EHRs and Medical Students: How to educate Medical Students

Practicing medicine today means interacting not just with patients, but also with computers. As of 2013, nearly 80% of office-based physicians were using electronic health records. But medical schools have been slow to keep up with the trend. There's no national standard yet for how med students should be trained on EHRs. Some are using computer systems from day one of their education. While others may be forced to sink or swim once they start to practice. This is a report for iHealthBeat, a daily news service of the California HealthCare Foundation.

<Audio Transcript>

I'm Ali Budner Priyanka Chilakamarri is a fourth-year medical student at the University of Vermont. From very early on, she and her fellow students were expected to engage with their lessons through computer screens. (Chilakamarri): "When I first started medical school ... they gave all the students laptops." They also immediately started using computers in their interactions with patients. That meant learning how to use an EHR system. But EHRs are complex and notoriously hard to teach. (Jemison): "Because inevitably the computers are attached to walls, your back is to a patient, there's a lot of physical reconfiguring you have to do in order to take notes." Jill Jemison is the director of technology services at UVM, Chilakamarri's school. (Jemison): "We're teaching them how to do a good note, how to put all the information in it, how to collect the right thing." The third year of med school is when students would typically be exposed to EHRs, when they start clinical rotations. But in her very first year at UVM, Chilakamarri was already practicing on what's called a "dummy EHR," a system that's been stripped of identifying personal information to protect patient privacy.

Comments:

Harold Lehmann

Consider constructing a curriculum around a virtual (or multiple virtual patients). Cases should be created in the training environment, not only for the purpose of training in the use of the EHR per se, but also for teaching how to practice medicine in this machine-centric environment. Hopefully, one can teach how to be efficient, yes, but also, how to *think* in multiple screens that are not designed necessarily to aid cognition.

June 18, 2015 at 2:38 PM

Lauren La Barge

Many of my friends and colleagues are medical students, and I was fortunate to live with many medical students at a top ranked institution. They are interested in curious about EHRs generally, but lose interest as they are unable to interact with them. Suddenly when they are in a clinical setting using EHRs for the first time, there is a lot of frustration and confusion. My friend, a first year anesthesia resident, used to take hours of work home on Epic! Teaching EHR use in the medical curriculum needs to be a part of the medical school experience.

June 18, 2015 at 10:44 AM

Michael Warner

Medical students are in a tough position today as they are hands-off when it comes to the EHR. I was not allowed to write in the chart either, when I was a nurse's aid. I realize the legal ramifications, but patients are now able to view their records on patient portals and enter information. Why not allow the student doctor to partner with the patients and construct the History component of the encounter note? In research study that just concluded, patients where able to "co-author" their health record by writing a Pre-History. Imagine if medical student partnered with a patient to document her or her story? This might lead to a future where patients and providers get closer - while using the EHR as a tool.

July 2, 2015

Gary Levin M.D.

The clinical practice of medicine is changing rapidly. Advances in basic and clinical science challenge praactitioners as well as neophyte trainees. Today a new curriculum is developing in medical school focused on health information technology. Electronc health records and eRX are just two of the niches.

Today pre- medical students have a computer, pc tablet or are given one when they enter medical school. Much of the curriculum and even examinations are offered via this tool. Medical students enter school with considerable exposure to computer technology and operating systems.  They are facile with the hardware.  This is not so for EHR software.

Some thought is being given to  training students to use EHRs. However hospitals, and clinics may use different EHRs, and training students to use one does not necessarily translate to using another one.  In fact studies have shown it is easier to teach a student an  EHR if they have never used one.  Changing EHRs requires unlearning the original EHR to use the new EHR.

In general it may be more important to teach  adaptive skills, such as where to place a computer monitor or keyboard to minimize visual isolation from a patient. Digital health space believes that tablet PCs are the most user-friendly in the clinical environment.  It can be used much like a classical paper progress note... The addition of touch screen functionality is even more useful.

The Future of Medicine lies in Human Capital

Innovation Is Sweeping Through U.S. Medical Schools

Preparing doctors—and in greater numbers—for new technologies and methods has only recently been  put in the forefront of health reform. Without an increase in efficiency and primary care physicians offering insurance is meaningless without having access to the care. The Wall Street Journal  features an article on the changes coming to Medical Schools.

Century-Old Model

Medical educators say such innovations are long overdue. The U.S. health-care system is rapidly becoming ever more data-driven, evidence-based, patient-centered and value-oriented. But for reasons having to do with tradition, accreditation concerns and preparing students for national board exams, the designers of medical-school curricula have been slow to shift their focus.

“The reality is that most medical schools are teaching the same way they did one hundred years ago,” says Wyatt Decker, chief executive of the Mayo Clinic’s operations in Arizona, which include a medical school in Scottsdale, Ariz., that is scheduled to enroll its first class in 2017. “It’s time to blow up that model and ask, ‘How do we want to train tomorrow’s doctors?’ ”

Doctors today are well schooled in the science of medicine, says Susan Skochelak, the American Medical Association’s vice president for medical education. “What’s been missing is the science of health-care delivery. How do you manage chronic disease? How do you focus on prevention and wellness? How do you work in a team?”

