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Garber A, Garabedian P, Wu L, Lam A, Malik M, Fraser H, Bersani K, Piniella N, Motta-Calderon D, Rozenblum R, Schnock K, Griffin J, Schnipper JL, Bates DW, Dalal AK. Developing, pilot testing, and refining requirements for 3 EHR-integrated interventions to improve diagnostic safety in acute care: a user-centered approach. JAMIA Open 2023; 6:ooad031. [PMID: 37181729 PMCID: PMC10172040 DOI: 10.1093/jamiaopen/ooad031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 01/04/2023] [Accepted: 04/20/2023] [Indexed: 05/16/2023] Open
Abstract
Objective To describe a user-centered approach to develop, pilot test, and refine requirements for 3 electronic health record (EHR)-integrated interventions that target key diagnostic process failures in hospitalized patients. Materials and Methods Three interventions were prioritized for development: a Diagnostic Safety Column (DSC) within an EHR-integrated dashboard to identify at-risk patients; a Diagnostic Time-Out (DTO) for clinicians to reassess the working diagnosis; and a Patient Diagnosis Questionnaire (PDQ) to gather patient concerns about the diagnostic process. Initial requirements were refined from analysis of test cases with elevated risk predicted by DSC logic compared to risk perceived by a clinician working group; DTO testing sessions with clinicians; PDQ responses from patients; and focus groups with clinicians and patient advisors using storyboarding to model the integrated interventions. Mixed methods analysis of participant responses was used to identify final requirements and potential implementation barriers. Results Final requirements from analysis of 10 test cases predicted by the DSC, 18 clinician DTO participants, and 39 PDQ responses included the following: DSC configurable parameters (variables, weights) to adjust baseline risk estimates in real-time based on new clinical data collected during hospitalization; more concise DTO wording and flexibility for clinicians to conduct the DTO with or without the patient present; and integration of PDQ responses into the DSC to ensure closed-looped communication with clinicians. Analysis of focus groups confirmed that tight integration of the interventions with the EHR would be necessary to prompt clinicians to reconsider the working diagnosis in cases with elevated diagnostic error (DE) risk or uncertainty. Potential implementation barriers included alert fatigue and distrust of the risk algorithm (DSC); time constraints, redundancies, and concerns about disclosing uncertainty to patients (DTO); and patient disagreement with the care team's diagnosis (PDQ). Discussion A user-centered approach led to evolution of requirements for 3 interventions targeting key diagnostic process failures in hospitalized patients at risk for DE. Conclusions We identify challenges and offer lessons from our user-centered design process.
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Affiliation(s)
- Alison Garber
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Pamela Garabedian
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Lindsey Wu
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Alyssa Lam
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Maria Malik
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Hannah Fraser
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Kerrin Bersani
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Nicholas Piniella
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Daniel Motta-Calderon
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Ronen Rozenblum
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Kumiko Schnock
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | | | - Jeffrey L Schnipper
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - David W Bates
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Anuj K Dalal
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Puranik C, Slavik A, Pickett K, Dani A, Generalovich Z, Neveaux L, de Peralta T. Development of integrated electronic medical and dental record competencies and impact of training modalities. J Dent Educ 2023; 87:660-668. [PMID: 36718532 DOI: 10.1002/jdd.13175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 10/23/2022] [Accepted: 12/17/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The American Recovery and Reinvestment Act provided incentives for the adoption of electronic health records. The integrated electronic medical and dental records (iEMDRs) can minimize healthcare charting errors. The use of iEMDR by healthcare students requires training and competence. There are no defined student competencies to assess the effective and responsible use of iEMDR in dentistry. The goal of this study was to propose a student competency model and study the impact of training modalities on iEMDR competency. METHODS This retrospective observational cohort study evaluated de-identified assessment scores (AS) and performance scores (PS) in predoctoral dental student (PDS) and advanced standing predoctoral (ASP) student cohorts that received remote or in-person iEMDR training. The AS and PS evaluated the knowledge and application of iEMDR, respectively. A voluntary survey evaluated students' self-perceived preparedness for iEMDR use. Linear regressions were used to determine the association between training modality and scores. Mantel-Haenszel ordinal chi-square tested differences between groups and agreement by training type. Statistical significance was set at 0.05. RESULTS The sample size (N = 214) provided 95% power to detect differences between study groups. The knowledge of iEMDR (AS) was not impacted due to the training type (p = 0.90) in either student cohorts, whereas the application of knowledge (PS) was higher in ASP student cohort after remote training (p < 0.001) as compared to PDS student cohort. Higher proportion of students perceived preparedness after remote learning in comparison to in-person training (p < 0.001). DISCUSSION The iEMDR competency model was useful to test the effective and responsible use of iEMDR, and remote training improved students' self-perceived preparedness.
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Affiliation(s)
- Chaitanya Puranik
- Department of Pediatric Dentistry, Children's Hospital Colorado and School of Dental Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Amanda Slavik
- Doctor of Dental Surgery Candidate, School of Dental Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Kaci Pickett
- Center for Research Outcomes in Children's Surgery (ROCS), Children's Hospital Colorado, Aurora, Colorado, USA
| | - Aditee Dani
- Graduate Student in Analytics Program, University of Harrisburg, Harrisburg, Pennsylvania, USA
| | - Zora Generalovich
- Clinical Application Services, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Lindsay Neveaux
- Department of Pediatric Dentistry, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Tracy de Peralta
- Senior Associate Dean of Academic Affairs and Inovation, School of Dental Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Kim M, Chan N, Evans J, Min JK, Hayton AC. Improving Medical Student Inpatient Documentation Through Feedback Using a Note Assessment Tool. Cureus 2022; 14:e23369. [PMID: 35475068 PMCID: PMC9020806 DOI: 10.7759/cureus.23369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction Documentation within the Electronic Health Record (EHR) is an essential skill for medical students to succeed in residency and post-residency training. The increased use of medical student progress notes for billable services raises the need for the education and assessment of quality note writing. We hypothesized that structured note feedback using a note assessment tool would improve the quality of medical student inpatient progress notes. Methods We conducted a retrospective study to review the quality of student inpatient progress notes written before and after structured feedback using the Responsible Electronic Documentation (RED) checklist throughout a third-year internal medicine clerkship. The first intervention group received feedback from clerkship directors in the 2017-2018 academic year and the second intervention group received feedback from ward residents/attendings in the 2018-2019 academic year. Within each intervention group, the total note scores from pre and post-intervention were compared. Results Feedback from clerkship directors yielded a greater increase in students’ total note score from pre to post-intervention compared to ward resident/attending feedback (F(1,255) = 12.84, p < 0.001). Cohen’s d effect size value was greater for the clerkship director feedback arm (d=0.71) compared to the ward resident/attending feedback arm (d=0.24). Post-hoc analyses using dependent sample t-tests revealed that there were significant increases in total note scores from pre to post-intervention for both the clerkship director arm (t(123) = 8.26, p < 0.001, d = 0.71) and the ward resident/attending arm (t(132) = 2.85, p = 0.005, d = 0.24). Conclusion Clerkship director feedback led to a greater increase in medical student documentation compared to ward attending/resident feedback. Nonetheless, structured feedback with a note assessment tool, whether from clerkship directors or ward attendings/residents, leads to a significant improvement in medical student documentation. Though there are various methods for providing feedback, educators can use the RED checklist to provide clear guidelines that will facilitate note-writing feedback.
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Cuddy MM, Foster LM, Wallach PM, Hammoud MM, Swanson DB. Medical Student Experiences With Electronic Health Records Nationally: A Longitudinal Analysis Including School-Level Effects. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:262-270. [PMID: 34348385 DOI: 10.1097/acm.0000000000004290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
PURPOSE Increasingly, medical school graduates have been expected to be competent in the knowledge and skills associated with effective electronic health record (EHR) use. Yet little is known about how student experiences with EHRs have changed over time or how these trends vary by medical school. This study examined shifts in U.S. medical student interactions with EHRs during their clinical education, 2012-2016, and how these interactions varied by clerkship within and across medical schools. METHOD Data came from an online survey about EHR use administered to medical students after completing the Step 2 Clinical Knowledge portion of the United States Medical Licensing Examination. For a sample of 17,202 medical students from 140 U.S.-based Liaison Committee on Medical Education accredited medical school campuses, multilevel modeling techniques were used to estimate overall and school-specific trends in student access to and entry of information into EHRs for 7 core inpatient clerkships. RESULTS Results showed upward trajectories in likelihood of student EHR experiences, with smaller increases found for information entry compared with access. These trends varied by inpatient clerkship rotation, with some disciplines exhibiting more rapid increases than others. For both access and information entry, estimated clerkship-specific trajectories differed by medical school in terms of size and direction. For all clerkships, greater school-to-school variation in the likelihood of student entry, compared with student access, remained at the end of the study period. CONCLUSIONS Increases in medical student interactions with EHRs suggest a growing commitment to educating students on safe and effective EHR use. Nonetheless, at some schools and in some clerkships, students may receive inadequate educational opportunities to practice using EHRs. In turn, medical students may be differentially prepared to effectively engage with EHRs upon entering residency, particularly with the knowledge and skills needed to effectively document and transmit information in EHRs.
