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Use of Electronic Medical Records by Physicians and Students in Academic Internal Medicine Settings

Mintz, Matthew MD; Narvarte, Hugo J. MD; O'Brien, Kevin E. MD; Papp, Klara K. PhD; Thomas, Matthew MD; Durning, Steven J. MD

doi: 10.1097/ACM.0b013e3181bf9d45
Quality and Safety

Purpose Electronic medical records (EMRs) have been touted as one method to improve quality and safety in medical care, and their use has recently increased. The purpose of this study is to describe current use of EMRs by medical students at U.S. and Canadian medical schools.

Method In 2006 the authors performed a cross-sectional survey of the Clerkship Directors in Internal Medicine institutional members at U.S. and Canadian academic health centers. Outcome measures included implementation of EHRs, EHR use by students, and the challenges of having students use EMRs.

Results Of 110 members, 82 (74.5%) responded. Of those 82, 48 (58%) reported using an EMR in the ambulatory setting (excluding Veterans' Affairs medical centers) of their institutions, and only 21 of those 48 (44%) had policies regarding medical student documentation of progress notes in the EMR during the ambulatory internal medicine (IM) clerkship. Schools were dichotomously split; about half (23/48, 48%) required and about half (25/48, 52%) prohibited allowing students to document in the EMR. The programs that prohibited medical students from documenting in the EMR primarily cited billing concerns. Other issues regarding student use of EMRs included student access, faculty concerns, and note quality.

Conclusions Use of EMRs by IM clerkship students is common, yet many institutions do not have policies regarding student use. Where policies do exist, they vary, and many prohibit students from using EMRs. Concerns about documentation as it relates to billing seem to be a significant factor in prohibiting students' use of EMRs.

Dr. Mintz is director, Primary Care Clerkship, and associate professor of medicine, Department of Medicine, The George Washington University School of Medicine, Washington, DC.

Dr. Narvarte is co-clerkship director, Medicine Clerkship, and associate professor of medicine, The University of South Florida College of Medicine, Tampa, Florida.

Dr. O'Brien is co-clerkship director, Medicine Clerkship, and associate professor of medicine, The University of South Florida College of Medicine, Tampa, Florida.

Dr. Papp is director, Center for the Advancement of Medical Learning, and senior research associate, Case Western Reserve University School of Medicine, Cleveland, Ohio.

Dr. Thomas is director, Medicine Clerkship, and assistant professor, Mayo Clinic College of Medicine, Rochester, Minnesota.

Dr. Durning is director, Introduction to Clinical Reasoning Course, and associate professor of medicine and pathology, Uniformed Services University, Bethesda, Maryland.

Correspondence should be addressed to Dr. Mintz, Office ACC 2-105 B, 2150 Pennsylvania Avenue NW, Washington, DC 20037; telephone: (202) 741-2194; fax: (202) 741-2185; e-mail: (

Electronic medical records (EMRs) are becoming an increasingly prevalent feature of health care delivery in the United States. The Institute of Medicine (IOM),1 governmental officials,2–5 practicing physicians,6 residents in training,7 and other stakeholders8–10 have all called for widespread implementation of EMRs to help improve quality of care and patient satisfaction and to reduce medical errors. Likewise, the IOM has called for a nationwide commitment to developing an information technology infrastructure such that most handwritten clinical data would be eliminated by the end of the decade.1 The exact composition of an EMR varies depending on individual practice and institutional preferences; however, most EMRs include the following: clinical documentation (notes) and patient data (demographics, laboratory results, radiographic studies, other test results, problem lists, and medication lists).11,12 Other features may include computerized order entry (for prescriptions and tests), electronic prescribing transmission, clinical messaging between providers and staff, and decision support systems such as alerts, warnings, and reminders.11,12 Models suggest that these latter higher-level features are critical to realizing the full benefits of EMRs in terms of patient safety, quality, and costs.13–15 These benefits may extend beyond a single individual patient, for whom pertinent information is available at the point of care, to entire patient populations, whereby data exploration can be used to undertake disease management initiatives.