To encourage med schools to move their curricula in that direction, an AMA initiative called Accelerating Change in Medical Education is giving $1 million to each of 11 schools to help fund novel programs. Of the nation’s 141 medical schools, 118 competed for the 11 grants.

“We should have done this 10 years ago,” Dr. Decker says of the many med school changes. Then he quotes a Chinese proverb: “The best time to plant a tree is 20 years ago. The next best time is tomorrow.”

At the new Hofstra North Shore-LIJ School of Medicine in Hempstead, N.Y, students spend their first eight weeks not in lecture classes but becoming certified emergency medical technicians, learning split-second lifesaving skills on 911 calls.

At Penn State College of Medicine in Hershey, Pa., first-year students work as “patient navigators,” helping the ill, injured and their families traverse the often-confusing medical system and experiencing it from their perspective.

At New York University School of Medicine, one required course delves into a database that tracks every hospital admission and charge in the state. Discussions center on why, say, the average tab for delivering a baby is $3,000 in a rural area and $22,000 in New York City.

Century-Old Model

Medical educators say such innovations are long overdue. The U.S. health-care system is rapidly becoming ever more data-driven, evidence-based, patient-centered and value-oriented. But for reasons having to do with tradition, accreditation concerns and preparing students for national board exams, the designers of medical-school curricula have been slow to shift their focus.

“The reality is that most medical schools are teaching the same way they did one hundred years ago,” says Wyatt Decker, chief executive of the Mayo Clinic’s operations in Arizona, which include a medical school in Scottsdale, Ariz., that is scheduled to enroll its first class in 2017. “It’s time to blow up that model and ask, ‘How do we want to train tomorrow’s doctors?’ ”

Doctors today are well schooled in the science of medicine, says Susan Skochelak, the American Medical Association’s vice president for medical education. “What’s been missing is the science of health-care delivery. How do you manage chronic disease? How do you focus on prevention and wellness? How do you work in a team?”

New MCAT

To that end, in April, a new MCAT—the Medical College Admission Test—will be administered, the test’s first major revision since 1991. The new version is 2 hours longer (6 hours and 30 minutes) and tests knowledge of behavioral and social sciences as well as biology, physics and chemistry. One sample question has applicants read a passage, then asks which of four statements “is most consistent with the sociological paradigm of symbolic interactionism?”

Styles of teaching and learning are also changing.

“We’ve replaced ‘the sage on the stage’ with ‘the guide on the side,’ ” says Richard Zimmerman, a neurosurgeon and medical director for education for the new Mayo med school in Scottsdale.

At both the new school and Mayo’s existing medical school in Rochester, Minn., much of the material traditionally taught in lecture classes will be converted to electronic formats that students can absorb on their own, leaving class time for discussions and case studies.

Mayo also is creating a new course of study, called the Science of Health Care Delivery, which will run through all four years and include health-care economics, biomedical informatics and systems engineering. With a few additional credits, students can graduate with both an M.D. and a master’s in health-care delivery from Arizona State University.

In a course called Checkbook, Mayo students will track all of the services provided to their assigned patients during clinical rotations and look for redundancies or routine tests that add little value.

Focus on Teams

Learning to work in teams is a main focus at Mayo—and a sharp departure from traditional training for doctors.

“The old model was, you’d go on rounds; the attending would ask a question, and the young resident had to get the right answer,” says Dr. Decker in Scottsdale. “In the new model, you’re part of a team, and somebody else might have the right answer.”

To understand the roles of team members who aren’t doctors, first-year Mayo students spend half-days shadowing clinic schedulers, registered nurses, nurse practitioners and physician assistants. They also assist in managing a panel of patients, as care coordinators do. For example, they review records to see which diabetes patients aren’t managing their health well; they call the patients on the phone to discuss why they are struggling; then the students consult with the patients’ primary-care doctors to determine the next steps.

Managing Stress: Med Student Well Being Index,

In another departure from med schools past, Mayo is making an organized effort to help students avoid burnout. Classes in the first two years are pass/fail, not graded, and students can evaluate their level of stress, fatigue and risk of suicide in a confidential Med Student Well Being Index,

Less Memorization

What’s being left out of medical education to make room for the new material?

Some schools are placing far less emphasis on memorizing facts, such as which drugs do what and how they interact with other drugs. Such information is now readily available electronically.

“The fund of medical knowledge is now growing and changing too fast for humans to keep up with, and the facts you memorize today might not be relevant five years from now,” says NYU’s Dr. Triola. Instead, what’s important is teaching “information-seeking behavior,” he says, such as what sources to trust and how to avoid information overload.

Technology

Is also changing how med students learn. Simulators that look like patients and can be programmed to go into cardiac arrest, have strokes, spike fevers, cry, vomit and eliminate are particularly useful for teaching.

Some schools are condensing the typical four-year curriculum into three years, to let students start their residencies sooner and graduate with less debt. 

“We should have done this 10 years ago,” Dr. Decker says of the many med school changes. Then he quotes a Chinese proverb: 

“The best time to plant a tree is 20 years ago. The next best time is tomorrow.”

The Future of Medicine lies in Human Capital