5 Things You Need to Know About Electronic Health Records in Medical Education - Part 1


by SimGHOSTS Board member, Dr. Scott Crawford 


Graphical representation of electronic health record implementation within U.S. hospital systems.[i]


The Background

Electronic health records (EHRs), also called electronic medical records (EMRs), began to be utilized as a database system as far back as the 1960s with the use of a Problem Oriented Medical Record attributed to Larry Weed. The first true EHR is attributed to the Regenstrief Institute in 1972. [ii]  Widespread adoption of EHRs however was still not possible until the cost decline and increased availability of personal computers in the 1990s. Despite the availability of the technology and advancement of these systems over the past 30 years, utilization of EHR systems is still only now becoming ubiquitous. Nine out of 10 clinicians have a certified EHR system as of October 2018. [iii]


The Drive

While the thought of using a paper-based system to those in current generations is unimaginable, widespread adoption has been slow and is still in the process of implementation across even large healthcare institutions. A driver behind the development and adoption of EHRs was from a governmental mandate by the Centers for Medicare & Medicaid Services. This mandate is pushing for a set of goals for EHR implementation known as “Meaningful Use.” The following five outcome-based goals are the basis for any EHR implementation: [iv]

  1. Improving quality, safety, efficiency, and reducing health disparities
  2. Engage patients and families in their health
  3. Improve care coordination
  4. Improve population and public health
  5. Ensure adequate privacy and security protection for personal health information

While these concepts seem intuitive and integral to computer-based utilization they have not been so easily adopted. Although a cultural shift has occurred within the last generation to require electronic interaction across all business sectors, this has not been integrated into medical training and goes against the humanistic patient care interactions taught in medical school.

Atul Gawande, a surgeon, public health researcher, and writer may be best known in the world of healthcare simulation and patient safety for his book The Checklist Manifesto. This work advocated for and popularized the concept of fixing system processes to improve medical outcomes by using checklists and empowering team communication. Dr. Gawande recently spoke out about the state of electronic health records in an article published in the November 12, 2018 issue of the New Yorker. This exposé titled “The Upgrade” describes the experience of receiving training on the use of an electronic health record and its impact on healthcare delivery among a variety of specialties. He describes the effect of separating the human interaction with patients and its toll on job satisfaction and burnout. Many of the activities previously performed by medical assistants has become the responsibility of the physician. The ability to generate immense amounts of data and reports actually obfuscated the simple and critical information previously written in short hand written notes. This information overload may actually increase the time to find and act on information, not decreased it.



Electronic health records are not going away, but many physicians have negative views about them. Dr. Gawande describes a greater impact of EHR documentation on primary care specialties where patient interactions predominate over procedural specialties such as surgery. Within the emergency department it has been found that a physician is likely to click over 4,000 times on each 10 hour shift. [v]  In another study, it was found that it took over 13 minutes on average to document a patient interaction in the Cerner EHR by emergency resident physicians in a simulation training session.[vi]  This did not including time spent talking to or physically examining a patient. A method to improve this system process has included the use of medical scribes. These are often non-medically trained individuals who follow a physician around on shift and write down information about the patient’s history and physical examination thus allowing increased focus on the patient interaction. A new extreme form of this reported by Dr. Gawande in his article “The Upgrade” included a discussion of a new company, IKS Health, that is offering audio recordings of office visits that are transmitted to physicians in Mumbai India who will review and transcribe the encounter. This company proports to offer increased accuracy and maximized billing.


The Simulation View

Given the importance and prevalence of EHRs and their impact on the delivery of care it is imperative that medical training integrate these tools into the training environment. Simulation is arguably the most effective way to do this. [vii] . Many training tools have been suggested to accommodate this need. Use of a training environment for an existing EHR may be useful as it provides direct experience with a system that will be encountered in practice. Although this may be an important consideration it was found that years of experience overall had a greater effect on speed of documentation even compared to the introduction of a new EHR interface. [viii] This gives further support for the need to provide training on the effective use of EHR and to introduce learners to the systems and processes involved.

Please check back in for part 2 of this blog for a discussion about issues and thoughts on how to actually find and implement an EHR into your simulation training program.

[i] https://dashboard.healthit.gov/quickstats/pages/2015-edition-market-readiness-hospitals-clinicians.php#hospitals

[ii] https://elearning.scranton.edu/resource/health-human-services/emr_the-progress-to-100-percent-electronic-medical-records

[iii] https://dashboard.healthit.gov/quickstats/pages/2015-edition-market-readiness-hospitals-clinicians.php#hospitals

[iv] https://www.cdc.gov/ehrmeaningfuluse/introduction.html

[v] Hill Jr, R. G., Sears, L. M., & Melanson, S. W. (2013). 4000 clicks: a productivity analysis of electronic medical records in a community hospital ED. The American journal of emergency medicine, 31(11), 1591-1594.

[vi] Crawford, S., Kushner, I., Wells, R. & Monks, S., (2018) Electronic Health Record Documentation Times Among Emergency Medicine Trainees. Perspectives in Health Information Management

[vii] Wilbanks, B. A., Watts, P. I., & Epps, C. A. (2018). Electronic Health Records in Simulation Education: Literature Review and Synthesis. Simulation in Healthcare, 13(4), 261-267.

[viii] Crawford, S., Kushner, I., Wells, R. & Monks, S., (2018) Electronic Health Record Documentation Times Among Emergency Medicine Trainees. Perspectives in Health Information Management