Despite these potential benefits, the majority of ambulatory care practices in the United States have not yet implemented EMRs. National surveys estimate EMR use in these settings at between 12.9% and 23%. Further, the United States lags behind other industrialized nations in EMR adoption.6,16,17 Larger practices, practices in urban areas or in the western region of the United States, and practices that teach medical students or residents are more likely to have EMRs.6,16,17 Cited barriers to more widespread adoption include financial costs, loss of productivity, lack of computer skills and technical support, and privacy/security concerns.16

Academic health centers (AHCs) have been proposed as potential champions of adopting EMRs given their financial resources, access to technical support, and an atmosphere that may be more conducive to innovation and change.18 However, research on EMRs in the educational arena is still in its infancy, and there is a paucity of literature assessing the impact of EMRs on undergraduate medical education. Implementing EMRs at academic institutions has the potential not only to enhance patient care (by preventing adverse drug interactions, eliminating duplicate testing, and improving the legibility of notes for consultants) but also to potentially improve student education. Students need access to EMRs to be knowledgeable and skilled in their use—and to improve their understanding of system-based practice—because future medical practice environments will likely include the use of EMRs. Just as medical schools currently teach proper documentation as part of good clinical care in a paper-based world, they should be similarly obligated to teach students proper use of an EMR in an increasingly electronic world. It is equally possible, however, that use of EMRs by students at AHCs could have a minimal effect or even potentially an adverse impact on student education. Research from multiple fields, including music, sports, physics, mathematics, and medicine, suggests that growing expertise requires deliberate practice as opposed to simple duplication or repetition.19 Deliberate practice is the effortful, concentrated practice of specific skills (e.g., medical note writing), usually under the direction of a coach or mentor. If students (or other trainees) document only in the EMR, they might lose the opportunity to develop expertise through deliberate practice; they would not have the benefits of constructing the note de novo or receiving essential feedback regarding their strengths and areas needing improvement. If they use a templated note, or copy a previous note and edit, the feedback is likely not as meaningful because the note was not entirely theirs. In addition, in a paper chart, students can literally tear out a paper note and insert a new one. Beginning anew is much harder to do in an electronic world. When electronic notes are edited, they are often done as an addendum, so even if the students do the note in the EMR and get feedback, starting over is much harder to do. Given that an overarching goal of medical education is growing learner independence, note writing is an essential skill for internship and eventual independent practice; thus, this potential negative impact of student use of EMRs is disconcerting.

The degree of EMR implementation in the inpatient and outpatient settings at AHCs is unknown, as are students' use of EMRs and the challenges of allowing students to use EMRs. The purpose of our study was (1) to determine the use of EMRs in academic settings, especially ambulatory settings, by both students and attending physicians, (2) to delineate existing policies regarding EMR use, and (3) to identify potential educational barriers and challenges that EMR use might create. We chose to focus on academic institutions using EMRs in the ambulatory setting, as opposed to looking at all academic institutions using EMRs in either the inpatient or outpatient setting, for several reasons. Our primary reason for emphasizing the ambulatory setting was our desire to focus on student documentation, which is extremely varied in the inpatient setting because of the documentation of residents who usually work separately from students in the ambulatory setting.

Our hypotheses were

  1. EMR implementation at clinical sites used by academic institutions (including hospitals, ambulatory clinics, faculty practices, and community settings) is variable,
  2. policies pertaining to student use of the EMR are limited and likely variable, and
  3. clerkship directors' perceptions are that EMR use at AHCs has had both educational benefits and negative consequences for students.
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In response to multiple communications on its listserve regarding EMRs, the research committee of the Clerkship Directors in Internal Medicine (CDIM), a national organization representing internal medicine (IM) educators, chose to include EMR questions on the 2006 national survey of institutional members. The entire survey had 140 questions.

The first section of the 2006 CDIM institutional survey pertained to demographic information about the respondent including age, gender, and academic rank; another section of nine questions addressed EMRs. The section on EMRs was developed on an a priori basis. One of us (M.M.) reviewed the available literature and developed items based on this review in addition to discussions with other clerkship directors. The items were then shown to other faculty to ensure face validity, and no further changes were made. Next, the members of the CDIM research committee pilot-tested the EMR section, and as a result additional revisions were made. Members of the CDIM council further revised the questionnaire before e-mailing the annual voluntary and confidential survey in April 2006 to its U.S. and Canadian institutional members (there is one institutional member per institution even if the institution employs more than one clerkship director). Of 142 eligible schools, CDIM has 110 institutional members (the other 32 schools do not have CDIM members).

