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Review Article | Open Access
Volume 2019 |Article ID 7341841 | 9 pages | https://doi.org/10.1155/2019/7341841
Utilisation of Electronic Health Records for

Public Health in Asia: A Review of Success
Factors and Potential Challenges
Lesley Dornan,1 Kanokporn Pinyopornpanish,1 Wichuda Jiraporncharoen,1 Ahmar Hashmi,1 Nisachol
Dejkriengkraikul,1 and Chaisiri Angkurawaranon 1
Show more
Academic Editor: Lucia Lopalco
Received01 Mar 2019
Revised10 Jun 2019
Accepted27 Jun 2019
Published08 Jul 2019
Abstract
Introduction. Electronic health records offer a valuable resource to improve health surveillance
and evaluation as well as informing clinical decision making. They have been introduced in
many different settings, including low- and middle-income countries, yet little is known of the
progress and effectiveness of similar information systems within Asia. This study examines the
implementation of EHR systems for use at a population health level in Asia and to identify their
current role within public health, key success factors, and potential barriers in
implementation. Material and Methods. A systematic search process was implemented. Five
databases were searched with MeSH key terms and Boolean phrases. Articles selected for this
review were based on hospital provider electronic records with a component of implementation,
utilisation, or evaluation for health systems or at least beyond direct patient care. A proposed
analytic framework considered three interactive components: the content, the process, and the
context. Results. Thirty-two articles were included in the review. Evidence suggests that benefits
are significant but identifying and addressing potential challenges are critical for success. A
comprehensive preparation process is necessary to implement an effective and flexible
system. Discussion. Electronic health records implemented for public health can allow the
identification of disease patterns, seasonality, and global trends as well as risks to vulnerable
populations. Addressing implementation challenges will facilitate the development and efficacy
of public health initiatives in Asia to identify current health needs and mitigate future risks.
1. Introduction
The implementation of electronic health records (EHR) in medical practice has seen a significant
increase in recent years. EHR systems present a valuable opportunity to improve health
surveillance and evaluate service provision potentially leading to improvements in the
management and the promotion of public health [1]. Findings suggest that most clinicians use the
information available to examine the overall condition of the patient and inform clinical decision
making and for shared communication across patient care teams [2]. By June 2013, three-
quarters of office-based physicians in the United States had incorporated EHR into their
practices [3]. The purchase and implementation of EHR systems are a significant investment of
resources but the effectiveness of the approach also depends on the physicians’ willingness to
adopt the new technology into everyday practices [4].
Primary clinical care and population health have complementary goals of improving the health of
patients and communities but seldom create effective partnerships to increase the wellness of
both the patient and populations [5–7]. Changing healthcare goals require flexible systems. In the
current financial climate, it may be argued that population health requires the proactive
application of strategies and interventions to defined groups of individuals to improve the health
of those individuals at the lowest cost [8]. Researchers have been using EHR systems to gather
rich data in areas such as heart disease, smoking, and the delivery of preventative services
[9, 10]. EHR have allowed for the tracking and consolidation of vaccination programmes,
enabling improved design and sustainability of effective immunisation strategies [11]. For most
healthcare providers, EHR provide easy access to patient information, and although the value of
EHR in clinical settings is not to be underestimated, the technological requirements for health
information are ever-changing [12]. For example, in the United States, the introduction of the
Patient Protection and Affordable Care Act (ACA) was predicted to radically change the
functions of health departments, requiring new developments in health technology in an effort to
track those changes and potentially creating competitive pressures [13]. Data sharing—in
keeping pace with policy changes—brings a new level of complexity. A recent international
comparative study of the use of electronic medical records (EMR) for research found that the
procedures for information governance, levels of adoption, and required time and ease of
obtaining consent varied significantly across the countries [14]. Existing systems for collecting
and analysing data frequently lack coordination and effective interconnectedness within the
departmental and hospital systems, creating challenges in the analysis and interpretation of
patient outcomes, particularly as it pertains to a specific population or community [15–17]. The
ability to provide effective and preventative care management will require a more sophisticated
and expansive level of data collection on selected populations that currently outstrips the
capacity of most healthcare organizations [18].
However, the gap between medical demands and supply also varies significantly between high-
and low- and middle-income countries (HIC; LMIC) [17]. The challenge facing public health
practitioners is that as EHR and EHR systems progress, the gap between high- and low- and
middle-income countries widens, increasing the risk that the most vulnerable populations are left
further behind in the provision of effective healthcare and public health strategies. While
developed countries such as the United States and United Kingdom have led the way in the
implementation of EHR, less is known of the progress and effectiveness of similar information
systems within Asia. Understanding the progress that has been made and the processes by which
EHR is adapted to different settings in Asia allows practitioners an opportunity to learn valuable
lessons and implement effective systems to promote and improve individual and community
health.
Therefore, this review examines the implementation of EHR systems for use at a population
health level in Asia and to identify their current role within public health, key success factors,
and potential barriers in implementation.
2. Material and Methods
2.1. Analytical Framework
The analytical framework for this review was adapted from studies examining the impact of
EHR in medical office settings and a conceptual framework for data visualisation using EHR
[19, 20]. In order to examine the content for utilisation in public health, one needs to consider it
along with two other interactive components: the context and process [19]. The context can be
further classified as internal and external. For the purposes of this review, the internal context
refers to the structure, culture, and resources of the organization utilising the EHR. The external
context refers to the larger socioeconomic and political environment in which the organisation
