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Medical Students’ Observations, Practices, and Attitudes Regarding Electronic Health Record Documentation a
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Heather L. Heiman , Sonya Rasminsky , Jennifer A. Bierman , Daniel B. Evans , Kathryn c
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G. Kinner , Julie Stamos , Zoran Martinovich & William C. McGaghie
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Department of Medicine and Augusta Webster, MD, Office of Medical Education , Northwestern University Feinberg School of Medicine , Chicago , Illinois , USA b
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Department of Psychiatry , Northwestern University Feinberg School of Medicine , Chicago , Illinois , USA c
Department of Medicine , Northwestern University Feinberg School of Medicine , Chicago , Illinois , USA d
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Center for Education in Medicine , Northwestern University Feinberg School of Medicine , Chicago , Illinois , USA Published online: 09 Jan 2014.
To cite this article: Heather L. Heiman , Sonya Rasminsky , Jennifer A. Bierman , Daniel B. Evans , Kathryn G. Kinner , Julie Stamos , Zoran Martinovich & William C. McGaghie (2014) Medical Students’ Observations, Practices, and Attitudes Regarding Electronic Health Record Documentation, Teaching and Learning in Medicine: An International Journal, 26:1, 49-55, DOI: 10.1080/10401334.2013.857337 To link to this article: http://dx.doi.org/10.1080/10401334.2013.857337
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Teaching and Learning in Medicine, 26(1), 49–55 C 2014, Taylor & Francis Group, LLC Copyright ISSN: 1040-1334 print / 1532-8015 online DOI: 10.1080/10401334.2013.857337
Medical Students’ Observations, Practices, and Attitudes Regarding Electronic Health Record Documentation Heather L. Heiman Department of Medicine and Augusta Webster, MD, Office of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
Sonya Rasminsky Department of Psychiatry, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
Jennifer A. Bierman, Daniel B. Evans, and Kathryn G. Kinner Downloaded by [University of Connecticut] at 22:27 02 February 2015
Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
Julie Stamos Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
Zoran Martinovich Department of Psychiatry, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
William C. McGaghie Center for Education in Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
notes, and 22% (26/119) reported copying from residents. Only 10% (12/119) indicated that copying from other providers is acceptable, whereas 83% (98/118) believe copying from their own notes is acceptable. Most students use templates and auto-inserted data; 43% (51/120) reported documenting while signed in under an attending’s name. Greater use of documentation efficiency tools is associated with plans to enter a procedural specialty and with lack of awareness of the medical school copy–paste policy. Conclusions: Students frequently use a range of efficiency tools to document in the electronic health record, most commonly copying their own notes. Although the vast majority of students believe it is unacceptable to copy–paste from other providers, most have observed clinical supervisors doing so.
Background: Medical students are increasingly documenting their patient notes in electronic health records (EHRs). Documentation short-cuts, such as copy–paste and templates, have raised concern among clinician-educators because they may perpetuate redundant, inaccurate, or even plagiarized notes. Little is known about medical students’ experiences with copy-paste, templates and other “efficiency tools” in EHRs. Purposes: We sought to understand medical students’ observations, practices, and attitudes regarding electronic documentation efficiency tools. Methods: We surveyed 3rd-year medical students at one medical school. We asked about efficiency tools including copy–paste, templates, auto-inserted data, and “scribing” (documentation under a supervisor’s name). Results: Overall, 123 of 163 students (75%) responded; almost all frequently use an EHR for documentation. Eighty-six percent (102/119) reported at least sometimes observing residents copying data from other providers’ notes and 60% (70/116) reported observing attending physicians doing so. Most students (95%, 113/119) reported copying from their own previous
Keywords
electronic health records, documentation, professionalism, medical student education
INTRODUCTION Electronic health records (EHRs) are an increasingly central part of medical practice, with proliferation of these systems accelerating due to the Health Information Technology for Economic and Clinical Health Act of 2009.1 Announcing the $29 billion investment to support the adoption and “meaningful use” of EHRs and other health information technology over the next 10 years, President Obama declared that electronic health records “will reduce errors, bring down costs, ensure privacy, and save lives.”2 EHRs impact every facet of patient care, from
This research was conducted at Northwestern University Feinberg School of Medicine, Chicago, Illinois. The authors wish to thank Berna Jacobson for her administrative support of this project, and Rebekah Dommel for her assistance with data preparation and review of the manuscript. We would also like to thank the Feinberg clerkship directors and deans of medical education. Correspondence may be sent to Heather L. Heiman, Clinical Education Center, 240 East Huron Street #1-442, Chicago, IL 60611, USA. E-mail: [email protected]
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data gathering to clinical decision making to documentation to billing, and although EHRs have the potential to improve each of these parts of care, these systems also create new challenges. Electronic records are more legible, accessible, and portable than paper charts, and they can filter and organize data to facilitate efficient and accurate diagnosis and treatment.3 They can also increase speed and quantity of documentation, through various “efficiency tools.” With a few clicks, providers can automatically insert data such as labs and vital signs, employ templates that are prepopulated with “normal” paragraphs such as the review of systems or the physical exam, and copy all or part of an old note to paste into a new note. Prior research shows that residents feel positively about templates4 and that attendings and residents use the copy–paste function extensively.5,6 Although convenient, efficiency tools can render notes lengthy and redundant, and they may obscure the writer’s clinical reasoning.7,8 Copy–paste within the medical record raises special concerns about plagiarism and inaccuracy.9 Several articles suggest that copying and pasting may lead to duplication of outdated information and to the introduction and perpetuation of errors in the patient’s chart.10–12 Authors suggest that the highest risk portions of the chart to copy–paste are the history of present illness or the physical examination, where errors could potentially harm patients or subject the provider to legal risk.13,14 In addition, there is some early evidence to suggest that the use of copied information in the plan may be associated with a lower quality of patient care.15 Physicians learn their documentation habits as medical students. The Alliance for Clinical Education stated in 2012 that medical education leaders must ensure their students become skillful and ethical users of electronic health records.9 They recommend that schools develop competencies in EHR documentation, which all students should achieve. Right now, limited educational frameworks exist for teaching students proper EHR documentation.16 The existing literature on medical students has focused primarily on variability of medical school policies and discussion from a logistical or legal perspective about whether students should be allowed to document in the EHR,17–20 though concern about student use of templates and copy–paste has been expressed by clerkship directors and others.20–23 Student voices have rarely been solicited. We found one student survey touching on documentation; it showed that 3rd-year students tended to think their notes in the EHR were more complete than notes on paper and to appreciate access to normal exam templates.24 More data from student experience could be helpful as a starting point for the curriculum that Alliance for Clinical Education recommends. Northwestern University Feinberg School of Medicine (Feinberg)’s official medical student policy is that students are prohibited from copying and pasting another person’s note but are permitted to copy their own note from a previous day if they revise it to reflect changes in the patient’s condition. The policy does not provide explicit guidance about the use of templates, scribing, or auto-inserted data.25 It is unknown whether
students’ actual experiences with EHR documentation reflect the policy. The purpose of this study was to investigate Feinberg students’ observations, behaviors, and attitudes regarding the electronic health record, as part of a needs assessment in advance of developing a curriculum on responsible electronic documentation for 3rd-year medical students.