Most of the EMR questions required a yes/no or other close-ended answer (i.e., “Do you or the site[s] have a policy regarding medical student documentation of progress notes in the EMR during the ambulatory IM clerkship?”). Some questions were unstructured, allowing for open-ended answers (i.e., “If you replied yes to the previous question, please briefly explain your policy.”). Only those participants who responded that they do use an EMR in the outpatient setting answered questions about EMR use in the inpatient setting. We instructed participants not to comment on EMR experiences at Veterans' Affairs medical centers (VAMCs) because those experiences and policies are uniform across the country and widely known. The CDIM e-mailed the survey and followed up with as many as three contacts to nonresponders via e-mail, regular mail, or telephone. The institutional review board at the Uniformed Services University reviewed the study and deemed the survey exempt.

We analyzed data with descriptive statistics, using Microsoft Excel for organization and chart creation (we used no other software). We classified all of the responses to unstructured questions into themes in the grounded theory tradition. We merged themes where appropriate. When a response did not have a clear theme and/or was a separate idea, we categorized it as “other.” When more than one response constituted a theme, we counted the number of responses to show frequencies; however, based on the study design, the open responses were in no way quantitative. All of the authors approved the open response tables.

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Of the 110 institutional members, 82 responded to this section of the survey and 83 answered the survey overall, for a response rate of 74.5%. Respondents had a mean age of 44.9 ± 7.0 years, and 51 of them (62%) were male. Most of the respondents (54, 66%) were associate or full professors; 28 (34%) were assistant professors. These demographic distributions are similar to prior annual surveys of CDIM institutional members.20

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Overall EMR use

Forty-eight of the respondents (58.5%) reported using an EMR in the ambulatory settings (excluding the VAMCs) of their institutions; 17 of the respondents (21%) stated that they did not use one, 8 (10%) were uncertain, and 9 (11%) did not answer this question. Of the 48 who reported using an EMR, 30 (63%) stated that attending physicians were required to document in the EMR, 7 (15%) stated that attendings were encouraged to document in the EMR, and 6 (13%) indicated that attending physicians did not use EMRs for progress notes. Interestingly, we found a dichotomy of policies regarding student use of EMRs (List 1); about half of these institutions (23, 48%) allowed students to document in the EMR and about half (25, 52%) prohibited them from doing so.

List 1 Various Policies Regarding Student Documentation in Electronic Medical Records (EMRs) in Ambulatory Internal Medicine Settings (23 TotalOpen-EndedResponses)

List 1 Various Policies Regarding Student Documentation in Electronic Medical Records (EMRs) in Ambulatory Internal Medicine Settings (23 TotalOpen-EndedResponses)

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EMR policies

Of those institutions with a reported EMR (n = 48), only 21 (44%) had policies regarding medical student documentation of progress notes in the EMR during the ambulatory IM clerkship. Medical student EMR policies varied at the different clinical sites to which students rotated within single institutions. For example, the policy for the faculty practice ambulatory clinic may differ from the policy for the community-based clinic.

Policies prohibiting student documentation in the EMR were generally strict prohibitions, whereas policies that allowed students to document notes in the EMR varied from requirements that all students document in the EMR to suggestions regarding proper documentation by students. Several of the policies focused specifically on billing, indicating schools' concerns about proper documentation (including by whom) for billable services; for example, one respondent wrote, “The documentation of an Evaluation and Management service by a student that may be referred to by the teaching physician is limited to documentation related to the review of systems and/or past family/social history.” Other prohibitive policies focused on processes such as using “students as scribes,” duplicating notes, and maintaining security.

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Practices of institutions at which students use EMR

At institutions where medical students did document in the EMR (n = 23), there was lack of uniformity in policies regarding the proportion of students' notes that went into the EMR:

  • 9 (39%) reported that EMRs almost never included students' notes,
  • 5 (22%) reported that most of students' notes go into either the EMR or the paper chart, and
  • 9 (39%) reported that most students' notes go in the paper chart. (See Figure 1.)
  • Figure 1

    Figure 1

There was also discrepancy regarding signature requirements (in an EMR, a signature comprises one's username and password, which together verify and document authorship of the note). Of those schools where students wrote notes in the EMR, 20 responded to the signature questions as follows: 8 (40%) used only the attending physician's electronic signature, another 8 (40%) required that both the student and the attending sign, and 4 respondents (20%) reported other processes. Importantly, no school allowed the student to sign electronically without an attending cosignature (List 2).

