As a part of an informatics group of a large medical educational institution, we have been asked to focus on student documentation within the electronic health record (EHR). We are examining the core EHR features in relation to accurate and complete healthcare information. To illustrate the importance of medical education, medical programs of study consist of rigorous curriculums that use applications of science-based knowledge geared toward preventing and curing diseases. Fundamentally, medical students are highly trained and educated individuals seeking to improve health; the golden standard of all medical professionals. Clearly, medical educational institutions have been successful in producing quality physicians. However, there is question as to whether these establishments are equipping their medical students with enough knowledge regarding documentation of digital health information. Electronic health records are considered tools that are used to foster patient-provider interactions and relationships and are designed with the focus of delivering high quality of care. In addition to medical course curricula, medical students need sufficient training on how to use an EHR effectively and accurately. As paper charts and records are becoming obsolete, the electronic health record has become the standard by which patient care is documented, evaluated, and retrieved. As part of healthcare reform, the mandatory adoption of electronic medical records was mandated in 2014, and as a result, medical education institutional policies have been affected. Also, the rules governing the Health Insurance Portability and Accountability Act have been updated, Joint Commission standards have changed, state laws have improved, and recently, The Centers for Medicare and Medicaid services revised the policy concerning medical student documentation; all to conform to the qualities and measures associated with the integration of electronic health systems. Since medical students are part of the healthcare system, their roles in documentation have limits as well as liabilities. Medical students should be well-informed in the differences in a patient’s legal health record and what constitutes the designated record set. Evidence-based practice can be derived from the data within EHRs, and as health systems implement best practices, it is imperative that medical professionals are properly trained and can demonstrate proficiency in EHR functions to be considered fully prepared in their careers.
Medical education, at entry-level, is where students are taught the fundamentals of medical practice and where integration of science and interpersonal communication skills are put to test. As a case in point, good communication is a core competency for any medical student. This skill paves the way for achieving clinical proficiency. Furthermore, interpersonal and communication skills have a significant impact on patient care and quality outcomes (Choudhary & Gupta, 2015). In the same way, communication skills can be demonstrated by utilizing an EHR. In fact, the EHR acts as an important communication tool in patient-provider relationships and can promote patient-physician interactions.
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To illustrate, the EHR is a tool that contains tools; specifically, tools for documentation. For students to become evidence-based clinicians, their knowledge and expertise lies partly within utilization of an EHR, as the EHR is the fundamental tool for mining data, applying evidence, and generation of evidence (www.nap.edu). As a case in point, “the electronic health record is one key to a shift to systems approaches to evidence-based care that is nonetheless individualized” (www.nap.edu). To ensure that students are documenting properly, the EHR must contain several key features that will not only protect the privacy of the patient but will contribute to student learning the functions and processes of the EHR. For example, an EHR should contain elements that are consistent with medical integrity, which include, but not limited to “functionalities that address student needs such as assigning separate access controls or creating separate student tabs, and features that prohibit copying a student’s note or that track the source of a copied note” (Altman, 2018). One example of a tool that should be included as a key feature of EHR systems in medical education institutions is QNOTE. QNOTE allows teaching physicians to evaluate and assess medical documentation notes for quality, completeness, and efficiency. This feature identifies the gaps in documentation, so students can learn how to properly document patient information (Habboush, Hoyt, & Beidas, 2018). Additionally, EHR key features should include clinical decision support, “which include alerts, reminders and clinical practice guidelines” (Hoyt & Hersh, 2018, p. 73).
