Students overlook information in the electronic health record

Context and setting Electronic health records (EHRs) are being implemented in medical systems across the world; however, in the USA, the availability of EHRs remains highly variable across settings. Although increased use of EHRs is promoted in the USA as a way to improve patient safety and reduce costs, introducing EHRs into new health care settings can be challenging and sometimes results in clinician errors. Why the idea was necessary Studies have shown that data retrieval errors are common with EHRs and that clinicians are challenged to communicate effectively while accessing the EHR in the presence of the patient. Communication with patients while using an EHR is not an area of focus during routine clinical or EHR training. This pilot study sought to determine whether medical students who had undergone routine EHR training and were familiar with the EHR would: (i) successfully retrieve critical information embedded in the EHR, and (ii) maintain a patient-centred approach to communication in the presence of an EHR, in the context of a simulated patient (SP) encounter. What was done A sample of 197 medical students encountered an SP EHR challenge during a six-station summative clinical skills examination at the beginning of their final year (Year 4). These students had trained on the medical centre’s EHR system at the start of Year 3 and had worked with EHRs during their Year 3 clinical rotations. The SP portrayed a 43-year-old man admitted for chemotherapy, now complaining of acute chest pain. A mock patient EHR was created within the medical centre’s EHR training environment and made accessible during the encounter. The EHR included basic patient information as well as documentation of: (i) myocardial infarction (MI) during a previous admission, and (ii) thrombocytopenia; the patient was not aware of either finding. The student had 15 minutes in which to conduct a focused history and physical examination and to explore the patient’s EHR using a computer terminal in the examination room. After the encounter, the student documented his or her findings, differential diagnosis and plan, and the SP completed a data-gathering checklist and a communication scale. Evaluation of results and impact All students accessed the EHR; 174 (88%) explained to the patient why they were using the computer. Only 36 (18%) asked the patient about the prior MI. In the post-encounter note, 37 students (19%) documented a prior history of an MI and 45 (23%) noted the thrombocytopenia. Only 12 students (6%) documented both thrombocytopenia and MI. The mean patient-centred communication score was 84% (standard deviation 7%), which was equivalent to scores on other SP stations. Medical students with a year of EHR experience maintained patient-centred communication while using the EHR, but failed to identify critical clinical information embedded in it. Retrieval errors in students may reflect a variety of causes, ranging from ineffective EHR searching techniques to developmental challenges, such as an inability to focus on the EHR while interacting with a patient (distraction error), or inexpert clinical reasoning, resulting in poorly focused searches for relevant information. Future studies might investigate these possibilities and pilot interventions to help students explore the EHR with greater success.