METHODS We administered a confidential survey to all 3rd-year medical students at Feinberg. We developed the survey after a literature review that included the prior survey of physician attitudes regarding copy–paste by O’Donnell et al.5 using input from a multispecialty group of five clinician-educators (HH, SR, JB, JS, DE), a 4th-year medical student (KK), and an expert in medical education research (WM).26 Questions were reviewed by Feinberg clerkship directors and medical education deans for face validity. The survey contained 38 items, including a combination of selected-response and constructed-response items. Question domains included demographic data (including anticipated specialty choice), receipt of training and feedback; attitudes toward copy–paste and scribing (documenting while signed in under a supervisor’s name); behaviors regarding the use of copy–paste, scribing, templates, auto-inserted data; observations of others’ behavior; and knowledge about Feinberg’s copy–paste policy. In the text of the survey, we explicitly defined the term scribing as having “a member of your team ask you to sign in to the EHR under their name/password in order to write a note that will be saved in their name,” the term “auto-inserted data” as “data taken from elsewhere in the chart using dotphrases,” and the term templates as “a pre-written basic structure or drop-down menu.” Responses were either yes/no or rated on a 5-point Likert-type scale ranging from strongly disagree to strongly agree or never to always. In addition, students were asked under what circumstances they thought that copy–paste should be allowed or forbidden, to describe scenarios in which copy–paste impacted patient care, to comment about feedback they had received about copy–paste, and to make suggestions for improvement regarding note writing in the EHR. The Northwestern University Institutional Review Board approved this study. The survey, which took about 15 minutes to complete, was sent electronically (Survey Monkey, Portland, OR) to 163 thirdyear medical students at Feinberg. The survey was open from February 2011 until April 2011. Data were downloaded from Survey Monkey and respondents were deidentified. The entire survey is available as the appendix (which can be found online as supplemental material). Descriptive statistics were used to summarize student observations, behaviors, feedback, and attitudes. To examine associations, we grouped together thematically similar items into four scales: (a) observations of others’ copying (“observation” scale); (b) behavior regarding copying, use of templates and auto-inserted data, and scribing (“behavior” scale); (c) attitudes
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toward copying and scribing (“attitude” scale); and (d) receipt of feedback concerning EHR notes. For each scale, we calculated internal consistency reliabilities (Cronbach’s alpha). We also measured Pearson correlations between scales. Analyses were run using SPSS Statistics Version 20.0.0. Scale distributions on the observations, behaviors, and attitudes scales were contrasted via Mann-Whitney U-tests for groups defined by (a) awareness of the Feinberg copy/paste policy, (b) receipt of any feedback concerning one’s own copy/paste behavior, and (c) the student’s anticipated specialty choice, classified into procedural (anesthesia, emergency medicine, obstetrics/gynecology, or surgery) and nonprocedural (family medicine, internal medicine, neurology, pediatrics, or psychiatry) subtypes. Means, standard deviations, and effect sizes (Cohen’s d) were estimated for contrasted groups.
RESULTS Of the 163 students who received links to the survey, 123 responded and consented to data inclusion (a 75% response rate). Almost all students (97%; 117/121) responded that they use an EHR either frequently or always to document patient encounters. Only 12% (14/115) report getting frequent feedback on their EHR notes. Thirty-two percent of students (37/117) estimated that residents rarely or never read their notes, and 70% (82/117) estimated that attendings rarely or never read their notes. Only 16% (19/116) of students recall ever getting specific feedback about their use of the copy–paste function. The majority of students perceive that their peers and supervisors often copy from other providers (Table 1). Eighty-six percent (102/119) report at least sometimes witnessing residents copying from another provider, 60% (70/116) report at least sometimes observing an attending copying another provider, and 59% (70/119) report observing fellow students copying other providers. Ninety-five percent (113/119) of students say they copy their own notes at least sometimes; 66% (79/119) do so frequently or nearly always (Table 2). Students less commonly report copying others: 22% (26/119) of students copy their residents at least sometimes, and 13% (15/119) copy their attendings sometimes or frequently. Almost all (97%; 114/118) students who copy their own or another provider’s notes assert that they review each copied statement and edit it as necessary. There is widespread use of other efficiency tools such as templates (both for the entire note and for the physical exam) and auto-inserted data for medications, vital signs, and labs (Table 2). Students also report frequently being asked to scribe for their clinical supervisors, that is, to write a note that will be saved under that supervisor’s name. Forty-three percent (51/119) have scribed for an attending at least sometimes, and 23% (28/119) have scribed for a resident. The vast majority of students (83%; 98/118) agree that it is generally acceptable to copy and paste from their own previous notes (Table 3). Labs are the most common portion of the note
TABLE 1 Descriptive statistics for M3 students’ observations of copy–paste behavior among supervisors and peers
I Have Witnessed . . . Residents copying and pasting elements of another provider’s note Attendings copying and pasting elements of another provider’s note Students copying and pasting elements of another provider’s note Observation scale score (mean of these three items)
No. Responding “Sometimes or More”/No. Answering Item (%)
M Item Scorea (SD)
102/119 (86)
3.36 (.94)
70/116 (60)
2.71 (1.1)
70/119 (59)
2.66 (.92)
2.9 (.82)
a Mean response on a 5-point scale from 1 (never) to 5 (nearly always).
