Incorporating Electronic Medical Records into the Physician Assistant Educational Curriculum

TECHNoLoGy ANd EduCATIoN

Jacqueline S. Barnett, MSHS, PA-C, the George Washington university, School of Medicine and Health Sciences, Department of Physician Assistant Studies, Washington, DC Introduction Currently, there is a strong push in the US health system to increase the use of electronic medical records (EMR) in the delivery of health care.1 EMRs serve as a mechanism to document, communicate, and integrate patient information to promote effective decision-making and quality health care. Use of EMRs is expected to decrease health care costs, while improving efficiency, safety, and patient outcomes.2 However, EMRs in and of themselves will not meet this intended benefit if end users are not sufficiently trained to use this technology. The lack of adequate knowledge and skills by health care providers to use EMR systems has been cited as a consistent barrier to the broad adoption of EMRs in the United States.3 The Institute of Medicine (IOM) recommended that all health professional training programs incorporate health information technology and informatics into their training curricula.4 Physician assistant (PA) and medical education training include system-based practices and practice-based learning improvements as core professional competency requirements.5,6 However, many schools have not formally incorporated EMRs into their curricula7 as a mechanism to help learners improve their patient care practices. Due to incentives in the American Recovery and Reinvestment Act of 2009,8 EMRs will most likely increasingly be used to document the patient’s encounter, and PAs will be expected to use this technology to manage their patients’ health. In order to equip future 48

PAs with the requisite skills to use EMRs to their full potential, PA educators should consider integrating these systems into their current curricula. This paper provides a brief description of EMRs and a literature review on their use in health professional training curricula, and proposes a framework for implementing this technology into the PA educational curriculum.

feature Editor’s Note: the Electronic Medical Record (EMR) is here to stay and physician assistant educators should incorporate EMR training into their curriculua. Even though there is a plethora of different systems, there are basic components common to all. this article reviews the issues, barriers, and solutions for training the next generation of technology savvy physician assistant graduates.

OverviewofEMRs Electronic medical records (EMRs) as referred to throughout this paper are computerized systems used to create and store a legal medical record. A fully interoperable EMR allows providers to communicate with all involved in the patient’s care; document the clinical note; provide portals for computerorder entry, decision-support systems, and prescription and test results management; and increase patients’ access to their medical records. Providers can use EMRs to assist with the diagnosis and management of chronic diseases and track and monitor longitudinal patient data and preventive care measures that help to improve patient care and health outcomes.2 A fully interoperable EMR system could also be used to teach students basic research and data management skills required to manage an individual or population health project.

LiteratureReviewofEMRs inEducation The literature review was conducted using Medline, Ovid, CINHAL, PubMed, and EBSCOhost, using these

– Allan Platt, MMSc, PA-C Jacqueline Barnett can be reached at [email protected].

the technology and Education feature is intended as a forum for the presentation and discussion of technology in PA programs and education generally. Appropriate submissions include articles related to uses of technology in the classroom, web-based platforms, distance learning, and products and programs. Articles describing the effect of new technologies on student behavior and learning are also welcome. Features should be submitted to journal staff at jpae@PAEA online.org. 2013 Vol 24 No 2 | the Journal of Physician Assistant Education

Incorporating Electronic medical Records into the physician Assistant Educational Curriculum

keywords: health information, electronic medical records, electronic health records, medical students, residents, medical education, physician assistants, and physician assistant education. Although EMRs are expected to transform the future of health care, the literature search revealed limited published work regarding their integration into health professionals’ educational curricula.

PAEducation The PA literature revealed one article related to EMRs that is applicable to this paper. Researchers at Central Michigan University implemented a grant-funded pilot project aimed at increasing faculty and student exposure to geriatric medicine.9 One aspect of this project involved the patient’s primary provider working along with students and faculty to establish EMRs for this patient population. The EMR could then assist the researchers with tracking patient outcomes to meet the objectives of the grant. This pilot project took about a year to establish and there doesn’t appear to be any further published outcomes.

