Should medical students track former patients in the electronic health record? An emerging ethical conflict

A patient follow-up intervention to improve medical decision making at an internal medicine residency program

OBJECTIVES

Practice-based learning and improvement (PBLI) is an ACGME (Accreditation Council for Graduate Medical Education) core competency. Learning and reflecting on patients through follow-up is one method to help achieve this competency. We therefore designed a study evaluating a structured patient follow-up intervention for senior internal medicine (IM) residents at the University of Colorado Hospital (UCH).

METHODS

Trainees completed structured reflections after performing chart review of prior patients during protected educational time. Two-month follow-up surveys evaluated the exercise's potential influence on clinical and reflective practices.

RESULTS

Forty out of 108 (37 %) eligible residents participated in the exercise. Despite 62.5 % of participants lacking specific questions about patient outcomes before chart review, 81.2 % found the exercise at least moderately helpful. 48.4 % of participants believed that the review would change their practice, and 60.9 % felt it reinforced their existing clinical practices. In our qualitative data, residents learned lessons related to challenging clinical decisions, improving transitions of care, the significance of early goals of care conversations, and diagnostic errors/strategies.

CONCLUSIONS

Our results indicate that IM residents found a structured patient follow-up intervention educational, even when they lacked specific patient outcomes questions. Our results underscore the importance of structured self-reflection in the continuous learning process of trainees and suggest the benefit of dedicated educational time for this process.

How to Keep Training-After Residency Training

Lifelong learning in medicine is an important skill and ethical obligation, but many residents do not feel prepared to be effective self-directed learners when training ends. The learning sciences offer evidence to guide self-directed learning, but these insights have not been integrated into a practical and actionable plan for residents to improve their clinical knowledge and reasoning. We encourage residents to establish a self-directed learning plan, just as an athlete employs a training plan in the pursuit of excellence. We highlight four evidence-based learning principles (spaced practice, mixed practice, retrieval practice, and feedback) and four training strategies comprising a weekly training plan: case tracking, simulated cases, quizzing, and new evidence integration. We provide tips for residents to implement and refine their approach and discuss how residency programs can foster these routines and habits. By optimizing their scarce self-directed learning time with a training plan, residents may enhance patient care and their career satisfaction through their pursuit of clinical mastery.

Electronic health record-based patient tracking by emergency medicine physicians

Objectives

Emergency medicine (EM) physicians commonly track the progress of former patients to learn about their clinical outcome. While some studies have described the behavior, little is known about the specific information sought during tracking. The objective of this study was to determine how often EM physicians track patients and the motivations, strategies, and barriers to tracking.

Methods

In June 2019 we surveyed EM physicians practicing at six hospitals. We defined patient tracking as viewing the chart of a patient who was no longer under the physician's care or contacting the patient or the patient's subsequent providers to learn about the patient's progress. The survey asked respondents how often they track patients, by what mechanisms, and for what reasons. The survey also asked what information physicians sought when tracking and what barriers to tracking exist.

Results

Of the 156 EM physicians invited to respond, 111 completed the survey (72% response rate). Of those, 109 (98%) reported tracking their patients, and residents reported tracking a higher percentage of patients than attendings. Reasons for tracking included an unusual or complex case (98%), uncertain diagnosis (89%), and concern about a potential error (48%). Most respondents (86%) said that knowledge gained from patient tracking changed their subsequent practice patterns, and almost all respondents (98%) strongly agreed or agreed that tracking helps physicians avoid future mistakes. The most commonly sought information types during tracking were the hospital discharge summary or emergency department note from the index visit, test results since the index visit, and new diagnoses added since the index visit. Physicians cited time limitations and difficulty accessing information as the leading barriers to tracking.

Conclusions

Patient tracking is nearly ubiquitous among surveyed EM physicians, who find it valuable for learning and patient safety.

The role of undergraduate medical students training in respect for patient confidentiality

BACKGROUND

Encouraging professional integrity is vital for providing a standard of excellence in quality medical care and education and in promoting a culture of respect and responsibility. The primary objective of this work consisted of studying the relationship of medical students to the right to patient privacy in Spain, specifically by analysing the conditions for accessing patient clinical histories (CHs).

METHODS

A cross-sectional study was conducted based on a questionnaire sent by e-mail to final-year students at 41 Spanish universities. It had 14 multiple choice and closed questions framed in 3 large blocks. The first question addressed basic general knowledge issues on the right to privacy and the obligation for confidentiality. The two remaining blocks were made up of questions directed towards evaluating the frequency with which certain requirements and action steps related to students attending patients were performed and regarding the guarantees associated with accessing and handling patient CHs both on paper and in the Electronic Medical Record.

