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Rwigema C, Fang WH, Chen X, Lane C, Jones IA, Vangsness CT. Orthopedic Resident and Patient Perception of Electronic Medical Record Use During the Clinic Visit. Cureus 2023; 15:e43885. [PMID: 37746356 PMCID: PMC10511670 DOI: 10.7759/cureus.43885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2023] [Indexed: 09/26/2023] Open
Abstract
Background The transition from paper charts to electronic medical records (EMRs) has resulted in greater efficiency and reduced medical errors. This study aimed to examine the perception of patients and orthopedic residents regarding computer use during the clinic visit. Methodology This study utilized a cross-sectional cluster design. Orthopedic resident physicians were given a one-time general pre-visit survey. Additional surveys were given to patients and resident physicians post-visit. Surveys included questions that assessed satisfaction and the perceived impact of computer usage on doctor-patient interactions. Logistic generalized estimating equations were run to determine if there was an association between patient response and clinician assessment, adjusting for repeated measures within clinicians. Results A total of 80 patients and 15 residents completed the surveys. Results from the physician pre-visit survey showed that more residents perceived the computer as having a "negative" (47%) than "positive" (26%) effect on their relationship with patients. According to the post-visit analysis, patients perceived the residents' use of the EMR as having an overall positive effect on their ability to establish a personal connection and having a positive effect on their ability to give them attention. Conclusions Overall, there was little correlation between patient and resident perception of the computer's effect on their relationship. Patients generally perceived the computer as having a positive effect on their interaction with the residents even when residents had a negative perception of the computer's effect on their interaction.
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Affiliation(s)
- Chris Rwigema
- Department of Orthopaedics, University of Southern California Keck School of Medicine, Los Angeles, USA
| | - William H Fang
- Department of Translational Medicine, Western University of Health Sciences, Los Angeles, USA
| | - Xiao Chen
- Department of Orthopaedics, University of Southern California Keck School of Medicine, Los Angeles, USA
| | - Christina Lane
- Southern California Clinical and Translational Science Institute, University of Southern California Keck School of Medicine, Los Angeles, USA
| | - Ian A Jones
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA
| | - C Thomas Vangsness
- Department of Orthopaedics, University of Southern California Keck School of Medicine, Los Angeles, USA
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Bell A, Chung HO. Learners and EHRs: A path forward. MEDICAL EDUCATION 2023; 57:298-300. [PMID: 36403109 DOI: 10.1111/medu.14976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 11/15/2022] [Indexed: 06/16/2023]
Affiliation(s)
- Amanda Bell
- Niagara Regional Campus, Michael G. DeGroote School of Medicine, Department of Family Medicine, McMaster University, St. Catharines, Ontario, Canada
| | - Han-Oh Chung
- Niagara Regional Campus, Michael G. DeGroote School of Medicine, Department of Medicine, McMaster University, St. Catharines, Ontario, Canada
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Shepherd L, McConnell A, Watling C. Good for patients but not learners? Exploring faculty and learner virtual care integration. MEDICAL EDUCATION 2022; 56:1174-1183. [PMID: 35732194 DOI: 10.1111/medu.14861] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 06/15/2022] [Accepted: 06/20/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND The pandemic catapulted the adoption of virtual care far ahead of its anticipated maturation date, forcing faculty to role model and teach learners with barely enough time to master it themselves. With a scant body of prepandemic literature now accompanied by experience gained under extraordinary circumstances, we can benefit from understanding ad hoc strategies implemented by those on the front lines and from listening to learners about what is working and what is not. The purpose of this study was to explore the experience of learner integration into virtual care from both the faculty and learner perspectives. METHODS Using a constructivist grounded theory methodology and sociomateriality as a sensitising concept, we recruited participants using purposeful and theoretical sampling from a Canadian University with limited prepandemic virtual care provision. We interviewed 16 faculty and 5 learners spanning a breadth of specialties and years of practice/education to probe their experience of teaching and learning virtual care. Data collection and analysis were conducted iteratively with themes identified through constant comparative analysis. RESULTS Integrating learners into virtual care proved challenging initially because of a lack of familiarity with the process and later because of disrupted workflow, triggered by the structure and logistics of the virtual care clinic. Both faculty and learners identified learning deficiencies in the virtual care experience when compared with in-person clinics, but several unique and valuable learning affordances were noted. All faculty expressed a desire to keep virtual care as part of their future clinic practice, but paradoxically most felt that they were unlikely to include learners. CONCLUSIONS Training learners in virtual care is an educational challenge that will not disappear with COVID-19, even if our participants wished it could. The perceived value for patients but not learners begs a reconsideration of the sociomaterial contribution to this pandemic paradox.
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Affiliation(s)
- Lisa Shepherd
- Centre for Education Research & Innovation, Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Allison McConnell
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Christopher Watling
- Department of Oncology and Centre for Education Research & Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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Schaye V, Guzman B, Burk-Rafel J, Marin M, Reinstein I, Kudlowitz D, Miller L, Chun J, Aphinyanaphongs Y. Development and Validation of a Machine Learning Model for Automated Assessment of Resident Clinical Reasoning Documentation. J Gen Intern Med 2022; 37:2230-2238. [PMID: 35710676 PMCID: PMC9296753 DOI: 10.1007/s11606-022-07526-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 03/29/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Residents receive infrequent feedback on their clinical reasoning (CR) documentation. While machine learning (ML) and natural language processing (NLP) have been used to assess CR documentation in standardized cases, no studies have described similar use in the clinical environment. OBJECTIVE The authors developed and validated using Kane's framework a ML model for automated assessment of CR documentation quality in residents' admission notes. DESIGN, PARTICIPANTS, MAIN MEASURES Internal medicine residents' and subspecialty fellows' admission notes at one medical center from July 2014 to March 2020 were extracted from the electronic health record. Using a validated CR documentation rubric, the authors rated 414 notes for the ML development dataset. Notes were truncated to isolate the relevant portion; an NLP software (cTAKES) extracted disease/disorder named entities and human review generated CR terms. The final model had three input variables and classified notes as demonstrating low- or high-quality CR documentation. The ML model was applied to a retrospective dataset (9591 notes) for human validation and data analysis. Reliability between human and ML ratings was assessed on 205 of these notes with Cohen's kappa. CR documentation quality by post-graduate year (PGY) was evaluated by the Mantel-Haenszel test of trend. KEY RESULTS The top-performing logistic regression model had an area under the receiver operating characteristic curve of 0.88, a positive predictive value of 0.68, and an accuracy of 0.79. Cohen's kappa was 0.67. Of the 9591 notes, 31.1% demonstrated high-quality CR documentation; quality increased from 27.0% (PGY1) to 31.0% (PGY2) to 39.0% (PGY3) (p < .001 for trend). Validity evidence was collected in each domain of Kane's framework (scoring, generalization, extrapolation, and implications). CONCLUSIONS The authors developed and validated a high-performing ML model that classifies CR documentation quality in resident admission notes in the clinical environment-a novel application of ML and NLP with many potential use cases.
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Affiliation(s)
- Verity Schaye
- NYU Grossman School of Medicine, New York, NY, USA. .,NYC Health & Hospitals/Bellevue, New York, NY, USA.
| | | | | | - Marina Marin
- NYU Grossman School of Medicine, New York, NY, USA
| | | | | | - Louis Miller
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Jonathan Chun
- Stanford University School of Medicine, Stanford, CA, USA
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Wang M, Sun Z, Jia M, Wang Y, Wang H, Zhu X, Chen L, Ji H. Intelligent virtual case learning system based on real medical records and natural language processing. BMC Med Inform Decis Mak 2022; 22:60. [PMID: 35246134 PMCID: PMC8895690 DOI: 10.1186/s12911-022-01797-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 02/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Modernizing medical education by using artificial intelligence and other new technologies to improve the clinical thinking ability of medical students is an important research topic in recent years. Prominent medical universities are actively conducting research and exploration in this area. In particular, given the shortage of human resources, the need to maintain social distancing to prevent the spread of the epidemics, and the increase in the cost of medical education, it is critical to harness online learning to promote medical education. A virtual case learning system that uses natural language processing technology to process and present a hospital's real medical records and evaluate student responses can effectively improve medical students' clinical thinking abilities. OBJECTIVE The purpose of this study is to develop a virtual case system, AIteach, based on actual complete hospital medical records and natural language processing technology, and achieve clinical thinking ability improvement through a contactless, self-service, trial-and-error system application. METHODS Case extraction is performed on a hospital's case data center and the best-matching cases are produced through natural language processing, word segmentation, synonym conversion, and sorting. A standard clinical questioning data module, virtual case data module, and student learning difficulty module are established to achieve simulation. Students can view the objective examination and inspection data of actual cases, including details of the consultation and physical examination, and automatically provide their learning response via a multi-dimensional evaluation system. In order to assess the changes in students' clinical thinking after using AIteach, 15 medical graduate students were subjected to two simulation tests before and after learning through the virtual case system. The tests, which included the full-process case examination of cases having the same difficulty level, examined core clinical thinking test points such as consultation, physical examination, and disposal, and generated multi-dimensional evaluation indicators (rigor, logic, system, agility, and knowledge expansion). Thus, a complete and credible evaluation system is developed. RESULTS The AIteach system used an internal and external double-cycle learning model. Students collect case information through online inquiries, physical examinations, and other means, analyze the information for feedback verification, and generate their detailed multi-dimensional clinical thinking after learning. The feedback report can be evaluated and its knowledge gaps analyzed. Such learning based on real cases is in line with traditional methods of disease diagnosis and treatment, and addresses the practical difficulties in reflecting actual disease progression while keeping pace with recent research. Test results regarding short-term learning showed that the average score (P < 0.01) increased from 69.87 to 85.6, the five indicators of clinical thinking evaluation improved, and there was obvious logical improvement, reaching 47%. CONCLUSION By combining real cases and natural language processing technology, AIteach can provide medical students (including undergraduates and postgraduates) with an online learning tool for clinical thinking training. Virtual case learning helps students to cultivate clinical thinking abilities even in the absence of clinical tutor, such as during pandemics or natural disasters.