operates. For this review, “process” is classified into the input process and output process [20].
The input process considers all factors related to data entry, which may consider cultural factors
or available resources. Output process considers all factors related to data visualisation and its
output (Figure 1).
Figure 1
Analytical framework exploring the role of electronic health records in public health in Asia.
2.2. Search Strategy
A systematic search process was completed to identify relevant articles related to utilisation of
EHR for public health in Asia. Specifically, articles to be included must fulfil two key
components:(1)The article must(a)be based on hospital/service provider electronic records
AND(b)have a component of implementation, utilisation, OR evaluation(2)The article must be
related to public health by fulfilling one of the following criteria:(a)Going beyond direct clinical
or patient care OR(b)Being health systems related
Electronic records or systems not related to public health as well as summary or opinion papers,
abstracts, news articles, and reviews were excluded. Medical Subject Headings (MeSH) were
identified and used as search terms including “information systems,” “database management
systems,” “medical record systems,” “hospital information systems,” “information technology,”
and “software, software design, and software validation.” MeSH keywords fitting outcomes of
interest included “decision making,” “health planning,” “health policy,” “public health,”
“systems integration,” and “organisational culture.” Finally, these terms focused on Asia with
articles published from January 2008 to May 2019. A total of five databases were searched:
CINAHL, EMBASE, Medline, Web of Science, and PubMed.
For each study, we extracted its current content and utilisation in public health and key
information including its aim, methods, findings, and limitations as identified by the original
authors of the studies (Appendix Table 1). Key success factors and barriers to implementation as
identified by the original authors were extracted. Relevant information from each study was
classified into two key components outlined above: context and process (Appendix Table 2).
2.3. Search Outcomes
Following searches in all the named databases, a total of 465 articles were identified. To ensure
identification of all relevant articles, the initial search focused on all articles including EHR
and/or Asia and/or public health related activities. Specific details have been summarized in
Figure 2. Four researchers (LD, WJ, AH, and CA) performed the abstract reviews and assessed
the full texts. Six researchers (LD, WJ, KP, AH, ND, and CA) were responsible for data
extraction of the included reviews. In addition to following the analytical framework outlined
above, each paper was examined for common themes associated with challenges and good
practice. A thematic analysis as guided by the framework was applied and performed by three
investigators (LD, AH, and CA), with extracted data compiled and analysed using NVivo 12
(QSR International, Doncaster, Victoria, Australia).
Figure 2
Flow chart of studies examining the role of electronic health records in public health in Asia.
3. Results
A total of 32 studies (Figure 2) were included from 15 countries and/or regions, including one
study from multiple cities across Asia, one study reporting from Africa and Asia, and Singapore
(n=6); China (n=4); Iran (n=1); Malaysia (n=3); Thailand (n=3); Indonesia (n=2); Myanmar
(n=2); South Korea (n=2); Taiwan (n=3); India (n=1); Japan (n=1); the Philippines (n=1); and
Vietnam (n=1). The studies included in this review reflected both the complexity of this field of
research and the breadth of practice within the public health discipline. In addition, these studies
come from highly variable contexts with respect to the “maturity” of the electronic systems and
socioeconomic differences as they relate to technological and health systems infrastructure.
Studies reviewed here also occurred in different contexts and at different levels of a health
system, including research across international contexts (n=3); at national levels (n=7); at
provincial or state levels (n=4); across organizations (i.e., nongovernmental organizations; n=2);
at the district, community, or village levels (n=4); and in tertiary care facilities (n=13).
Public health research being carried out within Asia included preparedness for pandemics,
communicable and infectious diseases such as leprosy, sexual health, maternal health, and cancer
(Appendix Table 2). It also incorporated evaluations of systems already in place in urban and/or
rural regions ranging from primary to tertiary care as well as across different health care
providers, such as nongovernmental organizations.
3.1. Role and Benefits of Electronic Health Records to Public Health
It was clear from several of the studies that—while recognizing difficulties in integration and
development of EHR within Asia—there were also significant benefits. The benefits of
leveraging electronic systems focused primarily on disease-, patient-, or situation-specific
interventions as well as improvement of “systems-level” functioning, or both (Figure 3). A key
element of public health in Asia is the utilisation of EHR for disease surveillance and monitoring
systems. EHR have the ability to help identify and predict seasonal outbreaks and high risk areas
and prevent infections or diseases as well as assisting in the coordination of demographic
information and community profiles, which are invaluable in the current public health climate.
However, concerns about confidentiality were noted [21–26]. Another key utilisation of EHR is
their implementation to improve health care systems. The identification of risk factors through
electronic health systems allows health professionals to recognize and track them over time,
helping both in clinical decision making, planning for outbreaks, and identifying transmission of
diseases [27, 28]. For example, a study of cancer patients allowed the tracking and analysis of
diagnostic patterns, the number of investigations completed by physicians, and transfer of
information as well as factors for the diagnoses [29].
Figure 3
Role and benefits of electronic health records to public health in Asia.
3.2. Success Factors and Potential Barriers
3.2.1. Context
Of the studies reviewed, 26 of 32 noted external contextual factors, from all countries
represented across all studies. Of all studies, 17 commented on internal contextual factors within
the system the study was conducted; and 15 studies had commentary on both external and
internal contexts. External contextual challenges often related to the wider infrastructure, such as
variability in contexts relating to centralisation of information and human resource and
information and communication technology (ICT) constraints [21, 25, 26, 30–34]. For example,
Kimura et al. observed healthcare system issues arising during the implementation of EHR for
intractable diseases in Japan [30], where a complex, decentralized administrative system and
language barriers related to the Japanese script required country-specific tools and expertise to
overcome data entry challenges. A study from Taiwan explored ways to overcome the challenge
of data exchange between hospitals [34]. A lack of funds for healthcare technology as well as a
