Tech-savvy med students fear life without EMRs

Young doctors trained on technology say they feel less capable if they have to go into an environment that does not have it.

By — Posted Dec. 29, 2008

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For the next generation of physicians, information technology is as essential a tool as the stethoscope -- so much so that they are uneasy when they are confronted with practicing in a paper-based environment.

A study published in the December 2008 issue of Academic Medicine, the journal of the Assn. of American Medical Colleges, found that new physicians coming out of high-tech learning environments feel less capable of providing safe patient care when placed in environments with less health information technology.

Kevin Johnson, MD, associate professor and vice chair of Vanderbilt University Medical Center's Dept. of Biomedical Informatics, conducted a survey of Vanderbilt graduates and medical students who were placed in environments with less health IT than where they were trained. Eighty percent of 328 respondents reported "feeling less able to practice safe patient care, to utilize evidence at the point of care, to work efficiently, to share and communicate information, and to work effectively within the local system."

Dr. Johnson said medical students' trepidation about transitioning into a situation where they were more responsible for decision-making was exacerbated by the lack of technology available to help check decisions, provide error alerts and produce a more complete patient record.

One conclusion survey respondents and experts have come to, based on the Vanderbilt findings, is that eventually younger doctors trained with electronic medical records are going to seek residencies and practices that have them. But that was not happening in 2004 and 2005, when the the survey was taken.

For the moment, some will be like fourth-year Vanderbilt medical student Bryan Harris, who said he would become an advocate for technology adoption if he moved into a low-tech environment.

"I can understand how residents and new physicians feel how paper-based systems put them at a disadvantage," said Memory Baker, a managing consultant with Cumberland Consulting Group, a national technology implementation and project management firm based in Brentwood, Tenn. "Most [who come out of school] are looking for hospitals that have already adopted the systems. These providers have grown up with computers and the Internet and expect to practice medicine in this way, too."

In the interim, the study, as well as other schools' own experience with medical students leaving for lower-tech environments, has prompted many schools to adopt low-tech training as part of their curricula so their students can adapt more easily in those situations. Vanderbilt is in the process of adding some classes on working in paper-based environments, Dr. Johnson said.

"We will make the case that at Vanderbilt we are one of the most wired facilities, and you should know the system of care is different in a lot of other places. You need to pay attention to things like what is the copyright of this book you are using for research. Take paper-based records and focus on rapid retrieval of information that is key to that case," he said.

Baker said most medical students get a taste of several different environments through rotations. She thinks it would be a waste of time for schools intentionally to add paper-based training to the curriculum.

Technology adoption "is the wave of the future. It is inevitable. It's just going to happen. It's easier for them to learn it now," Baker said. "For schools to go back and teach how to work in a paper-based environment would be like me teaching you how to use a typewriter."

The need to know both

John Mahoney, MD, associate dean for medical education at the University of Pittsburgh School of Medicine, said that even in high-tech environments, there is always down time. It could be scheduled down time for maintenance or intervals when the systems are down due to technical problems. Doctors don't stop working when this happens, he said.

Dr. Mahoney said teaching about working in both technology-and paper-based situations helps students form an opinion on the type of environment in which they would like to practice. "All of our medical students are extremely bright, and they can learn by the demonstration of good things and less than optimal things."

The survey found that 78% of the respondents had less IT in the hospital where they ended up after leaving Vanderbilt. Only 23% said availability of technology was important in deciding where to practice.

Still, high-tech environments might have an edge when it comes to recruiting, says C. Peter Waegemann, CEO and president of Boston-based Medical Records Institute.

"Physicians want to use the latest technology. The question is what is the alternative? If there are two options for anyone to go to a hospital and if one has better technology, this is the one that they will favor."

David M. Nestler, MD, in his second year as an attending emergency physician at Mayo Clinic in Rochester, Minn., said he is fortunate that everywhere he has worked has had some level of electronic medical records, although at varying degrees.

He said health IT is one of many factors in choosing where to practice. "But I wanted to make sure that any place I worked had some level of electronic medical records, because I feel it's much easier to obtain medical histories, know what critical medications the patient uses, and get more timely answers and timely results to tests we order if we have some type of electronic system."

The Vanderbilt study found that 24.3% said they agree and 47.1% said they strongly agree that they miss having the availability of an electronic medical record.

Dr. Nestler said that he could work without health IT, but it wouldn't be his preference.

"I would compare it to this: Once you are used to communicating with family by e-mail, it's hard to go back to pen, paper and stamps."

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Better with an EMR?

Researchers at Vanderbilt University Medical Center asked medical students and residents their attitudes toward health information technology. The majority said they felt health IT made them more efficient and increased their ability to practice safely.

How do electronic systems affect your efficiency as a clinician?
More efficient77%
Less efficient11%
No effect10%
No answer2%
How do electronic systems affect your ability to deliver safe care?
Increase safety78%
No effect18%
Decrease safety2%
No answer2%
Total 100%

Source: "Performing Without a Net: Transitioning Away from a Health Information Technology-Rich Training Environment," Academic Medicine, December 2008. The survey, conducted in 2004 and 2005, included 240 residents who graduated from Vanderbilt University Medical Center between 2001 and 2003, and 88 medical students.

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