Electronic medical records (EMRs) are now used in the vast majority of ambulatory practices,1 and as such, medical students commonly encounter EMRs during their family medicine clerkships. Although EMRs are now an integral part of medical practice, how medical students interact with this technology varies tremendously across institutions. For many students, opportunities to learn the skills required for effective EMR use are limited. According to a 2009 study of clerkship directors of various specialties, 32% of schools with policies allowing medical students to access the EMR did not allow those students to write notes.2 Another study of medical education deans reported that 93% of respondents felt that precluding students from writing notes in the EMR would negatively affect the students’ education; despite this opinion, only 42% had a policy regarding student documentation.3 The same survey showed that the vast majority of deans felt that limiting students’ note-writing ability would negatively affect their preparation for internship,3 an important issue given that the Association of American Medical Colleges (AAMC) has deemed documentation of patient encounters in the medical record 1 of 13 Entrustable Professional Activities that medical school graduates must master to be prepared for residency training.4
Another major concern for physicians working with students is documentation compliance. Regulations issued by the Centers for Medicare and Medicaid Services (CMS) state that the history of present illness, physical examination, assessment, and plan, as documented by students, may not be used in support of billing to CMS.5 Concerns about complying with this regulation have undermined efforts to educate students in working with medical records of any kind and EMRs in particular. For example, the AAMC Compliance Officer’s Forum in 2011 issued an advisory recommending that “the only parts of a medical student’s note that should become part of the medical record are ROS [review of systems] and PFSH [past, family, and/or social history].”6 In 2014, the AAMC updated this advisory to clarify that these two parts of a student’s note are the only parts that the billing physician should be able to copy.7
In response to such problems and in support of education, the Alliance for Clinical Education (ACE) in 2012 developed a policy statement recommending that all medical schools develop competencies regarding the use of the EMR and that all students be required to demonstrate competency prior to graduation.8 More recently, the Society of Teachers of Family Medicine issued a position statement endorsing the ACE statement and providing documentation strategies for clinicians working with students.9 Additionally, some schools have developed formal curricula for students to learn how to use the EMR, including how to document progress notes.10–13 Most recently, the American Medical Association has adopted a policy supporting “medical student acquisition of hands-on experience in documenting patient encounters and entering clinical orders into patients’ EHRs [electronic health records], with appropriate supervision,”14 as was the case with paper charting.
Medical students themselves have voiced variable opinions about the value of EMRs in their training. One study showed that students who had participated in an ambulatory internal medicine/family medicine clerkship generally felt positive about using an EMR in this setting.15 Many reported that they received more feedback on their EMR notes than on their paper notes. Other studies have raised concerns about the specifics of student documentation when students do write notes in an EMR. One survey found that 95% of students had copied and pasted notes (either from their own notes or from those of residents), and almost half had documented in the medical record when signed in under an attending’s name.16 These concerns were addressed in 2014 by the updated AAMC Compliance Advisory, which provided further guidance on ways to mitigate the risk of inappropriate student use of the EMR.7 Further, faculty have expressed concerns about the effect of the EMR on medical student education: Almost half of the clinical faculty at one institution reported decreased enthusiasm for teaching following EMR implementation, and the majority reported that the EMR led them to teach less.17 Dishearteningly, the most enthusiastic medical educators in this study were the most likely to reduce their time teaching following EMR implementation.17
Little research to date has evaluated the impact of EMRs on medical student education in ambulatory practice. One previous study—in ambulatory academic internal medicine practices—found multiple reasons physicians did not allow students to write progress notes, including compliance and billing concerns, lack of student-specific access, difficulties with templates and attestations, and lack of time (partly attributed to the additional time required to navigate the EMR).18 On the basis of informal conversations with ambulatory preceptors and medical students at our three institutions, we have found that the preceptors who use EMRs frequently are unable to, or simply do not, provide medical students adequate opportunities to write and get feedback on progress notes. These preceptors corroborate the barriers found in the internal medicine study,18 mentioning institutional and logistical challenges such as an inability or unwillingness to pay student licensing fees, as well as individual barriers such as fear of medicolegal issues. Formally documenting the magnitude of the barriers to adequate training for medical students in the use of EMRs in outpatient family medicine settings is important. Medical educators must have current information both to support improved policies regarding medical student documentation at community sites and to assist in the development of curricula for faculty on how to integrate medical student documentation in the EMR into their teaching.