lack of public health government initiatives and a fragmented healthcare system also created
challenges in health care provision [21, 33]. Access to mobile networks and web-based
technologies demonstrated the variability in “maturity” of the different contexts, where important
constraints particular to LMIC contexts were observed in three studies conducted in India,
Myanmar, and China. In these contexts, inconsistent power supplies led to difficulties in EHR
system implementation and intermittent internet availability constrained the development of
web-based services [21–23]. However, a number of studies were able to leverage mobile
networks and web-based platforms to wider benefit [24, 35–38]. Studies reported different levels
of maturity vis-à-vis EMR systems reach within a given context [27, 29, 39–46]. However,
studies conducted during earlier stages of EMR introduction documented progression from paper
to electronic documentation as particularly time-consuming and requiring significant human
resource allocation [21, 22, 47]. In rural China, for example, data entry was required to transfer
data from paper-based systems to web-based forms by on-site staff or through instructions from
mobile phone conversations, landlines, or fax, which carried a higher risk of human error
requiring data entry supervision [22].
Internal contextual factors were often couched within the larger, external context, but specifically
related to an organisation’s local access to ICT support [27, 47]; human resource needs in
transitioning from paper to electronic records [23, 28, 31, 38]; local access to existing systems at
higher levels, i.e., national/provincial/state infrastructure, web-based platforms [35, 39, 43, 45];
and locally existing (or lack of) EMR systems [29, 41, 45, 46, 48–50].
3.2.2. EHR Input Process
All studies (n=32) reported elements of the EHR input process. Several of the studies highlighted
the importance of internal organisational cultures and the impact this had upon the EHR input
process. Key areas of intervention or identifying potential EMR inputs was related to conceptual
approaches [37, 46] or cultural considerations [27, 30, 51]. Infrastructural considerations related
to hardware or workforce training were noted in studies by Herbst et al. and Sutiono et al.
[32, 37]. Specifically with regard to the workforce, many studies assessed end-user (or potential
users) evaluation of previously implemented or planned ICT interventions
[23, 31, 38, 42, 43, 45, 46, 48, 50]. Multiple studies highlighted interventions based around
software, web-based platforms, or mobile technologies [21, 24, 25, 36, 37, 46]. Specific ICT
interventions incorporated elements of automation [28, 30, 44, 49, 52]; data standardization or
quality control [17, 22, 24, 31–33, 35, 47]; data visualisations or data mapping
[21, 35, 37, 38, 44, 45, 49]; and data analysis tools [22, 24, 29, 39–41, 46]. Finally, some studies
also specifically mentioned measures protecting patient information [17, 33, 36, 38].
3.2.3. EMR Output Process
Most studies (n=31) reported EMR outputs for the various ICT interventions covered. Disease-
specific recommendations were made in three studies from China [27], Indonesia [25], and
Taiwan [52]. Workforce and human resource considerations were reported in several studies
[23, 42–45, 50], particularly with regard to transition from older electronic and computerized
systems to more technical interfaces and tracking systems. Several studies highlighted important
recommendations related to outputs and visualisations such as standardization of unique patient
identifiers; modular, flexible information systems structures; bilingual and user-friendly
interfaces; and ease of uploading and sharing important clinical information based on the
authors’ findings [26, 31, 44, 47, 48]. Clinical and health dashboards constituted a common
intervention [22, 33, 35, 37, 40, 46, 52], with additional studies also incorporating automated
alert systems [28, 29, 45], and a number of studies focused on data analysis and public health
reporting [21, 24, 25, 30, 32, 36, 38, 40, 41, 52]. Finally, studies in Taiwan [27]; Africa and Asia
[32]; South Korea [53]; and China [47] documented the creation of online tools and data
repositories as a result of their respective interventions.
4. Discussion
This review summarises efforts to implement EHR systems for use in different capacities in
Asia. We highlight 32 studies conducted in 15 countries with two studies comparing sites across
countries in Asia. This review compiles information on EHR systems across a diversity of
country and healthcare contexts including LMIC settings, varying organisational structures and
different levels within health systems. It represents varied technological infrastructure and EHR
system “maturity” and their resultant human resource needs.
This review highlights challenges that exist in utilising EHR systems to improve public health in
Asia. Highly variable infrastructural constraints related to supporting EHR systems (e.g., reliable
electricity and mobile technologies) add a layer of complexity in terms of system requirements
and the level of EHR sophistication that can be supported. Therefore, within a given context,
risks may be inherent in introduction of EHR for use in public health. Barriers of note relate to
the organisational culture and highlight the need for well-trained technological support in
healthcare settings in Asia. Hospitals frequently find that delays in EHR implementation can
occur due to the nonadoption of the system by physicians and health professionals [54]. A study
in Iran identified that organisational barriers in the implementation of EHR included a lack of
efficient planning, a lack of skilled manpower, and limitations in information technology training
for healthcare professionals [55]. Given these concerns, ways forward would include a
priori evaluations of organisational cultures and settings where EHR systems are introduced that
assess the required technical support; explore staff awareness, skill levels, and willingness to
utilise new technologies; and evaluate current data collection methods in an effort to stymie early
barriers to implementation. Addressing staff concerns of using new ICT interventions prior to
implementation can prevent reluctance to adopting new practices, as well as allaying concerns
regarding the management of and workloads associated with the new system. Such explorations
may help with implementation within a given health system or across an organisation, allowing a
more tailored approach to EHR interventions that are contextualised based on specific
externalities that may pose barriers but cannot be effected at the level of implementation.
In addition to technological and practical risks, studies also highlighted ethical concerns in
introducing EHR interventions. As EHR become more commonplace in LMIC settings, on-going
debates in HIC regarding patient confidentiality, privacy, informed consent, and data security
remain salient in resource-poor contexts [56]. This reflects that, globally, EHR systems are
developing at a rapid rate and in a manner that may outstrip the ability of LMIC contexts to
manage such concerns arising from EHR implementation. Many smaller healthcare providers