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Affiliation(s)
- Monica M Cuddy
- M.M. Cuddy is measurement scientist, National Board of Medical Examiners, Philadelphia, Pennsylvania
| | - Lauren M Foster
- L.M. Foster is data analyst, National Board of Medical Examiners, Philadelphia, Pennsylvania
| | - Paul M Wallach
- P.M. Wallach is executive associate dean, Educational Affairs and Institutional Improvement, and professor of medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Maya M Hammoud
- M.M. Hammoud is professor of obstetrics and gynecology and professor of learning health sciences, University of Michigan Medical School, Ann Arbor, Michigan
| | - David B Swanson
- D.B. Swanson is vice president, Certification Standards and Programs, American Board of Medical Specialties, Chicago, Illinois, professor (honorary) of medical education, University of Melbourne Medical School, Melbourne, Victoria, and professor (honorary), University of Queensland Faculty of Medicine, Brisbane, Queensland, Australia
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Lamb CR, Shaw RD, Hilty BK, Wong SL, Rosenkranz KM. A Targeted Needs Assessment for the Development of a Surgical Sub-internship Curriculum. JOURNAL OF SURGICAL EDUCATION 2021; 78:e121-e128. [PMID: 34362707 DOI: 10.1016/j.jsurg.2021.06.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 05/18/2021] [Accepted: 06/26/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Medical students often feel inadequately prepared for the responsibilities of surgical internship because of insufficient exposure to resident responsibilities prior to starting residency. This lack of preparation may contribute to burnout and attrition early in residency. Sub-internships should provide these experiences. Significant variation, however, exists in the structure of these rotations. We conducted a targeted needs assessment to inform the development of a didactic curriculum to address gaps in the surgical sub-internship experience and better prepare students for general surgery residency. DESIGN A 25-item needs assessment survey was developed and distributed to senior medical students in their surgical sub-internship, current junior residents, and prior students (alumni) from the past 4 years who matched into general surgery residencies at other institutions. SETTING Geisel School of Medicine at Dartmouth/Dartmouth-Hitchcock Medical Center, a tertiary-care academic medical center. PARTICIPANTS Nine senior medical students; 12 current residents and 14 alumni, including 9 PGY-1, 13 PGY-2, and 4 PGY-3 residents. RESULTS The topics rated most important by medical students were floor management topics, specifically lines, tubes, and drains, hypotension, post-operative fever, chest pain, oliguria, and post-operative pain. In contrast, there was a wider variety of topics rated highly by residents. Residents emphasized non-technical communication and documentation skills. Residents at every training level rated presenting patients on rounds as the most important skill for incoming interns to acquire, whereas only one-third of medical students considered this to be an essential topic. CONCLUSIONS Medical students rank management of common clinical problems as the most critical aspect in their preparation for residency. Residents recognized these topics as important, but also placed high emphasis on non-technical communication and documentation skills. The findings from this need's assessment can be used to guide content structure for a sub-intern curriculum.
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Affiliation(s)
- Casey R Lamb
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Robert D Shaw
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Bailey K Hilty
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Sandra L Wong
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Kari M Rosenkranz
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
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Stevens LA, Pageler NM, Hahn JS. Improved Medical Student Engagement with EHR Documentation following the 2018 Centers for Medicare and Medicaid Billing Changes. Appl Clin Inform 2021; 12:582-588. [PMID: 34233368 DOI: 10.1055/s-0041-1731342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Medical student note writing is an important part of the training process but has suffered in the electronic health record (EHR) era as a result of student notes being excluded from the billable encounter. The 2018 CMS billing changes allow for medical student notes to be used for billable services provided that physical presence requirements are met, and attending physicians satisfy performance requirements and verify documentation. This has the potential to improve medical student engagement and decrease physician documentation burden. METHODS Our institution implemented medical student notes as part of the billable encounter in August 2018 with support of our compliance department. Note characteristics including number, type, length, and time in note were analyzed before and after implementation. Rotating medical students were surveyed regarding their experience following implementation. RESULTS There was a statistically significant increase in the number of student-authored notes following implementation. Attending physicians' interactions with student notes greatly increased following the change (4% of student notes reviewed vs. 84% of student notes). Surveyed students reported that having their notes as part of the billable record made their notes more meaningful and enhanced their learning. The majority of surveyed students also agreed that they received more feedback following the change. CONCLUSION Medical students are interested in writing notes for education and feedback. Inclusion of their notes as part of the billable record can facilitate their learning and increase their participation in the note writing process.
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Affiliation(s)
- Lindsay A Stevens
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, United States.,Information Services, Stanford Children's Health, Palo Alto, California, United States
| | - Natalie M Pageler
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, United States.,Information Services, Stanford Children's Health, Palo Alto, California, United States
| | - Jin S Hahn
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, United States.,Information Services, Stanford Children's Health, Palo Alto, California, United States
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Almulhem JA. Medical students' experience with accessing medical records in Saudi Arabia: a descriptive study. BMC MEDICAL EDUCATION 2021; 21:272. [PMID: 33980207 PMCID: PMC8117651 DOI: 10.1186/s12909-021-02715-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 04/28/2021] [Indexed: 06/12/2023]
Abstract
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.
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Affiliation(s)
- Jwaher A Almulhem
- Medical Informatics and E-learning Unit, Medical Education Department, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia.
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Komasawa N, Terasaki F, Nakano T, Kawata R. Correlation of student performance on clerkship with quality of medical chart documentation in a simulation setting. PLoS One 2021; 16:e0248569. [PMID: 33720982 PMCID: PMC7959337 DOI: 10.1371/journal.pone.0248569] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 03/01/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Medical chart documentation is an essential skill acquired in a clinical clerkship (CC). However, the utility of medical chart writing simulations as a component of the objective structured clinical examination (OSCE) has not been sufficiently evaluated. In this study, medical chart documentation in several clinical simulation settings was performed as part of the OSCE, and its correlation with CC performance was evaluated. METHODS We created a clinical situation video and images involving the acquisition of informed consent, cardiopulmonary resuscitation, and diagnostic imaging in the emergency department, and assessed medical chart documentation performance by medical students as part of the OSCE. Evaluations were conducted utilizing original checklist (0-10 point). We also analyzed the correlation between medical chart documentation OSCE scores and CC performance of 120 medical students who performed their CC in 2019 as 5th year students and took the Post-CC OSCE in 2020 as 6th year students. RESULTS Of the OSCE components, scores for the acquisition of informed consent and resuscitation showed significant correlations with CC performance (P<0.001 for each). In contrast, scores for diagnostic imaging showed a slightly positive, but non-significant, correlation with CC performance (P = 0.107). Overall scores for OSCE showed a significant correlation with CC performance (P<0.001). CONCLUSION We conducted a correlation analysis of CC performance and the quality of medical chart documentation in a simulation setting. Our results suggest that medical chart documentation can be one possible alternative component in the OSCE.