that students consider acceptable to copy from day to day (87%; 103/119), and physical exam is the least common (37%; 44/119). In contrast, only 10% (12/119) think that it is acceptable to copy and paste from other providers. However, 55% (64/116) think doing so is acceptable if the text is in quotes. Students demonstrate ambivalence about the impact of copy–paste on clinical care. Eighty-three percent (98/117) of students believe it improves efficiency, but only 22% (26/118) think it improves patient care, and 11% (13/118) think it improves patient safety. Items about student observations, behaviors, attitudes, and feedback were grouped together into four scales. Internal consistency (Cronbach’s alpha) for the feedback, observations, behaviors, and attitudes scales was 0.74, 0.78, 0.70, and 0.89, respectively. Receiving general feedback on one’s notes was not correlated with observations, behavior, or attitudes (Pearson correlations .083, .025, and –.055, respectively). Specific feedback on the use of copy–paste was related significantly only to attitude. Students who viewed copy–paste more positively were also more likely to report having received specific feedback about their use of copy–paste. Students who intended to specialize in a procedurally intensive field (anesthesia, emergency medicine, obstetrics/gynecology, or surgery) were significantly more likely to report using copy–paste and other efficiency tools than their peers choosing nonprocedural fields (family medicine, internal medicine, neurology, pediatrics, or psychiatry). In addition, the procedurally bound students reported a more favorable attitude toward these tools (Table 4).
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TABLE 2 Descriptive statistics for M3 students’ self-reported documentation behaviors, Northwestern Feinberg School of Medicine, 2011
Copy–paste I copy elements of my own previous notes I copy elements of residents’ notes I copy elements of attendings’ notes I copy elements of other students’ notes Templates and auto-inserted data I use auto-inserted data for vital signs I use auto-inserted data for lab results I use auto-inserted data for the medication list I use templates for the entire note I use templates for the physical or mental status exam I use auto-inserted data for the problem list Scribing (documenting while signed in under another team member’s name) Frequency of documenting while signed in under an attending’s name Frequency of documenting while signed in under a resident’s name Behavior scale score (mean of above 12 items)
No. Responding “Sometimes or More”/No. Answering Item (%)
M Item Scorea (SD)
113/119 (95) 26/119 (22) 15/119 (13) 2/119 (2)
3.73 (0.80) 1.85 (0.82) 1.55 (0.73) 1.25 (0.47)
117/119 (98) 115/117 (98) 115/119 (97) 100/118 (85) 98/118 (83) 37/118 (31)
4.7 (0.63) 4.5 (0.71) 4.2 (0.81) 3.6 (1.1) 3.5 (1.0) 2.1 (1.2)
51/119 (43) 28/119 (23)
2.2 (0.99) 1.8 (.89) 2.9 (0.42)
a
1 (never) and 5 (almost always).
Only 42% (48/113) of students were aware that there is a medical school policy on copying and pasting. Students who were aware of the policy were significantly less likely to report using copy–paste and other electronic documentation efficiency tools we asked about, and they reported a less favorable attitude toward copy–paste (Table 4).
DISCUSSION The Alliance for Clinical Education, a multidisciplinary group of clinical educators of medical students, recently stated that it is essential for students to document within electronic health records.9 In this study, we found the use of efficiency tools such as copy–paste, templates, and auto-inserted data to be widespread among a cohort of students who frequently document notes in EHRs. Students regularly copy their own notes from day to day and witness their supervisors copying from other providers. This study adds a student perspective to prior literature on high use of copy–paste among residents and faculty physicians.5,6 Students’ attitudes are generally congruent with the school’s policy that copying from one’s own notes is acceptable, whereas copying others’ is not. However, many students endorse copying from their own prior physical exam sections and from the history of present illness, sections defined by prior authors as “high risk.”13,14 Students assert that they always scrupulously edit the copied content of their notes. Although the literature suggests documentation errors relating to copied notes is frequent among
practicing physicians,11,12,14 we do not have data about whether students make the same errors, or whether these errors only emerge with increasing patient care demands later in training. Our results show that students who are familiar with the school’s policy about copy–paste tend to copy less. This finding suggests that publicizing and enforcing the copy–paste policy across the continuum of training might significantly affect behavior. In contrast, perceived receipt of feedback on one’s notes had minimal association with behaviors. Our study reveals that students get little feedback in general about their electronic notes, and even less on their use of the copy–paste function. In addition, feedback comes from a wide range of teachers, each of whom may have a slightly different opinion about efficiency tools. It is possible that improving quality and consistency of feedback about students’ documentation would impact behavior. In our study, students’ attitudes and behaviors regarding copy–paste were significantly associated with anticipated specialty choice. Students choosing more procedurally intensive specialties tended to use documentation efficiency tools more often. This finding suggests that efforts to change behavior should target multiple hospital departments to distribute messages about responsible documentation. Our study has several limitations. It was conducted at a single institution, and it was self-reported. We did not attempt to confirm or refute reports. For instance, students reported observing their peers copying from others, but they rarely admitted doing so themselves. Students may have worried about the consequences of admitting to copying, although the survey was