and individual hospitals are still looking to implement effective EHR systems or convert from
disparate applications provided by multiple suppliers to an effective, unified system [57].
Merging such systems in LMIC requires careful consideration of patient-provider interactions
that include cultural appropriateness, ethnic health disparities, low levels of patient literacy,
linguistic challenges, and necessary institutional oversight of the patient-provider relationship
[56]. Ways forward would include more systematic, comprehensive preparations prior to
implementing effective and flexible EHR systems to meet public health needs. As with technical
and practical barriers observed by introducing EHR interventions, considerations of ethical
issues are also integral in the successful implementation of effective EHR programmes.
Providing the context for EHR implementation and formal instruction of ethical risks should
provide health care professionals and support staff with means of mitigating patient risks.
This study reflects findings from other reviews of the use of EMR/EHR in LMIC settings.
Williams and Boren point out that most developing countries have constraints often external to
the health systems within which EMR/EHR are implemented, such as infrastructure and energy
constraints [58]. With a focus on quality of health data and health information management, a
review of community and district levels in LMIC outlined poor quality data, poor management
of hospital information systems, and low utilisation of health information as the predominant
barriers to implementation [59]. Another insightful review recognised implementing EMR
interventions in LMIC as an “evolving,” long-term process, with no comprehensive blueprint for
a given health system, when considering the complex social systems encompassing such
interventions [60]. Applying a stakeholder perspective, Akhlaq et al. concluded that higher
societal level factors, such as political will and financial commitments, were integral to wide-
scale hospital information exchange improvements [61]. In addition to substantiating many of
these findings from other LMIC settings, this review adds an Asian focus that also allows a
comparison across varying health systems across a broad region, focuses specifically on EMR
for public health interventions, and highlights factors both within organisations and external to
an organisation in implementing EMR interventions.
This study has some limitations. As only articles published in English were included, it is
possible that some studies from the region may have been omitted if published in local
languages. However, thematic analysis of data obtained from the 32 studies determined recurring
themes that were corroborated by multiple researchers, suggesting robust analysis. The overall
findings suggest that the benefits of EHR in public health should far outweigh the challenges
faced in the region. An international comparative study including China, Indonesia, Taiwan, and
India suggested that the adoption of EHR had considerable potential to improve the safety,
quality, and efficiency of healthcare as well as being a valuable resource for research [14]. For
efficient implementation of systems and utilisation of data for public health and research, an
effective collaboration of academia, regulated industries, policy makers, patients, and health
professionals is critical [62]. The lack of interoperability between systems requires an effective,
unified information system and can prove to be a major roadblock to those attempting to move
healthcare forward to an integrated system of care [63]. The process of moving from a paper-
based to an electronic database system and subsequently to a platform or web-based scheme can
be arduous. The knowledge, expertise, and software required for these systems can be a
challenge but with the increased reach of the internet, resources can become available. The
selection of systems best suited to meet an organization’s needs and define the implementation
plays a critical role in the success of a given EHR project [64]. However, there is a potential need
for long-term and systematic funding to develop nationally or regionally integrated systems.
5. Conclusion
The progress and capacity of EHR systems is far-reaching and effective. Understanding broader
and local contexts, access to available resources, addressing organisational challenges, and
implementing well thought-out approaches in the development of EHR projects should go a long
way to address potential barriers to EHR implementation. The values of EHR are significant and
go beyond individual clinical decision-making in its ability to identify disease patterns, seasonal
and global trends, and the potential risks to vulnerable populations as well as to strengthen
coordination of care between different sectors. Understanding the potential capabilities and
preparing for potential challenges of EHR as highlighted in this study will help facilitate the
development and implementation of public health initiatives in Asia to address current needs and
identify future risks.
Abbreviations
EHR: Electronic health record
ICT: Information and communication technology
HIC: High-income country
LMIC: Low- and middle-income country.
Data Availability
All data generated or analysed during this study are included in this publish article and its
supplementary information files.
Ethical Approval
Ethical approval and consent was not required as the manuscript does not report on or involve
the use of any animal or human data or tissue. Ethical waiver was obtained from the Faculty of
Medicine, Chiang Mai University (reference number 089/2016)
Conflicts of Interest
The authors declare that they have no competing interests.
Authors’ Contributions
Lesley Dornan and Chaisiri Angkurawaranon were responsible for conception of the study.
Lesley Dornan, Ahmar Hashmi, and Chaisiri Angkurawaranon implemented the search strategy.
Lesley Dornan, Wichuda Jiraporncharoen, Ahmar Hashmi, and Chaisiri Angkurawaranon
conducted review of abstracts. Lesley Dornan, Wichuda Jiraporncharoen, Kanokporn
Pinyopornpanish, Nisachol Dejkriengkraikul, Ahmar Hashmi, and Chaisiri Angkurawaranon
were responsible for data extraction. Lesley Dornan, Ahmar Hashmi, and Chaisiri
Angkurawaranon drafted the manuscript. All authors (Lesley Dornan, Kanokporn
Pinyopornpanish, Wichuda Jiraporncharoen, Ahmar Hashmi, Nisachol Dejkriengkraikul, and
Chaisiri Angkurawaranon) critically revised the manuscript. All authors approved the final
version of the manuscript.
Acknowledgments
This work was supported by Faculty of Medicine Research Fund, Chiang Mai University,
Chiang Mai, Thailand (Reference number 079/2559). The authors would also like to thank Dr.
Nida Buawangpong for her help in creating Figure 3.
Supplementary Materials
Appendix Table 1. Summary of articles included in the review. Appendix Table 2. Summary of
thematic analysis of articles included in the review. (Supplementary Materials)
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Copyright
Copyright © 2019 Lesley Dornan et al. This is an open access article distributed under
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reproduction in any medium, provided the original work is properly cited.
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Teaching and Learning in Medicine