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Affiliation(s)
- Nobuyasu Komasawa
- Medical Education Center, Osaka Medical College, Osaka, Japan
- * E-mail:
| | - Fumio Terasaki
- Medical Education Center, Osaka Medical College, Osaka, Japan
| | - Takashi Nakano
- Medical Education Center, Osaka Medical College, Osaka, Japan
| | - Ryo Kawata
- Medical Education Center, Osaka Medical College, Osaka, Japan
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Foote DC, Reddy RM, Matusko N, Sandhu G. Surgery clerkship offers greater entrustment of medical students with supervised procedures than other clerkships. Am J Surg 2020; 220:537-542. [PMID: 32139105 DOI: 10.1016/j.amjsurg.2020.02.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 01/09/2020] [Accepted: 02/25/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Medical student procedural participation is increasingly limited, creating concerns over poor preparation for internship. Inadequate experiences may also compromise patient safety. This study explores variances in procedural entrustment of medical students between core clerkships during the first clinical year. METHODS Students completing their first clinical year were surveyed on procedure participation. Holistic entrustment decisions are complex, thus participation was used as an objective proxy for entrustment. RESULTS 138 students responded (66% response rate); 89% (123/138) wished they had performed more procedures. Students had higher participation rates during procedural clerkships (surgery, obstetrics/gynecology). Entrustment was highest during surgery, and lowest during pediatrics. Surgery gave statistically significantly higher entrustment for subcuticular suturing (compared to obstetrics/gynecology) and nasogastric tube removal (compared to internal medicine). Entrustment was generally inversely proportional to procedure complexity within each specialty. CONCLUSIONS Students encounter higher entrustment during procedural clerkships, especially surgery. Targeted areas for increased procedural involvement can be identified in all specialties.
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Affiliation(s)
- Darci C Foote
- University of Michigan Medical School, 1305 Catherine St., Ann Arbor, MI, 48109, USA.
| | - Rishindra M Reddy
- Department of Surgery, University of Michigan Health System, 1500 E. Medical Center Dr., 2120 Taubman Center, Ann Arbor, MI, 48109, USA
| | - Niki Matusko
- Department of Surgery, University of Michigan Health System, 1500 E. Medical Center Dr., 2120 Taubman Center, Ann Arbor, MI, 48109, USA
| | - Gurjit Sandhu
- Department of Surgery, University of Michigan Health System, 1500 E. Medical Center Dr., 2120 Taubman Center, Ann Arbor, MI, 48109, USA.
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Blatt AE, Nofziger AC, Levy PC. Incorporating Medical Student Documentation Into the Billable Encounter: A Pragmatic Approach to Implementation of the 2018 Centers for Medicare & Medicaid Services Rule Revision. Chest 2020; 158:698-704. [PMID: 32084393 DOI: 10.1016/j.chest.2020.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 01/24/2020] [Accepted: 02/05/2020] [Indexed: 10/25/2022] Open
Abstract
In early 2018, the Centers for Medicare & Medicaid Services released the Medical Review of Evaluation and Management (E/M) Documentation, which allows supervising teaching physicians to rely on a medical student's documentation to support billing for E/M services. This change has potential to enhance education, clinical documentation quality, and the satisfaction of students, postgraduate trainees, and teaching physicians. However, its practical adoption presents many challenges that must be navigated successfully to realize these important goals in compliance with federal and local requirements, while avoiding unintended downstream problems. Implementation requires careful planning, policy creation, education, and monitoring, all with collaboration between institutional leaders, compliance and information technology professionals, educators, and learners. In this paper, we review the 2018 Centers for Medicare & Medicaid Services rule change, address common questions and potential impacts, outline practical workflows to meet the supervision requirement, and discuss steps for successful implementation.
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Affiliation(s)
- Amy E Blatt
- Department of Internal Medicine and Pediatrics, University of Rochester Medical Center, Rochester, NY.
| | - Anne C Nofziger
- Department of Family Medicine, University of Rochester Medical Center, Rochester, NY
| | - Paul C Levy
- Department of Internal Medicine, University of Rochester Medical Center, Rochester, NY
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(En)trust me: Validating an assessment rubric for documenting clinical encounters during a surgery clerkship clinical skills exam. Am J Surg 2020; 219:258-262. [DOI: 10.1016/j.amjsurg.2018.12.055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 12/21/2018] [Accepted: 12/21/2018] [Indexed: 11/19/2022]
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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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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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Medical Student Documentation in the Emergency Department in the Electronic Health Record Era-A National Survey. Pediatr Emerg Care 2019; 35:220-225. [PMID: 28291152 DOI: 10.1097/pec.0000000000001095] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Implementation of electronic health record (EHR) has generated a new challenge in the practice of medical student documentation in the emergency department (ED). This study discerns both the current practices and consensus opinions of pediatric ED directors and Association of American Medical Colleges (AAMC) student representatives regarding best practices for documentation by medical students in the ED EHR nationwide. METHODS The authors conducted a cross-sectional Web-based survey of the directors of academic pediatric EDs and AAMC student representatives using Qualtric survey engine. The survey asked participants to describe their current practices and their opinion regarding the utility of and best practices for medical student documentation in the ED. RESULTS Approximately 47% (35/74) of pediatric ED directors and 54% (70/129) of AAMC medical schools' student representatives responded to the survey. Both groups demonstrated similar opinions of the critical importance and advantage of medical students' documentation in the ED (P ≥ 0.99). However, these 2 groups differed in opinion on the impact of medical student documentation on clinical care of the ED patients (P = 0.008). The survey found that 83% of medical students and 74% of ED directors believe that medical students should be documenting in the EHR. The majority of both groups (51% of medical students and 65% of ED directors) preferred a single, combined attending physician-medical student note for clinical documentation. CONCLUSIONS This study presents data describing the current practice of medical student documentation in academic pediatric EDs in the United States. There is a strong consensus among educators and students on the usefulness of medical student documenting patient encounters in the ED.
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Cassese T, Sharkey MS, Pincavage AT, Schwanz K, Farnan JM. Avoiding Pitfalls While Implementing New Guidelines on Student Documentation. Ann Intern Med 2019; 170:193-194. [PMID: 30641548 DOI: 10.7326/m18-1924] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Todd Cassese
- Albert Einstein College of Medicine, Bronx, New York (T.C.)
| | - Melinda S Sharkey
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York (M.S.S.)
| | - Amber T Pincavage
- The University of Chicago Pritzker School of Medicine, Chicago, Illinois (A.T.P., K.S., J.M.F.)
| | - Korry Schwanz
- The University of Chicago Pritzker School of Medicine, Chicago, Illinois (A.T.P., K.S., J.M.F.)
| | - Jeanne M Farnan
- The University of Chicago Pritzker School of Medicine, Chicago, Illinois (A.T.P., K.S., J.M.F.)
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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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Foster LM, Cuddy MM, Swanson DB, Holtzman KZ, Hammoud MM, Wallach PM. Medical Student Use of Electronic and Paper Health Records During Inpatient Clinical Clerkships: Results of a National Longitudinal Study. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2018; 93:S14-S20. [PMID: 30365425 DOI: 10.1097/acm.0000000000002376] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
PURPOSE An important goal of medical education is to teach students to use an electronic health record (EHR) safely and effectively. The purpose of this study is to examine medical student accounts of EHR use during their core inpatient clinical clerkships using a national sample. Paper health records (PHRs) are similarly examined. METHOD An online survey about health record use within the inpatient component of six core clerkships was administered to medical students after they completed Step 2 Clinical Knowledge of the United States Medical Licensing Examination. The sample included 17,202 U.S. medical students graduating between 2012 and 2016. Mean percentages of clerkships in which students engaged in various health record activities were computed, and analysis of variance was used to examine differences. RESULTS The mean percentages of clerkships in which a student accessed or entered information into an EHR increased from 78% to 93% and 59% to 72%, respectively. For students who used an EHR, the mean percentage of clerkships in which they entered information remained constant at 76%. Students entered notes during the majority of their clerkships, with increases over time. However, students entered orders in less than a quarter of their clerkships, with decreases over time. The percentage of clerkships in which students used PHRs was lower and declining. CONCLUSIONS Although students used an EHR in the majority of their inpatient core clerkships, they received limited educational experiences related to order and note writing, which could translate into a lack of preparedness for future training and practice.
