medical schools and teaching hospitals, like many organizations today, have become more risk averse—are “impacting the learner’s ability to look at the [patient] record and be able to document care in it,” said Morgan Passiment, AAMC director of information resources policy and programs. “In many cases, medical students have become observers of EHRs rather than full-fledged users—if they even get to do that.”

Part of the problem is technological. According to Jill Jemison, technology services director at the University of Vermont College of Medicine, EMRs were designed as support for hospital billing, not a tool for medical education. Trying to mesh student opportunities for training on EMRs into a system designed for billing is a “square peg-round hole” conundrum, she said. Addressing that disconnect is more challenging because EMRs are designed and supported by professionals whose focus is not medical education. In addition, EMRs often do not communicate well across computer systems.

“EMRs are not at all easily accessible for educational purposes,” said Sandrijn M. van Schaik, M.D., Ph.D., an associate professor of clinical pediatrics at the University of California, San Francisco, School of Medicine (UCSF), who also serves as the education director of the university’s Kanbar Center for Simulation, Clinical Skills, and Telemedicine Education. As part of its work, the center designs opportunities for students to train on EMRs in a simulated environment—a workaround to the problem of student access to true patient EMRs.

An opinion piece published last month in the Journal of the American Medical Association suggested that the Accreditation Council for Graduate Medical Education should update its competencies to “promote optimal integration of the EMR into clinical practice.” In addition, the AAMC’s Learning Objectives for Medical Student Education calls for students to be able to “document and share patient-specific information, demonstrating the ability to record in information systems specific findings about a patient and orders directing the further care of the patient.”

Vanderbilt University School of Medicine has embedded EMR training in the medical student’s experience. “We felt strongly that students should have authentic value-added roles on their teams when they are in the clinical phases of training,” said Anderson Spickard, M.D., M.S., associate professor of medicine and biomedical informatics. “Our approach has been that our students will write notes on their patients and the notes would be displayed in the medical records of the patients.”

Having developed its own EHR system, Vanderbilt has the luxury of enabling students to write directly into patient records. The entire patient note gets copied automatically to a different secure server that houses the student’s personal electronic portfolio. In that environment, notes are evaluated to assess students’ documentation and reasoning skills.

“We feel that this is an opportunity, not something to shy away from,” Spickard said. “More than ever, our [students] need to learn to operate in a complex health learning system.”

Systems study is a core component of a new medical school curriculum that UCSF is developing. Recently, a task force was asked to outline competencies in the use of EHRs that all UCSF physicians and physicians-intraining should master. Noting she would be surprised if training in EMRs was not a focus of that new curriculum, van Schaik said she anticipates a future where “from day one, students will realize that we deliver health care in most of the Western world through the EMR.”

January 2014 Home

“We feel this is an opportunity, not something to shy away from. More than ever, our [students] need to learn to operate in a complex health learning system.”

—Anderson Spickard, M.D.