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Perspectives And Editorials
Medical Student Documentation in Electronic

Health Records: A Collaborative Statement From
the Alliance for Clinical Education
Maya M. Hammoud,John L. Dalrymple,Jennifer G. Christner,Robyn A. Stewart,Jonathan
Fisher,Katherine Margo, show all
Pages 257-266 | Published online: 10 Jul 2012
 Download citation
 https://doi.org/10.1080/10401334.2012.692284
In this articleClose
 INTRODUCTION
 INTEGRATION OF EHR DOCUMENTATION INTO THE MEDICAL STUDENT CURRICULUM
 EVALUATION
 SUMMARY
 References
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Abstract
Purpose: The electronic health record (EHR) is an important advancement in health

care. It facilitates improvement of health care delivery and coordination of care, but it
creates special challenges for student education. This article represents a collaborative
effort of the Alliance for Clinical Education (ACE), a multidisciplinary group formed in
1992. ACE recognizes the importance of medical student participation in patient care
including the ability of documentation. This article proposes guidelines that can be used
by educators to establish expectations on medical student documentation in
EHRs. Summary: To provide the best education for medical students in the electronic
era, ACE proposes to use the following as practice guidelines for medical student
documentation in the EHR: (a) Students must document in the patient's chart and their
notes should be reviewed for content and format, (b) students must have the
opportunity to practice order entry in an EHR—in actual or simulated patient cases—
prior to graduation, (c) students should be exposed to the utilization of the decision aids
that typically accompany EHRs, and (d) schools must develop a set of medical student
competencies related to charting in the EHR and state how they would evaluate it. This
should include specific competencies to be documented at each stage, and by time of
graduation. In addition, ACE recommends that accreditation bodies such as the Liaison
Committee for Medical Education utilize stronger language in their educational
directives standards to ensure compliance with educational principles. This will
guarantee that the necessary training and resources are available to ensure that
medical students have the fundamental skills for lifelong clinical practice. Conclusions:
ACE recommends that medical schools develop a clear set of competencies related to
student in the EHR which medical students must achieve prior to graduation in order to
ensure they are ready for clinical practice.
INTRODUCTION
The electronic health record (EHR) is an important advancement in the delivery of

health care. Based on regulatory and governmental recommendations, 1 the EHR is
being adapted in an increasing number of academic institutions as well as in private
practice settings. 2 The EHR in many ways facilitates improvement of health care
delivery billing and coordination of care, 3 yet creates special challenges for student
education. This article provides a review of these challenges and proposes guidelines
that can be used by educators to establish expectations on medical student
documentation in EHRs.
As EHRs become more commonplace, it is incumbent upon medical school leadership

to ensure students are skillful users of the technologies that will be in place as they care
for patients. The Liaison Committee on Medical Education (LCME) specifically states
that curriculum must “prepare medical students for entry into graduate medical
education” and “include specific instruction in communication skills as they relate to
physician responsibilities, including communication with patients and their families,
colleagues, and other health professionals.” 4 Written communication, in the form of
medical documentation, comprises a large and critical portion of health care
communication. The Association of American Medical Colleges (AAMC) has also
recognized the importance of educating medical students in documentation stating that
medical students should be able to “communicate effectively, both orally and in writing,
with patients, patients’ families, colleagues, and others with whom physicians must
exchange information in carrying out their responsibilities.” 5 The United States Medical
Licensing Examination (USMLE) evaluates a student's ability to write notes as part of
the USMLE Step 2 Clinical Skills Exam. 6 Furthermore, medical record documentation is
a skill that is expected of residents and the Accreditation Council for Graduate Medical
Education (ACGME) specifically states that residents are expected to “maintain
comprehensive, timely, and legible medical records.” 7
For decades, there has been no physical barrier to students’ access to patient records,
as they simply picked up the physical chart. The need for permission to use hospital
computers to access the EHR with attendant passwords, and Medicare concerns about
physicians’ inappropriate use of trainees’ findings, 8 has created new challenges.
Despite the obvious need for students to learn documentation in the EHRs, educational
mandates that can provide guidelines to medical schools on how to teach and assess
student skills in EHR proficiency do not exist. In addition, very little research has been
conducted examining how best to incorporate medical informatics competencies into
medical school curricula. 9 , 10 Indeed, great variability in trainees’ access to the
numerous capacities of the EHR exists. A survey of clerkship directors in internal
medicine in the United States and Canada showed that 48% of schools required
medical student documentation of progress notes in the EHR during the ambulatory
internal medicine clerkship whereas 52% of schools prohibited student documentation
in the EHR. 11 A study of 137 students on their internal medicine clerkship at Johns
Hopkins showed that those who worked at hospitals with computerized order entry
placed significantly fewer orders than those with paper-based order entry. 12 According
to a recent survey of clerkship directors by the Alliance of Clinical Education (ACE), only
an estimated 64% of programs currently allow students any use of EHRs; of these only
two thirds allowed students to write notes within the electronic record. 13 Overall,
clerkship directors acknowledged many advantages to EHRs, but many educational
concerns were raised regarding their current use.
In a recent study, more than 90% of medical education deans in the United States and
Canada responded to a survey stating that medical students’ notes belong in the
medical records and that failing to include student documentation in medical records
would have a negative effect on medical student education. 14 Not only does medical
school leadership value this skill, but medical students do as well. Students desire
training and the ability to practice and receive feedback on EHR. 15 , 16 Despite these
findings, less than half of medical schools have written policies regarding student
documentation in the electronic records. 14 Published literature suggests that the impact
of the EHR on medical education is variable, 12 , 15 , 17 – 20 and limited published data exist
on how best to train medical students and residents in use of EHR. 21 There is the
potential that skills in written communication will become degraded in the medical
school curriculum.
TABLE 1 Alliance for Clinical Education member organizations