MedicalEducation Despite the increasing importance of EMRs in physician training, there is limited published information regarding the integration of EMRs in medical education as an instructional tool10–12 or learners’ competency with these systems. Keenan et al (2006) completed an extensive review of the medical literature, yielding less than 50 published articles on the use of EMRs in medical education.13

study, students who were taught EMR communication skills (positioning the computer, engaging the patient, and using the EMR to enhance the quality of patient care) performed EMR-specific communication skills better than the control group.14 A study at the University of Kansas found that 72% of third-year medical students reported improved history taking when using EMRs with prompts; 69% reported the use of EMRs improved their chart documentation; and 39% admitted to receiving more feedback when they used EMRs versus paper notes.15 However, 48% of the students reported they spent less time looking at the patient when using EMRs. Generally, the students voiced concerns about the potential impact of the EMR on the provider-patient encounter. In a study by Rouf and colleagues, medical residents also reported that EMRs in the exam room negatively affected their interpersonal contact with the patients.16 It is possible that with increased experience students and residents will feel more comfortable using EMRs in the exam room, but additional research is needed to understand this phenomenon. An earlier study at Johns Hopkins concluded that students placed fewer orders when using EMRs as opposed to paper-based records.17 Older studies also examined the use of EMRs to teach clinical problem solving,18 log clinical experiences,19,20 understand the effect of EMRs on student and resident workflow,21–23 and improve resident education and patient counseling.24

LearnerAttitudesRegardingEMRs UseofEMRsinMedicalEducation Effective communication is an important competency skill in PA and medical education. Researchers at the University of Texas Southwestern Medical Center used EMRs to teach first-year medical students specific patient–physician communication skills.14 In this randomized

It appears the more residents use EMRs the more comfortable they are with these systems. A study conducted in 1999 revealed that although residents reported some benefits of EMRs, they remained ambivalent and frustrated with these systems.25 However, a study done at Yale a few years later

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found that 99% of residents were happy with EMRs and believed the benefits of these systems outweighed any inconveniences.26 Rouf and colleagues found that medical students were pleased with EMRs’ ability to organize information, and 70% admitted that essential information was easier to find when using EMRs.15

BarrierstoEMRsasan EducationalTool There are several barriers related to using EMRs as an educational tool. Significant barriers include the lack of faculty trained in EMRs, a shortage of informatics departments within educational institutions to assist in EMR implementation, too many EMR vendors with different systems requiring vendor-specific training to operate each system, poor access to EMR systems to review or practice, and the absence of a framework or generic course that provides basic instruction on the common functional abilities and use of all EMRs.10 Mixed attitudes regarding the effectiveness of EMRs as an educational tool and faculty’s low enthusiasm for teaching these systems27 also serve as barriers to EMR implementation. Some suggest that EMRs may promote chart documentation errors because of the copy and paste function.28 There are also concerns that EMRs may interfere with the learner’s ability to synthesize clinical information,29 and the various prompts, templates, and problem lists associated with EMRs may be distracting and impede clinical decision-making skills.30 Medicare billing requirements and institutional legal concerns also serve as potential barriers to students using EMRs in the clinic environment.7,31,32

ProposedFrameworksfor IncorporatingEMRsinto Education A few universities have successfully used a variety of frameworks to incor49

Incorporating Electronic medical Records into the physician Assistant Educational Curriculum

porate EMRs into their curricula. The University of Arkansas proposes an integrative framework that uses EMRs across medical and health professional training programs.33 During the academic phase of the curriculum, specific EMR seminars introduce students to the overall concepts and applications related to EMRs as well as security regulations and ethics. Over the course of the curriculum, students use EMRs with clinical decision-support systems and point-of-care training tools during classroom and simulation activities along with standardized and real patient encounters.33 The University of Victoria created an integrative framework that introduced students and faculty to a web-based EMR portal where they can learn a variety of EMR systems.34 This portal provides simulated, hands-on EMR experience that can be incorporated into the curriculum and delivered via classroom, laboratory, and distance education instruction. Stephen, Gimbel, and Pagaro propose the “Reporter/Interpreter/Manager/Educator” framework for incorporating EMRs into medical education.35 This framework teaches and evaluates EMR competency skills in areas such as clinical data entry, data assessment and assimilation, and clinical decision making. Other researchers have used a live EMR system to teach students how to record consultations, code clinical encounters, prescribe medications, and access and use clinical information tools and other skills to enhance learning in a primary care setting.36 Lastly, the University of Minnesota proposes a framework for integrating basic sciences and clinical concepts into patient care using an EMR through a web-based virtual clinic.37 Students use EMRs to manage virtual patients through this web-based weekly clinic. Although longitudinal qualityimprovement data regarding EMRs as an educational tool were absent from the literature, several researchers suggest 50

that teaching quality improvement is easier using EMRs.13,36,38 Increased exposure to EMRs in the educational setting will help prevent errors associated with its use in patient care settings.39,40