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Affiliation(s)
- Mengying Wang
- Information Management and Big Data Center, Peking University Third Hospital, Beijing, China
| | - Zhen Sun
- Information Management and Big Data Center, Peking University Third Hospital, Beijing, China
| | - Mo Jia
- Information Management and Big Data Center, Peking University Third Hospital, Beijing, China
| | - Yan Wang
- Education Section, Peking University Third Hospital, Beijing, China
| | - Heng Wang
- Education Section, Peking University Third Hospital, Beijing, China
| | - Xingxing Zhu
- Goodwill Hessian Health Technology Co. Ltd, Beijing, China
| | - Lianzhong Chen
- Goodwill Hessian Health Technology Co. Ltd, Beijing, China
| | - Hong Ji
- Information Management and Big Data Center, Peking University Third Hospital, Beijing, China.
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Schaye V, Miller L, Kudlowitz D, Chun J, Burk-Rafel J, Cocks P, Guzman B, Aphinyanaphongs Y, Marin M. Development of a Clinical Reasoning Documentation Assessment Tool for Resident and Fellow Admission Notes: a Shared Mental Model for Feedback. J Gen Intern Med 2022; 37:507-512. [PMID: 33945113 PMCID: PMC8858363 DOI: 10.1007/s11606-021-06805-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 04/03/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Residents and fellows receive little feedback on their clinical reasoning documentation. Barriers include lack of a shared mental model and variability in the reliability and validity of existing assessment tools. Of the existing tools, the IDEA assessment tool includes a robust assessment of clinical reasoning documentation focusing on four elements (interpretive summary, differential diagnosis, explanation of reasoning for lead and alternative diagnoses) but lacks descriptive anchors threatening its reliability. OBJECTIVE Our goal was to develop a valid and reliable assessment tool for clinical reasoning documentation building off the IDEA assessment tool. DESIGN, PARTICIPANTS, AND MAIN MEASURES The Revised-IDEA assessment tool was developed by four clinician educators through iterative review of admission notes written by medicine residents and fellows and subsequently piloted with additional faculty to ensure response process validity. A random sample of 252 notes from July 2014 to June 2017 written by 30 trainees across several chief complaints was rated. Three raters rated 20% of the notes to demonstrate internal structure validity. A quality cut-off score was determined using Hofstee standard setting. KEY RESULTS The Revised-IDEA assessment tool includes the same four domains as the IDEA assessment tool with more detailed descriptive prompts, new Likert scale anchors, and a score range of 0-10. Intraclass correlation was high for the notes rated by three raters, 0.84 (95% CI 0.74-0.90). Scores ≥6 were determined to demonstrate high-quality clinical reasoning documentation. Only 53% of notes (134/252) were high-quality. CONCLUSIONS The Revised-IDEA assessment tool is reliable and easy to use for feedback on clinical reasoning documentation in resident and fellow admission notes with descriptive anchors that facilitate a shared mental model for feedback.
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Affiliation(s)
- Verity Schaye
- NYU Grossman School of Medicine, New York, NY, USA. .,NYC Health + Hospitals/Bellevue, New York, NY, USA.
| | - Louis Miller
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | | | - Jonathan Chun
- Stanford University School of Medicine, Stanford, CA, USA
| | | | | | | | | | - Marina Marin
- NYU Grossman School of Medicine, New York, NY, USA
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Cristiano JA, Jackson JM, Shen E, Williams DM, Ellis LR. Integrating the Electronic Health Record Into Patient Encounters: An Introductory Standardized Patient Exercise for Preclinical Medical Students. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2022; 18:11209. [PMID: 35047666 PMCID: PMC8727442 DOI: 10.15766/mep_2374-8265.11209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 09/25/2021] [Indexed: 05/12/2023]
Abstract
INTRODUCTION Increasingly, use of the electronic health record (EHR) is interwoven into even the most basic patient care tasks. Accordingly, learning how to utilize the EHR during patient encounters is important for medical students as they develop their clinical skills. Existing EHR curricula have focused primarily on doctor-patient relationship skills. We developed a session for our preclinical students on EHR-related doctor-patient relationship skills as well as on using the EHR to verify data and focus one's history taking. METHODS We developed student notes, three training videos, four standardized patient (SP) cases, and a simplified, simulated EHR based on these cases. Students reviewed the notes and videos prior to class. During class, students practiced EHR-related communication and data-collection strategies by interviewing an SP while interacting with the simulated EHR. Following each encounter, students received feedback from a small group of peers and faculty. RESULTS Two-hundred eighty-nine second-year medical students participated this session in 2019 and 2020, and 27 (19%, 2019) and 40 (28%, 2020) students, respectively, completed the postsession evaluation. Most respondents rated the SP activity as extremely or quite effective for practicing doctor-patient relationship strategies while interacting with the EHR (89%, 2019; 83%, 2020) and for practicing verification of EHR data during a patient encounter (81%, 2019; 86%, 2020). DISCUSSION This training session was effective for introducing preclinical medical students to fundamental concepts and skills related to incorporating the EHR into patient encounters and offers a low-cost approach to teaching early medical students these important skills.
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Affiliation(s)
- Joseph A. Cristiano
- Assistant Professor, Department of Internal Medicine, Section of General Internal Medicine, Wake Forest School of Medicine
- Corresponding author:
| | - Jennifer M. Jackson
- Associate Professor, Department of Pediatrics, Section of Pediatric Hospital Medicine, Wake Forest School of Medicine
| | - E Shen
- Assistant Professor, Department of Internal Medicine, Section of General Internal Medicine, Wake Forest School of Medicine
| | - Donna M. Williams
- Associate Professor, Department of Internal Medicine, Section of General Internal Medicine, Wake Forest School of Medicine
| | - Leslie R. Ellis
- Associate Professor, Department of Internal Medicine, Section on Hematology and Oncology, Wake Forest School of Medicine
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Wandell GM, Giliberto JP. Otolaryngology resident clinic participation and attending electronic health record efficiency-A user activity logs study. Laryngoscope Investig Otolaryngol 2021; 6:968-974. [PMID: 34667838 PMCID: PMC8513420 DOI: 10.1002/lio2.648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/03/2021] [Accepted: 08/13/2021] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES In an era of increasing electronic health record (EHR) use monitoring and optimization, this study aims to quantify resident contributions and measure the effect of otolaryngology resident coverage in clinic on attending otolaryngologist EHR usage. METHODS In one academic otolaryngology department, monthly attending provider efficiency profile metrics, data collected by the EHR vendor (Epic Systems Corporation) between January and June 2019 were accessed. Using weekly resident schedules, resident coverage of attending outpatient clinics was categorized by junior (post-graduate year [PGY] 1-3) and senior levels (PGY-4 through fellows) and correlated with attending EHR metrics using linear mixed effect models.Results: Thirteen attending otolaryngologists on average spent 58.8 minutes per day interacting with the EHR. In modeling, one day of trainee clinic coverage was associated with a 22 minutes reduction (95% CI [-37, -6]) in total daily attending EHR time and a 12 minutes reduction (95% CI [-21, -3]) in per day note time (P < .05). When stratifying by trainee level, senior coverage was associated with significantly reduced total daily time in EHR, per day time in clinical review, notes, and orders, as well as per appointment time in notes and clinical review (P < .05). Junior coverage was only associated with reduced per day note time (P < .05). CONCLUSIONS Increasing resident clinic coverage was inversely related to attending time spent in the EHR and writing notes. Resident contributions to EHR workflows and hospital system productivity should continue to be studied and considered in EHR use measurement studies. LEVEL OF EVIDENCE Level 4.
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Affiliation(s)
- Grace Michel Wandell
- Department of Otolaryngology—Head and Neck SurgeryUniversity of WashingtonSeattleWashingtonUSA
| | - John Paul Giliberto
- Department of Otolaryngology—Head and Neck SurgeryUniversity of WashingtonSeattleWashingtonUSA
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Constantino E, Vikas R. Use of Clinical Narratives in Electronic Records: a New Resident Course Using a Writing Group Format. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2021; 45:388-392. [PMID: 33786780 DOI: 10.1007/s40596-021-01432-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 03/02/2021] [Indexed: 06/12/2023]
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10
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Arnold MH. Teasing out Artificial Intelligence in Medicine: An Ethical Critique of Artificial Intelligence and Machine Learning in Medicine. JOURNAL OF BIOETHICAL INQUIRY 2021; 18:121-139. [PMID: 33415596 PMCID: PMC7790358 DOI: 10.1007/s11673-020-10080-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 12/23/2020] [Indexed: 05/05/2023]
Abstract
The rapid adoption and implementation of artificial intelligence in medicine creates an ontologically distinct situation from prior care models. There are both potential advantages and disadvantages with such technology in advancing the interests of patients, with resultant ontological and epistemic concerns for physicians and patients relating to the instatiation of AI as a dependent, semi- or fully-autonomous agent in the encounter. The concept of libertarian paternalism potentially exercised by AI (and those who control it) has created challenges to conventional assessments of patient and physician autonomy. The unclear legal relationship between AI and its users cannot be settled presently, an progress in AI and its implementation in patient care will necessitate an iterative discourse to preserve humanitarian concerns in future models of care. This paper proposes that physicians should neither uncritically accept nor unreasonably resist developments in AI but must actively engage and contribute to the discourse, since AI will affect their roles and the nature of their work. One's moral imaginative capacity must be engaged in the questions of beneficence, autonomy, and justice of AI and whether its integration in healthcare has the potential to augment or interfere with the ends of medical practice.
