Medical Schools, Technology, and the Crisis in HIT Education

By Glenn Laffel, MD, PhD
Senior Vice President, Clinical Affairs
Practice Fusion

Not too long ago, it seemed safe and reasonable to define health information technology (HIT) narrowly as the management of health information and its secure exchange between patients, providers, and insurers.[1]

For many, the definition effectively compartmentalized HIT. It was for someone else, not me.

That began to change when quality initiatives started forcing physicians to deal with performance data and patients began showing up with reprints of journal articles they hadn’t read themselves.

But nothing could have prepared physicians to handle the flood of HIT that inundates them today, a flood that threatens to sweep away established codes of professional conduct and disrupt the very processes by which care is rendered and doctors communicate with patients.

Consider these examples:

1) Dr. Jain, a medical intern[2] receives a friend request on Facebook from Erica Baxter. As a medical student, Jain helped deliver Baxter’s baby. Is Baxter simply a grateful patient interested in sharing news about her child, or does she have other motives? Jain clicks “confirm,” granting Baxter access to his network of friends, his personal photographs and blog, and the scrawls of others on his wall.

2) Dr. Margolis, a middle-aged pulmonologist, receives 120 emails per day. The assortment reflects her busy life. There’s one from her child who needs a lift at 6:30. Her dentist has an opening for her prophylaxis, and her secretary just added a patient to her afternoon schedule.

And then there are emails from her patients, some of which require immediate attention.

Problem is, Dr. Margolis can’t read all her emails. She has a thousand unread messages in her inbox. She worries that some contain time-sensitive information from patients.

3) Dr. Tapscott, nearing the end of his career in family practice, is convinced by office personnel to adopt an electronic health record (EHR).

But the implementation goes poorly. He can’t get the hang of it and believes it puts a barrier between himself and his patients. Five months and $20,000 later, he ditches the system.

Physicians have faced emerging ethical challenges before. Their struggle to develop professional identities is as old as the profession itself. And this isn’t the first time they’ve have had to incorporate new innovations, but the HIT Deluge multiplies these challenges several fold, and creates myriad new ones, many of which remain vexing even to deep thinkers in the field.

The Impact of EHRs on Medical Education

EHRs are a prime example of this. They have begun an inevitable march into the lives of all physicians, stimulated by the American Recovery and Reinvestment Act, which allocated $21 billion to encourage “meaningful use” of such systems[3].

The Fed’s largesse is based on the premise that EHRs will improve quality and reduce the costs of care, but the move will impact the health care system in other ways as well. One such area is medical education.

What kind of impact can we expect? In some ways, EHRs appear to enhance medical education, but in others, the impact appears to be negative.

Benefits
Two studies suggest that EHRs improve documentation[4] by medical students. In the first, Morrow and Dobbie found that first-year students who used an EHR to document a history recorded more features of pain [5]than those using paper charts.

In another survey of third-year students, Rouf and Chumley showed that 72% reported asking more history questions when prompted by an EHR.

These authors also assert that EHRs make it easier for faculty to give feedback to students[6], track the procedures they perform and store records of interesting cases for future use.

Beyond this, EHR speeds access to the medical literature which should facilitate learning and encourage students to rely on medical evidence.

Risks
EHRs have some negative impact as well, particularly relating to the learning environment and patient-physician communication.

EHRs can disrupt the learning environment by creating shortcuts that threaten the time-honored process by which trainees synthesize patient’s symptoms, signs, and lab results into a coherent story and present them to senior clinicians for feedback and discussion.

One example of this is the process by which trainees copy and paste chart notes and other information created by others, and send them to supervisors for feedback. This discourages critical thinking by the trainee[7].

The potential negative impact of EHRs on physician-patient communication is particularly acute for medical students who are just finding their voices as professionals. Inserting a terminal into the middle of a student’s session with a patient adds complexity to the interaction, might reduce eye contact and stilt the conversation, and prevent her from seeing how her words and body language affect her patients.

Tweaking Medical Education to Leverage EHR Benefits

As these issues show, the quality-improving, cost-reducing benefits of EHRs can only be realized by aligning multiple systems and user-based factors. Educators can begin the alignment in three ways:

Begin EHR Education Early
The process should begin in Year 1. Non-science oriented courses like “Introduction to the Patient,” present ideal opportunities to introduce the medium.

If students master EHR skills before their clinical rotations, they can focus the latter time on traditional learning exercises, such as clinical reasoning, diagnosis and so on.

What to Teach
Students should be taught how to use basic EHR functions like order entry, lab look-up, messaging and charting. This exposure should occur away from patients so students can focus on the EHR itself.

They should also be exposed to the nuances of physician–patient communication in the presence of an EHR. Specific communication techniques include:

-        adjusting the spacing between patient, physician and computer so the patient can see what the physician is doing on the computer,

-        encouraging the physician to walk-through data on the screen with patients,

-        spending no more than 30 seconds at a time typing into the computer,

-        making eye contact with the patient; assessing the patient’s emotional status and understanding of the information provided

Don’t Forget Faculty
Most medical school faculty have received no EHR training, yet until they become facile, they can’t be good role models for students. This topic is beyond the scope of this article.

Social Media: Disruptive Force in Medicine

In medicine, social media including Facebook, Twitter, YouTube, blogs and virtual physician communities has grown explosively.

Enterprising providers have deployed sophisticated social media strategies to extend their brand around the world. The Mayo Clinic, for example, maintains several blogs[8], a Facebook fan page[9] (which has 8,800 fans), a library of YouTube videos and a Twitter stream[10] (7,120 followers)[11].