OBSERVATIONS, PRACTICES, ATTITUDES REGARDING EHRs
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TABLE 3 Descriptive statistics for representative items regarding M3 students’ attitudes toward electronic documentation, Northwestern Feinberg School of Medicine, 2011
Copy-paste from self It is acceptable to copy and paste from my own previous notes It is acceptable to copy and paste the following part of my own previous note into my note: HPI and review of systems Medications Physical or mental status exam Lab data/radiographic study results Assessment & plan Copy-paste from other providers It is acceptable to copy and paste from other providers’ notes Copying and pasting parts of other providers’ notes is acceptable as long as the text is quoted It is acceptable to copy and paste the following parts of another provider’s note into my note: History of present illness Review of systems Past medical, family and social history Medications Physical or mental status exam Lab data/radiographic study results Assessment and plan Impact of copy-paste Notes written using the copy-paste function (CPF) are less accurate than notes written without using the CPF Copying and pasting causes problems with patient care Scribing (documenting while signed in under another team member’s name) I felt comfortable documenting under my attending’s nameb I felt comfortable documenting under my resident’s nameb Attitude scale score (average all attitude items)c
No. Responding “Agree” or “Strongly Agree”/ No. Responding (%)
M Item Scorea (SD)
98/118 (83)
4.0 (.90)
75/119 (62) 97/119 (81) 44/119 (36) 103/119 (87) 81/119 (68)
3.4 (1.2) 3.9 (.94) 2.9 (1.1) 4.0 (.90) 3.6 (1.1)
12/119 (10) 64/116 (55)
2.0 (.90) 3.5 (.90)
8/119 (7) 4/119 (3) 36/117 (31) 37/119 (31) 1/117 (1) 66/119 (55) 2/119 (2)
1.7 (.88) 1.7 (.75) 2.7 (1.2) 2.6 (1.2) 1.4 (.59) 3.3 (1.3) 1.4 (.66)
54/117 (46)
3.3 (.88)
53/119 (45)
3.3 (.82)
47/80 (59) 31/66 (47)
3.4 (1.8) 2.8 (1.8) 3.0 (.46)
1 = strongly disagree and 5 = strongly agree. Denominator excludes students who had never been asked to document under another provider’s name. c Attitude scale comprised 32 items including those in the table. The scale is available in its entirety in the appendix. For the attitude scale, the Likert scale on each item was arranged such that 5 indicates strongest attitude in favor of the practice. a
b
confidential. Also, this cross-sectional survey only allowed us to describe associations between copy–paste and student traits, it did not allow us to propose cause and effect. Our study reveals the vast majority of students learn early in their medical careers to use copy-paste and other efficiency tools. Despite the medical school policy, many of our students observe supervisors copying other providers’ notes. Students seem to be aware of the complexity of the issues involved in electronic documentation, and they express the desire to use these tools responsibly. To improve electronic documentation, edu-
cational interventions that reproducibly change behavior across the continuum of training are needed. We are now working to develop and implement a curriculum on responsible electronic documentation, which directly responds to the use of copy–paste and other efficiency tools. The curriculum will focus on the inpatient progress note. We plan to teach students how to write concise, well reasoned, and updated assessments and plans that are not merely copied and pasted day to day but substantially changed to reflect the patient’s changing status. We will reemphasize the prohibition on
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TABLE 4 Predictors of student observations, behaviors and attitudes concerning electronic documentation, Northwestern Feinberg School of Medicine, 2011
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Attitude
Intended specialtya Procedural(n = 26) Nonprocedural (n = 52) p valueb Cohen’s dc Aware of copy/paste policy No (n = 65) Yes (n = 48) p value Cohen’s d Received feedback on copy/paste No (n = 95) Yes (n = 19) p value Cohen’s d
Behavior
Observation
M
(SD)
M
(SD)
M
(SD)
3.20 2.97
(0.43) (0.44) .029 .51
3.10 2.84
(0.35) (0.36) .007 .72
3.00 2.94
(0.98) (0.67) .401 .08
3.01 2.97
(0.47) (0.49) .525 .09
2.98 2.81
(0.41) (0.42) .0496 .41
3.05 2.70
(0.83) (0.79) .015 .43
2.93 3.23
(0.50) (0.31) .009 –.63
2.88 3.07
(0.42) (0.36) .083 –.41
2.85 3.18
(0.85) (0.62) .109 –.40
a
Procedural specialties were surgery, obstetrics/gynecology, emergency medicine and anesthesia. Nonprocedural specialties were internal medicine, pediatrics, family medicine, psychiatry, and neurology. b Asymptotic (two-tailed) significance level based on Mann-Whitney U-test. c Cohen’s d is the size of the mean difference described in pooled standard deviation units.
copying from others. We will show students physical exams which are specific and individualized, contrasted with those that are just copied or taken verbatim from a template. We will discuss how to import or summarize a minimal number of essential labs or studies rather than automatically inserting copious data that lengthen notes unnecessarily and that can be found elsewhere in the chart. We plan to give individual feedback to students about their notes on real patients in order to address the feedback deficiencies students reported in this survey. FUNDING The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article. This study was supported by an Augusta Webster, MD Grant for Educational Innovation at the Feinberg School of Medicine, Northwestern University. Dr. McGaghie’s contribution was supported in part by the Jacob R. Suker, MD, Professorship in Medical Education at Northwestern University and by grant UL 1 RR025741 from the National Center for Research Resources, National Institutes of Health. The National Institutes of Health had no role in the preparation, review, or approval of the manuscript. SUPPLEMENTAL MATERIAL Supplemental data for this article can be accessed on the publisher’s website at http://dx.doi.org/10.1080/ 10401334.2013.857337.