List 2 Process for Student Note Writing in Electronic Medical Records (EMRs) in Ambulatory Internal Medicine Settings (N = 20)

List 2 Process for Student Note Writing in Electronic Medical Records (EMRs) in Ambulatory Internal Medicine Settings (N = 20)

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EMRs in the inpatient setting

Of the 48 directors whose institutions used an EMR in the ambulatory setting, 46 responded to questions regarding EMR use in the inpatient setting. Of these 46 respondents, 15 (33%) stated that attending physicians were required to document in the EMR in the inpatient setting (List 3), 5 (11%) noted that attending physicians were encouraged to document, and 21 (46%) reported not using EMRs for inpatient progress notes.

List 3 Use of Electronic Medical Records (EMRs) in Inpatient Settings

List 3 Use of Electronic Medical Records (EMRs) in Inpatient Settings

Only 20 of the 48 respondents who use EMRs in the ambulatory clinic stated that they have students write clinical notes in an inpatient EMR as well. Of these 20 respondents, 7 (35%) reported that when students use an inpatient EMR, both student and attending sign, whereas 4 (20%) reported that only the attending physician's electronic signature is used, and another 4 (20%) allowed the student to sign electronically without an attending cosignature. The remaining five reported other processes (List 3).

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Challenges of student use of EMRs

A number of challenges regarding the use of EMRs emerged from our analysis of free-text responses. Respondents noted these challenges in both the ambulatory and inpatient settings (List 4). Problems included issues of access (e.g., obtaining log-ins and passwords for students), faculty issues (e.g., using EMRs slows them down and makes teaching even more difficult), and issues concerning devaluing the students' role (if students are prohibited from documenting in the EMR). Respondents also expressed concerns regarding the use of note templates. Some note templates provide major section headings and some preset text, and some include automatically populated data. In addition, drop-down menus and pick lists allow physicians to select signs and symptoms. The concern is that such templates and drop-down menus will not allow students to learn the skill of independently recognizing the important items that they need to document. Directors raised another concern: the capacity to copy and paste information into a new note. Some EMRs allow portions, or even the entire note, to be copied and pasted into a new note. Respondents noted that this could potentially lead to ethical concerns regarding plagiarism and documenting portions of the note that were never actually performed. In addition, one respondent noted a level of hypocrisy and poor role modeling if attending physicians use the copy-and-paste functionality when students are prohibited from doing so.

List 4 Problems With Electronic Medical Records (EMRs) in the Inpatient or Outpatient Setting (N = 15 Responses)

List 4 Problems With Electronic Medical Records (EMRs) in the Inpatient or Outpatient Setting (N = 15 Responses)

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Overall EMR use and EMR policies

EMRs are becoming common in academic IM ambulatory and inpatient settings. Consistent with prior studies,6,16,17 our findings confirm widespread EMR use at AHCs. We surveyed a national sample of medical schools, focusing on EMR use in the ambulatory setting, and found that more than half of CDIM member institutions use EMRs in these settings, yet fewer than half of these institutions (with EMRs) actually had policies regarding medical student use of EMRs. And among these institutions (with policies), the actual policies varied with respect to incorporating students' notes (how much of a student's notes should an EMR include?) and ownership (who should sign the EMR?). One prior survey of students suggested that they desire to be involved in all aspects of patient care, including placing orders, making referrals, prescribing medications, and, importantly, writing progress notes21; therefore, limiting students' access to and use of EMRs may marginalize them, mar their educational experiences, reduce their opportunities for developing expertise in writing notes in EMRs, and reduce their confidence in their own abilities.21 Furthermore, students identify education regarding EMRs as important.22 The apparent division among educators regarding appropriate use of EMRs, as reflected by inconsistent practices and policies, may be due to a number of factors including lack of faculty experience in the use of EMRs, lack of comfort with EMR use even if experienced, lack of guidance regarding the role of EMRs in student education, and lack of data on how to best integrate EMRs into medical education.11 In addition, multiple challenges regarding EMRs clearly exist, even within institutions that have already incorporated EMRs into their clinical practice. Challenges mentioned by respondents include cost, access, and EMR variability at different clinical sites, and these challenges likely relate to the disparate and uncertain role of how to use EMRs in medical education. Despite the challenges and barriers, students should practice with EMRs; if they do not learn to use them appropriately, or if they learn to use them inappropriately, they will be poorly equipped after their training to practice medicine in settings in which EMRs are becoming more commonplace.