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Affiliation(s)
- Lauren M Foster
- L.M. Foster is data analyst, National Board of Medical Examiners, Philadelphia, Pennsylvania. M.M. Cuddy is measurement scientist, National Board of Medical Examiners, Philadelphia, Pennsylvania. D.B. Swanson is vice president of academic programs and services, American Board of Medical Specialties, Chicago, Illinois, and professor of medical education, University of Melbourne, Melbourne, Victoria, Australia. K.Z. Holtzman is director, Assessment and International Operations, American Board of Medical Specialties, Chicago, Illinois. M.M. Hammoud is professor of obstetrics and gynecology and professor of learning health sciences, University of Michigan Medical School, Ann Arbor, Michigan. P.M. Wallach is executive associate dean for educational affairs and institutional improvement and professor of medicine, Indiana University School of Medicine, Indianapolis, Indiana
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Rausch N, Harendza S. Successful completion of clinical electives - Identification of significant factors of influence on self-organized learning during clinical electives with student focus groups. GMS JOURNAL FOR MEDICAL EDUCATION 2018; 35:Doc39. [PMID: 30186949 PMCID: PMC6120151 DOI: 10.3205/zma001185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 05/29/2018] [Accepted: 06/12/2018] [Indexed: 06/08/2023]
Abstract
Background: The Medical Licensure Act prescribes a total of four months of clinical electives in which the medical students are to work in a self-organized manner in outpatient and inpatient care. Since no specific learning objectives or learning content are given and students come into contact with different structures of outpatient and inpatient care, the learning success in a clinical elective is often rather random. In order to make self-organized learning (SOL) in clinical electives as effective as possible, we identified factors in the area of inpatient care that have an influence on SOL and thus the learning success during a clinical elective. Methods: To investigate this question a qualitative and explorative approach was chosen. In 2015, a total of 21 students from semester 1 to 11 participated in six semi-structured focus group discussions at Hamburg Medical Faculty. In these, the students were asked about their experiences and expectations with regard to SOL in clinical electives. The interviews were transcribed literally and analyzed using Grounded Theory in parallel to further data collection. Results: Three main categories were identified, which had an impact on SOL in clinical electives, each with two sub-categories: People (elective students and physicians), learning itself (learning content and learning process) and the framework (local conditions and organizational structure). For example, elective students exhibiting openness and self-initiative as well as a good working atmosphere and few hierarchical structures were conducive to SOL, while shyness and lack of integration into the ward's medical team inhibited SOL. A mentor formally assigned to the student can promote SOL through guidance, supervision and the transfer of responsibility. Continuous feedback from mentors or peers promotes SOL. Framework conditions, such as a smooth administrative organization, also affect SOL, but elective students have limited influence over these. Conclusion: The creation of suitable framework conditions and considering the needs of the people involved in clinical electives and the requirements of learning itself are necessary steps in order to enable successful SOL during clinical electives. Suitable framework conditions could be compiled and widely disseminated on an empirical basis. Training for teachers and elective students on various aspects of clinical electives, from professional behavior to practical skills, could be a suitable preparatory measure to promote SOL in clinical electives and contribute to a better learning success of the elective students.
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Affiliation(s)
- Natalie Rausch
- Universitätsklinikum Hamburg-Eppendorf, III. Medizinische Klinik, Hamburg, Germany
| | - Sigrid Harendza
- Universitätsklinikum Hamburg-Eppendorf, III. Medizinische Klinik, Hamburg, Germany
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19
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Pereira AG, Kim M, Seywerd M, Nesbitt B, Pitt MB. Collaborating for Competency-A Model for Single Electronic Health Record Onboarding for Medical Students Rotating among Separate Health Systems. Appl Clin Inform 2018; 9:199-204. [PMID: 29564849 DOI: 10.1055/s-0038-1635096] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Use of the electronic health record (EHR) is widespread in academic medical centers, and hands-on EHR experience in medical school is essential for new residents to be able to meaningfully contribute to patient care. As system-specific EHR training is not portable across institutions-even when the same EHR platform is used-students rotating across health systems are often required to spend time away from clinical training to complete each system's, often duplicative, EHR training regardless of their competency within the EHR. METHODS We aimed to create a single competency-based Epic onboarding process that would be portable across all the institutions in which our medical students complete clinical rotations. In collaboration with six health systems, we created online EHR training modules using a systematic approach to curriculum development and created an assessment within the Epic practice environment. RESULTS All six collaborating health systems accepted successful completion of the developed assessment in lieu of standard site-specific medical student EHR training. In the pilot year, 443 students (94%) completed the modules and assessment prior to their clinical training and successfully entered clinical rotations without time consuming, often repetitive onsite training, decreasing the cumulative time as student might be expected to engage in Epic onboarding as much as 20-fold. CONCLUSION Medical schools with multisystem training sites with a single type of EHR can adopt this approach to minimize training burden for their learners and to allow them more time in the clinical setting with optimized access to the EHR.
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Affiliation(s)
- Anne G Pereira
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, United States
| | - Michael Kim
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, United States
| | - Marcus Seywerd
- Fairview Health Services, Minneapolis, Minnesota, United States
| | - Brooke Nesbitt
- Department of Integrated Education, Clinical Experiences, University of Minnesota Medical School, Minneapolis, Minnesota, United States
| | - Michael B Pitt
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, United States
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20
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Sklar DP, Hemmer PA, Durning SJ. Medical Education and Health Care Delivery: A Call to Better Align Goals and Purposes. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2018; 93:384-390. [PMID: 28930760 DOI: 10.1097/acm.0000000000001921] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The transformation of the U.S. health care system is under way, driven by the needs of an aging population, rising health care spending, and the availability of health information. However, the speed and effectiveness of the transformation of health care delivery will depend, in large part, upon engagement of the health professions community and changes in clinicians' practice behaviors. Current efforts to influence practice behaviors emphasize changes in the health payment system with incentives to move from fee-for-service to alternative payment models.The authors describe the potential of medical education to augment payment incentives to make changes in clinical practice and the importance of aligning the purpose and goals of medical education with those of the health care delivery system. The authors discuss how curricular and assessment changes and faculty development can align medical education with the transformative trends in the health care delivery system. They also explain how the theory of situated cognition offers a shared conceptual framework that could help address the misalignment of education and clinical care. They provide examples of how quality improvement, health care innovation, population care management, and payment alignment could create bridges for joining health care delivery and medical education to meet the health care reform goals of a high-performing health care delivery system while controlling health care spending. Finally, the authors illustrate how current payment incentives such as bundled payments, value-based purchasing, and population-based payments can work synergistically with medical education to provide high-value care.
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Affiliation(s)
- David P Sklar
- D.P. Sklar is distinguished professor emeritus, University of New Mexico School of Medicine, Albuquerque, New Mexico, and editor-in-chief, Academic Medicine. P.A. Hemmer is professor of medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland. S.J. Durning is professor of medicine and pathology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, and deputy editor for research, Academic Medicine
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21
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Welcher CM, Hersh W, Takesue B, Stagg Elliott V, Hawkins RE. Barriers to Medical Students' Electronic Health Record Access Can Impede Their Preparedness for Practice. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2018; 93:48-53. [PMID: 28746069 DOI: 10.1097/acm.0000000000001829] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Medical students need hands-on experience documenting clinical encounters as well as entering orders to prepare for residency and become competent physicians. In the era of paper medical records, students consistently acquired experience writing notes and entering orders as part of their clinical experience. Over the past decade, however, patient records have transitioned from paper to electronic form. This change has had the unintended consequence of limiting medical students' access to patient records. This restriction has meant that many students leave medical school without the appropriate medical record skills for transitioning to residency.In this article, the authors explore medical students' current access to electronic health records (EHRs) as well as policy proposals from medical societies, innovative models implemented at some U.S. medical schools, and other possible solutions to ensure that students have sufficient experiential learning opportunities with EHRs in clinical settings. They also contend that competence in the use of EHRs is necessary for students to become physicians who can harness the full potential of these tools rather than physicians for whom EHRs hinder excellent patient care. Finally, the authors argue that meaningful experiences using EHRs should be consistently incorporated into medical school curricula and that EHR-related skills should be rigorously assessed with other clinical skills.
