Refocusing medical education in the EMR era.

There is increasing recognition that medical education should be adapted to address the integration of the electronic medical record (EMR) into medical practice, but how this should occur and the specific educational goals have not been well defined. In this Viewpoint, we offer suggestions for updating the Accreditation Council for Graduate Medical Education (ACGME) competencies to promote optimal integration of the EMR into clinical practice, guidance for using data available within the EMR to support and evaluate the achievement of ACGME milestones, and specific steps that individual institutions can take to support this evolution in medical education. Introduction of the EMR is greatly changing the practice of medicine, bringing the benefits of increased access to data, automated clinical decision support, and opportunities for enhanced communication among physicians and with patients. As with many new technologies, the introduction of the EMR has also introduced a wide range of unintended negative consequences. A recent commentary by a ward attending at a major academic medical center described how his trainees held rounds in a secluded work room and were overly focused on the patients’ data in the EMR, often failing to incorporate significant information from the physical examination and interactions with the patient into their assessments.1 Others have noted examples of clinicians’ attention to the computer disrupting the patientphysician relationship in the pediatric examination room, to poignant effect.2 Trainees may use EMR functionality to copy large amounts of data into their progress notes, making them difficult to read and understand.3 Furthermore, clinicians are susceptible to automation bias, the tendency to place too much trust in decision support systems without recognizing the limitations of such systems.4 Given these examples of poor integration of the EMR into clinical practice, as well as the unrealized potential for the EMR to enhance medical education, it is important to examine the effect of the EMR on each of the core competencies and the role it may play in supporting the achievement of educational milestones. The medical education community has recognized that stakeholders expect physicians to use health information technology to optimize both individual and population health. The 2013 ACGME common program requirements list use of information technology as one of the competencies under practice-based learning and improvement.5 But information technology significantly affects all aspects of medical practice and therefore relates to all ACGME core competencies.6 Competency in use of the EMR should not be a goal but instead integrated into each aspect of medical practice as a tool for helping trainees achieve the 6 core competencies. For example, physician training should explicitly address and provide feedback on trainees’ ability to balance engagement with the patient and the EMR to both strengthen the patient-physician relationship and promote highly reliable patient care through accurate documentation and prudent use of clinical decision support. Communication subcompetencies should evolve to include skills for appropriately identifying and using online media such as e-mail, patient portals, and evolving mobile technologies to maintain and enhance the patient-physician relationship between office visits. As part of practice-based learning and improvement, trainees should be taught to access reports from the EMR that show their patterns of patient management for patients with specific diseases and enable the trainees to identify for themselves possible areas for practice improvement. The Table provides additional examples of potential EMR-related subcompetencies. Although this table is structured around graduate medical education core competencies, many of the lessons about optimal integration of the EMR into patient care can and should start with medical students. Emphasizing the key supportive role that technology can play in each of the core competencies should help trainees maintain the patient as the focus of attention and appropriately position the EMR as a tool to support the core mission of patient care. In addition to introducing new required skills and associated training requirements, the EMR provides new tools that can be harnessed to help achieve and evaluate previously identified milestones. The routine collection of electronic data enables the production of reports to track trainees’ experience with various types of patients, documentation of procedures, compliance with best practice guidelines in management of patients with specific diseases (eg, adequate blood pressure control in patients with hypertension), and quality of documentation of key patient information such as medication and problem lists. Specific clinical decision support tools can be developed to directly address knowledge gaps,7 and reports of alerts can be used to help identify such gaps. The Table summarizes medical education tools that should be available within a highly functional EMR. Individual academic institutions can take several steps to enable these suggestions. First, institutions can create simulated EMR environments for simulationbased training and testing of medical students and residents. In these environments, trainees can gather information from a mock patient record, be coached on how to best enter new information, and receive feedback on their ability to balance engagement with the patient and electronic documentation of the encounter. Second, academic medical centers can routinely allow medical students access to the EMR during their clinical rotations for documentation and order entry.8 Although students take care of relatively few patients, the opportuVIEWPOINT