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Billing and Medicare

Given the dichotomy of policies and the respondents' focus on billing and on ownership of notes, it seems that student documentation for billable services is a major factor in determining students' permission to document in and use an EMR. Most health insurance policies follow Medicare guidelines. These guidelines are clear about appropriate documentation and billable services for resident physicians, and they include an exemption for patients followed in a primary care setting in a resident clinic.23 The guidelines clearly state that services provided by a student are not reimbursable but that students may document in the medical record. Documentation guidelines for students allow them to note only the social/family history and the review of systems. All other components of the clinical encounter and medical decision making must be performed and documented by the attending physician.23 However, educating students in the context of direct clinic care, particularly in the ambulatory setting, takes a considerable amount of time; research has shown that even without an EMR, working with a student in clinic adds an extra 32 minutes to a typical half-day session.24 Student assistance with documentation can lessen the burden for the teaching physician. In some settings, students act as scribes, documenting the entire encounter, as some policies permit attendings to use students in this way (Medicare guidelines allow for scribes to document the billable encounter). However, scribes technically do not participate in the clinical encounter; rather, they merely transcribe what the physician dictates to them. In our view, this is not an appropriate role for the medical student.

Interestingly, Medicare policies regarding students have not changed, even prior to the advent of EMR. Other medical educators have previously suggested that the safest and least frustrating way to comply with Medicare guidelines is to exclude student notes from the paper patient record.25 Despite this, most AHCs have allowed students to write their own progress note in the paper chart, and then attending physicians, who would also place a note in the chart, signed or cosigned the document. Since the current student documentation guidelines were established in 1998, two important trends have occurred in medical education: increasing emphasis on ambulatory medicine with attendings working directly one-on-one with students (without residents), and increasing reliance on EMRs. Electronic progress notes from an attending and from a student, both using templates and similar structures, are therefore likely to look similar. Thus, because physicians fear committing fraud by using, as supporting documentation for billable services, a note written partially or fully by a student, we are not surprised that our survey identified conflicting policies at various institutions across the United States.

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CDIM institutional members also highlighted educational and ethical issues regarding note templates and copying and pasting. On one hand, EMRs' capacity to use templates for documentation can be time saving, allowing physicians to focus more on patient care and less on documentation. However, templates have several potential pitfalls including improper documentation and reliance on templates leading to lack of critical thinking. Notes in EMRs (including templates) can often be copied forward at the time of a patient's subsequent visit. Forwarding notes may lead to similar problems including perpetuating misinformation if the initial note was incorrect. Although training students on the use of templates and other EMR features may prepare them for use of EMRs in future practice, use of some of these features may detract from the cognitive exercise of writing a progress note from scratch and/or lead to observing poor practice that has been modeled with EMR use.

Finally, clerkship directors cited technical, structural, and financial barriers to students using EMRs. Each user of an EMR generally requires a log-in ID and password, which is generated by the institution's information technology team. This support generally requires some amount of work, which often translates to cost. If proprietary software is used, it generally requires a fee for each licensed user. In addition, responders mentioned the logistical problems this caused, such as ensuring that all clerkship students had a log-in ID, password, and appropriate training before the start of a rotation. Because many academic institutions use multiple sites, many with their own systems, this problem becomes compounded as students move from one site to another with each rotation. Furthermore, training, experience, and time are necessary before students become facile with any given EMR system, and a systematic review of health information technology in 2006 suggests that the effect on time use/efficiency is mixed.26 Research shows that these logistical and training issues, in addition to the presence of computers in examination rooms, limit the amount of interpersonal contact between physicians and patients, particularly with more novice providers.27 We must ensure that students have adequate training and contact time with the EMR systems they are using so that computer use does not adversely affect the clinical encounter.