Given that EHRs have been widely adopted in most healthcare organizations, “competence in the use of EHRs is necessary for students to become physicians who can harness the full potential of these tools rather than physicians for whom EHRs hinder excellent patient care” (Welcher, Hersh, William, Takesue, Stagg Elliott, Hawkins, 2018). To gain competence with EHR use, medical students need hands-on experience by “documenting clinical encounters as well as entering orders to prepare for residency” (Welcher et al., 2018). Students should have access to training on EHR systems through the school they attend. As a case in point, medical universities should integrate EHR training within their course curriculum. Education simulation would be beneficial as well. Welcher et al. states that some institutions have already implemented simulated EHR training for medical students and those who do not have consistent access to EHRs in clinical settings. Considering that The Association of American Medical Colleges (AAMC) identifies student EHR proficiency as a competency, medical students should “use information technology to optimize learning and care” (Welcher et al., 2018). Regardless of what specialty the medical student chooses, students might be expected to perform EHR competency skills on the first day of residency, without direct supervision (Welcher et al., 2018). Additionally, the United States Medical Licensing Examination Step 2 Clinical Skills exam requires that students be able to write notes in an electronic form” (Welcher et al., 2018). Also, students could act as a medical scribe in clinical settings. Scribing along with utilization of an EHR could give students an edge by putting them ahead of their peers in some areas of medical education. Students that scribe strengthen their medical knowledge and clinical decision-making, as well as improved patient interaction and relationships (Welcher et al., 2018). While it is apparent that EHR training is necessary for student competency, the problem is that institutions vary as to what is considered teaching evidence-based practices. Moreover, “stronger educational efforts related to evidence assessment are needed to equip healthcare professionals with the tools and skills to continually bring the best evidence to bear on practice” (Institute of Medicine, 2007). Having mentioned that, several changes must occur to ensure best of practice applications. For example, medical teaching institutions must adopt models of care that recognize the importance of EHR training and proficiency. Likewise, hospital medical boards must also change their bylaws in accordance with CMS rules, while abiding by HIPAA rules and state laws. Beyond that, the most significant issue in medical education discipline is that there is considerable variance in the level of evidence integration into education. To illustrate, “education of doctoral research students concentrates on analyzing evidence; training of clinical doctoral students focuses on implementing evidence” (Institute of Medicine, 2007).
Despite the advancements made in EHR usability, there are still many obstacles to overcome when deploying education and training in EHR processes and programs within medical education institutions. The question of who has access to patient information and who can use it is determined by rules, policies, and laws. For instance, every institution has its own set of policies, procedures, rules and regulations, which follow in line according HIPAA rules. “HIPAA applies to covered entities, defined by the rule to include health plans, healthcare clearinghouses, and healthcare providers that transmit specific information electronically” (AHIMA Practice Brief) In addition, the Privacy Rule generally requires HIPAA covered entities to provide individuals with access to the protected health information (PHI) about them in one or more “designated record sets” maintained by or for the covered entity (“HIPAA Privacy Rule”, n.d.). The designated record set, as defined by the HIPAA Policy Rule, is “a group of records maintained by or for a covered entity that may include patient medical and billing records; the enrollment, payment, claims, adjudication, and cases or medical management record systems maintained by or for a health plan; or information used in whole or in part to make care-related decisions” (AHIMA, 2011). In sum, the designated record set includes all protected health information as well as business information unrelated to patient care, which fully encompasses the legal health record. In contrast, the legal health record includes only information that is used to make decisions about patient treatment. According to AHIMA (2014), there is no one set definition for the legal health record and designated record set. The healthcare organization in which the medical student attends must explicitly define both as a multidisciplinary task. For example, the medical staff should provide guidance to ensure that patient care needs will be met for immediate, long-term, and research use. Likewise, organizations should consider the capabilities of their electronic systems, such as: functions of the EHR system and how it generates relevant information, storage capacity and costs for the required retention period of the record, the data’s importance for long-term use, and whether the EHR system is able to provide both electronic and paper copies of all components of the legal health record. The organization should seek guidance from the organization’s legal counsel, while taking in consideration community standards of care, federal regulations, state laws and regulations, standards of accrediting agencies, and the requirements of third-party payers. (AHIMA, 2011).
Furthermore, The Joint Commission on Accreditation of Healthcare Organizations requires that a hospital protect the privacy of information. The AHIMA Practice Brief (2014) states that the elements of performance standards include that a hospital has a written policy that addresses privacy of health information and that said policy is implemented. Additionally, a hospital only uses health information for purposes permitted by law and regulation, or as further limited by its policy on privacy. Also, a hospital only discloses health information as authorized by the patient or as otherwise consistent with law and regulation. Lastly, a hospital monitors compliance with its policy of privacy health information (AHIMA Practice Brief, 2014). Having said that, medical students subject to the Joint Commission standards, just as licensed healthcare professionals. However, medical students are just that: students. Kirch, 2014 mentioned that they are solely learners; thus, they do not have a license and are not deemed providers. They are not considered an intern or a resident. Thus, their notes cannot be used for billing purposes, unless their notes are authenticated (Kirch, 2014). In addition to complying with HIPAA rules, medical students are subjected to the powers of the institution, as well as state laws that govern the institution. Just as defining what constitutes a legal health record and what defines a legal health record and designated record set, organizations must look to regulatory bodies as to what medical students are allowed to do within in them. To illustrate, “regulatory bodies and other payers also have supervisory stipulations concerning medical students.” These include state regulations, accrediting agencies, medical staff bylaws, and medical school curricula, to name a few (Altman, 2018).