CSVDisplay Table
The ACE represents the commitment of the clinical disciplines to work together to
provide the appropriate training for medical students to acquire the fundamental clinical
skills needed for their professional careers. This article represents the collaborative
effort of representatives from the clerkship organizations that comprise ACE (Table 1) to
provide guidelines that can be used by deans, clerkship directors, and faculty educators
to establish expectations for medical student documentation in EHRs. This article
addresses the following:
1.The integration of EHR documentation teaching into the medical student curriculum.
2.The evaluation of specific competencies related to documentation.
3.The ethical, legal, and social issues pertaining to student documentation in the EHR.
4.The call for a unified policy among medical educators regarding medical student
documentation in EHRs.
INTEGRATION OF EHR DOCUMENTATION INTO THE
MEDICAL STUDENT CURRICULUM
Rationale
Documentation in the medical records and writing of physician orders is an essential

part of caring for patients. It creates a record of the encounter either for initial
assessment or to follow a patient's progress, provides a way to communicate between
providers, and serves legal and financial functions. Medical students need to learn to
write notes just as they would any other skill critical to function as physician. Moreover,
writing patient notes provides an opportunity for students to synthesize the patient
encounter, allows for the student to have a sense of ownership and responsibility for the
patient as part of the team, and creates the ability for the supervision and feedback.
Excluding students from real responsibility in the EHR relegates any achievement to the
level of abstract skill, divorced from real responsibility. Legitimate peripheral
participation is generally accepted as the initial step in the acceptance of professional
responsibility; 22 denying students this role robs them of a key, legitimate role that they
can meaningfully fill prior to obtaining their MD degree.
With the implementation of the Patient Protection and Affordable Care Act of
2010, 23 EHR usage will rise. Academic medical centers and faculty will need to develop
innovative teaching strategies and technological solutions to educate medical students,
train them in the skills needed by each successive generation of EHRs, and educate
them in the professional attitudes required for ethical use of the EHR. Due to lack a
single universal EHR platform, and the significant differences between EHRs, defining
best tools for teaching the EHR to trainees in medicine is difficult. A meta-analysis
regarding errors within EHR systems revealed “that error sources resolved down to
training issues, implementation issues, and the time needed to become accustomed to
the system.” 24 Therefore, it is important to provide a safe training environment to train
on the EHR. Medical students can explore the EHR concept and prototypical features
on one of many free open source EHR systems (see Table 2 under Teaching Tools).
They should subsequently be able to apply some basic principles to any EHR they will
utilize posttraining. Once students have mastered the “basic” concepts of an EHR
individually, they can move forward to maximize face time with the live EHR trainer.
TABLE 2 Free EHR systems and associated Web site

CSVDisplay Table
Preclinical Years
Introduction of the EHR should begin in the 1st year of the undergraduate medical
education curriculum and continue throughout the entire 4 years. It can begin with a
general overview of the EHR as a health care tool and its implications for health care
delivery in courses such as Introduction to Clinical Medicine. The traditional approach of
having students learn and then practice documenting the various elements of the history
and physical examination (H&P; chief complaint, history of present illness, past medical
history, etc.) should also include opportunities for entry into the EHR, or at this stage of
training, into a simulated but realistic version of the EHR. This would provide students
with hands-on practical experience. In addition, live demonstrations of how patient note
documentation is incorporated directly into real-time patient care would provide
meaningful clinical experiences and early integration of EHR into the preclinical years.
One practical approach for incorporating EHR in the preclinical years would be through
use of standardized patients (SPs). Once a student has evaluated the SP, the student
could then have an opportunity to document the encounter directly into a simulated
EHR. This could be accomplished as an untimed activity in which the student has
unlimited access to the EHR system, or as a time-limited activity used as a means to
evaluate a student's clinical documentation performance (as described next). There
would also be an opportunity to address the effect on the doctor–patient relationship of
having an EHR and develop strategies to overcome the barriers involved in
documenting during a visit.
Incorporation of other aspects of EHR into the preclinical curriculum can be achieved
through problem-based or case-based learning sessions. 25 By using simulated EHR
patient entries, cases can be built around the actual EHR of a patient in which data
(e.g., vital signs, laboratory data, radiologic images, etc.) can be gradually introduced
and extracted by students as the case unfolds. 26 For example, a problem-based
learning case during the renal physiology or pathophysiology block might focus on a
patient with kidney function impairment for which interpretation of electrolytes, renal
chemistries, arterial blood gases, and urinalysis may help address topics such as
acid/base disturbances and kidney function abnormalities. Instead of directly giving
students patient data, they would have the opportunity to “discover” and interpret such
data on their own. These approaches help further achieve vertical integration of clinical
medicine and the basic sciences and provide students an opportunity to develop
problem-solving and critical thinking skills. As students progress and further integrate
basic science material with clinical applications, simulated patient EHR entries may
allow students to enter notes (e.g., H&P, SOAP notes) that incorporate patient “data”
into their assessments. 27 , 28
The ultimate objective of introducing EHR training in the preclinical years is to provide
students with an opportunity to become familiar, comfortable, and knowledgeable with
the EHR and how it is directly incorporated into clinical medicine. As students begin to
achieve EHR literacy, they will be more prepared for their clinical clerkships.
Clinical Years
As students transition to the traditional inpatient hospital-based and outpatient