Many physicians also leverage social media to help patients access support networks, a heretofore difficult undertaking for homebound or geographically isolated patients, or those with rare diseases.[12]

But social media also creates challenges for physicians.

In some ways, the challenges are most acute for the youngest physicians, who grew up with Facebook. Unlike their counterparts, they are familiar with social media, but some have become ensnared by it.

Thousands of young physicians have created personal social histories and exposed them on Facebook. Their challenge is to manage this archive while forging identities as professionals.

A study by Thompson and colleagues the University of Florida sheds light on the challenge. They found that of the 44% of students at the UF Medical School who maintained Facebook profiles, only 37% made their entries private. More than half shared information regarding their sexual orientation, while 58% shared their relationship status and half shared political opinions.

A closer inspection of the profiles of 10 randomly-selected medical students revealed that 7 included photos showing them drinking alcohol. Five of these implied excessive drinking. Three students had joined groups that were flagrantly sexist (“Physicians looking for trophy wives in training”) or racially charged (“I should have gone to a blacker college”).[13]

The boundary-blurring effects of social media extend in every direction since medical students, nurses, housestaff, fellows and faculty are linked[14], and the chain is only as strong as its weakest link.

What has been done to mitigate risks associated with social media?

Many have issued warnings. “Caution is recommended,” wrote Jules Dienstag in an email to Harvard medical students. The Dean for Medical Education explained that when “using social networking sites such as Facebook…items that represent unprofessional behavior that are posted by you reflect poorly on you and the medical profession. Such items may become public and could subject you to unintended consequences.”

Similarly, Drexel University College of Medicine warned students that information on social-networking sites can impact decision making regarding their applications to residency programs[15].

Warnings like these are analogous to a “Dangerous Rip-Currents” sign at the beach. By the time people read it, they have arrived in wet suits, having driven an hour to get there.

Some believe the challenges posed by social media are large enough to warrant promulgation of guidelines for its use in health care, modeled after AMIA’s “Guidelines for the Use of Electronic Mail with Patients” which were published just as providers began relying on that medium.[16]

Such an approach begs questions like who has the authority to issue such guidelines, or whether they could impact behavior without an associated means for enforcement. And since no one believes that social media utilization in healthcare should be regulated, the alternative is to modify medical school curricula and beef-up CME.

With social media, the genie is out of the bottle.

Innovations That Make a Difference

Even though EHRs and social media have had a large impact on medicine, it does not necessarily follow that medical education should be modified to account for them.

After all, thousands of technologies have disseminated into the mainstream; medicine accommodates them organically.

To some extent, this is happening with social media. In the Florida study of Facebook utilization for example[17], 64% of medical students were found to have fully public Facebook accounts, whereas only 12% of residents did.

It’s also true that finding space to teach HIT in a packed medical school curriculum means subtracting time from something else.

Still, we argue that the HIT Deluge presents unprecedented challenges to patient-physician communication and while blurring social boundaries in ways that generate ethical challenges and legal risks that cannot be ignored.

Medical schools including Harvard, Stanford, Vanderbilt and UCSF approach the conundrum by offering elective courses in HIT, often in conjunction with other graduate schools.

HST.921, “Information Technology in the Health Care System of the Future,”[18] is an example. The course is open to all graduate students at Harvard and MIT, including those at Harvard Medical School.

In it, students learn how HIT improves health care quality and provides new options for patient education and self-care.

Florida State University College of Medicine, one of the nation’s newest medical schools, has taken a more aggressive approach. Bypassing the above-mentioned incremental approach, its  Internet-age curriculum has HIT woven into its fabric.

FSU students receive laptops upon arrival. Their textbooks are on line. During orientation and first semester, they learn to access library resources on line and gain exposure to decision support tools.

In the second semester, they receive PDAs and learn how to carry out literature reviews and manage bibliographies on line.

In their fourth semester, FSU students learn to use SOAPware, a laptop-supportable EHR. During their third year, they use SOAPWare during supervised patient encounters and receive feedback from supervising physicians.

And what about all the physicians who graduated medical school years ago and have had no HIT education whatsoever? That’s where Russ Cucina, an associate medical director of IT at UCSF plays a vital role. Cucina, you see, teaches a CME class called, “Blogs, Tweets, and Facebook: What the Hospital and Medical Administrator Needs to Know.”

We hear it’s filling up fast.

[2] http://content.nejm.org/cgi/content/full/361/7/649?ijkey=Tarf0DE9052Gc&keytype=ref&siteid=nejm

[3] http://www.ehrbloggers.com/2009/07/meaningful-use-take-ii.html

[4] http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000069

[5] http://www.stfm.org/fmhub/fm2008/July/Heidi462.pdf

[6] http://www.biomedcentral.com/bmcmededuc/

[7] http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000069

[8] http://www.mayoclinic.org/blogs/index.html

[9] http://www.facebook.com/pages/Mayo-Clinic/7673082516

[10] http://twitter.com/mayoclinic

[11] http://www.informationweek.com/news/healthcare/patient/showArticle.jhtml?articleID=219200127

[12] http://www.nytimes.com/2009/06/11/health/11chen.html?_r=1

[13] http://news.ufl.edu/2008/07/10/facebook/

[14] http://content.nejm.org/cgi/content/full/361/7/649?ijkey=Tarf0DE9052Gc&keytype=ref&siteid=nejm

[15] ibid

[16] http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=9452989

[17] http://news.ufl.edu/2008/07/10/facebook/

[18] http://www.hst921.org/home/

Glenn Laffel is Senior Vice President of Clinical Affairs for Practice Fusion.  Practice Fusion addresses the complexities and critical needs of today’s healthcare environment by providing a free, web-based Electronic Health Record (EHR) application to physicians.