Currently, most South Carolina health care providers must follow the HIPAA Privacy Rule, and it only covers health care providers that use computers to send health information for certain administrative or financial purposes (Pritts & Kudszus, 2005). Regarding medical students, under South Carolina state law, students can practice medicine as long as they are within an educational setting or training program associated with the medical university (South Carolina Legislature). Consequently, medical universities are health care facilities. What that means for medical students is that they are considered a “covered entity” under the HIPAA Privacy Rule. For example, “a university may be a single legal entity that includes an academic medical center’s hospital that conducts electronic transactions for which the HHS has adopted standards. Because the hospital is part of the legal entity, the whole university, including the hospital, will be a covered entity” (“HIPAA Privacy Rule,” n.d.). Additionally, “the HIPAA Security Rule establishes national standards to protect individuals’ electronic personal health information that is created, received, used, or maintained by a covered entity. The Security Rule requires appropriate administrative, physical and technical safeguards to ensure the confidentiality, integrity, and security of electronic protected health information” (“HIPAA Privacy Rule,” n.d.).
Since medical students fall under the umbrella of being a “covered entity,” they can access, review, and document private patient information. As a matter of fact, The Centers for Medicare & Medicaid Services (CMS) updated its policy on Evaluation and Management (E/M) documentation, which now allows students to document all services in the medical record. However, the teaching physician must verify any student documentation of components of E/M services, rather than re-documenting the work. To illustrate, “the teaching physician must personally perform (or re-perform) the physical exam and medical decision-making activities of the E/M service being billed but may verify any student documentation of them rather than re-documenting this work” (“Documentation…,” 2019). In addition to verifying student documentation, any E/M services billed by teaching physicians require that the medical records must demonstrate that the teaching physician was physically present during critical portions of the service when performed by the resident, and the teaching physician was active in the management of the patient. Furthermore, “the patient medical record must document the extent of the teaching physician’s participation in the review and direction of the services furnished to each beneficiary, as well as demonstrated in the notes within the medical records made by physicians, nurses, or residents (“Documentation…,” 2019).
Before CMS updated the policy regarding medical student documentation, a survey was performed and determined that “the most common reasons for not allowing students to document a patient encounter were hospital or medical school rule forbidding student documentation, concern for medical liability, and inability of student notes to support medical billing (Wittels, Wallenstein, Patwari, & Patel, 2017. Even though CMS updated the policy, there seems to be an ongoing disconnect between educational goals and institutional policies related to documentation. Of key importance is the issue of medical liability. Some institutional policies and procedures are so restrictive that students avoid documenting all together. The survey also concluded that additional issues related to not allowing medical students to document lies in the fact that there is an imbalance between education with clinical productivity, as well as the lack of available workspace in billing departments. According to Habboush et al. (2018), physicians are spending an average of 49% of their working hours on EHR documentation and other tasks related to patient care, which translates into less time spent with the actual patient. Given the significant amount of time physicians spend on EHR-related tasks, educators have an opportunity to help students enhance their EHR capabilities; thus, improve the quality of patient care (Habboush et al., 2018). While time spent in the EHR is significant, the problem is that there is much focus on educating medical education and not enough focus on proper documentation within the scope of electronic document management.
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With these issues in mind, medical educational institutions should support student documentation to enhance learning and leverage use of electronic health systems. As a suggestion, institutions should follow a framework that is consistent with best practices of the institution as well as the best practices of an EHR. As outlined by the Accreditation Council for Graduate Medical Education (ACGME) with the Reporter-Interpreter-Manager-Educator (RIME) model, the framework exists to expand assessments of student performance related to the use of EHRs. This framework acts as a guide that demonstrates how EHRs are used in clinical education settings. These competencies are centered around the EHR and include practice-based learning and improvement, patient care and procedural skills, systems-based practice, medical knowledge, interpersonal and communication skills, and professionalism (Habboush et. al., 2018)
Besides the CCM framework, The American Medical Association (AMA) recently adopted a policy aimed at ensuring that medical students receive quality clinical documentation experience using EHRs, which helps to ensure future physicians are prepared to meet the needs of patients in the modern health system (American Medical Association, 2018). Furthermore, the policy encourages medical schools and programs to design clinical documentation and EHR training that provides feedback regarding the value and effectiveness of the training, as well as providing EHR professional development resources for a faculty. This would “assure appropriate modeling of EHR use during physician/patient interactions” (American Medical Association, 2018).