AProposedFrameworkto IncorporateEMRsintothe PACurriculum Based on the literature review, medical and health professional students have limited exposure to EMR systems especially in the classroom setting. Much of the exposure to these systems occurs during the clinical internships and in residency training where they are required to learn how to provide patient care and manage disease processes, while learning the fundamentals of the EMR system. Learning EMRs in this format does not provide the necessary in-depth training required to facilitate learners’ understanding of the design, usability, strengths, and limitations of this technology in a manner that will influence clinical practice and improve patient outcomes. Using a program’s current curriculum, EMRs could be implemented into an existing course using an academic electronic medical record system (AEMR) such as Cerner’s AEMR system41 (see Table 1, listing of EMR websites). An AEMR is a secure computerized EMR system that has the capabilities of actual EMR systems used in clinical settings. An AEMR would provide PA programs with the basic tools to teach students the design and functional abilities of EMR systems, and better prepare students to use them in the clinical setting. Selection of an AEMR should be based on its ability to provide broad user access and compatibility with EMR systems that students will encounter during their clerkship training. For example, if the PA program is housed in an academic medical center or affiliated with a teaching hospital, consider selecting an AEMR that is

compatible with its system. The AEMR should include clinical guidelines, electronic drug books, point-ofcare tools, and decision-support systems. In many cases, the school’s library purchases licenses for these electronic resources, and the librarians provide additional training and support (A. Linton, medical school librarian, oral communication, November 2012).

IntegratingEMRsintoan ExistingCourse All PA programs include didactic and clinical curricula. Several learning outcomes could be linked to using EMRs in the didactic curriculum to help prepare students to use these systems in the clinical phase (see Box 1, Educational Objectives). During the didactic phase, most programs offer courses or instruction in patient history taking and physical examination, oral presentation, chart documentation, basic sciences, clinical medicine, and clinical decision making. EMRs could be integrated into the structure of these courses using a combination of the frameworks proposed by the University of Arkansas33 and the University of Minnesota.37 Introductions to EMRs could be held in a computer training room during orientation or the first week of courses. Students would complete interactive computer modules to learn basic instruction in system mechanics, interfacing, and usability, followed by online assessments to evaluate their comprehension and application of each module. Using a generic PA program curriculum as an example (see Table 2, Generic Curriculum), EMRs could be integrated across the curriculum. During the history and physical course in the first semester, students would meet weekly in small groups with faculty to elicit and document a mock patient’s history into the AEMR. As the semester progresses, students would document both the history and physical exam into the AEMR and use 2013 Vol 24 No 2 | the Journal of Physician Assistant Education

Incorporating Electronic medical Records into the physician Assistant Educational Curriculum Table 1. Examples of websites that offer EmR Information and/or demonstrations Name of EMR System

EMR Websites

lippincot DocuCare

http://thepoint.lww.com/lwwdocucare Provides a demo for an EHR learning product designed for nursing student education.

Cerner Academic www.cerner.com/solutions/Education_and_training/Academic_Education_Solution/?langtype=1033 Electronic Health Record Provides a video that discusses the EMR platform built for the nursing, medicine, and physical therapy programs at the university of Kansas. Practice Fusion

www.practicefusion.com/pages/academic_program.html Provides a free EMR system to students and faculty that is available to use upon registration. unsure if it is built as an educational tool versus just an EMR for practice.

VA VistA CPRS

www.ehealth.va.gov/EHEAltH/CPRS_Demo.asp Provides a free downloadable demo EMR system used by the VA health care system for PCs only (not Mac).

the following EMRs offer a demonstration with registration, but they do not offer an educational product. Comchart

www.comchart.com/ComChart-EMR-Virtual-tour/

Allscripts

www.allscripts.com/en/offers/landing-page/EHR-sem2.html?src=GoogleAd&CiD=GOOGlE&_kk=%2Belectronic%20% 2Bmedical%20%2Brecords&_kt=f94228d0-51de-48e5-9562-35286b8fd1d&gclid=CJmhye2CxbACFyhM4Aod5C9iXw

EMR Experts

www.emrexperts.com/emr-demo/index.php

NextGen Healthcare

www.nextgen.com/Community/VirtualOffice/Demologin.aspx?Requestid=f120e668

Open MRS

http://openmrs.org/demo/

this record to orally present their patient cases. During the second semester of the academic year, students would attend a virtual clinic and manage mock or virtual patient cases as part of the clinical decision-making course. Students would use the clinical guidelines, electronic drug resources, and decision-support services offered via the AEMR to develop a differential diagnosis and propose a treatment plan. Students would have to track and manage the patient’s disease progress, laboratory studies, and prescriptions, and code the patient cases in adherence to Medicare, Medicaid, and insurance billing guidelines. The final EMR experience would occur during the clinical applications course. Using standardized patients, this course would mimic real life

box 1. Educational objectives of the Academic Electronic medical Record

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Students should be able to use the Academic Electronic Medical Record to: • Access the patient’s health record • Document the patient’s encounter (history, physical, etc.) • Communicate with other members of the health care team • use longitudinal patient data to track and manage chronic diseases • Access and manage test results (eg, laboratory and radiographic data) • Access consultation notes, hospital summaries, and discharge notes • Manage medications and order prescriptions • use clinical guidelines and decisional-support systems to assist in the clinical decisionmaking process • Provide efficient service and thereby improve patient care quality at the point of service • Audit patient data and thereby decrease the potentiation of medical errors and improve patient outcomes • Manage the health of a population of patients and perform research-related projects with the patient data • learn the full capability and informatics of these systems for improved utilization during the clinical year and graduate clinical practice