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Affiliation(s)
- Mark Henderson Arnold
- School of Rural Health (Dubbo/Orange), Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.
- Sydney Health Ethics, School of Public Health, University of Sydney, Sydney, Australia.
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Rosdahl JA, Zhang W, Manjunath V. The Button Project: Using Chart Rounds for Teaching Clinical Ophthalmology with an Electronic Medical Record. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2019; 10:1039-1044. [PMID: 31853212 PMCID: PMC6916686 DOI: 10.2147/amep.s237076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 11/24/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Chart rounds have traditionally been used effectively for clinical teaching in ophthalmology. The introduction of the electronic health record has altered practice patterns and some evidence suggests interference with resident education. The purpose of this study was to investigate the use of chart rounds in our ophthalmology department and to see if a simple intervention, an "education button", could positively impact clinical teaching. DESIGN We used a cross-sectional survey, and pre- and post-intervention surveys to assess the utility of an intervention - an "education button". SETTING Department of Ophthalmology at Duke University, a tertiary care academic ophthalmology practice, in Durham, North Carolina. PARTICIPANTS Ophthalmology trainees (37), including residents and clinical fellows, and clinical faculty (50) in the department were surveyed anonymously. The overall response rate for the cross-sectional survey was 83% (72/87). The overall response rate for the educational study was 53% for the first time-point and 59% for the second time-point. RESULTS For the cross-sectional survey, trainees found chart rounds to be useful and would like to increase their frequency. Most faculty reported doing them regularly, although not having enough time was the most common barrier (76% of the faculty). In the pre- and post-assessment of the "education button" (overall response rate 53%), the overall impression was positive with the button easy to use, but the implementation of the button did not appear to change the quality or frequency of chart rounds; nor did it appear to have an effect on covering learning objectives. CONCLUSION While the "education button" could help with communication between the faculty and trainees during a busy clinic session to identify cases for discussion, it did not address the most common barrier identified by faculty members, that of not having enough time.
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Affiliation(s)
- Jullia A Rosdahl
- Department of Ophthalmology, Duke Eye Center, Duke University, Durham, NC, USA
| | - Wenlan Zhang
- Department of Ophthalmology, Duke Eye Center, Duke University, Durham, NC, USA
| | - Varsha Manjunath
- Department of Ophthalmology, Duke Eye Center, Duke University, Durham, NC, USA
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12
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Herrmann-Werner A, Holderried M, Loda T, Malek N, Zipfel S, Holderried F. Navigating Through Electronic Health Records: Survey Study on Medical Students' Perspectives in General and With Regard to a Specific Training. JMIR Med Inform 2019; 7:e12648. [PMID: 31714247 PMCID: PMC6913756 DOI: 10.2196/12648] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 06/14/2019] [Accepted: 08/19/2019] [Indexed: 01/16/2023] Open
Abstract
Background An electronic health record (EHR) is the state-of-the-art method for ensuring all data concerning a given patient are up to date for use by multidisciplinary hospital teams. Therefore, medical students need to be trained to use health information technologies within this environment from the early stages of their education. Objective As little is known about the effects of specific training within the medical curriculum, this study aimed to develop a course module and evaluate it to offer best practice teaching for today’s students. Moreover, we looked at the acceptance of new technologies such as EHRs. Methods Fifth-year medical students (N=104) at the University of Tübingen took part in a standardized two-day training procedure about the advantages and risks of EHR use. After the training, students performed their own EHR entries on hypothetical patient cases in a safe practice environment. In addition, questionnaires—standardized and with open-ended questions—were administered to assess students’ experiences with a new teaching module, a newly developed EHR simulator, the acceptance of the health technology, and their attitudes toward it before and after training. Results After the teaching, students rated the benefit of EHR training for medical knowledge significantly higher than before the session (mean 3.74, SD 1.05). However, they also had doubts about the long-term benefit of EHRs for multidisciplinary coworking after training (mean 1.96, SD 0.65). The special training with simulation software was rated as helpful for preparing students (88/102, 86.2%), but they still did not feel safe in all aspects of EHR. Conclusions A specific simulated training on using EHRs helped students improve their knowledge and become more aware of the risks and challenges of such a system. Overall, students welcomed the new training module and supported the integration of EHR teaching into the medical curriculum. Further studies are needed to optimize training modules and make use of long-term feedback opportunities a simulated system offers.
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Affiliation(s)
- Anne Herrmann-Werner
- Department of Psychosomatic Medicine and Psychotherapy, Internal Medicine, University Hospital Tübingen, Tübingen, Germany
| | - Martin Holderried
- Process and Quality Management, Department of Medical Structure, University Hospital Tübingen, Tübingen, Germany
| | - Teresa Loda
- Department of Psychosomatic Medicine and Psychotherapy, Internal Medicine, University Hospital Tübingen, Tübingen, Germany
| | - Nisar Malek
- Department of Gastroenterology, Hepatology and Infectious Diseases, Internal Medicine, University Hospital Tübingen, Tübingen, Germany
| | - Stephan Zipfel
- Department of Psychosomatic Medicine and Psychotherapy, Internal Medicine, University Hospital Tübingen, Tübingen, Germany
| | - Friederike Holderried
- Department of Gastroenterology, Hepatology and Infectious Diseases, Internal Medicine, University Hospital Tübingen, Tübingen, Germany
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13
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Olaf MF. Pupil Prose Appraisal: Four Practical Solutions to Medical Student Documentation and Feedback in the Emergency Department. AEM EDUCATION AND TRAINING 2019; 3:403-407. [PMID: 31637360 PMCID: PMC6795385 DOI: 10.1002/aet2.10384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 07/22/2019] [Accepted: 07/31/2019] [Indexed: 06/10/2023]
Abstract
Documentation is part of a critical foundation of skills in the undergraduate medical education curriculum. New compliance rules from the Centers for Medicare and Medicaid Services will impact student documentation practices. Common barriers to student documentation include limited access to the electronic medical record, variable clerkship documentation expectations, variable advice regarding utilizing the electronic medical record, and limited time for feedback delivery. Potential solutions to these barriers are suggested to foster documentation skill development. Recommendations are also given to mitigate compliance and legal risk.
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Affiliation(s)
- Mark F. Olaf
- Geisinger Commonwealth School of MedicineGeisinger HealthDanvillePA
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14
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Rosdahl JA, Rudd M, Benjamin R, Wiener JS, Sloane R, Brown A, Robert Lee W, Turner D, Qin R, Atwater AR. Effect of the Adoption of a Comprehensive Electronic Health Record on Graduate Medical Education: Perceptions of Faculty and Trainees. South Med J 2019; 111:476-483. [PMID: 30075473 DOI: 10.14423/smj.0000000000000847] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Health systems are adopting electronic health records (EHRs). There are few studies on the effects of EHR implementation on graduate medical education. The authors sought to longitudinally assess perceptions of the impact of EHRs on graduate medical education during implementation and 2 years after implementation. METHODS A survey was distributed to faculty and trainees during the first year (2013) of adoption of the EHR system. A follow-up survey was distributed 2 years later (2015). The χ2 test was used to compare the quantitative responses, and factor analysis was conducted to identify correlations between items. Free text responses were analyzed qualitatively. RESULTS The initial survey (in 2013) included 290 faculty and 106 trainees; the follow-up survey (in 2015) included 353 faculty and 226 trainees. In 2013, respondents had a positive impression of EHRs. During the implementation phase, participants believed that face-to-face teaching was negatively affected (P = 0.001). Faculty believed EHRs had a negative effect on trainees' ability to take a history/conduct physical examinations (P = 0.002) and to formulate a differential diagnosis/plan independently (P = 0.003). In 2015, faculty opinions of the impact of the EHR remained unchanged; trainee responses were more positive than in 2013 in some areas. Qualitative analysis showed that the most frequent strategies to enhance the educational process were the development of EHR skills and improved chart access and note assistance. CONCLUSIONS Respondents remain positive about the EHR 2 years after implementation. Faculty remain concerned about its effect on the educational process, whereas residents appear more positive regarding the potential for EHRs to enhance their education.