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Affiliation(s)
- Catherine M Welcher
- C.M. Welcher is senior policy analyst, Medical Education Outcomes, American Medical Association, Chicago, Illinois. W. Hersh is professor and chair, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon. B. Takesue is assistant professor of clinical medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana. V.S. Elliott is technical writer, Medical Education Outcomes, American Medical Association, Chicago, Illinois. R.E. Hawkins is vice president, Medical Education Outcomes, American Medical Association, Chicago, Illinois
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22
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Gonzalo JD, Thompson BM, Haidet P, Mann K, Wolpaw DR. A Constructive Reframing of Student Roles and Systems Learning in Medical Education Using a Communities of Practice Lens. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2017. [PMID: 28640036 DOI: 10.1097/acm.0000000000001778] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Health systems are in the midst of a transformation that is being driven by a variety of forces. This has important implications for medical educators because clinical practice environments play a key role in learning and professional development, and evolving health systems are beginning to demand that providers have "systems-ready" knowledge, attitudes, and skills. Such implications provide a clear mandate for medical schools to modify their goals and prepare physicians to practice flexibly within teams and effectively contribute to the improvement of health care delivery. In this context, the concepts of value-added medical education, authentic student roles, and health systems science are emerging as increasingly important. In this Article, the authors use a lens informed by communities of practice theory to explore these three concepts, examining the implications that the communities of practice theory has in the constructive reframing of educational practices-particularly common student roles and experiences-and charting future directions for medical education that better align with the needs of the health care system. The authors apply several key features of the communities of practice theory to current experiential roles for students, then propose a new approach to students' clinical experiences-value-added clinical systems learning roles-that provides students with opportunities to make meaningful contributions to patient care while learning health systems science at the patient and population level. Finally, the authors discuss implications for professional role formation and anticipated challenges to the design and implementation of value-added clinical systems learning roles.
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Affiliation(s)
- Jed D Gonzalo
- J.D. Gonzalo is assistant professor of medicine and public health sciences and associate dean for health systems education, Penn State College of Medicine, Hershey, Pennsylvania; ORCID: http://orcid.org/0000-0003-1253-2963. B.M. Thompson is professor of medicine and associate dean for learner assessment and program evaluation, Penn State College of Medicine, Hershey, Pennsylvania. P. Haidet is professor of medicine, humanities, and public health sciences and director of medical education research, Penn State College of Medicine, Hershey, Pennsylvania. K. Mann was professor emeritus, Division of Medical Education, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada. D.R. Wolpaw is professor of medicine and humanities, senior consultant for education innovation, Regional Medical Campus, and director, Doctors Kienle Center for Humanistic Medicine, Penn State College of Medicine, Hershey, Pennsylvania
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23
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White J, Anthony D, WinklerPrins V, Roskos S. Electronic Medical Records, Medical Students, and Ambulatory Family Physicians: A Multi-Institution Study. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2017; 92:1485-1490. [PMID: 28379934 DOI: 10.1097/acm.0000000000001673] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
PURPOSE Medical students commonly encounter electronic medical records (EMRs) in their ambulatory family medicine clerkships, but how students interact with this technology varies tremendously and presents challenges to students and preceptors. Little research to date has evaluated the impact of EMRs on medical student education in the ambulatory setting; this three-institution study aimed to identify behaviors of ambulatory family medicine preceptors as they relate to EMRs and medical students. METHOD In 2015, the authors sent e-mails to ambulatory preceptors who in the preceding year had hosted medical students during family medicine clerkships, inviting them to participate in the survey, which asked questions about each preceptor's methods of using the EMR with medical students. RESULTS Of 801 ambulatory preceptors, 265 (33%) responded. The vast majority of respondents used an EMR and provided students with access to it in some way, but only 62.2% (147/236) allowed students to write electronic notes. Of those who allowed students electronic access, one-third did so by logging students in under their own (the preceptor's) credentials, either by telling the students their log-in information (22/202; 10.9%) or by logging in the student without revealing their passwords (43/202; 21.3%). CONCLUSIONS Ambulatory medical student training in the use of EMRs not only varies but also requires many preceptors to break rules for students to learn important documentation skills. Without changes to the policies surrounding student access to and use of EMRs, future physicians will enter residency without the training they need to appropriately document patient care.
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Affiliation(s)
- Jordan White
- J. White is assistant professor of family medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island. D. Anthony is associate professor of family medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island. V. WinklerPrins is associate professor of family medicine, Georgetown University School of Medicine, Washington, DC. S. Roskos is associate professor of family medicine, Michigan State University College of Human Medicine. East Lansing, Michigan
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Tanner JA, Rao KT, Salas RE, Strowd RE, Nguyen AM, Kornbluh A, Mead-Brewer E, Gamaldo CE. Incorporating students into clinic may be associated with both improved clinical productivity and educational value. Neurol Clin Pract 2017; 7:474-482. [PMID: 29431166 DOI: 10.1212/cpj.0000000000000394] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background In this study, we aimed to evaluate ambulatory clinic responsibilities that neurology clerkship students perceive as having the highest educational value and to evaluate the association between a student's presence and level of responsibility and a preceptor's clinical and financial productivity during a clinic session. Methods Physician preceptors (n = 43) and medical students (n = 67) in the Johns Hopkins Neurology clerkship from 2014 to 2015 were included. Students rated their experience and responsibilities in 291 neurology clinic sessions. Productivity metrics (e.g., relative value units [RVU]/clinic) were collected for each preceptor in the presence and absence of students. Results A student's rating of a clinic as an effective learning experience increased with each additional patient the student interviewed (odds ratio [OR] 1.89, p < 0.001), presented (OR 1.86, p < 0.001), or documented (OR 2.00, p < 0.001). The mean RVU/session for preceptors also increased based on the number of patients interviewed (β = 2.64, p = 0.026), presented (β = 2.42, p = 0.047), and documented (β = 2.70, p = 0.036) by students. On average, preceptor RVU/session increased by 42% (mean 5.6 ± 1.2, p < 0.0001) when a student was present in clinic compared to sessions without students. In addition, preceptor invoices increased by 35% (mean 2.7 ± 0.6, p < 0.0001) and charges by 39% (mean $929 ± $210, p < 0.0001) when a student was present in clinic. Conclusions This observational study suggests a mutual benefit to preceptor clinical productivity and student-perceived educational value when students have active responsibilities in neurology clinics. Despite concerns that students slow down preceptors in clinic, these results suggest that preceptors may have an overall boost in productivity, potentially by performing billable work while students independently see patients.
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Affiliation(s)
- Jeremy A Tanner
- Department of Neurology (JAT, KTR, RE Salas, RE Strowd, AMN, AK, EM-B, CEG), Johns Hopkins Medicine, Baltimore, MD; and Department of Neurology (RE Strowd), Wake Forest School of Medicine, Winston-Salem, NC
| | - Karthik T Rao
- Department of Neurology (JAT, KTR, RE Salas, RE Strowd, AMN, AK, EM-B, CEG), Johns Hopkins Medicine, Baltimore, MD; and Department of Neurology (RE Strowd), Wake Forest School of Medicine, Winston-Salem, NC
| | - Rachel E Salas
- Department of Neurology (JAT, KTR, RE Salas, RE Strowd, AMN, AK, EM-B, CEG), Johns Hopkins Medicine, Baltimore, MD; and Department of Neurology (RE Strowd), Wake Forest School of Medicine, Winston-Salem, NC
| | - Roy E Strowd
- Department of Neurology (JAT, KTR, RE Salas, RE Strowd, AMN, AK, EM-B, CEG), Johns Hopkins Medicine, Baltimore, MD; and Department of Neurology (RE Strowd), Wake Forest School of Medicine, Winston-Salem, NC
| | - Angeline M Nguyen
- Department of Neurology (JAT, KTR, RE Salas, RE Strowd, AMN, AK, EM-B, CEG), Johns Hopkins Medicine, Baltimore, MD; and Department of Neurology (RE Strowd), Wake Forest School of Medicine, Winston-Salem, NC
| | - Alexandra Kornbluh
- Department of Neurology (JAT, KTR, RE Salas, RE Strowd, AMN, AK, EM-B, CEG), Johns Hopkins Medicine, Baltimore, MD; and Department of Neurology (RE Strowd), Wake Forest School of Medicine, Winston-Salem, NC
| | - Evan Mead-Brewer
- Department of Neurology (JAT, KTR, RE Salas, RE Strowd, AMN, AK, EM-B, CEG), Johns Hopkins Medicine, Baltimore, MD; and Department of Neurology (RE Strowd), Wake Forest School of Medicine, Winston-Salem, NC
| | - Charlene E Gamaldo
- Department of Neurology (JAT, KTR, RE Salas, RE Strowd, AMN, AK, EM-B, CEG), Johns Hopkins Medicine, Baltimore, MD; and Department of Neurology (RE Strowd), Wake Forest School of Medicine, Winston-Salem, NC
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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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Wittels K, Wallenstein J, Patwari R, Patel S. Medical Student Documentation in the Electronic Medical Record: Patterns of Use and Barriers. West J Emerg Med 2016; 18:133-136. [PMID: 28116025 PMCID: PMC5226747 DOI: 10.5811/westjem.2016.10.31294] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 09/26/2016] [Accepted: 10/27/2016] [Indexed: 11/24/2022] Open
Abstract
Introduction Electronic health records (EHR) have become ubiquitous in emergency departments. Medical students rotating on emergency medicine (EM) clerkships at these sites have constant exposure to EHRs as they learn essential skills. The Association of American Medical Colleges (AAMC), the Liaison Committee on Medical Education (LCME), and the Alliance for Clinical Education (ACE) have determined that documentation of the patient encounter in the medical record is an essential skill that all medical students must learn. However, little is known about the current practices or perceived barriers to student documentation in EHRs on EM clerkships. Methods We performed a cross-sectional study of EM clerkship directors at United States medical schools between March and May 2016. A 13-question IRB-approved electronic survey on student documentation was sent to all EM clerkship directors. Only one response from each institution was permitted. Results We received survey responses from 100 institutions, yielding a response rate of 86%. Currently, 63% of EM clerkships allow medical students to document a patient encounter in the EHR. The most common reasons cited for not permitting students to document a patient encounter were hospital or medical school rule forbidding student documentation (80%), concern for medical liability (60%), and inability of student notes to support medical billing (53%). Almost 95% of respondents provided feedback on student documentation with supervising faculty being the most common group to deliver feedback (92%), followed by residents (64%). Conclusion Close to two-thirds of medical students are allowed to document in the EHR on EM clerkships. While this number is robust, many organizations such as the AAMC and ACE have issued statements and guidelines that would look to increase this number even further to ensure that students are prepared for residency as well as their future careers. Almost all EM clerkships provided feedback on student documentation indicating the importance for students to learn this skill.
