title: Use of electronic medical records by physicians and students in academic internal medicine settings.
abstract: 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.
authors: Department of Medicine, The George Washington University School of Medicine, Washington, DC, USA. mmintz@mfa.gwu.edu
authors: Matthew
authors: M
authors: Mintz
authors: Hugo J
authors: HJ
authors: Narvarte
authors: Kevin E
authors: KE
authors: O'Brien
authors: Klara K
authors: KK
authors: Papp
authors: Matthew
authors: M
authors: Thomas
authors: Steven J
authors: SJ
authors: Durning
mesh_terms: 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