Curbside Consult with Dr. Jayne 8/28/23

I enjoy working with residents and students, so I was glad to see this recent article looking at the role of electronic health records in medical residency training programs.

When I was working in the EHR industry, I saw a tremendous variation in how organizations wanted to treat learners with respect to electronic documentation. Some organizations would not allow students to access the EHR in any capacity other than read-only, which almost certainly hampered their abilities to learn how to manage the EHR when conducting patient interviews or when taking a medical history. Others would allow students to have limited interaction with the EHR, but placed their documentation in a separate clinical note, distinct from the attending physician and others on the care team. This approach is problematic because it fails to see the student as a member of the care team, and also creates additional work for the attending physician to perform completely separate documentation rather than being able to update and affirm the student’s documentation.

As far as residency programs, I’ve seen a wide spectrum of access and EHR usage there as well. I’ve seen organizations that have graduated security groups, where interns have less access than lower-level residents who may have less access than the highest level of residents. It can be complicated to advance everyone to different security groups from year to year, especially if an entire class doesn’t advance at the same time due to taking family or medical leave or having to repeat a rotation.

Generally speaking, in the US, a physician who has completed the intern year and who has passed the appropriate licensing exams can get a permanent medical license (as opposed to a training license), which might bring with it their own DEA number and state controlled substance number. This becomes fun when the resident might be rotating on some services as a learner and needs to operate under one set of credentials but also moonlights on a different service at the same hospital under their permanent credentials.

A friend of mine who works in the process improvement department at a major health system has been asked to do a pilot project around these issues at one of the hospitals, which is having challenges getting its residents the right access to do their jobs. It will be interesting to see how that unfolds since they won’t have the opportunity to pilot the new workflows until the next class of interns is selected in March 2024.

Back to the JAMIA article, it looks at the ways in which EHRs impact resident clinical skills and how the systems’ use impacts patient encounters. The authors conducted qualitative interviews with 32 residents and 13 faculty members or clinical staff in an internal medicine residency program affiliated with a US medical school. The latter point is an important differentiator, because not all training programs are affiliated with medical schools. Those that aren’t are referred to as community-based programs, and although some provide the same experience as those programs that are associated with medical schools, there may be some subtle differences in how residents interact with preceptors and other members of the teaching staff. Although that’s a relatively small sample size and only represents the experiences of those in a single medical specialty, the authors had some interesting findings.

For background, the authors note the breadth of EHR use in the US, with 96% of hospitals and 78% of office-based practices using certified EHRs. I visited one of that remaining 22% of medical practices just last week and gazed with nostalgia at their giant rolling racks of patient charts. I didn’t envy the physician scribbling away during my visit, but I felt I received good care in a timely way, so I didn’t miss the presence of an EHR in the visit. Interestingly, I also received an invitation to visit the practice’s patient portal, so I’ll have to see what it actually contains when I get some free time. The authors also note the continued increase in EHR documentation requirements in the US, which has been partially enabled by the presence of EHRs.

I found it interesting that the researchers interviewed residents on days when residents were scheduled to be in an outpatient clinic, although they noted that they selected days where “resident schedules at the clinic were typically less busy.” The authors, who are also faculty members at the residency program, would ask the residents to be interviewed “during a break in their day,” which is interesting as to the other stressors that residents might have been experiencing at the time of the interview. I’ve done plenty of qualitative research in my career, and I think I might have been more inclined to schedule interviews outside of the clinic environment. The approach they took only allowed them to interview 32 of the program’s 54 residents, but the authors noted that “repetition of responses and minimal novel information in later interviews indicated we had reached sufficient saturation in our sample.” The average interview lasted 23 minutes and was recorded. Interestingly, the recordings were initially transcribed using an AI-based web site, then were reviewed by paid assistants, with one of the authors conducting a final verification of the transcripts.

During the interviews, residents noted that the need to address quality measures during patient encounters added some challenges to the use of the EHR and contributed at times to shifting focus away from the primary reason for the patient’s visit. Addressing those measures also took time that some felt could have been spent coming to a diagnosis and creating a treatment plan for the patient’s presenting concern. The study methods indicated that patients were roomed by a medical assistant who took some preliminary information from the patient but who didn’t address quality measures. Based on some of the participant comments, it’s clear that data was in the chart for the provider to update the quality measures, so it’s unclear why the organization wouldn’t use a less-expensive resource, such as the medical assistant, to update the quality measures as opposed to expecting the physician to do it. That seems to violate one of the key tenets of clinical efficiency, which is to have all members of the team working at the top level of their licensure.

Most of the residents said they spent more than half of their clinic time working in the EHR and often had to access it at home. Although some residents felt that use of the EHR became easier as they worked through the training program, multiple senior residents felt they were still struggling with the EHR. Additionally, residents often had to ask questions about EHR use on the fly. Although that’s a great way to develop lifelong learning skills, it can be frustrating when you’re early on in your training and trying to learn the nuts and bolts of seeing patients. The authors found that due to these sentiments, some residents actively tried to avoid or at least minimize EHR use during patient visits.

Some of the raw resident comments were included. I found this one very telling as far as whether a good clinical informaticist was involved in the system build: “They just have these yellow boxes and some administrators told our attendings that we absolutely have to click these yellow boxes. But it’s basically just redundant because I’m already doing it. But if I don’t do it their way, then it doesn’t give them a little green light in their system.” It makes me sad to know that there are still systems out there that lack intelligent design and configuration.

The authors note that while it’s important to develop a culture where residents ask questions about EHR use, it’s also important to note that not everyone enters residency with the same experience with EHRs, the same computer skills, or the same motivation to learn. One faculty member described the EHR training that residents and faculty received as “frankly terrible and doesn’t really prepare you for the actual application or use of this software.” Residents reported learning from each other and from medical assistants as well as from the faculty, but I didn’t see any mentions of them reaching out to dedicated EHR trainers for additional support beyond their initial orientation training.

It definitely seems like a missed opportunity for education, especially since best practices for EHR implementation involve regular follow-up training to solidify skills and teach new content. This would also help counter any inhibitions that residents have about asking for help, if follow-up training is just part of the program for everyone.

The authors conclude by calling on residency programs to “find ways to effectively support their residents’ learning to incorporate EHRs into their work and streamline documentation requirements to maximize the development of residents’ clinical skills.” Since the authors are faculty at the residency program where this study was conducted, it would be interesting to see some follow-up on whether they were successful in changing some of the roles and responsibilities distribution found in team-based care in order to meet this objective. For example, did they hire additional medical assistants to better support the residents? Did they arrange for additional training to ensure mastery of the EHR? If anyone is connected with the University of Nevada Reno, I’d be interested to hear any updates.

What are your thoughts about EHR use by residents and other trainees? Leave a comment or email me.

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