A classroom at the University of Chicago’s Pritzker School of Medicine was packed earlier this month with both medical students and students in the Graduate Program in Health Administration and Policy (GPHAP) interested in learning more about the IHI and quality improvement. Dr. Chad Whelan, a hospitalist and institutional leader on quality improvement, facilitated an open discussion about some of the challenges in using electronic health records to improve quality of care and encourage physicians to practice more evidence based medicine. Some of the topics covered included the unintended consequences of using electronic records, the benefits of an electronic record from an administrative standpoint, and issues surrounding the quality of documentation. The meeting was organized by students in Pritzker’s Quality and Safety Track with guidance from Laura Botwinick, Director of GPHAP. During a lively and interactive question and answer session, here are just a few of the questions that were raised by students and the discussion that ensued.
How interoperable are the record systems? Why aren’t we using one single interoperable system? While interoperability is a focus of “meaningful use” that is part of American Recovery and Reinvestment Act of 2009, electronic health records industry is also a marketplace with vendors competing for market share. Because of that, interoperability may not have been achieved earlier. For larger healthcare systems such as the VA, the implementation of CPRS represents an example of an interoperable system across many hospitals nationwide. Since academic medical centers often have several teaching hospital affiliates, physicians and trainees have to learn to work in several different systems, some of which may not even talk to each other. While many urban medical centers have adopted electronic health records, a recent study demonstrated only 17% of hospitals capital investments.
What are the reasons behind the findings in the literature that mortality and errors sometimes increase when an EHR is installed? Medicine is a complex system and sometimes changing one thing without changing another will yield unexpected outcomes. Furthermore, if bad processes are automated, errors can happen much more quickly and systematically if they were being made in the first place. That is why it is important to use QI tools to improve systems before an EHR is laid over them. For example, during a QI intervention for pressure ulcers, the implementation of EHR for nursing documentation actually led to a decrease in the physician recording of pressure ulcers since they did not know where to access nursing notes.
How much training do practicing physicians get when an EHR is deployed? Training is definitely part of the EHR implementation strategy. One commonly used approach is to actively train early adopters who can champion it for the late adapters and laggards. At our hospital, that training included several hours of classroom time PLUS watching online video trainings at home with practice tutorials. However, as the faculty and others present agreed, the learning curve is steep and learning is an ongoing process. Anecdotally, there is often “reverse mentoring” with many of the residents who learn on the job are able to teach the attendings tricks of the trade.
What can be done to avoid the cut and paste problems that have emerged? Interestingly, hospitals often have the choice whether to disable cut and paste or keep it active. By disabling it however, the ability of EHRs to make doctors more efficient is sacrificed. However, enabling cut and paste creates the risk that the information is out of date or inaccurate. While many egregious examples have been described in the literature, there are some novel experiments being tried around the country include trying to use different colors for pasted information or creating patient records like wikis so multiple people are updating. In a handoff curriculum for residents, we do highlight avoiding CoPaGA syndrome (Copy and Paste Gone Amok) by highlighting that it is allowed to cut and paste but their responsibility is to cut, paste, and update.
Are medical students getting trained on electronic health records? Most learning at present is orientation to a specific system and on-the-job training. Principles of effective practice with EHR need to be translated into medical education as it is an important core skill that all medical graduates will need. While medical informatics is covered by in some form in many medical schools, recent debates highlight that more robust teaching on electronic health records needs to evolve and expand. Moreover, the EHR can be used to actually advance medical education by providing a record of what types of patients a resident sees and assist in performance evaluation of patient care.
–Anthony Aspesi MS2 (with Laura Botwinick and Vineet Arora)