Training in the Era of EHR: Examining the Experience of Medical Student Documentation in the Ambulatory Care Setting

This article was migrated. The article was marked as recommended. Purpose: Documenting clinical encounters in the electronic health record has become an important component of medical student training. Reflecting this trend, recent rule changes by the Centers for Medicare and Medicaid services now permit billing for medical student notes. We sought to investigate the educational value of student note-writing following implementation of these changes. Methods: We surveyed medical students at a private research university who participated in longitudinal ambulatory care experiences. Survey questions assessed the incorporation of student note-writing into clinic workflow, as well as the benefits and disadvantages of note-writing. Results: Thirty-six students completed the survey. A majority of students perceived benefits in regards to residency preparedness, engagement with the clinical team, and clinical reasoning ability as a result of writing notes in clinic. While some students reported seeing fewer patients as a result of note-writing, most felt that use of the electronic health record did not negatively impact patient interaction. Barriers cited included a lack of knowledge regarding billing requirements and preceptor apprehension toward student note-writing. Conclusion: The results of this study indicate that student note-writing continues to be a valuable part of medical training following recent billing changes. Our results also identify areas for improvement, including clarifying billing requirements and assuaging preceptor concerns.


Introduction
Documentation in the electronic health record (EHR) has become a prominent part of outpatient physician practice, with recent studies suggesting that physicians spend over one-half of their workday interacting with the EHR (Arndt et al., 2017;Young et al., 2018).As a result, the Association of American Medical Colleges lists the ability to document a clinical encounter among its Core Entrustable Professional Activities for Entering Residency, and the American Medical Association has similarly adopted policies encouraging EHR training in medical school and residency.In 2018, the Centers for Medicare and Medicaid Services revised their claims processing manual to allow medical student notes to be used for billing purposes, provided the information is verified and attested to by a supervising physician.With this seismic shift in the role of the medical student, we sought to investigate the educational impact of student EHR use in the ambulatory care setting.Specifically, we aimed to examine 1) how student note-writing is incorporated into clinic workflow, 2) benefits derived from student use of the EHR, and 3) potential areas for improvement in regards to the documentation experience.

Methods
We conducted a survey of medical students at the Duke University School of Medicine (DuSoM) in Durham, North Carolina (USA) who participated in a longitudinal ambulatory care experience during the 2018-2019 academic year, the first year in which DuSoM implemented billing for student notes.Students at Duke have 3 opportunities to participate in longitudinal ambulatory care experiences: Primary Care Leadership Track (PCLT), Longitudinal Integrated Clerkship (LIC), and Continuity Clinic (CC).PCLT and LIC are ambulatory care-focused clerkship tracks which serve as an alternative to the traditional 2 nd year clerkship training; students in these programs spend 7-8 months of the year rotating through various primary care and subspecialty clinics.CC is an opportunity for 3 rd year (research year) medical students to spend one half-day per week with a preceptor of their choice for 8-9 months.In September of 2019, a total of 91 students were emailed an invitation to complete a 19-question survey designed by the authors, which included Likert scale and free-response questions.Survey data was collected and managed using REDCap electronic data capture tools hosted at DuSoM (Harris et al., 2009).This study was granted exempt status by the DuSoM IRB.
Results/Analysis 36 students completed the survey (40% response rate).56% of respondents worked in primary care clinics with the remainder in subspecialty clinics.A majority of students saw 3-4 patients per half-day (69%) and wrote 3-4 notes (72%) (Figure 1A-B).Almost all (92%) students reported that their notes were used for billing.Major uses of the EHR in the patient room included documenting the HPI (47%) and reviewing pertinent labs (69%) and imaging (47%) (Figure 1C).Most students received direct feedback from their preceptor on the same day (42%) or during the following clinic session (42%).Many students also received indirect feedback by reviewing preceptor attestations (64%) (Figure 1D).
In terms of perceived benefits, nearly all respondents reported feeling more prepared for residency (94% strongly or slightly agree) and more integrated into the clinic workflow (92%) as a result of writing notes (Figure 2A-B).94% of students also felt their clinical reasoning skills were improved (Figure 2C).One student explained, "writing notes in the clinic setting where there are time constraints, I learned to write more quickly and effectively."Another described how note-writing "helped to consolidate my thinking and assessment of patients in a comprehensive, organized fashion." Regarding potential disadvantages, the majority of respondents did not feel that note-writing detracted from patient interactions (67% slightly or strongly disagree), though some felt it reduced the number of patients seen (44% slightly or strongly agree) (Figure 2D-E).Most students did not feel note-writing to be a significant time burden outside of clinic (64% slightly or strongly disagree) (Figure 2F).Other difficulties reported included lack of familiarity with billing requirements and preceptor apprehension toward student note-writing.

