Transcript The Electronic Medical Record: A Tool for Teaching

The Electronic Medical Record:
A Tool for Teaching
Nancy B. Clark, M.Ed.
Director of Medical Informatics Education,
FSU College of Medicine
For the Graylyn Conference, 9/13/05
http://www.med.fsu.edu/informatics/Workshops.asp
Hot topics and the Better Question
• How do we train students to use hospital
and outpatient systems?
• How should students use these systems?
• What are the barriers?
• How can we use this as a tool for teaching?
– What skills/knowledge?
– What level is appropriate?
Historic Perspective
“A complete medical record is essential to
reliable continuity of medical care….It
would seem most logical to have the
physician enter the problem statements
directly into the computer.”
Weed, L. (1968) Medical Records that
Guide and Teach. NEJM (278);11
AAMC MSOP
Medical School Objectives Project
• Medical informatics’ use in five major roles
played by physicians—
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Life-long Learner
Clinician
Educator/Communicator
Researcher
Manager
http://www.aamc.org/meded/msop/msop2.pdf
(June 1998)
Role of Clinician
• Retrieve patient-specific information from a
clinical information system, demonstrating
the ability to display selected subsets of the
information available about a given patient
Role of Clinician
• Make critical use of decision support,
demonstrating knowledge of the available
sources of decision support which range
from textbooks to diagnostic expert systems
to advisories issued from a computer-based
patient record.
Role of Clinician
• Document and share patient-specific
information, demonstrating the ability to
record in information systems specific
findings about a patient and orders directing
the further care of the patient.
• Use security-directed features of an
information system
Current Level of Adoption
• Urban hospitals in Florida- 52.2%
• Rural hospitals in Florida- 51.9%
• Physicians in Florida- 23.7%
Brooks RG. Menachemi N. Burke D. Clawson A. Patient safety-related
information technology utilization in urban and rural hospitals. Journal of
Medical Systems. 29(2):103-9, 2005 Apr.
Strategies
• Simulated EMR
– Minnesota
– Connecticut
– MedCases
– DxR
• Commercial EMRs
– FSU
FSU’s First Strategy
• No clinical activity – no real patients
• Clinical Learning Center - simulated
patients
– History Taking
– Physical Exam
– Documentation
• Electronic Medical Record System
Practice Partner
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Donated 40 user licenses
Established in 1985
5000+ doctors using
30+ residency programs
Practice based research network
Decision Support
– Drug interactions
– Drug allergy
– Knowledge base links
Strategy 2002
• Use in CLC
• Populate with simulated patient case
information
• Students access record before examining
patient
• Students document S & O parts of progress
notes in records
Problems Encountered
• Faculty time to build patient records
• Simultaneous access to one patient’s record
– Created 6 copies of same patient
• Faculty time to review progress notes
(emailed)
• Templates were above students level
• Abandoned 2003
EMR
Implementation in
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3
Year
• Doctoring 3 (2003)
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Longitudinal Experience
One half day per week – all year
Primary care physician
Each regional campus dean is
coordinator for his students
Objectives of D3 Longitudinal
• Demonstrate knowledge of
– the natural history of common chronic diseases.
– the factors that contribute to compliance with chronic
disease care including psychological, social, and
behavioral.
• Apply the principles of prevention and chronic
disease management to patients, families, and
populations.
• (2004) Demonstrate the ability to use an EMR to
document patient care.
“Physicians have for years been preoccupied
with episodic illness, with problems only
when they erupt into symptoms and only
with patients who can get themselves to the
doctor…. One must learn how to move
easily from a single-minded focus on one
problem to attention to the total list and
interrelations of multiple problems.”
L. Weed (1968)
Implementation
• Summer 2004 - Assigned a panel of 10-12
Pts with chronic problems
• Build a complete patient chart in Practice
Partner to include
– Problems list, medications list, PMHx, SHx,
FHx, Health Maintenance, Labs and Vital signs
for last year
– Progress notes for each visit with patient
HIPAA Compliance
• No real names
– Use student’s last name
• No real DOB
– Use Jan 1 of year closest to DOB
• No SSN, address, phone #, etc.
• No mention of real physician
• System userIDs and Passwords
Software Configuration
• Student laptops loaded with two versions of
software: Portable and Client
• Portable Version Practice Partner
– Does not need a connection
– Allows you to add information to charts
– Limitations: can not edit saved items
• At clinics, students enter data into patient
record on portable
On Campus
Server
Wireless node
Client Laptop
Patient
Database
• Students synchronize portable
to Server
• Use client to edit charts
• Print any part of chart
Supervision
• Regional campus deans and longitudinal
faculty
– Monitor student records
– Provide feedback on documentation, progress
notes
Longitudinal Faculty
• Help the student
– Identify appropriate health maintenance issues
– Discuss recommendations literature: guidelines and
articles on the topic
– Identify appropriate screening tests and lab work
– Discuss lab results
– Appreciate psychological, social and behavioral
issues that affect patients with chronic disease and
help plan ways to deal with these
– Determine which items (health maintenance,
counseling, labs, physical exam, and vital signs)
should be included in flow sheet
Challenges
• Technical problems
– Syncing portable over distance
– Initial transfer to portable
• Longitudinal faculty buy-in
• Paper records incomplete
Chart Transition Form
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Mine paper or EMR
Labs
Vitals
HM
Demographics
Typical Chronic Patient Record
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Margaret Smith
62 yr old
White
Female
Patient for 5 yrs
Practice Partner
Chart Summary
“Data involving physical findings, vital
signs, laboratory values, medications,
intakes and outputs can lead to sound
interpretations and decisions only if
they are organized by means of a flow
sheet to reveal clearly temporal
relations.”
L. Weed (1968)
Vital Sign Flow Sheet
Lab Tables
“One major goal of clinical teaching
should be to designate the problems
that should have a flow sheet, the
variables that should be included and
the frequency with which they should
be followed.”
L. Weed (1968)
Flow Sheets
Health Maintenance
Adding Disease Specific HM
HM Templates
Progress Note Templates Potential
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200 templates
Use point-and-click quick text
Populate other parts of medical record
Import from other parts of medical record
Include links to patient education materials
Include links to practice guidelines,
research
Controversy
• To allow or not to allow students to use
templates
• Some think yes—they teach the students the
proper things to document
• Course director things no—students don’t
learn the “words”
• We currently are not using them
Demonstration of Progress
Notes
If time
Teaching Opportunity
• Develop one template
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Follow-up visit
Appropriate S, O, A and P
All of your patient’s chronic diseases
Includes link-outs to appropriate clinical
practice guidelines
EMR Educational Objectives
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Access patient information
Documentation of Progress
Chronic Disease Management
Coding
Communication- Dr/Pt/Computer Triad
Decision Support
Patient Education Handouts
Prevention/Health Maintenance
Security and Privacy