In this context, we developed this anonymous survey and distributed it at three institutions to identify ambulatory preceptors’ behaviors regarding EMRs and medical students. This study is, to our knowledge, the first to directly assess the practices of ambulatory family medicine preceptors with regard to student interaction with the EMR.
We invited, via e-mail, ambulatory preceptors who in the preceding year had hosted medical students during the required family medicine clerkships at each of the three schools. The three institutions were The Warren Alpert Medical School of Brown University (AMS), Michigan State University College of Human Medicine (MSU), and Georgetown University School of Medicine (GUSOM). At AMS and GUSOM, only community-based preceptors received the survey tool, while at MSU, preceptors in more traditionally academic sites also received it. Knowing from our experiences as clerkship directors that individual members of group practices display disparate behaviors regarding medical student documentation, we sent the survey tool to each individual member of group practices that hosted medical students. In total, we invited 801 preceptors to participate in the study.
We initially developed the survey tool in paper form, and we piloted it with colleagues at our respective institutions. After refining the tool, we uploaded it to an online survey tool (SurveyMonkey, San Mateo, California) as three separate identical questionnaires, one for each institution (see Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/A440). We obtained ethical approval to conduct the survey from the institutional review boards of all three institutions: AMS, MSU, and GUSOM.
Each preceptor received an initial e-mail from his or her institutional clerkship director with an invitation to participate in the survey, along with a link to the survey tool. We sent a reminder e-mail in each of the two subsequent weeks. Since the survey inquired about behaviors with legal and regulatory implications, we ensured participants of their anonymity. We distributed the survey in January 2015 at two institutions and in May 2015 at the third.
The survey asked preceptors to provide the following information:
- their gender,
- the number of years they had been in practice,
- the type of practice (private, hospital owned, academic, federally qualified health center, or other) in which they worked,
- whether they used an EMR currently, and, if so, how many years they had been using their current EMR.
The survey asked all preceptors if they provided students with access to patients’ charts (paper or electronic), and whether they allowed students to write progress notes (on paper for those using paper charts; electronically for those using an EMR). Those who allowed students to write progress notes were further asked if they provided students with feedback on their notes.
Preceptors using an EMR who reported providing their students with access to the EMR were further asked how they provided access. Respondents could choose from the following options:
- providing students with their own student log-ins or accounts;
- providing students with the preceptor’s username and password;
- logging students in under the preceptor’s account, without showing students the password;
- having students log in under some other provider’s account (e.g., a medical assistant or another medical provider);
- printing a paper copy of the information in a patient’s chart without logging the student into the EMR; or
Lastly, preceptors using an EMR were asked if they had worked with students in an environment using paper charts in the past. Those responding “yes” to this question were asked four questions that compared paper charts to the EMR. They were asked if using an EMR, compared with a paper record, made it easier or harder (1) to allow students to access patients’ charts, (2) to allow students to write progress notes, (3) to provide students with feedback on their notes, and (4) to host students at their practice. For each of these items, preceptors answered using a five-point Likert-type scale.
We analyzed the distribution of baseline demographics and determined whether they varied by site using chi-square tests, dichotomizing years in practice at the median. We compared preceptors’ behaviors around allowing students access to patient charts, allowing students to write progress notes, and providing feedback on progress notes across baseline demographics using chi-square tests. Similarly, we compared relevant preceptors’ methods of allowing students to access the EMR across baseline demographics using chi-square tests. We calculated the mean responses to the Likert-type scale questions using values ranging from 1 = “a lot easier” to 5 = “a lot harder.” We performed all analyses using SPSS version 21 (IBM SPSS Statistics for Windows, Version 21.0, Armonk, New York) and Stata/SE version 14.1 (StataCorp Stata Statistical Software: Release 14, College Station, Texas). We considered an alpha of 0.05 to be significant for all comparisons.
Of the 801 preceptors we invited, 265 (33.1%) responded. The responses varied substantially across institutions. Specifically, fewer community preceptors from MSU responded to the survey compared with community preceptors from the other two schools. When comparing respondents from MSU with those from AMS and GUSOM, the only notable difference in baseline characteristics was in the distribution of practice types: Respondents from AMS were more likely to report working in a federally qualified health center and less likely to report working in an academic practice.