RESULTS

A total of 245 valid replies were considered. A total of 67.8 % of participants were women, with an average age of 24.05 ± 3.49 years. Up to 90.6 % were aware that confidentiality affected the data in CHs, although 43.3 % possessed non-anonymized photocopies of patient clinical reports outside the healthcare context, and only 49.8 % of the students were always adequately identified. A total of 59.2 % accessed patient CHs on some occasions by using passwords belonging to healthcare professionals, 77.2 % of them did not have the patients' express consent, and 71.9 % accessed a CH that was not anonymised.

CONCLUSIONS

The role of healthcare institutions and universities is considered to be fundamental in implementing educational measures regarding the risks and ethical and legal problems arising from the use of CHs among professionals and students. A thorough study of medical ethics is needed through the analysis of clinical cases and direct exposure to situations in which the patient's confidentiality is questioned.

Medical students' experience with accessing medical records in Saudi Arabia: a descriptive study

BACKGROUND

Medical students can enhance their knowledge by accessing patients' medical records and documenting patient care. This study assessed medical students' access to paper medical records and electronic health records (EHRs) in Saudi Arabia and compared students' experience of accessing paper medical records and EHR from their perspective.

METHODS

This cross-sectional study enrolled second-year to intern medical students randomly from different medical colleges in Saudi Arabia. A self-developed survey was administered to them. It comprised 28 items in three sections: general information about medical students and their level of accessing medical records, their experience with the medical record system used in hospitals, and their preference for the medical record type.

RESULTS

62.8% of participants had access to medical records, with 66.1% of them having access to EHRs and 83.27% had read-only access. The EHR group and paper group mostly liked being able to reach medical records effortlessly (70.1% and 67.1%, respectively). The EHR group had a better experience compared to the paper group with U = 5200, Mean Rank = 122.73, P = .04. Students who trained in University - owned and National Guard hospitals had better experiences compared to students who trained in other hospitals with Mean Ranks =122.35, and 147.99, respectively.

CONCLUSION

Incorporating EHR access into the medical curriculum is essential for creating new educational opportunities that are not otherwise available to medical students.

Examination and diagnosis of electronic patient records and their associated ethics: a scoping literature review

Background

Electronic patient record (EPR) technology is a key enabler for improvements to healthcare service and management. To ensure these improvements and the means to achieve them are socially and ethically desirable, careful consideration of the ethical implications of EPRs is indicated. The purpose of this scoping review was to map the literature related to the ethics of EPR technology. The literature review was conducted to catalogue the prevalent ethical terms, to describe the associated ethical challenges and opportunities, and to identify the actors involved. By doing so, it aimed to support the future development of ethics guidance in the EPR domain.

Methods

To identify journal articles debating the ethics of EPRs, Scopus, Web of Science, and PubMed academic databases were queried and yielded 123 eligible articles. The following inclusion criteria were applied: articles need to be in the English language; present normative arguments and not solely empirical research; include an abstract for software analysis; and discuss EPR technology.

Results

The medical specialty, type of information captured and stored in EPRs, their use and functionality varied widely across the included articles. Ethical terms extracted were categorised into clusters ‘privacy’, ‘autonomy’, ‘risk/benefit’, ‘human relationships’, and ‘responsibility’. The literature shows that EPR-related ethical concerns can have both positive and negative implications, and that a wide variety of actors with rights and/or responsibilities regarding the safe and ethical adoption of the technology are involved.

Conclusions

While there is considerable consensus in the literature regarding EPR-related ethical principles, some of the associated challenges and opportunities remain underdiscussed. For example, much of the debate is presented in a manner more in keeping with a traditional model of healthcare and fails to take account of the multidimensional ensemble of factors at play in the EPR era and the consequent need to redefine/modify ethical norms to align with a digitally-enabled health service. Similarly, the academic discussion focuses predominantly on bioethical values. However, approaches from digital ethics may also be helpful to identify and deliberate about current and emerging EPR-related ethical concerns.

"Closing the loop": a mixed-methods study about resident learning from outcome feedback after patient handoffs

Background Learning patient outcomes is recognized as crucial for ongoing refinement of clinical decision-making, but is often difficult in fragmented care with frequent handoffs. Data on resident habits of seeking outcome feedback after handoffs are lacking. Methods We performed a mixed-methods study including (1) an analysis of chart re-access rates after handoffs performed using access logs of the electronic health record (EHR); and (2) a web-based survey sent to internal medicine (IM) and emergency medicine (EM) residents about their habits of and barriers to learning the outcomes of patients after they have handed them off to other teams. Results Residents on ward rotations were often able to re-access charts of patients after handoffs, but those on EM or night admitting rotations did so <5% of the time. Among residents surveyed, only a minority stated that they frequently find out the outcomes of patients they have handed off, although learning outcomes was important to both their education and job satisfaction. Most were not satisfied with current systems of learning outcomes of patients after handoffs, citing too little time and lack of reliable patient tracking systems as the main barriers. Conclusions Despite perceived importance of learning outcomes after handoffs, residents cite difficulty with obtaining such information. Systematically providing feedback on patient outcomes would meet a recognized need among physicians in training.