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Affiliation(s)
- Jullia A Rosdahl
- From the Departments of Ophthalmology, Pediatrics, Radiation Oncology, and Dermatology, Duke Center for the Study of Aging and Human Development, and Duke Office of Clinical Research, Duke University Medical Center, Durham, North Carolina, and the Virginia Tech Carilion School of Medicine, Roanoke
| | - Mariah Rudd
- From the Departments of Ophthalmology, Pediatrics, Radiation Oncology, and Dermatology, Duke Center for the Study of Aging and Human Development, and Duke Office of Clinical Research, Duke University Medical Center, Durham, North Carolina, and the Virginia Tech Carilion School of Medicine, Roanoke
| | - Robert Benjamin
- From the Departments of Ophthalmology, Pediatrics, Radiation Oncology, and Dermatology, Duke Center for the Study of Aging and Human Development, and Duke Office of Clinical Research, Duke University Medical Center, Durham, North Carolina, and the Virginia Tech Carilion School of Medicine, Roanoke
| | - John S Wiener
- From the Departments of Ophthalmology, Pediatrics, Radiation Oncology, and Dermatology, Duke Center for the Study of Aging and Human Development, and Duke Office of Clinical Research, Duke University Medical Center, Durham, North Carolina, and the Virginia Tech Carilion School of Medicine, Roanoke
| | - Richard Sloane
- From the Departments of Ophthalmology, Pediatrics, Radiation Oncology, and Dermatology, Duke Center for the Study of Aging and Human Development, and Duke Office of Clinical Research, Duke University Medical Center, Durham, North Carolina, and the Virginia Tech Carilion School of Medicine, Roanoke
| | - Audrey Brown
- From the Departments of Ophthalmology, Pediatrics, Radiation Oncology, and Dermatology, Duke Center for the Study of Aging and Human Development, and Duke Office of Clinical Research, Duke University Medical Center, Durham, North Carolina, and the Virginia Tech Carilion School of Medicine, Roanoke
| | - W Robert Lee
- From the Departments of Ophthalmology, Pediatrics, Radiation Oncology, and Dermatology, Duke Center for the Study of Aging and Human Development, and Duke Office of Clinical Research, Duke University Medical Center, Durham, North Carolina, and the Virginia Tech Carilion School of Medicine, Roanoke
| | - David Turner
- From the Departments of Ophthalmology, Pediatrics, Radiation Oncology, and Dermatology, Duke Center for the Study of Aging and Human Development, and Duke Office of Clinical Research, Duke University Medical Center, Durham, North Carolina, and the Virginia Tech Carilion School of Medicine, Roanoke
| | - Rosie Qin
- From the Departments of Ophthalmology, Pediatrics, Radiation Oncology, and Dermatology, Duke Center for the Study of Aging and Human Development, and Duke Office of Clinical Research, Duke University Medical Center, Durham, North Carolina, and the Virginia Tech Carilion School of Medicine, Roanoke
| | - Amber Reck Atwater
- From the Departments of Ophthalmology, Pediatrics, Radiation Oncology, and Dermatology, Duke Center for the Study of Aging and Human Development, and Duke Office of Clinical Research, Duke University Medical Center, Durham, North Carolina, and the Virginia Tech Carilion School of Medicine, Roanoke
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Cheng DR, Scodellaro T, Uahwatanasakul W, South M. An Electronic Medical Record in Pediatric Medical Education: Survey of Medical Students' Expectations and Experiences. Appl Clin Inform 2018; 9:809-816. [PMID: 30406625 DOI: 10.1055/s-0038-1675371] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE This study sought to quantitatively characterize medical students' expectations and experiences of an electronic health record (EHR) system in a hospital setting, and to examine perceived and actual impacts on learning. METHODS Medical students from July to December 2016 at a tertiary pediatric institution completed pre- and postrotation surveys evaluating their expectations and experience of using an EHR during a pediatric medicine rotation. Survey data included past technology experience, EHR accessibility, use of learning resources, and effect on learning outcomes and patient-clinician communication. RESULTS Students generally reported high computer self-efficacy (4.16 ± 0.752, mean ± standard deviation), were comfortable with learning new software (4.08 ± 0.771), and expected the EHR to enhance their overall learning (4.074 ± 0.722). Students anticipated the EHR to be easy to learn, use, and operate, which was consistent with their experience (pre 3.86 vs. post 3.90, p = 0.56). Students did not expect nor experience that the EHR reduced their interaction, visual contact, or ability to build rapport with patients. The EHR did not meet expectations to facilitate learning around medication prescribing, placing orders, and utilizing online resources. Students found that the EHR marginally improved feedback surrounding clinical contributions to patient care from clinicians, although not to the expected levels (pre 3.50 vs. post 3.17, p < 0.01). CONCLUSION Medical students readily engaged with the EHR, recognized several advantages in clinical practice, and did not consider their ability to interact with patients was impaired. There was widespread consensus that the EHR enhanced their learning and clinician's feedback, but not to the degree they had expected.
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Affiliation(s)
- Daryl R Cheng
- EMR Team, The Royal Children's Hospital Melbourne, Parkville, Australia.,Department of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Carlton, Australia
| | - Thomas Scodellaro
- EMR Team, The Royal Children's Hospital Melbourne, Parkville, Australia
| | - Wonie Uahwatanasakul
- Department of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Carlton, Australia
| | - Mike South
- EMR Team, The Royal Children's Hospital Melbourne, Parkville, Australia.,Department of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Carlton, Australia
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Cox ML, Farjat AE, Risoli TJ, Peskoe S, Goldstein BA, Turner DA, Migaly J. Documenting or Operating: Where Is Time Spent in General Surgery Residency? JOURNAL OF SURGICAL EDUCATION 2018; 75:e97-e106. [PMID: 30522828 PMCID: PMC10765321 DOI: 10.1016/j.jsurg.2018.10.010] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 07/25/2018] [Accepted: 10/11/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE The utilization of electronic health records (EHR) has become essential in the daily activities of physicians for documentation and as an information source. However, the amount of time spent by residents utilizing the EHR has not been thoroughly evaluated, particularly within surgical specialties. This study aims to analyze EHR usage by general surgery residents and to assess the association between this use and case volume at a single academic institution. DESIGN For general surgery residents in clinical years (CY) 1-5, de-identified login and logout time data between September 2016 and June 2017 were retrospectively extracted from the Epic EHR (Verona, WI). A binary time series was created for each resident to indicate and track over time whether he or she was utilizing the EHR system. Comparisons between categorical variables were performed with Fisher's exact test. Continuous variables were compared using Wilcoxon rank sum test. Longitudinal linear mixed-effects models were used to assess the EHR usage among the surgery residents. The association between EHR time and the number of operative cases logged was evaluated with Pearson's correlation coefficient. SETTING This study was performed by the Department of Surgery in conjunction with the Office of Graduate Medical Education at Duke University Health System. PARTICIPANTS All active general surgery residents during the 2016-2017 academic year. RESULTS Thirty-six general surgery residents (28 males, 8 females) spent a median of 2.4 hours per day and 23.7 hours per week using the EHR. CY2 had the highest median usage per week (28.9 hours), while CY3 had the lowest (16.7 hours) but no significant difference based on EHR usage was found among the analyzed CYs (p = 0.164). Residents spent significantly more time logged into the EHR during the week compared to weekends and during the day compared to nights (all p < 0.001). For the residency program as a whole, a median of 151.5 total work hours per day was dedicated to documentation. On average, interns on dedicated night rotations spent 7% of their login time outside regularly scheduled duty hours while interns on dedicated day rotations spent 27%. There was no overall correlation between monthly case logs and EHR usage (r = 0.06, p = 0.30); however, CY2 had a significant negative correlation (r = -0.2, p = 0.038). CONCLUSIONS In the era of a maximum 80-hour work week, general surgery residents spend a substantial portion, at least 30%, of their time utilizing the EHR. One third of EHR usage by interns occurred outside the scheduled 12-hour shift, demonstrating the difficulties of completing paperwork as part of the scheduled work day. Additionally, the lack of correlation to case logs is likely due to an underestimation of the documentation burden associated with operating, which includes preparatory effort and operative notes. Ultimately, these quantitative EHR usage results will be correlated to burnout prior to implementing programs to improve efficiency and decrease the burden of charting.
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Affiliation(s)
- Morgan L Cox
- Department of Surgery, Duke University, Durham, North Carolina.
| | - Alfredo E Farjat
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - T J Risoli
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Sarah Peskoe
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Benjamin A Goldstein
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - David A Turner
- Graduate Medical Education, Duke University Hospital and Health System, Durham, North Carolina
| | - John Migaly
- Department of Surgery, Duke University, Durham, North Carolina
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Scott DJ, Labro E, Penrose CT, Bolognesi MP, Wellman SS, Mather RC. The Impact of Electronic Medical Record Implementation on Labor Cost and Productivity at an Outpatient Orthopaedic Clinic. J Bone Joint Surg Am 2018; 100:1549-1556. [PMID: 30234619 DOI: 10.2106/jbjs.17.01339] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Widespread adoption of electronic medical record (EMR) systems is increasing. EMR implementation can be costly and typically requires workflow redesign. To our knowledge, no studies to date have examined the impact of EMR implementation using advanced cost accounting methods or the impact of its implementation on orthopaedic surgeons in an outpatient setting. METHODS Time-driven activity-based costing (TD-ABC) was used to evaluate the effect of EMR implementation in an outpatient adult reconstruction clinic. One hundred and forty-three patients were prospectively timed throughout their visit to clinics, before implementation of a hospital system-wide EMR system and then again 2 months, 6 months, and 2 years after implementation. Data were analyzed to investigate the effects of EMR implementation on labor cost and provider time. RESULTS Total labor costs per patient visit significantly increased at 2 months after EMR implementation (from $36.88 to $46.04; p = 0.05). Drivers of this change included increases in the amount of time that attending surgeons spent per patient (from 9.38 to 10.97 minutes, with the cost increasing from $21.10 to $27.01), as well as increased time that certified medical assistants spent assessing patients (from 3.4 to 9.1 minutes; p < 0.001). Two months after EMR implementation, providers were spending more than twice as long documenting patient encounters (7.6 compared with 3.3 minutes; p < 0.001). However, by 6 months after implementation, total labor costs were similar to those before implementation ($38.75 compared with $36.88; p = 0.689) and they remained similar at 2 years after implementation ($36.88 compared with $37.73; p = 0.84). After the initial learning period following EMR implementation, providers spent more time documenting encounters (8.43 compared with 3.28 minutes; p < 0.001) but less time interacting with patients (10.03 compared with 14.65 minutes; p = 0.013). CONCLUSIONS Using TD-ABC, we observed the EMR implementation learning period, returning to pre-introduction efficiency at 6 months. Cost increases because of increased certified medical assistant time spent with patients and physician time on documentation were offset by less patient-physician interaction. Health-care systems and policymakers should be aware that the length of the implementation period is approximately 6 months and that implementation may alter the time that providers spend with patients. CLINICAL RELEVANCE This article offers insight into the impact of EMR implementation on the orthopaedic surgeon's clinic efficiency and workflows.