ambulatory clerkships in the clinical years, they should have already become familiar
with the format, approach, and rationale for documentation of patient encounters and
the wealth of information readily available in the EHR. Full access to all capacities of
EHR should be granted to allow students the opportunity to appreciate the role EHR
plays in direct patient care.
General EHR training should begin with a bird's-eye view during the orientation to the
clerkship year (or “transition to clerkship” courses that have become common), followed
by clerkship or site-specific orientation and training which would provide critical hands-
on experiences as to how particular components of EHR and the workflow applies to
that given specialty. For example, introducing students on their surgery rotation to EHR
features such as where and how to find vital signs, input/output data, intravenous fluid
orders, and morning lab results would help students facilitate early morning
prerounding. It is expected that early introduction of EHR in the preclinical years, will
translate into a smoother and easier transition of EHR use within the clerkships.
Curriculum committees and clerkship directors should develop specific objectives for
clinical use of EHR by students. Establishing discrete goals that guide both clinical
educators and students will help ensure achievement of key competencies, especially in
the realm of systems-based practice, professionalism, patient care, communication, and
practice-based learning. Some goals and guidelines are suggested later in this article.
As medical students receive most of their practical EHR training from house staff and
attendings in the clinical setting, it is critical that these educators be proficient and able
to assess the expected level of competence of the students. 29
For students in their final year of training, a higher level of knowledge and skill should
be expected. This may include introduction, training, and ultimately application and use
of the more clinically relevant aspects of direct patient care including laboratory data
interpretation, order entry, medication reconciliation, and use of decision support
programs, to name a few. It is essential that the higher responsibility that final-year
students are given be accompanied by a higher level of ethical practice. Errors simply
given corrective feedback at the start of the clerkship year—such as cutting-and-pasting
of incorrect information—might result in a more serious response as the student neared
graduation.
Once medical school graduates enter postgraduate training, it is generally expected that
they will be able to engage successfully in patient care. In addition to the core skills of
being able to approach a patient, obtain an appropriate history, perform the relevant
examination, and enter orders, interns and residents could be expected in most
Graduate Medical Education sites to effectively use the EHR in their own, direct patient
care. As most students will match at a program or hospital that is different from their
home medical school institution, it is anticipated that they will encounter a different EHR
system than one in which they trained with during medical school. As in any other new
hospital or clinical setting, it is likely that these new house officers will go through an
initial learning curve period in which familiarity with the EHR system takes place.
However, medical school graduates ideally should have mastered the basic approach,
knowledge, and skills of how any EHR functions and be able to effectively incorporate
any new system into their workflow. Suggested skills expected of a medical school
graduate are presented under Tools for Teaching (Table 3).
TABLE 3 EHR skills expected of a medical school graduate

CSVDisplay Table
TABLE 4 Guidelines for introduction of EHR templates for student use

CSVDisplay Table
As medical schools develop EHR curricula, it is important that specific goals and
objectives required of all graduates be reasonable; attainable; and, above all, practical.
Most important, UME goals must include the ethical use of the medical record, such as
avoiding inappropriate use of “cut-and-paste,” and protecting patient confidentiality and
privacy.
Guidelines for Note Writing
Initial guidelines for documenting notes in EHR will depend on individual school's
curricular objectives. If early exposure to EHR in the preclinical years is possible, then it
may be reasonable to allow students to enter H&P and progress (SOAP) notes in the
EHR immediately once they enter clinical rotations in the clerkship year. The more
challenging issue will be the role template use plays for medical students’
documentation. For house staff and attendings, use of templates may help to facilitate
workflow and provide documentation of medical information that can be used for coding
and billing purposes. These drivers and advantages are not important to medical
students whose initial goal is to become familiar and skilled at patient encounter
documentation. A major concern that is raised is whether a student will be able to
appreciate and understand the key elements of an H&P or progress note prior to relying
on the use of templates or prepopulated notes. Such entries may prompt the student
prematurely or handicap the student who may not have mastered the essential
elements of patient documentation that reflects their history taking or physical
examination skills. 11
In that regard, guidelines for what and how a student enters clinical documentation into
EHR must be explicit, with specific guidance on whether use of templates or
prepopulated notes is allowed, encouraged, or restricted. Guidelines as when to
introduce template use are presented under Tools for Teaching (Table 4).
Guidelines for Order Entry
Order entry is a more advanced, necessary skill that students begin to develop primarily
in the core clinical clerkships, with continued development in their senior year. It
encompasses many aspects of care, such as inpatient admission orders, postoperative
orders, daily order entries, discharge orders, and filling out prescriptions. Since orders
have a significant and direct effect on patient care, specific policies and procedures are
typically in place at hospitals and teaching institutions regarding student order entry
regardless of the EHR format or platform.
With the development of the EHR, order entry has also undergone a transition to use of
templates and order sets, with the main objective to reduce order entry, streamline
workflow, decrease costs, and improve patient safety. As with note writing, medical
students may eventually use predeveloped order sets, but a grounded understanding of
the reasoning process and rationale used in developing orders is essential, and a
demonstration of familiarity and competence in order writing should occur before use of
order-sets is allowed. A structured, graduated approach to order entry is presented
under Tools for Teaching (Table 5).
TABLE 5 Guidelines to order entry for medical students