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Affiliation(s)
- Kathleen Wittels
- Harvard Medical School, Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Joshua Wallenstein
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia
| | - Rahul Patwari
- Rush Medical College, Department of Emergency Medicine, Chicago, Illinois
| | - Sundip Patel
- Cooper University Health Care, Department of Emergency Medicine, Camden, New Jersey
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Taylor CT, Adams AJ, Albert EL, Cardello EA, Clifford K, Currie JD, Gonyeau M, Nelson SP, Bradley-Baker LR. Report of the 2014-2015 Professional Affairs Standing Committee: Producing Practice-Ready Pharmacy Graduates in an Era of Value-Based Health Care. AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2015; 79:S12. [PMID: 26691542 PMCID: PMC4678755 DOI: 10.5688/ajpe798s12] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Affiliation(s)
- Charles T Taylor
- Northeast Ohio Medical University College of Pharmacy, Rootstown, Ohio
| | | | - Erin L Albert
- Butler University College of Pharmacy and Health Sciences, Indianapolis, Indiana
| | | | - Kalin Clifford
- Texas Tech University Health Sciences Center School of Pharmacy, Dallas, Texas
| | - Jay D Currie
- The University of Iowa College of Pharmacy, Iowa City, Iowa
| | - Michael Gonyeau
- Northeastern University Bouve College of Health Sciences School of Pharmacy, Boston, Massachusetts
| | - Steven P Nelson
- American Society of Health-System Pharmacists, Bethesda, Maryland
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Denton GD, Lo MC, Brandenburg S, Hingle S, Meade L, Chheda S, Fazio SB, Blanchard M, Hoellein A. Solutions to common problems in training learners in general internal medicine ambulatory settings. Am J Med 2015; 128:1152-7. [PMID: 26071822 DOI: 10.1016/j.amjmed.2015.05.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 05/29/2015] [Indexed: 11/25/2022]
Affiliation(s)
- G Dodd Denton
- Ochsner Clinical School, University of Queensland, New Orleans, La.
| | - Margaret C Lo
- University of Florida College of Medicine, Gainesville
| | | | - Susan Hingle
- Southern Illinois University School of Medicine, Springfield
| | - Lauren Meade
- Tufts University School of Medicine, Baystate Medical Center, Springfield, Mass
| | - Shobhina Chheda
- University of Wisconsin School of Medicine and Public Health, Madison
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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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Taketomi K, Kikukawa M, Ito YM, Yamaoka A, Otaki J, Yoshida M. Comparison of students' encountered diseases and available diseases at clerkship sites by exploratory multivariate analysis: Are encountered diseases predictable? MEDICAL TEACHER 2015; 38:395-403. [PMID: 26089107 DOI: 10.3109/0142159x.2015.1047751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Students in clerkship are expected to gain clinical expertise by interacting with real patients in clinical situations. Monitoring and predicting the students' encounter diseases (EDs) is important for providing an optimal experience. EDs should be compared with the available diseases (ADs) at the clerkship site and with the required diseases described in some guidelines for the clinical curriculum. AIMS To explore the differences in ADs as learning resources among different types of clerkship sites and to investigate discrepancies between EDs and ADs. METHOD A retrospective observational study used secondary data from government statistics to compare ADs of various types of observable clerkship sites by biplot analyses, which allowed multivariate comparisons. EDs collected from logbooks during clerkships at a university hospital were also compared with ADs across sites. RESULTS The distributions of ADs differed according to institutional type, and EDs at Kyushu University Hospital were similar to the ADs for the category of hospitals in which it was placed. CONCLUSION EDs at a clerkship site may be predictable to some extent by analysing the site's distribution of ADs, but further study is needed. Biplot is useful for visualising these types of statistical similarity.
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Affiliation(s)
- Kikuko Taketomi
- a Center for Medical Education, Hokkaido University Graduate School of Medicine , Japan
| | - Makoto Kikukawa
- b Department of Medical Education , Faculty of Medical Sciences, Kyushu University , Japan
| | - Yoichi M Ito
- c Department of Biostatistics , Hokkaido University Graduate School of Medicine , Japan
| | | | - Junji Otaki
- a Center for Medical Education, Hokkaido University Graduate School of Medicine , Japan
| | - Motofumi Yoshida
- b Department of Medical Education , Faculty of Medical Sciences, Kyushu University , Japan
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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: 18] [Impact Index Per Article: 2.0] [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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Helstrom JM, Langenau EE, Sandella JM, Mote BL. Keyboard data entry use among osteopathic medical students and residents. J Osteopath Med 2015; 114:274-82. [PMID: 24677467 DOI: 10.7556/jaoa.2014.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
CONTEXT Candidates taking the Comprehensive Osteopathic Medical Licensing Examination-USA Level 2-Performance Evaluation (COMLEX-USA Level 2-PE) are currently evaluated on their ability to document clinical findings using a handwritten postencounter note. However, keyboard data entry is increasingly used for medical documentation. OBJECTIVE To determine the use and perception of keyboard data entry among osteopathic medical students and residents in educational and clinical settings. METHODS A Web-based survey regarding frequency of and preference for keyboard data entry was distributed to 9801 osteopathic medical students, 17,268 osteopathic residents, and 34 clinical deans of colleges of osteopathic medicine (COMs). In addition, 31 COMs' clinical skills center directors were contacted to participate in a telephone survey about the use of keyboard data entry in their centers. RESULTS A total of 1711 students, 1198 residents, 14 clinical deans, and 17 clinical skills center directors responded to the surveys. The majority of students (872 [51%]) reported using electronic keyboard data entry at their COM's clinical skills center for postencounter notes. Among respondents, 379 students (23%), 77 residents (9%), and 1 clinical dean reported that electronic keyboard data entry is never or rarely used during clinical rotations. Most trainees (1592 students [93%], 864 residents [94%]) reported that they were either comfortable or very comfortable with typing. Given the option of recording methods for SOAP (subjective, objective, assessment, plan) note findings on the COMLEX-USA Level 2-PE, 7 clinical deans were unsure of their students' preferences, while the remaining favored keyboard data entry (5) over handwriting (2). The majority of student and resident respondents would choose keyboard data entry (1009 [60%] and 511 [55%], respectively). CONCLUSION Osteopathic medical students and residents are comfortable with typing; they are exposed to and would prefer using an electronic form of entry for medical documentation. These results support a conversion from written postencounter notes to keyboard data entry of notes on the COMLEX-USA Level 2-PE.
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Affiliation(s)
- Julia M Helstrom
- Physician Trainer for Clinical Skills Testing, NBOME, 101 W Elm St, Suite 150, Conshohocken, PA 19428-2004.