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Affiliation(s)
- Daniel J Scott
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Eva Labro
- Kenan-Flagler Business School, University of North Carolina, Chapel Hill, North Carolina
| | - Colin T Penrose
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | | | - Samuel S Wellman
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Richard C Mather
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
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Harrill PA, Melon DE, Seshul MJ, Zanation A. Perceptions of Electronic Health Records Within Otolaryngology Residents Compared to Practicing Otolaryngologists. Laryngoscope 2018; 128:2726-2731. [PMID: 30194863 DOI: 10.1002/lary.27273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2018] [Indexed: 11/05/2022]
Abstract
OBJECTIVE This study investigated the perceived impact of electronic health records (EHR) on otolaryngology residents with regard to education, patient care, and workflow, and then compared the trends with those of practicing otolaryngologists. METHODS A descriptive, cross-sectional survey was developed for each core study group: the otolaryngology resident group (ORG) and the practicing otolaryngologist group (POG). In total, 536 surveys were submitted: 33 from the ORG survey and 510 from the POG survey. Response rates were 51.5% and 21.3%, respectively. RESULTS Within the two study groups, ORG reported a predominately neutral response relating to the impact of EHR on experience compared with the POG, which reported far more negative responses. The most negative reported change in the ORG related to feeling more like a passive observer and scribe in terms of how EHR negatively impacted the role of resident. Within the POG group, the majority of negative responses were recorded on the impact of EHR on practice efficiency, practice overhead, and number of employees required to maintain practice function. CONCLUSION With otolaryngologists making up 1.1% of the U.S. physician workforce in 2015, it is likely that software programing of EHR underrepresents the workflow needs of otolaryngologists at this time. Future studies investigating the impact of EHR on otolaryngology patient care and resident education are needed in the future. Laryngoscope, 128:2726-2731, 2018.
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Affiliation(s)
- Peter A Harrill
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, UNC Neuroscience Hospital, Chapel Hill, North Carolina, U.S.A
| | - David E Melon
- Carolina Ear, Nose & Throat-Head and Neck Surgery Center, PA, Hickory, North Carolina, U.S.A
| | - Merritt J Seshul
- Carolina Ear, Nose & Throat-Head and Neck Surgery Center, PA, Hickory, North Carolina, U.S.A.,Department of Otolaryngology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, U.S.A
| | - Adam Zanation
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, UNC Neuroscience Hospital, Chapel Hill, North Carolina, U.S.A
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The Future of Obstetrics and Gynecology: MACRA, Electronic Health Records, and More. Clin Obstet Gynecol 2018; 60:840-852. [PMID: 29035903 DOI: 10.1097/grf.0000000000000326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
There is immense change affecting obstetrical and gynecologic medical practice at this moment in time-involving reimbursement with the shift from volume-based to value-based care, increasing regulation, and workforce sustainability. Aspects to be reviewed in this chapter include reimbursements and Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), electronic medical records, physician satisfaction surveys, maintenance of certification, and physician burnout.
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Gagliardi JP, Rudd MJ. Sometimes determination and compromise thwart success: lessons learned from an effort to study copying and pasting in the electronic medical record. PERSPECTIVES ON MEDICAL EDUCATION 2018; 7:4-7. [PMID: 29687332 PMCID: PMC6002280 DOI: 10.1007/s40037-018-0427-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Jane P Gagliardi
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, USA.
| | - Mariah J Rudd
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, USA
- Education & Faculty Development, Office of Continuing Professional Development, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
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Kim JG, Rodriguez HP, Estlin KA, Morris CG. Impact of Longitudinal Electronic Health Record Training for Residents Preparing for Practice in Patient-Centered Medical Homes. Perm J 2018; 21:16-122. [PMID: 28746024 DOI: 10.7812/tpp/16-122] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Competence in using an electronic health record (EHR) is considered a critical skill for physicians practicing in patient-centered medical homes (PCMHs), but few studies have examined the impact of EHR training for residents preparing to practice in PCMHs. This study explored the educational outcomes associated with comprehensive EHR training for family medicine residents. METHODS The PCMH EHR training consisted of case-based routine clinic visits delivered to 3 resident cohorts (N = 18). Participants completed an EHR competency self-assessment between 2011 and 2016 (N = 127), examining 6 EHR/PCMH core skills. We compared baseline characteristics for residents by low vs high exposure to EHR training. Multivariate regression estimated whether self-reported competencies improved over time and whether high PCMH EHR training exposure was associated with incremental improvement in self-reported competencies over time. RESULTS Residents completed an average of 8.2 sessions: low-exposure residents averaged 5.3 sessions (standard deviation = 1.5), and high-exposure residents averaged 9.0 sessions (standard deviation = 0.9). High-exposed residents had higher posttest scores at training completion (84.4 vs 70.7). Over time, adjusted mean scores (confidence interval) for both groups improved (p < 0.001) from 12.2 (9.6-14.8), with low-exposed residents having greater score improvement (p < 0.001) because of their much lower baseline scores. CONCLUSION Comprehensive training designed to improve EHR competencies among residents practicing in a PCMH resulted in improved assessment scores. Our findings indicate EHR training as part of resident exposure to the PCMH measurably improves self-assessed competencies, even among residents less engaged in EHR training.
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Affiliation(s)
- Jung G Kim
- Clinical Teaching Associate in the Department of Family Medicine at the University of Washington School of Medicine in Seattle.
| | - Hector P Rodriguez
- Co-Director for the Center of Healthcare Organizational Innovation Research and a Professor of Health Policy and Management at the University of California School of Public Health in Berkeley.
| | | | - Carl G Morris
- Program Director at Group Health Family Medicine Residency and a Clinical Associate Professor in the Department of Family Medicine at the University of Washington School of Medicine in Seattle.
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Fuglestad MA, Schenarts PJ. Supervision Is Not Education: The Dark Side of Remote Access to the Electronic Health Record. J Grad Med Educ 2017; 9:714-715. [PMID: 29270259 PMCID: PMC5734324 DOI: 10.4300/jgme-d-17-00737.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Rodriguez Torres Y, Huang J, Mihlstin M, Juzych MS, Kromrei H, Hwang FS. The effect of electronic health record software design on resident documentation and compliance with evidence-based medicine. PLoS One 2017; 12:e0185052. [PMID: 28934326 PMCID: PMC5608474 DOI: 10.1371/journal.pone.0185052] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 09/06/2017] [Indexed: 12/03/2022] Open
Abstract
This study aimed to determine the role of electronic health record software in resident education by evaluating documentation of 30 elements extracted from the American Academy of Ophthalmology Dry Eye Syndrome Preferred Practice Pattern. The Kresge Eye Institute transitioned to using electronic health record software in June 2013. We evaluated the charts of 331 patients examined in the resident ophthalmology clinic between September 1, 2011, and March 31, 2014, for an initial evaluation for dry eye syndrome. We compared documentation rates for the 30 evidence-based elements between electronic health record chart note templates among the ophthalmology residents. Overall, significant changes in documentation occurred when transitioning to a new version of the electronic health record software with average compliance ranging from 67.4% to 73.6% (p < 0.0005). Electronic Health Record A had high compliance (>90%) in 13 elements while Electronic Health Record B had high compliance (>90%) in 11 elements. The presence of dialog boxes was responsible for significant changes in documentation of adnexa, puncta, proptosis, skin examination, contact lens wear, and smoking exposure. Significant differences in documentation were correlated with electronic health record template design rather than individual resident or residents’ year in training. Our results show that electronic health record template design influences documentation across all resident years. Decreased documentation likely results from “mouse click fatigue” as residents had to access multiple dialog boxes to complete documentation. These findings highlight the importance of EHR template design to improve resident documentation and integration of evidence-based medicine into their clinical notes.
