ELECTRONIC HEALTH RECORDS: HOW WILL STUDENTS LEARN IF THEY CAN’T PRACTICE?

Electronic health records (EHR) are becoming ubiquitous, with 78% of office-based physicians reporting use of an EHR in 2013.¹ EHR systems have the potential to enhance quality and safety, but there is a risk that medical students are entering residencies without adequate preparation to fully and effectively use this important instrument. Future physicians must learn skills to enhance relationships while using the EHR in modern clinical practices, avoiding barriers such as ‘continuous partial attention’ and minimizing the patient in favor of the ‘third person in the room.’^2–6 Learning how to elicit medical histories while electronically recording key findings, using EHR-associated decision-making tools and providing management plans requires full EHR access.⁵ Using the registry and analytic functions of EHRs is important for developing skills in population health management. Future physicians must also become familiar with safety reminders and point of care references to provide efficient and effective care. Unfortunately, students at many medical schools are not able to adequately access EHRs to receive this necessary training.

Surveys regarding student use of EHR^7,8 show broad institutional variation. Most differences are the result of varying local interpretations of Medicare guidelines on student EHR use.⁹ The most significant barriers to medical students’ access to the EHR include concerns regarding attribution of note ownership, billing elements, patient safety issues, and breaches of professionalism associated with use of the copy and paste function.⁸ Increasingly, students are training in a variety of ambulatory practice settings with voluntary faculty, where the cost of additional EHR licenses for students can also be a barrier.

The Association of American Medical Colleges’ (AAMC) updated Compliance Advisory released September 30, 2014 attempts to delineate the distinction between the medical students’ documentation in the medical record and the fact that they are not billing providers.¹² Interpretation by academic health centers across the country of AAMC’s 2012 Compliance Advisory, however, has resulted in markedly disparate policies around the country regarding medical student access to EHRs.⁹ Thus, students in some academic health centers are “forbidden any access”, “marginalized [in their] role of medical student”, and “hindered [in the] team function of care”.¹¹

The negative impact of such restrictive policies on student education and team-based care are potentially profound, posing barriers to achievement of 11 of 13 Core Entrustable Professional Activities for Entering Residency described by the AAMC.¹²

To fully prepare medical school graduates to assume roles of increasing responsibility and leadership in modern health care systems requires competence in patient-centered EHR use. For this to happen, all medical students should have access to the EHR that is based on educational need¹³ as opposed to risk aversion. We are confident that this can be done in a way which enhances education without compromising patient safety or third party regulatory requirements. We support the recommendations of the Society of Teachers of Family Medicine as a first step toward remedying current disparities in opportunities for EHR access for medical students. We look forward to collaborating with the AAMC on publicizing ways in which institutions can enable students to use electronic health records for educational and patient care benefit while still providing capability for physicians exclusively to document for billing purposes. To consider patient-centered EHR use as an Entrustable Professional Activity under appropriate supervision is in the best interest of learners and patients alike.

• © 2014 Annals of Family Medicine, Inc.