We have provided the baseline characteristics of the 265 respondents in Table 1. In all, 146 responding preceptors (55.1%) were male. The average number of years in practice was 17.6 (standard deviation [SD] 10.4; median 16). In subsequent bivariate analyses, we dichotomized years in practice at the median as less than or equal to 16 years or greater than 16 years. Of 262 respondents, 251 (95.8%) reported using an EMR currently—and of these 251 respondents, 236 (94.0%) reported hosting a student in the preceding year. Those using an EMR reported using their current EMR for an average of 3.24 years (SD 0.90), and this finding did not vary by school. Since we designed this study to measure the behaviors and attitudes of current ambulatory preceptors who use EMRs, we restricted subsequent analyses to those preceptors using EMRs who had hosted a student in the prior year.
Table 2 displays the reported teaching behaviors of preceptors using EMRs by baseline characteristics including institution. In all, 91.1% of respondents (215/236) reported providing students with access to an EMR. Of those 215 allowing EMR access, only 147 (68.4%) reported allowing students to write progress notes in the EMR. The overall percentage of preceptors allowing students to write notes in the actual electronic chart was 62.2% (147/236). We calculated this percentage by subtracting both those not allowing EMR access (n = 21) and those allowing EMR access but not allowing students to write progress notes (n = 68) from the total number of respondents (n = 236) and then dividing by that same total (236). All respondents who reported allowing students to write progress notes reported providing feedback to students on their notes.
We detected differences in teaching behaviors according to baseline characteristics (Table 2). In particular, preceptors at AMS were less likely than those at the other two schools to provide students with access to the EMR. Preceptors at MSU who provided students with EMR access were less likely than those at the other two institutions to allow students to write progress notes. Male preceptors were less likely than female preceptors to allow students to write notes (69/116 [59.5%] vs. 78/99 [78.8%]; P = .002). Teaching behaviors did not vary significantly by practice type, nor did they vary by either the number of years preceptors reported being in practice or the number of years preceptors had been using their current EMR (either when dichotomized or when handled as a continuous variable; data not shown).
Of those respondents who allowed students to access the EMR, 202 provided information about how they provided such access. These preceptors used a variety of methods to provide access (Figure 1). In all, 126 of them (62.4%) provided students with their own individual student log-in credentials, and 65 (32.2%) provided access by allowing students to log in under the preceptor’s credentials. Preceptors allowed students to log in under their credentials either by providing the students with their log-in information (22/202; 10.9%) or by logging in for the student without revealing their passwords (43/202; 21.3%). The remaining 11 preceptors (5.4%) provided access by printing out portions of the electronic chart for the student prior to entering the room. No preceptors reported having students log in under another provider’s account. These behaviors varied significantly by institution. Of 49 preceptors at AMS, 25 (51.0%) reported allowing students to log in under their own credentials, nearly double the rate at MSU, where respondents were more likely to provide students with their own student log-in credentials (87/121; 71.9%).
Of 233 respondents, 214 (91.8%) reported that they had previously hosted students in a setting where they used paper charts. Of these, 211 responded to questions comparing the effect of the EMR on clinical teaching relative to paper charts (see Figure 2). Regarding the ease of providing students with access to the chart, 103 respondents (48.8%) reported that the EMR made providing access somewhat or a lot harder, whereas 83 respondents (39.3%) reported that providing access was somewhat or a lot easier. The majority of preceptors—55.2% (116 of 210)—reported that the EMR made it somewhat or a lot harder to allow students to write notes. Regarding providing students with feedback on their progress notes, the most common single response (64 of 210; 30.5%) was that the EMR made no difference. Of 210 respondents, 86 (40.9%) reported that the EMR made providing feedback somewhat or a lot harder, and 60 (28.6%) reported that the EMR made providing feedback somewhat or a lot easier. Respondents were less negative about the effect of EMRs on how easy it is for them to host medical students at their practice; of the 209 answering the question, 104 (49.7%) reported that using an EMR made no difference relative to paper charts, 77 (36.8%) reported that the EMR made it somewhat or a lot harder to host students, and only 28 (13.4%) reported that the EMR made it easier.
In our study, more than one-third of ambulatory preceptors in family medicine clerkships do not allow clerkship students to write progress notes in the EMR. Additionally, among those providing students with EMR access, one-third break rules in order to do so.