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Affiliation(s)
- Yasaira Rodriguez Torres
- Department of Ophthalmology, Kresge Eye Institute, Detroit, Michigan, United States of America
- * E-mail:
| | - Jordan Huang
- School of Medicine, Wayne State University, Detroit, Michigan, United States of America
| | - Melanie Mihlstin
- Department of Ophthalmology, Kresge Eye Institute, Detroit, Michigan, United States of America
| | - Mark S. Juzych
- Department of Ophthalmology, Kresge Eye Institute, Detroit, Michigan, United States of America
| | - Heidi Kromrei
- Department of Ophthalmology, Kresge Eye Institute, Detroit, Michigan, United States of America
| | - Frank S. Hwang
- Department of Ophthalmology, Kresge Eye Institute, Detroit, Michigan, United States of America
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Factors Affecting in Adoption and Use of Electronic Medical Record Based on Unified Theory of Acceptance and Use of Technology in Iran. ACTA ACUST UNITED AC 2017. [DOI: 10.5812/semj.57582] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Solarte I, Könings KD. Discrepancies between perceptions of students and deans regarding the consequences of restricting students' use of electronic medical records on quality of medical education. BMC MEDICAL EDUCATION 2017; 17:55. [PMID: 28288618 PMCID: PMC5347834 DOI: 10.1186/s12909-017-0887-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 02/17/2017] [Indexed: 06/06/2023]
Abstract
BACKGROUND Electronic medical records (EMR) are more used in university hospitals, but the use of EMR by medical students at the workplace is still a challenge, because the conflict of interest between medical accountability for hospitals and quality of medical education programs for students. Therefore, this study investigates the use of EMR from the perspective of medical school deans and students, and determines their perceptions and concerns about consequences of restricted use of EMR by students on quality of education and patient care. METHODS We administered a large-scale survey about the existence of EMR, existing policies, students' use for learning, and consequences on patient care to 42 deans and 789 Residency Physician Applicants in a private university in Colombia. Data from 26 deans and 442 former graduated students were compared with independent t tests and chi square tests. RESULTS Only half of medical schools had learning programs and policies about the use of EMR by students. Deans did not realize that students have less access to EMR than to paper-based MR. Perceptions of non-curricular learning opportunities how to write in (E)MR were significantly different between deans and students. Limiting students use of EMR has negative consequences on medical education, according to both deans and students, while deans worried significantly more about impact on patient care than students. Billing issues and liability aspects were their major concerns. CONCLUSIONS There is a need for a clear policy and educational program on the use of EMR by students. Discrepancies between the planned curriculum by deans and the real clinical learning environment as experienced by students indicate suboptimal learning opportunities for students. Creating powerful workplace-learning experiences and resolving concerns on students use of EMR has to be resolved in a constructive collaboration way between the involved stakeholders, including also EMR designers and hospital administrators. We recommend intense supervision of students' work in EMR to take full advantage of the technological advances of EMR at the modern clinical site, both for patient care and for medical education.
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Affiliation(s)
- Ivan Solarte
- Pontificia Universidad Javeriana School of Medicine, Hospital Universitario San Ignacio, Carrera 7 40-62, Bogota, Colombia
| | - Karen D. Könings
- Department of Educational Development & Research and Graduate School of Health Professions Education, Maastricht University, Maastricht, The Netherlands
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Atwater AR, Rudd M, Brown A, Wiener JS, Benjamin R, Lee WR, Rosdahl JA. Developing Teaching Strategies in the EHR Era: A Survey of GME Experts. J Grad Med Educ 2016; 8:581-586. [PMID: 27777671 PMCID: PMC5058593 DOI: 10.4300/jgme-d-15-00788.1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 03/29/2016] [Accepted: 04/20/2016] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND There is limited information on the impact of widespread adoption of the electronic health record (EHR) on graduate medical education (GME). OBJECTIVE To identify areas of consensus by education experts, where the use of EHR impacts GME, with the goal of developing strategies and tools to enhance GME teaching and learning in the EHR environment. METHODS Information was solicited from experienced US physician educators who use EPIC EHR following 3 steps: 2 rounds of online surveys using the Delphi technique, followed by telephone interviews. The survey contained 3 stem questions and 52 items with Likert-scale responses. Consensus was defined by predetermined cutoffs. A second survey reassessed items for which consensus was not initially achieved. Common themes to improve GME in settings with an EHR were compiled from the telephone interviews. RESULTS The panel included 19 physicians in 15 states in Round 1, 12 in Round 2, and 10 for the interviews. Ten items were found important for teaching and learning: balancing focus on EHR documentation with patient engagement achieved 100% consensus. Other items achieving consensus included adequate learning time, balancing EHR data with verbal history and physical examination, communicating clinical thought processes, hands-on EHR practice, minimizing data repetition, and development of shortcuts and templates. Teaching strategies incorporating both online software and face-to-face solutions were identified during the interviews. CONCLUSIONS New strategies are needed for effective teaching and learning of residents and fellows, capitalizing on the potential of the EHR, while minimizing any unintended negative impact on medical education.
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Affiliation(s)
| | - Mariah Rudd
- Corresponding author: Mariah Rudd, BS, Duke University, Box 3951 DUMC, 200 Trent Drive, Durham, NC 27710, 919.613.3777, fax 919.684.8565,
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Rowlands S, Coverdale S, Callen J. Documentation of clinical care in hospital patients' medical records: A qualitative study of medical students' perspectives on clinical documentation education. Health Inf Manag 2016; 45:99-106. [PMID: 27105479 DOI: 10.1177/1833358316639448] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Clinical documentation is essential for communication between health professionals and the provision of quality care to patients. OBJECTIVE To examine medical students' perspectives of their education in documentation of clinical care in hospital patients' medical records. METHOD A qualitative design using semi-structured interviews with fourth-year medical students was undertaken at a hospital-based clinical school in an Australian university. RESULTS Several themes reflecting medical students' clinical documentation education emerged from the data: formal clinical documentation education using lectures and tutorials was minimal; most education occurred on the job by junior doctors and student's expressed concerns regarding variation in education between teams and receiving limited feedback on performance. Respondents reported on the importance of feedback for their learning of disease processes and treatments. They suggested that improvements could be made in the timing of clinical documentation education and they stressed the importance of training on the job. CONCLUSION On-the-job education with feedback in clinical documentation provides a learning opportunity for medical students and is essential in order to ensure accurate, safe, succinct and timely clinical notes.
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Affiliation(s)
- Stella Rowlands
- Sunshine Coast Hospital and Health Service, Australia .,Queensland University of Technology, Australia
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Tichelaar J, van Unen RJ, Brinkman DJ, Fluitman PHM, van Agtmael MA, de Vries TPGM, Richir MC. Structure, importance and recording of therapeutic information in the medical record: a multicentre observational study. J Eval Clin Pract 2015; 21:1129-34. [PMID: 26268691 DOI: 10.1111/jep.12432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/13/2015] [Indexed: 12/01/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Structuring the diagnostic section of the medical record (MR) improves diagnosis and communication between doctors. However, little is known about the therapeutic section of the MR. The aim of this study was to gain insight into the extent to which MRs are structured for therapeutic information, to determine which therapeutic data registrars and clinical consultants consider should be recorded in the MR and to what extent registrars record this information themselves. METHODS A multicentre observational study was carried out in the internal medicine outpatient clinics of five teaching hospitals in the Netherlands. Preformatted structure, importance and actual recording of therapeutic information was compared with a reference list of 35 therapeutic items based on the WHO Guide to Good Prescribing (e.g. drug name, indication for drug). RESULTS The preformatted structure of four paper MRs and one electronic MR was assessed. Eight of the 35 therapeutic items were listed in the paper MRs and 18 items in the electronic MR. Registrars and consultants agreed on the importance of recording most of the therapeutic items in the MR, 25 and 27 out of the 35 items, respectively; however, registrars recorded only 11 of the 35 items in the paper MR and 20 of the 35 items in the electronic MR. CONCLUSIONS The structure and content of paper and electronic MRs are not adequate. While both registrars and consultants agree on the importance of recording therapeutic items in the MR, registrars fail to record most of this information in practice. The results of this study can be used as starting point for the discussion regarding the necessity of structured recording of therapeutic information in the MR and its possible benefits with regard to medication safety and training of the new generation of prescribers.