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19. Friedman E, Sainte M, Fallar R. Taking note of the perceived value and impact of medical student chart documentation on education and patient care. Academic Medicine 2010;85:1440–4. 20. Mintz M, Narvarte HJ, O’Brien KE, Papp KK, Thomas M, Durning SJ. Use of electronic medical records by physicians and students in academic internal medicine settings. Academic Medicine 2009;84:1698–704. 21. Hammoud MM, Margo K Christner JG, Fisher J, Fischer SH, Pangaro LN. Opportunities and challenges in integrating electronic health records into undergraduate medical education: a national survey of clerkship directors. Teaching and Learning in Medicine 2012;24:219–24. 22. Peled JU, Sagher O, Morrow J, Dobbie AE. Do electronic health records help or hinder medical education? PLoS Medicine 2009;6:1–5. 23. Spencer DC, Choi, D, English C. Girard D. The effects of electronic health record implementation on medical student educators. Teaching and Learning in Medicine 2012:24:106–10. 24. Rouf E, Chumley H, Dobbie AE. Electronic health records in outpatient clinics: Perspectives of third year medical students. BMC Medical Education 2008;8:1–7. 25. Northwestern University Feinberg School of Medicine. Success on the Wards: A student to student guide of getting the most out of your third year Edition 23. Available from http://www.infoplex.northwestern.edu/ documents/Success%20on%20the%20Wards%202011.pdf. Accessed October 31, 2012. 26. Fowler FJ. Survey research methods. Los Angeles, CA: Sage, 2009.
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Medical Students’ Observations, Practices, and Attitudes Regarding Electronic Health Record Documentation a
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Heather L. Heiman , Sonya Rasminsky , Jennifer A. Bierman , Daniel B. Evans , Kathryn c
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Department of Medicine and Augusta Webster, MD, Office of Medical Education , Northwestern University Feinberg School of Medicine , Chicago , Illinois , USA b
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Center for Education in Medicine , Northwestern University Feinberg School of Medicine , Chicago , Illinois , USA Published online: 09 Jan 2014.
To cite this article: Heather L. Heiman , Sonya Rasminsky , Jennifer A. Bierman , Daniel B. Evans , Kathryn G. Kinner , Julie Stamos , Zoran Martinovich & William C. McGaghie (2014) Medical Students’ Observations, Practices, and Attitudes Regarding Electronic Health Record Documentation, Teaching and Learning in Medicine: An International Journal, 26:1, 49-55, DOI: 10.1080/10401334.2013.857337 To link to this article: http://dx.doi.org/10.1080/10401334.2013.857337
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Teaching and Learning in Medicine, 26(1), 49–55 C 2014, Taylor & Francis Group, LLC Copyright ISSN: 1040-1334 print / 1532-8015 online DOI: 10.1080/10401334.2013.857337
Medical Students’ Observations, Practices, and Attitudes Regarding Electronic Health Record Documentation Heather L. Heiman Department of Medicine and Augusta Webster, MD, Office of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
Sonya Rasminsky Department of Psychiatry, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
Jennifer A. Bierman, Daniel B. Evans, and Kathryn G. Kinner Downloaded by [University of Connecticut] at 22:27 02 February 2015
Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
Julie Stamos Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
Zoran Martinovich Department of Psychiatry, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
William C. McGaghie Center for Education in Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
notes, and 22% (26/119) reported copying from residents. Only 10% (12/119) indicated that copying from other providers is acceptable, whereas 83% (98/118) believe copying from their own notes is acceptable. Most students use templates and auto-inserted data; 43% (51/120) reported documenting while signed in under an attending’s name. Greater use of documentation efficiency tools is associated with plans to enter a procedural specialty and with lack of awareness of the medical school copy–paste policy. Conclusions: Students frequently use a range of efficiency tools to document in the electronic health record, most commonly copying their own notes. Although the vast majority of students believe it is unacceptable to copy–paste from other providers, most have observed clinical supervisors doing so.
Background: Medical students are increasingly documenting their patient notes in electronic health records (EHRs). Documentation short-cuts, such as copy–paste and templates, have raised concern among clinician-educators because they may perpetuate redundant, inaccurate, or even plagiarized notes. Little is known about medical students’ experiences with copy-paste, templates and other “efficiency tools” in EHRs. Purposes: We sought to understand medical students’ observations, practices, and attitudes regarding electronic documentation efficiency tools. Methods: We surveyed 3rd-year medical students at one medical school. We asked about efficiency tools including copy–paste, templates, auto-inserted data, and “scribing” (documentation under a supervisor’s name). Results: Overall, 123 of 163 students (75%) responded; almost all frequently use an EHR for documentation. Eighty-six percent (102/119) reported at least sometimes observing residents copying data from other providers’ notes and 60% (70/116) reported observing attending physicians doing so. Most students (95%, 113/119) reported copying from their own previous
Keywords
electronic health records, documentation, professionalism, medical student education
INTRODUCTION Electronic health records (EHRs) are an increasingly central part of medical practice, with proliferation of these systems accelerating due to the Health Information Technology for Economic and Clinical Health Act of 2009.1 Announcing the $29 billion investment to support the adoption and “meaningful use” of EHRs and other health information technology over the next 10 years, President Obama declared that electronic health records “will reduce errors, bring down costs, ensure privacy, and save lives.”2 EHRs impact every facet of patient care, from
This research was conducted at Northwestern University Feinberg School of Medicine, Chicago, Illinois. The authors wish to thank Berna Jacobson for her administrative support of this project, and Rebekah Dommel for her assistance with data preparation and review of the manuscript. We would also like to thank the Feinberg clerkship directors and deans of medical education. Correspondence may be sent to Heather L. Heiman, Clinical Education Center, 240 East Huron Street #1-442, Chicago, IL 60611, USA. E-mail: [email protected]