As medical students engage in patient care, factors of what, where, and how their work is documented are crucial to high-quality clinical notes. Medical record entries should be objective in nature and the basis for legal obligations that take root in accuracy and legibility of clinical record content, confidentiality and data protection, and patients’ access to their medical records (Mathioudakis, Rousalova, Gagnat, Saad, & Hardavella, 2016).
As a case in point, the condition or quality of documentation should be complete and legible and secured with the student’s password and initials. Pohlig states that documented information should include: the reason for the patient visit, patient history, physical exam findings and any prior diagnostic test results, clinical assessment, impression, and/or diagnosis, a plan for care, and most importantly, the date. Likewise, the student should describe the rationale for ordering diagnostic and ancillary services, list past and present diagnoses, along with any health-risk factor in their notations. Moreover, patient progress, changes in treatment, and/or diagnosis revisions should be noted. Also, documentation should fall in line with codes for billing purposes (Pohlig, 2008). Similarly, Kirch, 2014 describes what to document and who can document in an EHR is of importance and has certain stipulations. For example, Pohlig, 2008 states that information involving the review of symptoms (ROS)can be documented by anyone, including the patient. However, if ROS is documented by a medical student other than residents, the teaching physician should reference the ROS documentation in his/her progress notes. Re-documentation is not required unless a revision is necessary. The same rule applies regarding past, family, and social history (PFSH) documentation. Of importance, while PFSH is required when billing higher level consultations or initial inpatient care, it is not required when reporting subsequent services (Pohlig, 2008). History of present illness (HPI) can now be documented by a medical student. Under the new CMS policy, medical students can document all E/M components, with only verification of documentation by the teaching physician (“E/M Service Documentation…,” 2018) This change in policy will free up the teaching physician’s time spent with documentation, and perhaps more time will be dedicated to first, the patient, and second, training the student on the EHR and its functions.
In addition to the educational requirements and training needed for medical students to utilize EHRs appropriately, medical educational institutions need to abide by best practices and employ best practices of EHRs. Best practices of an institution consist of accreditation by the Joint Commission, compliance with HIPAA standards and guidelines, follow CMS rules regarding documentation of care and services, act in accordance with the state in which they reside, and abide by federal laws and regulations. An example of an EHR that supports best practices is Epic. Epic is a CMS-certified software program that provides an organization for with tools for Meaningful Use (MU), Promoting Interoperability (PI), Merit-Based Incentive Payment System (MIPS), Accountable Care Organizations (ACOs), and other regulatory programs (Epic Software). The Medical University of South Carolina (MUSC) uses Epic and in effort to advance best practices, MUSC recently launched a virtual care solution that connects with the health system’s Epic EHR platform. This introduction to real-time video fits directly into the EpicCare workflows of MUSC providers. This is just one example of how health care technology is continually advancing and demonstrates how Telehealth and virtual care are becoming best practices for value-based healthcare (Wicklund, 2016). In the same way, MUSC strives to follow best practices to ensure quality of healthcare delivery. MUSC generates and translates cutting edge discoveries and integrates them with learning, healthcare, and health promotion across the MUSC enterprise (www.web.musc.edu). Consequently, MUSC is the role model for other academic institutions. As an illustration, MUSC is “South Carolina’s only comprehensive academic health science center” (www.web.musc.edu). MUSC’s culture is a direct reflection in MUSC’s mission in making provisions in comprehensive healthcare (www.web.musc.edu).
In conclusion, medical education institutions are responsible for ensuring that future physicians are well prepared and equipped to practice medicine. In addition to facilitating healthcare education, medical students should leave the institution with proficiency in accurate and complete patient-care documentation. Educational needs of medical students should not only be geared toward science-based knowledge, but also a knowledge saturated in the technological aspects of an electronic health record. Students should come away from medical school with complete understanding of what, how, and where to document in a health record, and be well-informed of policies, standards, laws, and regulations that govern the art of documentation. To meet the needs of medical students, medical educational institutions should employ best practices of health care as well as best practices of EHR utilization. To solve the problem of balance in education and accurate documentation of care, medical educational institutions should incorporate EHR training for medical students and provide EHR continuing education to the faculty. Ultimately, this coupled with the stability of medical education will enhance student learning and advance provider capabilities. The result will have a profound influence on the delivery of healthcare across many health care systems in the future.
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