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Affiliation(s)
- Jelle Tichelaar
- Department of Internal Medicine, Section Pharmacotherapy, VU University Medical Center, Amsterdam, The Netherlands.,RECIPE (Research & Expertise Center In Pharmacotherapy Education), VU University Medical Center, Amsterdam, The Netherlands
| | - Robert J van Unen
- Department of Internal Medicine, Section Pharmacotherapy, VU University Medical Center, Amsterdam, The Netherlands.,RECIPE (Research & Expertise Center In Pharmacotherapy Education), VU University Medical Center, Amsterdam, The Netherlands
| | - David J Brinkman
- Department of Internal Medicine, Section Pharmacotherapy, VU University Medical Center, Amsterdam, The Netherlands.,RECIPE (Research & Expertise Center In Pharmacotherapy Education), VU University Medical Center, Amsterdam, The Netherlands
| | - Pieter H M Fluitman
- Department of Internal Medicine, Section Pharmacotherapy, VU University Medical Center, Amsterdam, The Netherlands
| | - Michiel A van Agtmael
- Department of Internal Medicine, Section Pharmacotherapy, VU University Medical Center, Amsterdam, The Netherlands.,RECIPE (Research & Expertise Center In Pharmacotherapy Education), VU University Medical Center, Amsterdam, The Netherlands
| | - Theo P G M de Vries
- Department of Internal Medicine, Section Pharmacotherapy, VU University Medical Center, Amsterdam, The Netherlands.,RECIPE (Research & Expertise Center In Pharmacotherapy Education), VU University Medical Center, Amsterdam, The Netherlands
| | - Milan C Richir
- Department of Internal Medicine, Section Pharmacotherapy, VU University Medical Center, Amsterdam, The Netherlands.,RECIPE (Research & Expertise Center In Pharmacotherapy Education), VU University Medical Center, Amsterdam, The Netherlands
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Overcoming Electronic Medical Record Challenges on the Obstetrics and Gynecology Clerkship. Obstet Gynecol 2015; 126:553-558. [DOI: 10.1097/aog.0000000000001004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Stewart E, Kahn D, Lee E, Simon W, Duncan M, Mosher H, Harris K, Bell J, El-Farra N, Sharpe B. Internal medicine progress note writing attitudes and practices in an electronic health record. J Hosp Med 2015; 10:525-9. [PMID: 26138806 DOI: 10.1002/jhm.2379] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 04/08/2015] [Accepted: 04/26/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND The electronic health record (EHR) has been viewed with both praise and skepticism. Multiple editorials have expressed concerns that EHR implementation and "efficiency tools" such as copy forward and auto population have resulted in a decrement in note accuracy, relevance, and critical thinking. OBJECTIVE To evaluate the perceptions of internal medicine housestaff and attendings on inpatient progress note quality at 4 academic institutions after the implementation of an EHR. DESIGN Cross-sectional survey. MEASUREMENTS We developed surveys that assessed housestaff and attendings opinion of current progress note quality, the impact of the EHR on quality, and the purposes of a progress note. RESULTS We received 99 completed surveys from interns (66%), 155 from residents (49%), and 153 from attendings (70%) across 4 institutions. The majority of housestaff responded that the quality of notes was "unchanged" or "better" following the implementation of an EHR, whereas attendings believed note quality was "unchanged" or "worse." Attendings' perceptions of housestaff notes were significantly lower than housestaff perceptions of their own notes across all domains. With regard to the effect of copy forward and autopopulation, the majority of housestaff viewed these to be "neutral" or "somewhat positive," whereas attendings viewed these as "neutral" or "somewhat negative." Housestaff and attendings had nearly perfect agreement regarding the purpose of the progress note. CONCLUSIONS Attendings and housestaff disagree on the current quality of progress notes and the impact of an EHR on note quality, but agree on the purpose of a progress note.
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Affiliation(s)
- Elizabeth Stewart
- Department of Medicine, Division of Hospital Medicine, University of California, San Francisco, San Francisco, California
- Department of Medicine, Division of Hospital Medicine, Alameda Health System, Oakland, California
| | - Daniel Kahn
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Edward Lee
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Wendy Simon
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Mark Duncan
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Hilary Mosher
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Katherine Harris
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - John Bell
- Department of Internal Medicine, Division of Hospital Medicine, University of California, San Diego, San Diego, California
| | - Neveen El-Farra
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Bradley Sharpe
- Department of Medicine, Division of Hospital Medicine, University of California, San Francisco, San Francisco, California
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Brisson GE, Neely KJ, Tyler PD, Barnard C. Should medical students track former patients in the electronic health record? An emerging ethical conflict. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2015; 90:1020-1024. [PMID: 25565261 DOI: 10.1097/acm.0000000000000633] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Medical students are increasingly using electronic health records (EHRs) in clerkships, and medical educators should seek opportunities to use this new technology to improve training. One such opportunity is the ability to "track" former patients in the EHR, defined as following up on patients in the EHR for educational purposes for a defined period of time after they have left one's direct care. This activity offers great promise in clinical training by enabling students to audit their diagnostic impressions and follow the clinical history of illness in a manner not possible in the era of paper charting. However, tracking raises important questions about the ethical use of protected health information, including concerns about compromising patient autonomy, resulting in a conflict between medical education and patient privacy. The authors offer critical analysis of arguments on both sides and discuss strategies to balance the ethical conflict by optimizing outcomes and mitigating harms. They observe that tracking improves training, thus offering long-lasting benefits to society, and is supported by the principle of distributive justice. They conclude that students should be permitted to track for educational purposes, but only with defined limits to safeguard patient autonomy, including obtaining permission from patients, having legitimate educational intent, and self-restricting review of records to those essential for training. Lastly, the authors observe that this conflict will become increasingly important with completion of the planned Nationwide Health Information Network and emphasize the need for national guidelines on tracking patients in an ethically appropriate manner.
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Affiliation(s)
- Gregory E Brisson
- G.E. Brisson is assistant professor in clinical medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois. K.J. Neely is assistant professor in medicine, Feinberg School of Medicine, Northwestern University, and chair, Medical Ethics Committee, Northwestern Memorial Hospital, Chicago, Illinois. P.D. Tyler was a final-year medical student, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, at the time this article was written. He is now a first-year resident, Beth Israel Deaconess Medical Center, Boston, Massachusetts. C. Barnard is director of quality strategies, Northwestern Memorial Hospital, and research associate professor, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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van Unen RJ, Tichelaar J, Nanayakkara PWB, van Agtmael MA, Richir MC, de Vries TPGM. A Delphi study among internal medicine clinicians to determine which therapeutic information is essential to record in a medical record. J Clin Pharmacol 2015; 55:1415-21. [PMID: 26096268 DOI: 10.1002/jcph.565] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 06/05/2015] [Indexed: 11/08/2022]
Abstract
Several studies have demonstrated that using a template for recording general and diagnostic information in the medical record (MR) improves the completeness of MR documentation, communication between doctors, and performance of doctors. However, little is known about how therapeutic information should be structured in the MR. The aim of this study was to investigate which specific therapeutic information registrars and consultants in internal medicine consider essential to record in the MR. Therefore, we carried out a 2-round Internet Delphi study. Fifty-nine items were assessed on a 5-point scale; an item was considered important if ≥ 80% of the respondents awarded it a score of 4 or 5. In total, 26 registrars and 30 consultants in internal medicine completed both rounds of the study. Overall, they considered it essential to include information about 11 items in the MR. Subgroup analyses revealed that the registrars considered 8 additional items essential, whereas the consultants considered 1 additional item essential to record. Study findings can be used as a starting point to develop a structured section of the MR for therapeutic information for both paper and electronic MRs. This section should contain at least 11 items considered essential by registrars and clinical consultants in internal medicine.
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Affiliation(s)
- Robert J van Unen
- RECIPE (Research and Expertise Center In Pharmacotherapy Education), VU University Medical Center, Amsterdam, the Netherlands.,Department of Internal Medicine, Section Pharmacotherapy, VU University Medical Center, Amsterdam, the Netherlands
| | - Jelle Tichelaar
- RECIPE (Research and Expertise Center In Pharmacotherapy Education), VU University Medical Center, Amsterdam, the Netherlands.,Department of Internal Medicine, Section Pharmacotherapy, VU University Medical Center, Amsterdam, the Netherlands
| | | | - Michiel A van Agtmael
- RECIPE (Research and Expertise Center In Pharmacotherapy Education), VU University Medical Center, Amsterdam, the Netherlands.,Department of Internal Medicine, Section Pharmacotherapy, VU University Medical Center, Amsterdam, the Netherlands.,Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands
| | - Milan C Richir
- RECIPE (Research and Expertise Center In Pharmacotherapy Education), VU University Medical Center, Amsterdam, the Netherlands.,Department of Internal Medicine, Section Pharmacotherapy, VU University Medical Center, Amsterdam, the Netherlands
| | - Theo P G M de Vries
- RECIPE (Research and Expertise Center In Pharmacotherapy Education), VU University Medical Center, Amsterdam, the Netherlands.,Department of Internal Medicine, Section Pharmacotherapy, VU University Medical Center, Amsterdam, the Netherlands
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Varpio L, Day K, Elliot-Miller P, King JW, Kuziemsky C, Parush A, Roffey T, Rashotte J. The impact of adopting EHRs: how losing connectivity affects clinical reasoning. MEDICAL EDUCATION 2015; 49:476-86. [PMID: 25924123 DOI: 10.1111/medu.12665] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 10/08/2014] [Accepted: 11/17/2014] [Indexed: 05/05/2023]
Abstract
CONTEXT As electronic health records (EHRs) are adopted by teaching hospitals, educators must examine how this change impacts trainee development. OBJECTIVES We investigate this influence by studying clinician experiences of a hospital's move from paper charts to an EHR. We ask: how does each chart modality present conceptions of time and data interconnections? How do these conceptions affect clinical reasoning? METHODS This two-phase, longitudinal study employed constructivist grounded theory. Data were collected at a paediatric teaching hospital before (Phase 1), during and after (Phase 2) the transition from a paper chart to an EHR system. Data collection consisted of field observations (146 hours involving 300 health care providers, 22 patients and 32 patient family members), think-aloud (n = 13) and think-after (n = 11) sessions, interviews (n = 39) and document retrieval (n = 392). Theories of rhetorical genre studies and visual rhetoric informed analysis. RESULTS In the paper flowsheet, clinicians recorded and viewed patient data in chronologically organised displays that emphasised data interconnections. In the EHR flowsheet, clinicians viewed and recorded individual data points that were largely chronologically and contextually isolated. Clinicians reported that this change resulted in: (i) not knowing the patient's evolving status; (ii) increased cognitive workload, and (iii) loss of clinical reasoning support mechanisms. CONCLUSIONS Understanding how patient data are interconnected is essential to clinical reasoning. The use of EHRs supports this goal because the EHR is a tool for collecting dispersed data; however, these collections often deconstruct data interconnections. Where the paper flowsheet emphasises chronology and interconnectedness, the EHR flowsheet emphasises individual data values that are largely independent of time and other patient data. To prepare trainees to work with EHRs, the ways of thinking and acting that were implicitly learned through the use of paper charts must be made explicit. To support clinical reasoning, medical educators should provide lessons in connectivity – the chronologically framed data interconnections upon which clinicians rely to provide patient care.