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data gathering to clinical decision making to documentation to billing, and although EHRs have the potential to improve each of these parts of care, these systems also create new challenges. Electronic records are more legible, accessible, and portable than paper charts, and they can filter and organize data to facilitate efficient and accurate diagnosis and treatment.3 They can also increase speed and quantity of documentation, through various “efficiency tools.” With a few clicks, providers can automatically insert data such as labs and vital signs, employ templates that are prepopulated with “normal” paragraphs such as the review of systems or the physical exam, and copy all or part of an old note to paste into a new note. Prior research shows that residents feel positively about templates4 and that attendings and residents use the copy–paste function extensively.5,6 Although convenient, efficiency tools can render notes lengthy and redundant, and they may obscure the writer’s clinical reasoning.7,8 Copy–paste within the medical record raises special concerns about plagiarism and inaccuracy.9 Several articles suggest that copying and pasting may lead to duplication of outdated information and to the introduction and perpetuation of errors in the patient’s chart.10–12 Authors suggest that the highest risk portions of the chart to copy–paste are the history of present illness or the physical examination, where errors could potentially harm patients or subject the provider to legal risk.13,14 In addition, there is some early evidence to suggest that the use of copied information in the plan may be associated with a lower quality of patient care.15 Physicians learn their documentation habits as medical students. The Alliance for Clinical Education stated in 2012 that medical education leaders must ensure their students become skillful and ethical users of electronic health records.9 They recommend that schools develop competencies in EHR documentation, which all students should achieve. Right now, limited educational frameworks exist for teaching students proper EHR documentation.16 The existing literature on medical students has focused primarily on variability of medical school policies and discussion from a logistical or legal perspective about whether students should be allowed to document in the EHR,17–20 though concern about student use of templates and copy–paste has been expressed by clerkship directors and others.20–23 Student voices have rarely been solicited. We found one student survey touching on documentation; it showed that 3rd-year students tended to think their notes in the EHR were more complete than notes on paper and to appreciate access to normal exam templates.24 More data from student experience could be helpful as a starting point for the curriculum that Alliance for Clinical Education recommends. Northwestern University Feinberg School of Medicine (Feinberg)’s official medical student policy is that students are prohibited from copying and pasting another person’s note but are permitted to copy their own note from a previous day if they revise it to reflect changes in the patient’s condition. The policy does not provide explicit guidance about the use of templates, scribing, or auto-inserted data.25 It is unknown whether
students’ actual experiences with EHR documentation reflect the policy. The purpose of this study was to investigate Feinberg students’ observations, behaviors, and attitudes regarding the electronic health record, as part of a needs assessment in advance of developing a curriculum on responsible electronic documentation for 3rd-year medical students.
METHODS We administered a confidential survey to all 3rd-year medical students at Feinberg. We developed the survey after a literature review that included the prior survey of physician attitudes regarding copy–paste by O’Donnell et al.5 using input from a multispecialty group of five clinician-educators (HH, SR, JB, JS, DE), a 4th-year medical student (KK), and an expert in medical education research (WM).26 Questions were reviewed by Feinberg clerkship directors and medical education deans for face validity. The survey contained 38 items, including a combination of selected-response and constructed-response items. Question domains included demographic data (including anticipated specialty choice), receipt of training and feedback; attitudes toward copy–paste and scribing (documenting while signed in under a supervisor’s name); behaviors regarding the use of copy–paste, scribing, templates, auto-inserted data; observations of others’ behavior; and knowledge about Feinberg’s copy–paste policy. In the text of the survey, we explicitly defined the term scribing as having “a member of your team ask you to sign in to the EHR under their name/password in order to write a note that will be saved in their name,” the term “auto-inserted data” as “data taken from elsewhere in the chart using dotphrases,” and the term templates as “a pre-written basic structure or drop-down menu.” Responses were either yes/no or rated on a 5-point Likert-type scale ranging from strongly disagree to strongly agree or never to always. In addition, students were asked under what circumstances they thought that copy–paste should be allowed or forbidden, to describe scenarios in which copy–paste impacted patient care, to comment about feedback they had received about copy–paste, and to make suggestions for improvement regarding note writing in the EHR. The Northwestern University Institutional Review Board approved this study. The survey, which took about 15 minutes to complete, was sent electronically (Survey Monkey, Portland, OR) to 163 thirdyear medical students at Feinberg. The survey was open from February 2011 until April 2011. Data were downloaded from Survey Monkey and respondents were deidentified. The entire survey is available as the appendix (which can be found online as supplemental material). Descriptive statistics were used to summarize student observations, behaviors, feedback, and attitudes. To examine associations, we grouped together thematically similar items into four scales: (a) observations of others’ copying (“observation” scale); (b) behavior regarding copying, use of templates and auto-inserted data, and scribing (“behavior” scale); (c) attitudes
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toward copying and scribing (“attitude” scale); and (d) receipt of feedback concerning EHR notes. For each scale, we calculated internal consistency reliabilities (Cronbach’s alpha). We also measured Pearson correlations between scales. Analyses were run using SPSS Statistics Version 20.0.0. Scale distributions on the observations, behaviors, and attitudes scales were contrasted via Mann-Whitney U-tests for groups defined by (a) awareness of the Feinberg copy/paste policy, (b) receipt of any feedback concerning one’s own copy/paste behavior, and (c) the student’s anticipated specialty choice, classified into procedural (anesthesia, emergency medicine, obstetrics/gynecology, or surgery) and nonprocedural (family medicine, internal medicine, neurology, pediatrics, or psychiatry) subtypes. Means, standard deviations, and effect sizes (Cohen’s d) were estimated for contrasted groups.