Discussion
As medical student notes now become utilized for billing, one potential concern is that the business aspects of notewriting might overshadow the educational benefits.Encouragingly, at our institution, the student response to EHR use in the outpatient setting following these billing changes has been overwhelmingly positive, with a vast majority of students perceiving benefits in regards to residency preparedness, engagement with the clinical team, and clinical reasoning ability.Although we did not investigate the specific aspects of student documentation that correlate with these benefits, it stands to reason that by encouraging students to clearly and concisely articulate patient histories, assessments, and plans, students learn to improve their communication and medical decision-making ability.As preceptors are now mandated to review student notes prior to attesting, the frequency of feedback has also likely increased, further enhancing the learning experience.Finally, because student notes are now being used for billing, as opposed to serving as redundant documentation, students may feel more valued as a member on the medical team.
Reassuringly, and in contrast to older studies (Rouf, Chumley and Dobbie, 2008), most students did not feel that use of the EHR adversely affected their interactions with patients, which may reflect increasing familiarity with and acceptance of the EHR by students and physicians alike.While some students reported seeing fewer patients as a result of note-writing, the learning derived from each patient may well have been greater.A notable minority of students also reported spending significant amounts of time outside clinic completing notes; as such, preceptors should take care in ensuring that notewriting does not become an undue burden on students.Finally, several students reported a lack of knowledge concerning billing requirements, underscoring a need for additional formalized training; at DuSoM, current training consists of viewing a brief 30-minute video tutorial.
Further study is needed to determine whether preceptors share similarly positive views.A prior nationwide survey of clerkship directors found more neutral opinions toward student EHR use (Hammoud et al., 2012), with some raising concerns regarding the "copy and paste" nature of notes, which might stifle students' ability to think for themselves; such practices are known to be widespread among students and physicians (Heiman et al., 2014).Indeed, in our study, several students reported preceptor apprehension toward student note-writing.Identifying and remedying the specific concerns of these preceptors should be a priority moving forward.

Conclusion
In this survey of medical students at a major tertiary care center in the United States, we demonstrate that documentation in the EHR remains an important aspect of medical student education following the implementation of billing for medical student notes.Students reported improvements in residency preparedness, clinical reasoning, and integration into the clinical team as a result of note-writing, without adverse effects on patient interaction.Areas for improvement include clarifying billing requirements and overcoming preceptor apprehension toward student note-writing, and future research should focus on how best to optimize training and implementation, with input from all stakeholders.

Take Home Messages
Medical student note-writing was well-received by students, with perceived benefits in regards to residency preparedness, integration into the clinical workflow, and clinical reasoning ability.
Medical students did not feel that note-writing adversely affected patient interactions.
Areas for improvement include clarifying billing requirements and overcoming preceptor apprehension toward student note-writing.
Future research should investigate preceptor attitudes toward student note-writing.a useful contribution.It is good to note that students felt this experience would prepare them for residency and not surprising that preceptors were more apprehensive.Interesting that because preceptors had to review the student entries the perhaps unintended (positive) consequence was that the students got more feedback.As a UK physician to understand that one could bill for medical student entries in the EHR was a learning point for me.

Figure 1 .
Figure 1.Integration of student documentation into clinic workflow (N = 36).Note for panels C-D, participants could select more than 1 response.
Charlton Tsai, Julia Bellantoni, and Omar Martinez-Uribe are medical students at the Duke University School of Medicine (Durham, NC, USA).Peyser, MD is a Professor of Medicine in the Division of General Internal Medicine at the Duke University School of Medicine (Durham, NC, USA).He also leads the school's Primary Care Leadership Track.