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Abstract
ISSUE Students devote hundreds of hours to writing notes during medical school clerkships but receive very limited feedback on that work. Medical student notes are like college essays-both are persuasive compositions. But attending physicians rarely scrutinize student notes like college professors analyze essays. This is a missed opportunity to teach clinical reasoning. EVIDENCE A survey at our institution showed that only 16% of students received written feedback and 31% received oral feedback on their notes from more than 3 attending physicians during the first 8 months of 3rd-year clerkships. Many studies have reported a paucity of feedback across multiple domains and a sense among students that clinical reasoning is not being adequately taught during clerkships. Meanwhile, college professors teach written composition and reasoning through interactive methods that help students to develop structured, well-reasoned arguments. A recent study showed that 85% of Oxford undergraduates favored these demanding and time-intensive tutorials. IMPLICATIONS Attending physicians who adopt a tutorial-based approach toward their students' notes would have a forum to teach clinical reasoning and emphasize the importance of written composition in medical practice.
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Affiliation(s)
- William Feldman
- a University of California San Francisco School of Medicine , San Francisco , California , USA
| | - Gurpreet Dhaliwal
- b Department of Medicine , University of California San Francisco School of Medicine , San Francisco , California , USA
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Matson C, Stephens M, Steiner B, Kozakowski SM. Electronic health records: how will students learn if they can't practice? Ann Fam Med 2014; 12:582-3. [PMID: 25384826 PMCID: PMC4226785 DOI: 10.1370/afm.1716] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Christine Matson
- Chair, Association of Departments of Family Medicine's (ADFM) Education Transformation Committee
| | - Mark Stephens
- Chair, Department of Family Medicine, Uniformed Services University and Member, ADFM Education Transformation Committee
| | - Beat Steiner
- Chair, Society of Teachers of Family Medicine's Medical Student Education Committee
| | - Stanley M Kozakowski
- Director, Division of Medical Education, American Academy of Family Physicians and Ardis Davis, MSW, ADFM Executive Director
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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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Lenert LA, Sakaguchi FH, Weir CR. Rethinking the discharge summary: a focus on handoff communication. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2014; 89:393-398. [PMID: 24448037 PMCID: PMC4090779 DOI: 10.1097/acm.0000000000000145] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The discharge summary is one of the most critical documents in medical care settings, but it is prone to systematic lapses that compromise the continuity of care. Discontinuity is fostered not only by incomplete inclusion of data (such as pending labs or medication reconciliations) but also by failure to document clinical reasoning and unfinished diagnostic workups. To correct these problems, the authors propose the Situation-Background-Assessment-Recommendations (SBAR) format for discharge summaries. SBAR is already used for handoffs the way Subjective-Objective-Assessment-Plan is for progress notes. The SBAR format supports the concise presentation of relevant information along with guidance for action. It shifts the paradigm and purpose of the discharge summary away from being a "Captain's Log" (a historical record of the events, actions taken, and their consequences during hospitalization) and towards being a handoff document (a tool for communication between health professionals aimed at ensuring continuity of care). To test SBAR as a template for discharge summaries, the authors have initiated a study to document the impact of the SBAR model on the quality of trainees' thinking in discharge summaries.
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Affiliation(s)
- Leslie A Lenert
- Dr. Lenert is professor, Departments of Biomedical Informatics and Internal Medicine, and associate chair for quality and innovation, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah. Dr. Sakaguchi is a postdoctoral fellow, Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah. Dr. Weir is associate professor, Department of Biomedical Informatics, University of Utah School of Medicine, and associate director, Veterans Affairs Health System Geriatric Research, Education, and Clinical Center and Salt Lake City Informatics, Decision Enhancement and Surveillance, Salt Lake City, Utah
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Heiman HL, Rasminsky S, Bierman JA, Evans DB, Kinner KG, Stamos J, Martinovich Z, McGaghie WC. Medical students' observations, practices, and attitudes regarding electronic health record documentation. TEACHING AND LEARNING IN MEDICINE 2014; 26:49-55. [PMID: 24405346 DOI: 10.1080/10401334.2013.857337] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND Medical students are increasingly documenting their patient notes in electronic health records (EHRs). Documentation short-cuts, such as copy-paste and templates, have raised concern among clinician-educators because they may perpetuate redundant, inaccurate, or even plagiarized notes. Little is known about medical students' experiences with copy-paste, templates and other "efficiency tools" in EHRs. PURPOSES We sought to understand medical students' observations, practices, and attitudes regarding electronic documentation efficiency tools. METHODS We surveyed 3rd-year medical students at one medical school. We asked about efficiency tools including copy-paste, templates, auto-inserted data, and "scribing" (documentation under a supervisor's name). RESULTS Overall, 123 of 163 students (75%) responded; almost all frequently use an EHR for documentation. Eighty-six percent (102/119) reported at least sometimes observing residents copying data from other providers' notes and 60% (70/116) reported observing attending physicians doing so. Most students (95%, 113/119) reported copying from their own previous notes, and 22% (26/119) reported copying from residents. Only 10% (12/119) indicated that copying from other providers is acceptable, whereas 83% (98/118) believe copying from their own notes is acceptable. Most students use templates and auto-inserted data; 43% (51/120) reported documenting while signed in under an attending's name. Greater use of documentation efficiency tools is associated with plans to enter a procedural specialty and with lack of awareness of the medical school copy-paste policy. CONCLUSIONS Students frequently use a range of efficiency tools to document in the electronic health record, most commonly copying their own notes. Although the vast majority of students believe it is unacceptable to copy-paste from other providers, most have observed clinical supervisors doing so.
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Affiliation(s)
- Heather L Heiman
- a Department of Medicine and Augusta Webster, MD, Office of Medical Education , Northwestern University Feinberg School of Medicine , Chicago , Illinois , USA
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Mészáros K, Barnett MJ, Lenth RV, Knapp KK. Pharmacy school survey standards revisited. AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2013; 77:3. [PMID: 23459404 PMCID: PMC3578335 DOI: 10.5688/ajpe7713] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Accepted: 08/09/2012] [Indexed: 05/27/2023]
Abstract
In a series of 3 papers on survey practices published from 2008 to 2009, the editors of the American Journal of Pharmaceutical Education presented guidelines for reporting survey research, and these criteria are reflected in the Author Instructions provided on the Journal's Web site. This paper discusses the relevance of these criteria for publication of survey research regarding pharmacy colleges and schools. In addition, observations are offered about surveying of small "universes" like that comprised of US colleges and schools of pharmacy. The reason for revisiting this issue is the authors' concern that, despite the best of intentions, overly constraining publication standards might discourage research on US colleges and schools of pharmacy at a time when the interest in the growth of colleges and schools, curricular content, clinical education, competence at graduation, and other areas is historically high. In the best traditions of academia, the authors share these observations with the community of pharmacy educators in the hope that the publication standards for survey research about US pharmacy schools will encourage investigators to collect and disseminate valuable information.
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Affiliation(s)
- Károly Mészáros
- College of Pharmacy, Touro University California, Vallejo, CA 94592, USA.
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Ratcliffe TA, Hanson JL, Hemmer PA, Hauer KE, Papp KK, Denton GD. The required written history and physical is alive, but not entirely well, in internal medicine clerkships. TEACHING AND LEARNING IN MEDICINE 2013; 25:10-14. [PMID: 23330889 DOI: 10.1080/10401334.2012.741538] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Effective written communication is a core competency for medical students, but it is unclear whether or how this skill is evaluated in clinical clerkships. PURPOSE This study identifies current requirements and practices regarding required written work during internal medicine clerkships. METHODS In 2010, Clerkship Directors of Internal Medicine (CDIM) surveyed its institutional members; one section asked questions about students' written work. RESULTS were compared to similar, unpublished CDIM 2001 survey questions. RESULTS Requirements for student-written work were nearly universal (96% in 2001 and 100% in 2010). Only 23% used structured evaluation forms and 16% reported written work was weighted as a percentage of the final grade, although 72% of respondents reported that written work was "factored" into global ratings. CONCLUSIONS Despite near universal requirements for student written work, structured evaluation was not commonly performed, raising concern about the validity of factoring these assessments into grades.
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Affiliation(s)
- Temple A Ratcliffe
- Department of Medicine , Uniformed Services University of the Health Sciences, Bethesda, MD 20892, USA.