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Affiliation(s)
- Lara Varpio
- Faculty of Medicine, Uniformed Services University for the Health Sciences, Bethesda, Maryland, USA; Faculty of Medicine, Academy for Innovation in Medical Education, University of Ottawa, Ottawa, Ontario, Canada
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Zonfrillo MR, Sauber-Schatz EK, Hoffman BD, Durbin DR. Pediatricians' self-reported knowledge, attitudes, and practices about child passenger safety. J Pediatr 2014; 165:1040-5.e1-2. [PMID: 25195160 PMCID: PMC4253538 DOI: 10.1016/j.jpeds.2014.07.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 06/11/2014] [Accepted: 07/23/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate pediatricians' self-reported knowledge, attitudes, and dissemination practices regarding the new American Academy of Pediatrics' (AAP) child passenger safety (CPS) policy recommendations. STUDY DESIGN A cross-sectional survey was distributed to pediatric primary care physicians via AAP e-mail distribution lists. Knowledge, attitudes, and practices related to current AAP CPS recommendations and the revised policy statement were ascertained. RESULTS There were 718 respondents from 3497 physicians with active e-mail addresses, resulting in a 20.5% response rate, of which 533 were eligible based on the initial survey question. All 6 CPS knowledge and scenario-based items were answered correctly by 52.9% of the sample; these respondents were identified as the "high knowledge" group. Pediatricians with high knowledge were more likely to be female (P < .001), to have completed a pediatrics residency (vs medicine-pediatrics) (P = .03), and have a child between 4 and 7 years of age (P = .001). CPS information was distributed more frequently at routine health visits for patients 0-2 years of age vs those 4-12 years of age. Those with high knowledge were less likely to report several specific barriers to dissemination of CPS information, more likely to allot adequate time and discuss CPS with parents, and had greater confidence for topics related to all CPS topics. CONCLUSIONS Although CPS knowledge is generally high among respondents, gaps in knowledge still exist. Knowledge is associated with attitudes, practices, barriers, and facilitators of CPS guideline dissemination. These results identify opportunities to increase knowledge and implement strategies to routinely disseminate CPS information in the primary care setting.
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Affiliation(s)
- Mark R Zonfrillo
- Division of Emergency Medicine, Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Erin K Sauber-Schatz
- Home, Recreation, and Transportation Branch, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA
| | - Benjamin D Hoffman
- Department of Pediatrics, Oregon Health & Science University Doernbecher Children's Hospital, Portland, OR
| | - Dennis R Durbin
- Division of Emergency Medicine, Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Chi J, Kugler J, Chu IM, Loftus PD, Evans KH, Oskotsky T, Basaviah P, Braddock CH. Medical students and the electronic health record: 'an epic use of time'. Am J Med 2014; 127:891-5. [PMID: 24907594 DOI: 10.1016/j.amjmed.2014.05.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 04/02/2014] [Accepted: 05/29/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Jeffrey Chi
- Department of Internal Medicine, Division of General Medical Disciplines, Stanford University School of Medicine, Stanford, Calif.
| | - John Kugler
- Department of Internal Medicine, Division of General Medical Disciplines, Stanford University School of Medicine, Stanford, Calif
| | - Isabella M Chu
- Department of Internal Medicine, Division of General Medical Disciplines, Stanford University School of Medicine, Stanford, Calif
| | - Pooja D Loftus
- Department of Internal Medicine, Division of General Medical Disciplines, Stanford University School of Medicine, Stanford, Calif
| | - Kambria H Evans
- Department of Internal Medicine, Division of General Medical Disciplines, Stanford University School of Medicine, Stanford, Calif
| | - Tomiko Oskotsky
- Department of Internal Medicine, Division of General Medical Disciplines, Stanford University School of Medicine, Stanford, Calif
| | - Preetha Basaviah
- Department of Internal Medicine, Division of General Medical Disciplines, Stanford University School of Medicine, Stanford, Calif
| | - Clarence H Braddock
- Department of Internal Medicine, Division of General Medical Disciplines, Stanford University School of Medicine, Stanford, Calif; Office of the Dean, UCLA David Geffen School of Medicine, Los Angeles, Calif
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Tierney MJ, Pageler NM, Kahana M, Pantaleoni JL, Longhurst CA. Medical education in the electronic medical record (EMR) era: benefits, challenges, and future directions. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2013; 88:748-52. [PMID: 23619078 DOI: 10.1097/acm.0b013e3182905ceb] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
In the last decade, electronic medical record (EMR) use in academic medical centers has increased. Although many have lauded the clinical and operational benefits of EMRs, few have considered the effect these systems have on medical education. The authors review what has been documented about the effect of EMR use on medical learners through the lens of the Accreditation Council for Graduate Medical Education's six core competencies for medical education. They examine acknowledged benefits and educational risks to use of EMRs, consider factors that promote their successful use when implemented in academic environments, and identify areas of future research and optimization of EMRs' role in medical education.
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Affiliation(s)
- Michael J Tierney
- Compensation and Pension and Ambulatory Care, VA Palo Alto Healthcare System, Palo Alto, California 94304, USA.
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Ellaway RH, Graves L, Greene PS. Medical education in an electronic health record-mediated world. MEDICAL TEACHER 2013; 35:282-286. [PMID: 23464893 DOI: 10.3109/0142159x.2013.773396] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
This paper reflects on the extent to which we are preparing learners for practice in an electronic health record (EHR)-mediated world. We are currently training the last generation to remember a world without the Internet and the first who will practice in a largely EHR-mediated practice environment. We undertook a thematic review of the literature connecting medical education with e-health using the concepts of 'electronic health record' or 'electronic medical record' as a proxy for the broader notion of e-health. Our findings are more equivocal and cautious than earlier commentators might have expected and while there are examples of good practice and successful integration, the majority of articles we reviewed raised issues and problems with the current links between EHRs and medical education. Medical professionals in particular are quite ambivalent about many of the changes brought about by EHRs, and in the absence of changes in perception and practice it is likely that the connections between medical education and e-health will continue to be problematic. We hope that this paper will lead to an improved understanding of these problems and will serve to advance the discourse on how medical education should engage with the world of e-health and the world of e-health with medical education.
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Gomes AW, Linton A, Abate L. Strengthening Our Collaborations: Building an Electronic Health Record Educational Module. ACTA ACUST UNITED AC 2013. [DOI: 10.1080/15424065.2012.762202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Oxentenko AS, Manohar CU, McCoy CP, Bighorse WK, McDonald FS, Kolars JC, Levine JA. Internal medicine residents' computer use in the inpatient setting. J Grad Med Educ 2012; 4:529-32. [PMID: 24294435 PMCID: PMC3546587 DOI: 10.4300/jgme-d-12-00026.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Revised: 05/10/2012] [Accepted: 05/14/2012] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Studies have suggested that patient contact time for internal medicine residents is decreasing and being replaced with computer-related activities, yet objective data regarding computer use by residents are lacking. OBJECTIVE The aim of this study was to objectively measure time use by internal medicine residents while on duty in the hospital setting using real-time, voice-capture technology. METHODS First- and third-year categoric internal medicine residents participated (n = 25) during a 3-month period in 2010 while rotating on general internal medicine rotations. Portable speech-recognition technology was used to record residents' activities. The residents were prompted every 15 minutes from an earpiece and asked to categorize the activity they had been doing since the last prompt, choosing from a predetermined list of 15 activities. RESULTS Of the 1008 duty-time responses, 493 (49%) were classified as computer-related activities, whereas 341 (34%) were classified as direct patient care, 110 (11%) were classified as noncomputer-related education, and 64 (6%) were classified as other activities. Of resident reported computer-use time, 70% was spent on patient notes and order entry. CONCLUSIONS The results of our study suggest that computer use is the predominant activity for internal medicine residents while in the inpatient setting. Work redesign because of duty hour regulations should consider how to free up residents' time from computer-based activities to allow residents to engage in more direct patient care and noncomputer-based learning.
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de la Torre-Díez I, López-Coronado M, Rodrigues JJPC. How to measure the QoS of a web-based EHRs system: development of an instrument. J Med Syst 2012; 36:3725-31. [PMID: 22427175 DOI: 10.1007/s10916-012-9845-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Accepted: 03/06/2012] [Indexed: 10/28/2022]
Abstract
The quality of service (QoS) can be treated as a set of concepts whose satisfaction/dissatisfaction generates a global positive/negative vision about the service provided by any application. The different nature of the services and its features require an analysis of the factors that have the greatest influence on the users' opinion and, therefore, measuring the quality of service in each application requires a specific instrument. This paper will introduce an instrument to measure the QoS offered to users by a general Web application for Electronic Health Records (EHRs). The collection of opinions from a pilot sample and the performance of an explanatory factor analysis will bring together the factors that best sum up the quality of an EHRs application. Subsequently, a confirmatory factor analysis will be performed to make the study reliable and, as its name suggests, to confirm that indeed the structure of the instrument developed measures the QoS in accordance with the requirements of the users.
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Affiliation(s)
- Isabel de la Torre-Díez
- Department of Signal Theory and Communications, University of Valladolid, Paseo de Belén, 15, 47011 Valladolid, Spain.
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