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By Sophia Babb
A new generation of tech-savvy doctors in training is confronting an entrenched system of electronic health records. It’s a mismatch that needs fixing through measures including better training of medical students, according to former government officials and other sources contacted by Bloomberg Law.
Electronic health records (EHRs) are used by doctors and medical staff every day, and their adoption has doubled since 2008. And a May blog post by a Department of Health and Human Services official noted that as of 2015, 96 percent of hospitals and 78 percent of office-based doctors were using certified electronic health records.
These records collect huge amounts of information on their patients, ranging from the most sensitive to the mundane. They are as much an everyday companion to doctors as they are a valued, powerful tool. But former government officials and health industry representatives say the records aren’t meeting their potential in transforming health care.
Learning to use electronic health records has historically been associated with transitioning from analog to digital records. But today’s medical students are going through a different kind of learning process, according to Karen DeSalvo, who was the HHS’s national coordinator for health IT from 2014-2016. DeSalvo now works as a professor at the University of Texas Dell Medical School.
DeSalvo told Bloomberg Law that when she witnessed younger physicians being recruited, they would expect to be working with a smooth, cloud-based computing system. But upon entering the workforce, students would often be met with outdated EHR systems and workflows that aren’t intuitive.
“The potential of technology and medicine within our health system is great,” DeSalvo said. “And I think we’re moving into a better generation of opportunity to make the systems a lot more user friendly.”
But how do students seize those opportunities?
A physicians’ group recently called for a remedy. Medical students increasingly need more exposure, access, and training on electronic health records, to realize the records’ full potential, according to a policy adopted by the American Medical Association in mid-June.
Susan Skochelak, vice president for medical education at the AMA, told Bloomberg Law on June 20 that too often students don’t have proper access to EHRs. Skochelak doesn’t mean that students are never seeing or using EHRs but, rather, they’re not being exposed to the EHRs’ full potential.
“We already train students on how to use stethoscopes or blood pressure pumps, but EHRs are used for hours during the day, and we’re not training them as if this is a tool they can use to make their patient care and clinical life more efficient,” Skochelak said.
Skochelak described an educational setting in which students are primarily trained on how to log in, enter data, and navigate the Health Insurance Portability and Accountability Act (HIPAA) regulations. This leaves out training on important skills, Skochelak said.
“If all you’re doing is training students to write notes in their system, they’re not going to do very much. But this isn’t so much about teaching them the basics of logging in, but more so showing them this is a part of our future so that we can be the best for our patients in the way we manage this information,” Skochelak said.
Right now there isn’t a standardized curriculum on electronic health record training, so Skochelak is in the process of participating in an EHR workgroup meant to develop a national, standardized curriculum on EHR training.
When EHRs have badly designed security features, medical students, staff, and doctors alike will look for workarounds, Deven McGraw, the deputy director of health information privacy at the HHS from 2015 to 2017, told Bloomberg Law.
“I saw cases where medical students would share patients’ identifiable data on publicly available file-sharing programs, like Dropbox or Google Docs,” McGraw said. “Mostly because they had not gotten properly trained on the electronic medical record system in their institutions, or because the EHR system wasn’t like the other technology they were accustomed to.”
McGraw said medical students are now “digital natives,” meaning they are people who grew up using technology for every aspect of their lives.
“They come into the medical system, and they may have some difficulty adapting to the technology that’s being used in the institution where they are getting training. They say to themselves, ‘Wow, how much easier would it be for me to share information among the clinical team, if we just put it up on Dropbox or Google Docs?’” McGraw said.
The problem with putting sensitive data on platforms like Dropbox or Google Docs, though, is when that data have been shared with an entity that is not necessarily in compliance with HIPAA, a security issue has been created for the institution.
“Medical students’ eagerness to apply technology to their workload should be applauded, but it’s also important that they know medical data is sensitive and subject to legal requirements in regards to how it’s shared,” McGraw said.
McGraw is now the general counsel and chief regulatory officer of Ciitizen, a Mountain View-Calif., based company that’s a platform to enable patients to collect their health information and share it to maximize their care.
Security measures within an EHR should be designed with the user in mind, McGraw said. If user friendliness isn’t accounted for, “You often get a situation where students or doctors will use workarounds to the security features to get their work done more quickly, more efficiently, and more effectively,” McGraw said.
McGraw said the idea is not to lock the data up so no one can access it; the idea should be that the right people are able to easily access the data, and the wrong people can’t.
Ross Koppel, a sociologist and scholar on health IT at the University of Pennsylvania, told Bloomberg Law there’s nothing wrong with doing more training on how to use EHRs, but that educators might consider spending their resources elsewhere.
“The problem is that EHR systems are so user-hostile that it’s like learning to drive a car that has a bad steering wheel. Wouldn’t it be better to have steering wheels on your car that work better? Some of the EHR user interfaces are so lousy, that the training is essentially teaching people how to deal with frustration,” Koppel said.
Koppel said young doctors are going to have to be using EHRs, and if there are some ways of improving their EHR skills, “so much the better.” But you can only train so much with a bad system, he said.
“It’s very obvious that there are two things that should be going on at the same time: one is to become better at using the technology, and the other is to make the technology better. Obviously, we need to do both, but I’d start by making the technology better,” Koppel said.
Blain Newton, executive vice president of Healthcare Information and Management Systems Society (HIMSS) Analytics, said health IT is rarely ever just about technology. HIMSS Analytics, a subsidiary owned by HIMSS, is a health IT research and advisory firm that provides guidance on electronic health record adoption to hospitals and clinical practices.
“It’s about people processing the technology,” Newton said. “We need to train students properly, and we need to make sure they’re trained consistently. But we also have to look closely at out processes to make sure we’re maximizing the leverage the technology can provide.”
A number of issues have affected EHR training, said Keith Horvath, senior director of clinical transformation at the Association of American Medical Colleges. Horvath told Bloomberg Law the first issue is, of course, the EHR itself.
The EHR has ideally been thought of as a tool to improve and help direct health care better, but by and large the EHRs began primarily as billing tools, he said. That’s changing now.
“There is the distinct possibility that voice generated, voice activated transcription techniques will be available. Some may even do audio or video recording to capture the entire interaction. That would take the entire health-care process to another level,” Horvath said.
But until we’re at that point, medical students will be able to get the rudimentary aspects of an EHR down fairly quickly. Past the basics, “We’re at the point where we should be teaching students how to use EHRs as comprehensive tools,” Horvath said.
Tyler Cymet, chief of clinical education at the American Association of Colleges of Osteopathic Medicine, said doctors need to understand what’s inside of an EHR to use it to its full potential.
“Ten years ago, two-thirds of our schools were already doing training at sites that used EHRs. Now, it’s close to a hundred percent of our schools. However, only 62 percent of those schools are actually allowing students to enter documentation into the record,” Cymet said.
And when students are allowed to enter documentation into the record, it’s usually background information on the patient, he said. “It’s not putting thinking into the document, it’s only aggregating information,” he said.
Cymet said students should be able to answer questions such as “How do you deal with a template that doesn’t include psychosocial issues?” or “What do you do when the template doesn’t suggest metastatic cancer when you enter in belly pain?”
Cymet said students should look under the hood of an EHR to know why it’s not working for them, or how it could work better. “Students need to learn how to leverage the technology, not rely on it.”
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