Time for an Acute Focus on Chronic Care in Undergraduate Medical Education

As the burdens of chronic disease rise in the United States, both undergraduate and graduate medical education must adapt to adequately equip future physicians with the skills to manage the increasingly complex health needs affecting the population. However, traditional models of undergraduate medical education (UME) have made focusing on chronic care education challenging. In this Invited Commentary, the authors advocate for strengthening UME based on five approaches to engage trainees in learning about chronic care across both the preclinical and clinical phases of their education: (1) introducing chronic care in the preclinical years; (2) prioritizing chronic care education across all specialties; (3) maximizing the fourth year of medical school through a chronic care focus; (4) creating chronic-disease-focused advanced clerkships; and (5) leveraging technology for education. These five approaches call for restructuring of both preclinical and clinical education to more comprehensively emphasize the skills and knowledge needed for trainees to manage chronic diseases. Such efforts will ensure that graduating medical students are well versed in the competencies needed to effectively care for patients with chronic conditions in advance of their transition to graduate medical education and clinical practice.

A Framework for Tracking Former Patients in the Electronic Health Record Using an Educational Registry

One challenge of contemporary medical education is that shorter lengths of stay and time-limited clerkships often interrupt a student's relationship with a patient before a diagnosis is made or treatment is completed, limiting the learning experience. Medical students sometimes use electronic health records (EHRs) to overcome these limitations. EHRs provide access to patients' future medical records, enabling students to track former patients across care venues to audit their diagnostic impressions and observe outcomes. While this activity has potential to improve clinical training, there is a risk of unintended harm to patients through loss of privacy. Students need guidance on how to perform this activity appropriately. This article describes an ethical framework for tracking using an "educational registry," a list of former patients housed within the EHR that one follows longitudinally for educational purposes. Guiding principles include obtaining permission from patients, having legitimate educational intent, and restricting review of records to those essential for training. This framework could serve as a foundation for institutions seeking to develop a policy on tracking former patients, and may facilitate research on the use of EHRs to improve medical education, such as reducing diagnostic error and promoting self-directed learning.

What Happened to My Patient? An Educational Intervention to Facilitate Postdischarge Patient Follow-Up

BACKGROUND

Following up on patients' clinical courses after hospital discharge may enhance physicians' learning and care of future patients. Barriers to this practice for residents include time constraints, discontinuous training environments, and difficulty accessing patient information.

OBJECTIVE

We designed an educational intervention facilitating informed self-assessment and reflection through structured postdischarge follow-up of patients' longitudinal clinical courses. We then examined the experience of interns who received this intervention in a mixed methods study.

METHODS

Internal medicine interns on a 4-week patient safety rotation received lists of hospitalized patients they had cared for earlier in the year. They selected patients for chart review and completed a guided reflection worksheet for each patient reviewed. Interns then discussed lessons learned in a faculty-led group debrief session.

RESULTS

Of 62 eligible interns, 62 (100%) participated in this intervention and completed 293 reflection worksheets. We analyzed worksheets and transcripts from 6 debrief sessions. Interns reported that postdischarge patient follow-up was valuable for their professional development, and helped them understand the natural history of disease and patients' illness experiences. After reviewing their patients' clinical courses, interns stated that they would advocate for earlier end-of-life counseling, improve care transitions, and adjust their clinical decision-making for similar patients in the future.

CONCLUSIONS

Our educational intervention created the time, space, and structure for postdischarge patient follow-up. It was well received by participants, and is an opportunity for experiential learning.

Erosion of Digital Professionalism During Medical Students' Core Clinical Clerkships

BACKGROUND

The increased use of social media, cloud computing, and mobile devices has led to the emergence of guidelines and novel teaching efforts to guide students toward the appropriate use of technology. Despite this, violations of professional conduct are common.

OBJECTIVE

We sought to explore professional behaviors specific to appropriate use of technology by looking at changes in third-year medical students' attitudes and behaviors at the beginning and conclusion of their clinical clerkships.

METHODS

After formal teaching about digital professionalism, we administered a survey to medical students that described 35 technology-related behaviors and queried students about professionalism of the behavior (on a 5-point Likert scale), observation of others engaging in the behavior (yes or no), as well as personal participation in the behavior (yes or no). Students were resurveyed at the end of the academic year.

RESULTS

Over the year, perceptions of what is considered acceptable behavior regarding privacy, data security, communications, and social media boundaries changed, despite formal teaching sessions to reinforce professional behavior. Furthermore, medical students who observed unprofessional behaviors were more likely to participate in such behaviors.

CONCLUSIONS

Although technology is a useful tool to enhance teaching and learning, our results reflect an erosion of professionalism related to information security that occurred despite medical school and hospital-based teaching sessions to promote digital professionalism. True alteration of trainee behavior will require a cultural shift that includes continual education, better role models, and frequent reminders for faculty, house staff, students, and staff.