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Mollo EA, Reinke CE, Nelson C, Holena DN, Kann B, Williams N, Bleier J, Kelz RR. The Simulated Ward: ideal for Training Clinical Clerks in an Era of Patient Safety. J Surg Res 2012; 177:e1-6. [DOI: 10.1016/j.jss.2012.03.050] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Revised: 03/10/2012] [Accepted: 03/22/2012] [Indexed: 11/29/2022]
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Assessment of medical student clinical reasoning by "lay" vs physician raters: inter-rater reliability using a scoring guide in a multidisciplinary objective structured clinical examination. Am J Surg 2012; 203:81-6. [PMID: 22172486 DOI: 10.1016/j.amjsurg.2011.08.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Revised: 08/30/2011] [Accepted: 08/30/2011] [Indexed: 11/22/2022]
Abstract
BACKGROUND To determine whether a "lay" rater could assess clinical reasoning, interrater reliability was measured between physician and lay raters of patient notes written by medical students as part of an 8-station objective structured clinical examination. METHODS Seventy-five notes were rated on core elements of clinical reasoning by physician and lay raters independently, using a scoring guide developed by physician consensus. Twenty-five notes were rerated by a 2nd physician rater as an expert control. Kappa statistics and simple percentage agreement were calculated in 3 areas: evidence for and against each diagnosis and diagnostic workup. RESULTS Agreement between physician and lay raters for the top diagnosis was as follows: supporting evidence, 89% (κ = .72); evidence against, 89% (κ = .81); and diagnostic workup, 79% (κ = .58). Physician rater agreement was 83% (κ = .59), 92% (κ = .87), and 96% (κ = .87), respectively. CONCLUSIONS Using a comprehensive scoring guide, interrater reliability for physician and lay raters was comparable with reliability between 2 expert physician raters.
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Hammoud MM, Margo K, Christner JG, Fisher J, Fischer SH, Pangaro LN. Opportunities and challenges in integrating electronic health records into undergraduate medical education: a national survey of clerkship directors. TEACHING AND LEARNING IN MEDICINE 2012; 24:219-224. [PMID: 22775785 DOI: 10.1080/10401334.2012.692267] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Few studies have reported on the utilization and the effect of electronic health records on the education of medical students. PURPOSE The purpose of this study was to describe the current use of electronic health records by medical students in the United States and explore the opportunities and challenges of integrating electronic health records into daily teaching of medical students. METHODS A survey with 24 questions regarding the use of electronic health records by medical students was developed by the Alliance for Clinical Educators and sent to clerkship directors across the United States. Both quantitative and qualitative responses were collected and analyzed to determine current access to and use of electronic health records by medical students. RESULTS This study found that an estimated 64% of programs currently allow student use of electronic health records, of which only two thirds allowed students to write notes within the electronic record. Overall, clerkship directors' opinions on the effects of electronic health records on medical student education were neutral, and despite acknowledging many advantages to electronic health records, there were many concerns raised regarding their use in education. CONCLUSIONS Medical students are using electronic health records at higher rates than physicians in practice. Although this is overall reassuring, educators have to be cautious about the limitations being placed on student's documentation in electronic health records as this can potentially have consequences on their training, and they need to explore ways to maximize the benefits of electronic health records in medical education.
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Affiliation(s)
- Maya M Hammoud
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, Michigan, USA.
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Hammoud MM, Dalymple JL, Christner JG, Stewart RA, Fisher J, Margo K, Ali II, Briscoe GW, Pangaro LN. Medical student documentation in electronic health records: a collaborative statement from the Alliance for Clinical Education. TEACHING AND LEARNING IN MEDICINE 2012; 24:257-66. [PMID: 22775791 DOI: 10.1080/10401334.2012.692284] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
PURPOSE The electronic health record (EHR) is an important advancement in health care. It facilitates improvement of health care delivery and coordination of care, but it creates special challenges for student education. This article represents a collaborative effort of the Alliance for Clinical Education (ACE), a multidisciplinary group formed in 1992. ACE recognizes the importance of medical student participation in patient care including the ability of documentation. This article proposes guidelines that can be used by educators to establish expectations on medical student documentation in EHRs. SUMMARY To provide the best education for medical students in the electronic era, ACE proposes to use the following as practice guidelines for medical student documentation in the EHR: (a) Students must document in the patient's chart and their notes should be reviewed for content and format, (b) students must have the opportunity to practice order entry in an EHR--in actual or simulated patient cases--prior to graduation, (c) students should be exposed to the utilization of the decision aids that typically accompany EHRs, and (d) schools must develop a set of medical student competencies related to charting in the EHR and state how they would evaluate it. This should include specific competencies to be documented at each stage, and by time of graduation. In addition, ACE recommends that accreditation bodies such as the Liaison Committee for Medical Education utilize stronger language in their educational directives standards to ensure compliance with educational principles. This will guarantee that the necessary training and resources are available to ensure that medical students have the fundamental skills for lifelong clinical practice. CONCLUSIONS ACE recommends that medical schools develop a clear set of competencies related to student in the EHR which medical students must achieve prior to graduation in order to ensure they are ready for clinical practice.
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Affiliation(s)
- Maya M Hammoud
- Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, Michigan, USA.
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Wong BM, Levinson W, Shojania KG. Quality improvement in medical education: current state and future directions. MEDICAL EDUCATION 2012; 46:107-19. [PMID: 22150202 DOI: 10.1111/j.1365-2923.2011.04154.x] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
CONTEXT During the last decade, there has been a drive to improve the quality of patient care and prevent the occurrence of avoidable errors. This review describes current efforts to teach or engage trainees in patient safety and quality improvement (QI), summarises progress to date, as well as successes and challenges, and lists our recommendations for the next steps that will shape the future of patient safety and QI in medical education. CURRENT STATUS Trainees encounter patient safety and QI through three main groups of activity. First are formal curricula that teach concepts or methods intended to facilitate trainees' participation in QI activities. These curricula increase learner knowledge and may improve clinical processes, but demonstrate limited capacity to modify learner behaviours. Second are educational activities that impart specific skills related to safety or quality which are considered to represent core doctor competencies (e.g. effective patient handover). These are frequently taught effectively, but without emphasis on the general safety or quality principles that inform the relevant skills. Third are real-life QI initiatives that involve trainees as active or passive participants. These innovative approaches expose trainees to safety and quality by integrating QI activities into trainees' day-to-day work. However, this integration can be challenging and can sometimes result in tension with broader educational goals. FUTURE DIRECTIONS To prepare the next generation of doctors to make meaningful contributions to the quality mission, we propose the following call to action. Firstly, a major effort to build faculty capacity, especially among teachers of QI, should be instigated. Secondly, accreditation standards and assessment methods, both during training and at end-of-training certification examinations, should explicitly target these competencies. Finally, and perhaps most importantly, we must refocus our attention at all levels of training and instil fundamental, collaborative, open-minded behaviours so that future clinicians are primed to promote a culture of safer, higher-quality care.
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Affiliation(s)
- Brian M Wong
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Schenarts PJ, Schenarts KD. Educational impact of the electronic medical record. JOURNAL OF SURGICAL EDUCATION 2012; 69:105-12. [PMID: 22208841 DOI: 10.1016/j.jsurg.2011.10.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Accepted: 10/27/2011] [Indexed: 05/04/2023]
Abstract
INTRODUCTION The electronic medical record (EMR) is commonly thought to improve the safety and quality of care; however, there is scant information on the impact the EMR has on graduate medical education (GME). METHODS A review of English language literature was performed using MEDLINE and OVID databases using or combining the terms, EMR, GME, electronic health record, education, medical student, resident, clinical decisions support systems, quality, and safety. RESULTS The EMR has a negative effect on teacher and learner interactions, clinical reasoning, and has an inconsistent impact on resident workflow. Data on the impact of the EMR on patient safety, quality of care, and medical finances are mixed. DISCUSSION Based on the literature to date, the EMR has not had as dramatic an effect on patient outcomes is commonly believed. While the overall impact of the EMR on education seems to be negative, there are actions that can be taken to mitigate this impact.
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Affiliation(s)
- Paul J Schenarts
- Department of Surgery, Division of Surgical Education, Brody School of Medicine, East Carolina University, Greenville, North Carolina 27858, USA.
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Roberts KB. The past decade in pediatric education: progress, concerns, and questions. Adv Pediatr 2011; 58:123-51. [PMID: 21736979 DOI: 10.1016/j.yapd.2011.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Kenneth B Roberts
- The University of North Carolina School of Medicine, Chapel Hill, Greensboro, NC 27599, USA.
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