Our study had several limitations. We chose to focus on EMRs used in the ambulatory setting. Because we were also interested in how the policies and use patterns of those institutions using EMRs in the ambulatory setting may have differed from those in their inpatient setting, we subsequently asked only those respondents who have ambulatory EMRs about their use of EMRs in the inpatient setting (See Method section). As previously mentioned, we chose this approach, rather than asking all participants about EMR use in either the inpatient or outpatient setting, for several reasons. First, our main focus pertained to student documentation of the clinical encounter. In the hospital setting, residents as well as students may document in the medical record, sometimes for the same clinical encounter. Hospital documentation by student and/or resident may vary by institution, site, or even ward team. In contrast, medical students in ambulatory IM clinics generally work directly with attending physicians and separately from residents. Second, most EMRs used in the ambulatory setting focus on documentation of the clinical encounter, whereas prior studies suggest EMRs used in the hospital vary widely and may include only order entry, vital signs, or laboratory values. Clarifying all of these differences on a survey would have been a major challenge. Finally, the implementation, use by students, and barriers of EMRs in the hospital setting are likely to be very different from in the ambulatory setting and thus may warrant a separate study.

Our study has several additional limitations. Not all of the clerkship directors at the 142 accredited MD-degree granting medical schools in the United States and Canada are represented in CDIM. Likewise, this survey represents the self-reported data and opinions of clerkship directors in IM; actual practice may differ from what we are reporting. This is particularly true for EMRs used in private practice or in a community setting which likely vary widely; thus, extrapolating findings to these settings remains a challenge. Educators in other disciplines of medicine may have different viewpoints regarding EMRs. Likewise, we sought the opinions of only medical educators and not medical students. Furthermore, our survey did not address EMR higher-level functions, such as computerized provider order entry, disease/population management, or profiling patient encounters.28

Though EMRs have the potential to provide accurate and timely information at the point of care, they may also be detrimental to medical student education. There are multiple barriers, especially in the ambulatory setting, that challenge the ability of students to document in the electronic chart and that could ultimately marginalize their role in patient care. In the ambulatory setting, the full patient experience, not just the history or physical findings, provides educational opportunities for faculty and students. Thus, ensuring student access to an electronic chart and maintaining the sanctity of the teachable moment are logistical hurdles that medical educators must successfully navigate as EMR implementation becomes more widespread. Furthermore, physicians and other health care providers must make strides to identify and limit copy/paste functions and note templates for trainees that may undermine their collection and analysis of data and their clinical reasoning, all of which form the core of each clinical encounter and are the underpinnings of proper and professional documentation. Current Medicare documentation guidelines may in fact impede the education of medical students with respect to EMRs even as progress toward more widespread implementation of the “paperless” medical record continues.

Given both the increasing use of EMRs in the inpatient and outpatient settings, and the current proposed changes to the U.S. health care system which will rely heavily on the adoption and use of EMRs,1 students may be ill prepared for future practice if medical schools do not address student use of EMRs, as highlighted in this report. Thus, our findings suggest that existing policies and practices require several changes. First, because the billing aspects of documenting the clinical encounter seem to be a key concern, it is crucial for educators, providers, and payers to come to a consensus on how to allow appropriate educational opportunities while ensuring that the attending physician actually performed the services that appear on the bill. As health policy makers consider possible changes to the way health care services are financed, they must consider ways of allowing for documentation of billable service by someone other than the provider. Doing so will not only benefit medical education but will also influence other proposed health care changes, such as pay for performance and the medical home.

Secondly, reducing financial barriers for EMRs will be critical for their implementation into clinical practice, as well as for educating health care professional students in their proper use. As health policy makers discuss ways to make EMRs more affordable and consider incentives for providers who adopt them, they should also consider economic factors for academic institutions. Helping to provide for additional educational costs as previously mentioned (i.e., the cost of extra licensees for student users) would be important for policy makers to consider.

Our results also highlight areas for further study. Medical educators and researchers need to determine how to effectively incorporate EMRs into medical student education. Our study focused primarily on use of EMRs by students, barriers to student use, and policies regarding student use. However, how and where to best incorporate information regarding the proper use of EMRs into the curriculum of medical and other health professional students is not known. Education regarding EMRs should likely be part of a broader range of medical and health information technology curricula that might include, but not be limited to, medical informatics, effective use of personal digital assistants, and the professional use of Web 2.0 platforms (i.e., blogs, Twitter, Facebook). Identifying and evaluating competencies in these areas also requires further study.

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The authors wish to acknowledge clerkship directors in Internal Medicine staff for their help in creating an online survey, as well as survey distribution, collection, and data entry.

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The opinions expressed in this paper are solely those of the authors and do not reflect the official policies of the Department of Defense, the United States Air Force, or other federal agencies.

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