RESULTS Of the 163 students who received links to the survey, 123 responded and consented to data inclusion (a 75% response rate). Almost all students (97%; 117/121) responded that they use an EHR either frequently or always to document patient encounters. Only 12% (14/115) report getting frequent feedback on their EHR notes. Thirty-two percent of students (37/117) estimated that residents rarely or never read their notes, and 70% (82/117) estimated that attendings rarely or never read their notes. Only 16% (19/116) of students recall ever getting specific feedback about their use of the copy–paste function. The majority of students perceive that their peers and supervisors often copy from other providers (Table 1). Eighty-six percent (102/119) report at least sometimes witnessing residents copying from another provider, 60% (70/116) report at least sometimes observing an attending copying another provider, and 59% (70/119) report observing fellow students copying other providers. Ninety-five percent (113/119) of students say they copy their own notes at least sometimes; 66% (79/119) do so frequently or nearly always (Table 2). Students less commonly report copying others: 22% (26/119) of students copy their residents at least sometimes, and 13% (15/119) copy their attendings sometimes or frequently. Almost all (97%; 114/118) students who copy their own or another provider’s notes assert that they review each copied statement and edit it as necessary. There is widespread use of other efficiency tools such as templates (both for the entire note and for the physical exam) and auto-inserted data for medications, vital signs, and labs (Table 2). Students also report frequently being asked to scribe for their clinical supervisors, that is, to write a note that will be saved under that supervisor’s name. Forty-three percent (51/119) have scribed for an attending at least sometimes, and 23% (28/119) have scribed for a resident. The vast majority of students (83%; 98/118) agree that it is generally acceptable to copy and paste from their own previous notes (Table 3). Labs are the most common portion of the note
TABLE 1 Descriptive statistics for M3 students’ observations of copy–paste behavior among supervisors and peers
I Have Witnessed . . . Residents copying and pasting elements of another provider’s note Attendings copying and pasting elements of another provider’s note Students copying and pasting elements of another provider’s note Observation scale score (mean of these three items)
No. Responding “Sometimes or More”/No. Answering Item (%)
M Item Scorea (SD)
102/119 (86)
3.36 (.94)
70/116 (60)
2.71 (1.1)
70/119 (59)
2.66 (.92)
2.9 (.82)
a Mean response on a 5-point scale from 1 (never) to 5 (nearly always).
that students consider acceptable to copy from day to day (87%; 103/119), and physical exam is the least common (37%; 44/119). In contrast, only 10% (12/119) think that it is acceptable to copy and paste from other providers. However, 55% (64/116) think doing so is acceptable if the text is in quotes. Students demonstrate ambivalence about the impact of copy–paste on clinical care. Eighty-three percent (98/117) of students believe it improves efficiency, but only 22% (26/118) think it improves patient care, and 11% (13/118) think it improves patient safety. Items about student observations, behaviors, attitudes, and feedback were grouped together into four scales. Internal consistency (Cronbach’s alpha) for the feedback, observations, behaviors, and attitudes scales was 0.74, 0.78, 0.70, and 0.89, respectively. Receiving general feedback on one’s notes was not correlated with observations, behavior, or attitudes (Pearson correlations .083, .025, and –.055, respectively). Specific feedback on the use of copy–paste was related significantly only to attitude. Students who viewed copy–paste more positively were also more likely to report having received specific feedback about their use of copy–paste. Students who intended to specialize in a procedurally intensive field (anesthesia, emergency medicine, obstetrics/gynecology, or surgery) were significantly more likely to report using copy–paste and other efficiency tools than their peers choosing nonprocedural fields (family medicine, internal medicine, neurology, pediatrics, or psychiatry). In addition, the procedurally bound students reported a more favorable attitude toward these tools (Table 4).
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TABLE 2 Descriptive statistics for M3 students’ self-reported documentation behaviors, Northwestern Feinberg School of Medicine, 2011
Copy–paste I copy elements of my own previous notes I copy elements of residents’ notes I copy elements of attendings’ notes I copy elements of other students’ notes Templates and auto-inserted data I use auto-inserted data for vital signs I use auto-inserted data for lab results I use auto-inserted data for the medication list I use templates for the entire note I use templates for the physical or mental status exam I use auto-inserted data for the problem list Scribing (documenting while signed in under another team member’s name) Frequency of documenting while signed in under an attending’s name Frequency of documenting while signed in under a resident’s name Behavior scale score (mean of above 12 items)
No. Responding “Sometimes or More”/No. Answering Item (%)
M Item Scorea (SD)
113/119 (95) 26/119 (22) 15/119 (13) 2/119 (2)
3.73 (0.80) 1.85 (0.82) 1.55 (0.73) 1.25 (0.47)
117/119 (98) 115/117 (98) 115/119 (97) 100/118 (85) 98/118 (83) 37/118 (31)
4.7 (0.63) 4.5 (0.71) 4.2 (0.81) 3.6 (1.1) 3.5 (1.0) 2.1 (1.2)
51/119 (43) 28/119 (23)
2.2 (0.99) 1.8 (.89) 2.9 (0.42)
a
1 (never) and 5 (almost always).
Only 42% (48/113) of students were aware that there is a medical school policy on copying and pasting. Students who were aware of the policy were significantly less likely to report using copy–paste and other electronic documentation efficiency tools we asked about, and they reported a less favorable attitude toward copy–paste (Table 4).
