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Almost all schools and their affiliated hospitals and clinics now use an electronic health record (EHR).  But as a student,

• Have you been taught how to use it?
• Are you allowed full access to the EHR?
• Can you write meaningful notes in it?
• Are you able to write orders using the EHR?

If you answered “No” to any of these questions, you may be worried that you might not be fully prepared to care for patients when you reach residency.  This is the concern of ACP and other medical education organizations involved with student and resident training.

Before the EHR, students simply wrote in the physical chart of the patients they saw; these notes were reviewed, corrected, and signed by your attending and were often used as the basis for discussing appropriate physician documentation as part of the learning process.  However, with the advent of EHRs, many hospitals and health systems began restricting student access to the medical chart or significantly limiting what students are able to do within the EHR.  Surveys show extremely wide variability in student use of the EHR, ranging from read-only access to full documentation and ordering privileges, with very few institutions providing specific teaching about how to effectively and appropriately use the EHR.

The reasons given for this change are many, including technical complexities for giving students access to the EHR, worries about patient privacy, and medicolegal concerns regarding student documentation in the chart that might lead to increased risk (although there has been no change in the law regarding student documentation since the transition from physical charts to electronic form).  Plus, current Medicare regulations severely limit the use of student notes for documentation used for billing; this raises concerns about potential billing noncompliance by attendings and the possibility of significant fines to the organization.  Collectively, these factors have led many hospitals, health systems, and clinics to severely restrict student documentation in the EHR to avoid these issues.

At the same time, almost all major medical education organizations recommend or require that students receive training and experience in use of the EHR in medical school to prepare them for residency.  This includes the Association of American Medical Colleges (the association of the nation’s medical schools), and the Accreditation Council for Graduate Medical Education (the organization that sets the standards for residency training in the US).  Additionally, the USMLE Step 2 Clinical Skills Examination requires that students be able to write notes in electronic form as part of that assessment.

The ACP believes that impaired medical student access to or limitations on student use of the EHR threatens development of these important skills needed for continued training and the lifelong practice of medicine.  

This belief led to a resolution introduced by the Education and Publications Committee of the �ܼ�����ˮ��̳ to address this issue.  The resolution was ultimately endorsed by the ACP Board of Governors and passed by the Board of Regents, which is the highest level of leadership in ACP and the one that ultimately determines College policy.

The resolution calls upon the major medical education regulatory bodies in the US to require that:

• Schools develop a set of medical student competencies related to charting in the EHR, including the specific competencies to be documented at each stage of training and by the time of graduation.
• Student interaction with the EHR during medical school training be meaningful, with recognition that information entered into the actual medical record by students during clinical rotations is valid information that contributes to patient care and serves a fundamental and critical educational purpose. 
• Students must be allowed to document directly in the patient’s chart and that their notes should be reviewed for content and format.

• Students must have the opportunity to practice order entry in an EHR—in actual or simulated patient cases—prior to graduation.
• Students should be exposed to the utilization of the decision aids that typically accompany EHRs.

A second part of the resolution requests that relevant federal agencies change their requirements to allow teaching physicians to refer to a student's verified documentation in his or her personal note, which would allow for billing but would also validate the student contribution to patient care and provide a real-time basis for learning accurate and effective documentation skills.

Four other important medical organizations have joined with ACP to support this resolution, including the Alliance for Academic Internal Medicine (the national organization of the chairs, residency and fellowship program directors, and undergraduate/clerkship medical educators in internal medicine); the American College of Osteopathic Internists (the national osteopathic internal medicinepractice society); the Society of Hospital Medicine (the professional society for hospitalists); and the Society of General Internal Medicine (the society representing the primary internal medicine teaching faculty in all of the medical schools and major teaching hospitals in the United States).

The resolution is being implemented in several ways. The College is communicating directly with the pertinent educational regulatory bodies to implement these recommended changes and requirements (you can see the letter here), and the ACP advocacy group in Washington, DC is coordinating efforts with the Center for Medicare and Medicaid Services to seek a change in the documentation requirements.

Although changes in student use of the EHR encouraged by this resolution will not be immediate, it is important to know that the College is actively working to ensure that you and your colleagues are well-prepared for residency and to care for patients as you move through your career.

See other important issues that the ACP is working on.

Back to October 2016 Issue of IMpact