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Incorporating Electronic medical Records into the physician Assistant Educational Curriculum Table 2. Generic physician Assistant program Curriculum didactic phase (first year of the program) All students progress through the didactic courses together as a cohort. Semester I Courses Anatomy and Physiology Behavioral Medicine in Primary Care Clinical Medicine i *Ethics in Medicine *History Taking and physical Examination introduction to the Physician Assistant Profession Microbiology Semester II Courses *Clinical decision making Clinical Medicine ii Epidemiology and infectious Disease Pharmacology i Pathophysiology Semester III Courses *Clinical Applications Clinical laboratory Medicine Evidence-Based Medicine Pharmacology ii Clinical phase (Second year of the program) Individualized Student Clerkships Schedules during Semesters IV, V, and VI Adult Outpatient internal Medicine Clinical Elective Emergency Medicine Hospital Medicine Pediatrics Primary Care Surgery Women’s Health *EMRs could be incorporated into these existing courses.

patient-care experiences and prepare students for their experiential clinical year. Students would meet weekly to manage a patient’s presenting “chief complaint” and presenting illness. Students would elicit the history and perform a focused physical examination on a standardized patient in the simulated training center or other comparable learning environment. Students would document the patient case in the EMR, use the decision-support system and evidence-based guidelines to develop the differential diagnosis and treatment plan, and order the appropriate 52

diagnostic studies. Once the diagnosis is determined, students would employ the system to write referrals, communicate with other providers, prescribe medications, provide the appropriate patient education and follow-up instructions, and code the patient’s visit. Students would then orally present the case to faculty. Student evaluations would be based on their overall patient interaction skills, ability to appropriately use the EMR to develop and document an accurate patient diagnosis and management plan, and overall oral presentation skills. This

course could serve as a summative evaluation of the students’ ability to synthesize and apply their medical knowledge and clinical skills and to effectively use the AEMR. Upon successful completion of this course, students would transition into the clinical phase better prepared to use EMRs in various patient care settings. In the clinical year, students would continue to use EMRs to manage patient cases. Students would submit a patient case after each clerkship. The cases would highlight the students’ use of evidence-based medicine tools, clinical practice guides, decision-support systems, prescription guidelines, and management of longitudinal patient data to deliver care. Students would appropriately code and bill each medical diagnosis and provide patient-centered education that promotes health and adheres closely to evidence-based guidelines. Academic and clinical courses would include grading rubrics and a grading schema that incorporate adequate use and competency of EMRs as a portion of the final course grades.

ConcludingDiscussion andSummary EMRs have the potential to change the future of health care. However, the success of these systems will only be as good as the provider’s ability to use them, and thus far, providers lack adequate proficiency with this technology. Based on the literature review, only one PA program has documented using EMRs as a teaching tool in PA education. Even in medical education, literature regarding the use of EMRs remains sparse and mostly reflects actual proposed frameworks and selfreports without validated longitudinal outcome data. Based on suggested frameworks, an AEMR could be implemented into the PA training curriculum and incorporated into an existing PA program course using casebased scenarios along with virtual and standardized patients. Exposure to the 2013 Vol 24 No 2 | the Journal of Physician Assistant Education

Incorporating Electronic medical Records into the physician Assistant Educational Curriculum

AEMR throughout the first year will help to ensure that PA students have the core clinical competency and informatics skills necessary to provide patient care in the clinical setting. Some question the use of EMRs as an educational tool because of their potential negative effect on decisionmaking skills. Although this may represent more of a fear than a reality, it will take clinical evidence and better-trained providers to diminish such fears. Billing and liability matters also threaten the use of EMRs in clinical education settings, and medical education officials and health policy lawmakers will have to address this issue. If widespread adoption of EMRs is the future of medicine, it will be imperative that faculty are adequately trained in EMR systems and students have access to this technology early in their PA curriculum. PA programs must aptly prepare graduates to practice in a modern health care system using EMR systems. Not only will future employers expect PAs to have basic competencies with these systems, effective use of EMRs will assist in national efforts to improve health care safety, quality, and outcomes.

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2013 Vol 24 No 2 | the Journal of Physician Assistant Education