These findings demonstrate the challenges that ambulatory preceptors face in meaningfully integrating the important educational process of documenting patient encounters into student experiences. The difficulties created by regulations surrounding student documentation, the barriers set up by EMR vendors that make additional log-in credentials for students difficult or expensive, and health care system policies that prioritize compliance over education all contribute to the inability of ambulatory preceptors to allow students appropriate access to and practice with clinical documentation. In our experience working with ambulatory preceptors, we find that those who allow students to log in under their own preceptor credentials are doing so out of an effort to provide an appropriate educational experience for students—they have no other means by which to allow students to write notes. This perception is supported by our observation that preceptors who allow students to log in under their preceptor credentials are more likely to allow students to write progress notes than those who do not. Our findings seem to indicate that ambulatory preceptors are challenged by institutional and system regulations and policies as well as by hardware availability and software capability. Our results show that medical students frequently are prevented from developing the basic skills of synthesizing patient visits and documenting these encounters for clinical care purposes.
Although we believe that the results of our study represent what is happening in the ambulatory setting nationally, we acknowledge our overall low response rate. Of note, AMS and GUSOM had high response rates, but the lower response rate at MSU deflated the overall response rate substantially. The lower response rate at MSU may be accounted for by the fact that compared with the other two schools, MSU covers a broader geographic area and has several regional campuses, which may weaken the perceived relationship between individual preceptors and the clerkship director who sent the e-mail invitation. Because this type of network exists at many schools, we believe the surveyed MSU preceptors provide an important perspective, despite the lower response rate. The MSU preceptors participating in the survey also differed slightly from their GUSOM and AMS counterparts; that is, while this study intended to primarily survey community-based rather than primarily academic physicians, MSU elected to include preceptors in academic settings (i.e., residency sites) since preceptors in these settings constitute a relatively larger proportion of their preceptor pool.
Additionally, this study is limited by a lack of details about individual preceptors. Information such as how many students a preceptor hosts per year, how many sessions or how much time per week a student spends with a preceptor, and whether a preceptor provides feedback on paper notes rather than electronic notes when electronic notes are not available might enable clerkship directors to determine preceptor-specific predictors of more robust teaching with the EMR. Exploring these and other issues in future studies would be useful.
Another limitation is that preceptors may have been unwilling to admit to behaviors that reflect poorly on either their teaching or their compliance with the regulations surrounding EMR use; if so, this study likely underestimates the prevalence of such behaviors. We believe we have mitigated this concern to some extent by clearly stating in the instructions that participation in the survey was voluntary and anonymous. The question about the ease of using EMRs versus paper charts could potentially be biased by preceptors’ challenging experiences with EMRs.
In summary, there is a need to clarify and simplify the regulations and policies regarding documentation by medical students in ambulatory settings. Further, EMR vendors and health care systems must design structures and processes allowing student access to EMRs, so that clinical teachers are not forced to choose between violating national regulations and providing meaningful learning for students. Multiple educators and organizations8–14 have called for reforms to ensure that students are receiving adequate training in EMR use, a skill of fundamental importance for future physicians who will be required to document notes on their own patients starting the first day of residency training. We acknowledge that while EMRs may facilitate documentation and clinical communication among members of a patient care team, they also have the potential to increase “inappropriate or even fraudulent documentation”19; however, our study shows that the experiences students are actually getting in the ambulatory setting are inadequate to warrant suspicion of fraud or misuse. Worse, students are witnessing their preceptors violate rules of EMR use, which perhaps adds to their own disregard for regulations and policies surrounding appropriate use of the EMR.
We interpret our findings as a call to action. We call on CMS to develop policies that encourage preceptors to allow students to write notes—that is, to acknowledge the importance of medical students learning to document patient encounters in the EMR as a necessary part of their training as future physicians. We call on EMR vendors to create simple, ready-made methods by which students may access their products without undue burden or expense. We call on health system compliance officers to work with regulators to create rules that prioritize the training of the future physician workforce while maintaining the integrity of the patient health record. Finally, we call on medical educators to ensure that medical informatics remains a priority for future physicians despite these challenges. Without reform, the current structure of ambulatory training in the EMR is untenable: Preceptors are left violating rules, and students are left without the training they need to care appropriately for their patients in the electronic world.
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