DISCUSSION The Alliance for Clinical Education, a multidisciplinary group of clinical educators of medical students, recently stated that it is essential for students to document within electronic health records.9 In this study, we found the use of efficiency tools such as copy–paste, templates, and auto-inserted data to be widespread among a cohort of students who frequently document notes in EHRs. Students regularly copy their own notes from day to day and witness their supervisors copying from other providers. This study adds a student perspective to prior literature on high use of copy–paste among residents and faculty physicians.5,6 Students’ attitudes are generally congruent with the school’s policy that copying from one’s own notes is acceptable, whereas copying others’ is not. However, many students endorse copying from their own prior physical exam sections and from the history of present illness, sections defined by prior authors as “high risk.”13,14 Students assert that they always scrupulously edit the copied content of their notes. Although the literature suggests documentation errors relating to copied notes is frequent among
practicing physicians,11,12,14 we do not have data about whether students make the same errors, or whether these errors only emerge with increasing patient care demands later in training. Our results show that students who are familiar with the school’s policy about copy–paste tend to copy less. This finding suggests that publicizing and enforcing the copy–paste policy across the continuum of training might significantly affect behavior. In contrast, perceived receipt of feedback on one’s notes had minimal association with behaviors. Our study reveals that students get little feedback in general about their electronic notes, and even less on their use of the copy–paste function. In addition, feedback comes from a wide range of teachers, each of whom may have a slightly different opinion about efficiency tools. It is possible that improving quality and consistency of feedback about students’ documentation would impact behavior. In our study, students’ attitudes and behaviors regarding copy–paste were significantly associated with anticipated specialty choice. Students choosing more procedurally intensive specialties tended to use documentation efficiency tools more often. This finding suggests that efforts to change behavior should target multiple hospital departments to distribute messages about responsible documentation. Our study has several limitations. It was conducted at a single institution, and it was self-reported. We did not attempt to confirm or refute reports. For instance, students reported observing their peers copying from others, but they rarely admitted doing so themselves. Students may have worried about the consequences of admitting to copying, although the survey was
OBSERVATIONS, PRACTICES, ATTITUDES REGARDING EHRs
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TABLE 3 Descriptive statistics for representative items regarding M3 students’ attitudes toward electronic documentation, Northwestern Feinberg School of Medicine, 2011
Copy-paste from self It is acceptable to copy and paste from my own previous notes It is acceptable to copy and paste the following part of my own previous note into my note: HPI and review of systems Medications Physical or mental status exam Lab data/radiographic study results Assessment & plan Copy-paste from other providers It is acceptable to copy and paste from other providers’ notes Copying and pasting parts of other providers’ notes is acceptable as long as the text is quoted It is acceptable to copy and paste the following parts of another provider’s note into my note: History of present illness Review of systems Past medical, family and social history Medications Physical or mental status exam Lab data/radiographic study results Assessment and plan Impact of copy-paste Notes written using the copy-paste function (CPF) are less accurate than notes written without using the CPF Copying and pasting causes problems with patient care Scribing (documenting while signed in under another team member’s name) I felt comfortable documenting under my attending’s nameb I felt comfortable documenting under my resident’s nameb Attitude scale score (average all attitude items)c
No. Responding “Agree” or “Strongly Agree”/ No. Responding (%)
M Item Scorea (SD)
98/118 (83)
4.0 (.90)
75/119 (62) 97/119 (81) 44/119 (36) 103/119 (87) 81/119 (68)
3.4 (1.2) 3.9 (.94) 2.9 (1.1) 4.0 (.90) 3.6 (1.1)
12/119 (10) 64/116 (55)
2.0 (.90) 3.5 (.90)
8/119 (7) 4/119 (3) 36/117 (31) 37/119 (31) 1/117 (1) 66/119 (55) 2/119 (2)
1.7 (.88) 1.7 (.75) 2.7 (1.2) 2.6 (1.2) 1.4 (.59) 3.3 (1.3) 1.4 (.66)
54/117 (46)
3.3 (.88)
53/119 (45)
3.3 (.82)
47/80 (59) 31/66 (47)
3.4 (1.8) 2.8 (1.8) 3.0 (.46)
1 = strongly disagree and 5 = strongly agree. Denominator excludes students who had never been asked to document under another provider’s name. c Attitude scale comprised 32 items including those in the table. The scale is available in its entirety in the appendix. For the attitude scale, the Likert scale on each item was arranged such that 5 indicates strongest attitude in favor of the practice. a
b
confidential. Also, this cross-sectional survey only allowed us to describe associations between copy–paste and student traits, it did not allow us to propose cause and effect. Our study reveals the vast majority of students learn early in their medical careers to use copy-paste and other efficiency tools. Despite the medical school policy, many of our students observe supervisors copying other providers’ notes. Students seem to be aware of the complexity of the issues involved in electronic documentation, and they express the desire to use these tools responsibly. To improve electronic documentation, edu-
cational interventions that reproducibly change behavior across the continuum of training are needed. We are now working to develop and implement a curriculum on responsible electronic documentation, which directly responds to the use of copy–paste and other efficiency tools. The curriculum will focus on the inpatient progress note. We plan to teach students how to write concise, well reasoned, and updated assessments and plans that are not merely copied and pasted day to day but substantially changed to reflect the patient’s changing status. We will reemphasize the prohibition on
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TABLE 4 Predictors of student observations, behaviors and attitudes concerning electronic documentation, Northwestern Feinberg School of Medicine, 2011
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Attitude
Intended specialtya Procedural(n = 26) Nonprocedural (n = 52) p valueb Cohen’s dc Aware of copy/paste policy No (n = 65) Yes (n = 48) p value Cohen’s d Received feedback on copy/paste No (n = 95) Yes (n = 19) p value Cohen’s d
Behavior
Observation
M
(SD)
M
(SD)
M
(SD)
3.20 2.97
(0.43) (0.44) .029 .51
3.10 2.84
(0.35) (0.36) .007 .72
3.00 2.94
(0.98) (0.67) .401 .08
3.01 2.97
(0.47) (0.49) .525 .09
2.98 2.81
(0.41) (0.42) .0496 .41
3.05 2.70
(0.83) (0.79) .015 .43
2.93 3.23
(0.50) (0.31) .009 –.63
2.88 3.07
(0.42) (0.36) .083 –.41
2.85 3.18
(0.85) (0.62) .109 –.40
a
Procedural specialties were surgery, obstetrics/gynecology, emergency medicine and anesthesia. Nonprocedural specialties were internal medicine, pediatrics, family medicine, psychiatry, and neurology. b Asymptotic (two-tailed) significance level based on Mann-Whitney U-test. c Cohen’s d is the size of the mean difference described in pooled standard deviation units.
copying from others. We will show students physical exams which are specific and individualized, contrasted with those that are just copied or taken verbatim from a template. We will discuss how to import or summarize a minimal number of essential labs or studies rather than automatically inserting copious data that lengthen notes unnecessarily and that can be found elsewhere in the chart. We plan to give individual feedback to students about their notes on real patients in order to address the feedback deficiencies students reported in this survey. FUNDING The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article. This study was supported by an Augusta Webster, MD Grant for Educational Innovation at the Feinberg School of Medicine, Northwestern University. Dr. McGaghie’s contribution was supported in part by the Jacob R. Suker, MD, Professorship in Medical Education at Northwestern University and by grant UL 1 RR025741 from the National Center for Research Resources, National Institutes of Health. The National Institutes of Health had no role in the preparation, review, or approval of the manuscript. SUPPLEMENTAL MATERIAL Supplemental data for this article can be accessed on the publisher’s website at http://dx.doi.org/10.1080/ 10401334.2013.857337.
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