Effect of the Adoption of a Comprehensive Electronic Health Record on Graduate Medical Education: Perceptions of Faculty and Trainees

Clinical Decision Support in the PICU: Implications for Design and Evaluation

OBJECTIVES

To assess the current landscape of clinical decision support (CDS) tools in PICUs in order to identify priority areas of focus in this field.

DESIGN

International, quantitative, cross-sectional survey.

SETTING

Role-specific, web-based survey administered in November and December 2020.

SUBJECTS

Medical directors, bedside nurses, attending physicians, and residents/advanced practice providers at Pediatric Acute Lung Injury and Sepsis Network-affiliated PICUs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The survey was completed by 109 respondents from 45 institutions, primarily attending physicians from university-affiliated PICUs in the United States. The most commonly used CDS tools were people-based resources (93% used always or most of the time) and laboratory result highlighting (86%), with order sets, order-based alerts, and other electronic CDS tools also used frequently. The most important goal providers endorsed for CDS tools were a proven impact on patient safety and an evidence base for their use. Negative perceptions of CDS included concerns about diminished critical thinking and the burden of intrusive processes on providers. Routine assessment of existing CDS was rare, with infrequent reported use of observation to assess CDS impact on workflows or measures of individual alert burden.

CONCLUSIONS

Although providers share some consensus over CDS utility, we identified specific priority areas of research focus. Consensus across practitioners exists around the importance of evidence-based CDS tools having a proven impact on patient safety. Despite broad presence of CDS tools in PICUs, practitioners continue to view them as intrusive and with concern for diminished critical thinking. Deimplementing ineffective CDS may mitigate this burden, though postimplementation evaluation of CDS is rare.

The Electronic Medical Record and Nephrology Fellowship Education in the United States: An Opinion Survey

BACKGROUND AND OBJECTIVES

An unintended consequence of electronic medical record use in the United States is the potential effect on graduate physician training. We assessed educational burdens and benefits of electronic medical record use on United States nephrology fellows by means of a survey.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We used an anonymous online opinion survey of all United States nephrology program directors (n=148), their faculty, and fellows. Program directors forwarded survey links to fellows and clinical faculty, indicating to how many they forwarded the link. The three surveys had parallel questions to permit comparisons.

RESULTS

Twenty-two percent of program directors (n=33) forwarded surveys to faculty (n=387) and fellows (n=216; 26% of United States nephrology fellows). Faculty and fellow response rates were 25% and 33%, respectively; 51% of fellows agreed/strongly agreed that the electronic medical record contributed positively to their education. Perceived positive effects included access flexibility and ease of obtaining laboratory/radiology results. Negative effects included copy-forward errors and excessive, irrelevant documentation. Electronic medical record function was reported to be slow, disrupted, or completely lost monthly or more by >40%, and these were significantly less likely to agree that the electronic medical record contributed positively to their education. Electronic medical record completion time demands contributed to fellow reluctance to do procedures (52%), participate in conferences (57%), prolong patient interactions (74%), and do patient-directed reading (55%). Sixty-five percent of fellows reported often/sometimes exceeding work-hours limits due to documentation time demands; 85% of faculty reported often/sometimes observing copy-forward errors. Limitations include potential nonresponse and social desirability bias.

CONCLUSIONS

Respondents reported that the electronic medical record enhances fellow education with efficient and geographically flexible patient data access, but the time demands of data and order entry reduce engagement in educational activities, contribute to work-hours violations, and diminish direct patient interactions.

Stroke Templates and Trainee Education are Associated With Improved Data Capture in an Academic Hospital

BACKGROUND

Effective medical record documentation is required to support accurate capture of diagnoses, patient acuity (case mix index [CMI]), and justify resource utilization for reimbursement. Billing code complexity and a lack of formal documentation education in training programs have created a need for academic medical centers to incorporate training for trainees (residents, fellows, and new nurse practitioners). We hypothesized that standardized stroke note templates, trainee education, and feedback from chart audits would improve documentation accuracy.

PURPOSE

To improve the accurate/complete capture of expected (E) length of stay (LOS) and CMI by designing/implementing ischemic and hemorrhagic stroke templates containing high-frequency complication and comorbidity diagnoses with the greatest impact on stroke populations, combined with trainee education and chart audits.

METHODS

Descriptive statistics were used for outcomes before/after implementation of the templates. Primary outcomes include ELOS and CMI. Wilcoxon rank-sum test or chi-square test was used for group comparison.

RESULTS

The post-template group demonstrated a significant improvement in ELOS from 5.84 to 8.27 days (p < .0001). Case mix index increased (1.73-1.75; p < .0001) in the post-template group.

CONCLUSIONS

Stroke-specific templates, trainee education, and chart audits were associated with significant improvement in documentation accuracy and an improved business model of stroke care in our hospital.