Use of electronic medical records by physicians and students in academic internal medicine settings.
OBJECTIVE
Electronic medical records (EMRs) have been touted as one method to improve quality and safety in medical care, and their use has recently increased. The purpose of this study is to describe current use of EMRs by medical students at U.S. and Canadian medical schools.


METHODS
In 2006 the authors performed a cross-sectional survey of the Clerkship Directors in Internal Medicine institutional members at U.S. and Canadian academic health centers. Outcome measures included implementation of EHRs, EHR use by students, and the challenges of having students use EMRs.


RESULTS
Of 110 members, 82 (74.5%) responded. Of those 82, 48 (58%) reported using an EMR in the ambulatory setting (excluding Veterans' Affairs medical centers) of their institutions, and only 21 of those 48 (44%) had policies regarding medical student documentation of progress notes in the EMR during the ambulatory internal medicine (IM) clerkship. Schools were dichotomously split; about half (23/48, 48%) required and about half (25/48, 52%) prohibited allowing students to document in the EMR. The programs that prohibited medical students from documenting in the EMR primarily cited billing concerns. Other issues regarding student use of EMRs included student access, faculty concerns, and note quality.


CONCLUSIONS
Use of EMRs by IM clerkship students is common, yet many institutions do not have policies regarding student use. Where policies do exist, they vary, and many prohibit students from using EMRs. Concerns about documentation as it relates to billing seem to be a significant factor in prohibiting students' use of EMRs.
Mintz
Matthew
M
Department of Medicine, The George Washington University School of Medicine, Washington, DC, USA. mmintz@mfa.gwu.edu
Narvarte
Hugo J
HJ
O'Brien
Kevin E
KE
Papp
Klara K
KK
Thomas
Matthew
M
Durning
Steven J
SJ
D002982:Clinical Clerkship; D003430:Cross-Sectional Studies; D004282:Documentation; D057286:Electronic Health Records / Q000706:statistics & numerical data*; D019538:Health Care Surveys; D006801:Humans; D007388:Internal Medicine / Q000193:education / Q000458:organization & administration*; D016134:Organizational Policy; D010820:Physicians / Q000706:statistics & numerical data*; D011216:Practice Management, Medical / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires