Statement on Medical Student Use of the Electronic Health Record

The American College of Surgeons (ACS) Board of Governors Surgical Training Workgroup developed the following Statement on Medical Student Use of the Electronic Health Record. The ACS Board of Regents approved the statement at its February 2018 meeting in Chicago, IL.

Six years after the 2012 publication of the collaborative statement on medical student documentation in electronic health records (EHR) by the Alliance for Clinical Education, medical students at most institutions continue to learn under a variety of rules and restrictions regarding their access to the EHR, even between institutions affiliated with the same medical school.¹ A compliance advisory published by the Association of American Medical Colleges (AAMC) in 2014 emphasized concern about the misuse of medical student notes in the EHR and risk mitigation.²

The AAMC advisory notes two of the core entrustable professional activities for entering residency that relate to use of the EHR: “Enter and discuss orders and prescriptions” and “Document a clinical encounter in the medical record.”³ Yet the advisory document’s emphasis on risk reflects a general concern about medical student access to patient medical records that was not present prior to the advent of the EHR. While acknowledging the differences in the opportunity to misuse entries, especially in the area of billing, in an electronic versus a paper-based medical record, it is also important to acknowledge that learning appropriate EHR documentation processes is a primary component of medical student education.

In 2015, the American Medical Association (AMA) announced its support for medical student access to the EHR, noting that “we must close the gaps that currently exist between how medical students are educated and how health care is delivered now and in the future.”⁴ AMA policy encourages accrediting bodies to work with medical schools and residency and fellowship training programs to educate students about EHRs, as well as support the medical student experience in EHR documentation and order writing with appropriate supervision.

Although they are not licensed providers, medical students are important members of the health care team whose training, as noted in a statement by the American Academy of Family Physicians, “depends on [their] ability to access relevant information available to other members of the care team, to document findings, to communicate with other providers, and to reflect independent clinical reasoning.”⁵ By restricting access or deleting medical student notes on patient discharge, student entries become parallel “shadow” records that are not part of the patient’s medical record. This restricted access also doesn’t provide students the ability to write orders and limits exposure to clinical decision protocols in EHR software, which is not only detrimental to student education, but also marginalizes the medical student’s importance to the health care team.

The ACS, the Association of Program Directors in Surgery, and the Association for Surgical Education each supports the following principles regarding medical student participation in the EHR:

• Medical students should have unrestricted access to the EHR of patients in whose care they are participating.
• Medical students’ documentation in the EHR carried out with appropriate supervision, while not used for billing, should remain a part of the patient’s permanent record.
• Medical students, with appropriate supervision and counter-signature, should be allowed to enter orders and participate in the use of clinical decision protocols.
• Medical schools should continue to develop curricula to address the education of medical students about the use and potential misuse of the EHR. As an educational tool, those responsible for medical student education should provide feedback to students about their written documentation in the EHR.
• EHR software developers must actively consider medical student education and consult with medical education experts when designing EHRs.

The ACS supports the Alliance for Clinical Education’s call for the Liaison Committee for Medical Education (LCME) to use stronger language in its educational directives standards to ensure compliance with EHR education principles, and urges the LCME to ensure compliance with the recommendations outlined in this statement for medical student use of the EHR by all medical education institutions.¹

References

1. Hammoud MM, Dalrymple JL, Christner JG, et al. Medical student documentation in electronic health records: A collaborative statement from the Alliance for Clinical Education. Teach Learn Med. 2012;24(3):257-266.
2. Association of American Medical Colleges. Compliance advisory: Electronic health records (EHRs) in academic health centers. Allowing medical student documentation in the electronic health record. 2014. Available at: www.aamc.org/em/aamc/compliance_advisory.pdf. Accessed February 16, 2018.
3. Association of American Medical Colleges. The core entrustable professional activities for entering residency. Available at: www.aamc.org/cepaer. Accessed February 12, 2018.
4. American Medical Association, AMA News Room. AMA supports medical student access to electronic health records. June 8, 2015. Available at: www.ama-assn.org/ama-supports-medical-student-access-electronic-health-records. Accessed February 15, 2018.
5. American Academy of Family Physicians. Medical student access to electronic medical record (EMR). 2012. Available at: www.aafp.org/about/policies/all/medical-student.html. Accessed February 12, 2018.