CSVDisplay Table
As with note writing, close supervision of students’ order entry is not only critical but
also mandatory for patient safety and legal issues; orders can only be written by
licensed providers, or residents, who are granted special status not extended to
students. It is expected that once hospitals and clinics transition to a completely
paperless EHR use, the traditional paper orders and prescription pads will become
obsolete and possibly unavailable. Teaching students what orders are, how they are
used, and what the essential elements are will become even more paramount early on
in the clinical years if they are to begin using EHR (when allowed) to enter orders.
“Practicing” on paper may seem like a mindless exercise, especially if paper orders no
longer exist, but such practice should be considered a critical opportunity to
demonstrate competence. Development and use by students of simulated EHR order
sets would provide an ideal opportunity to allow them the chance to practice and
demonstrate competence as well. In addition, EHR affords simple methods for
supervisors’ review of students’ orders from a remote workstation.
Use of Decision Aids
Decision aids or computerized clinical decision support systems designed to help

facilitate, enhance, and improve patient care are increasingly incorporated into EHRs.
These may include reference materials, diagnostic assistance systems, clinical alert
systems, drug dose or prescribing assistance, preventive care reminders, and chronic
disease management reminders. They may take the form of automatic windows that
pop up when an order is written, or they may be provider-initiated. 19 Regardless of the
format, their use among students may be seen as another educational resource and
teaching tool. Controversy exists, however, as to whether such use early on will reduce
learning and prevent learners from thinking through each order and decision.
Nonetheless, through the use of such decision aids, several competencies can be
addressed, including expansion of clinical fund of knowledge, enhancement of patient
care skills, improvement of practice-based learning skills, and further development and
appreciation of a systems-based practice. It is unclear, however, if enhanced knowledge
acquisition will result from decision aids. In one study, no difference in knowledge
scores was shown among students on a surgical rotation who had access to
educational material on a hospital information system through order entry compared to
students who utilized traditional hand-written orders in a paper chart without online
educational material. 21
Introduction of decision aids will vary depending on the EHR and appropriate clinical
application for students in the clinical years. Graduated use and incorporation into EHR
notes, orders, and workflow should occur as students develop competence in patient
care skills. 30
Communication Skills
Communication skills become a critical competency as direct patient care develops and
increases during a medical student's curriculum. Not only must a student learn to
interact professionally and communicate effectively with patients, their families, and
other health care team members (students, house staff, attendings, nurses, etc.), but
they must also be able to integrate the use of the EHR into this routine. The
EHR/computer becomes the third “person” in the room in addition to the patient and the
health care provider (or in this case, the medical student), and how the student
communicates with the patient while effectively integrating the use of the computer into
that patient-care interaction becomes an additional challenge and opportunity for skills
development. 11
As competencies within courses and clerkships evolve, developing specific objectives

related to EHR use as it relates to communication and maintaining a patient-centered
approach should be a high priority. It is essential that students be instructed on proper
EHR/computer “etiquette” early in their preclinical Introduction to Clinical Medicine
courses and that they be observed directly as they interview, examine, and document
within the EHR such patient encounters. One study indicated that patient-centered
communication scores were equivalent during an SP encounter that utilized the EHR
compared to other SP stations without the EHR, suggesting that students who
completed a clinical year with EHR were able to effectively incorporate its use into
patient care. 31 Role-playing, simulated demonstrations, the use of videotaping, patient
feedback (simulated or real), and direct preceptor observation are preliminary ways in
which communication and interpersonal skills can be taught and assessed in the
preclinical setting as outlined in more details in the upcoming Evaluation section.
Within the hospital setting, EHRs and computers are now widely available as mobile
units (COWs, or computers on wheels) or as stationary units outside (or even within)
each patient's room, thus facilitating workflow and rounds. Utilization of the paper chart
and hard copies of notes often used by students to present their patients or rounds will
become less available. The ability to present patients and communicate effectively with
or without the EHR is another skill that must be developed and refined during clinical
clerkships. Although presenting from memory is an ultimate goal, and one that senior
students should master, students early in their clerkship year may rely on the EHR
(direct reference or via printed copies of notes) to make presentations. Fumbling
through screens, waiting for pages to load, and technical difficulties/limitations are just
some of the barriers and obstacles that will interfere with a student's ability to learn
effective presentation and communication skills. As such, use of the EHR on rounds
should be restricted or limited early in the clerkships (either early in the academic year
or early in each clerkship), until competence in presentation skills is demonstrated
without its use. This is similar to the guidelines presented earlier for note-writing.
EVALUATION
Principles
Evaluation of students’ written communication within the EHR should follow general
tenets established for evaluations in the clinical setting, including use of the paper
medical record. These include quality and accuracy of the data entered, completeness
of the note, and originality of students’ entries. In addition, in order to enable proper
assessment, teachers should be able to access students’ entries within the system,
correct them, and provide feedback within a timely manner.
Evaluation Frameworks
Throughout this article we have emphasized the need for level-of-training-appropriate

expectations for skills and attitudes in use of the EHR. Currently popular frameworks to
set goals for medical education are mostly based on knowledge, skills, and attitudes
that divide competency into its discrete parts for individual assessment. Although this
framework provides goals of attainment for evaluation purposes, which can be applied
to written communication within the electronic medical record, it does not provide an
explicit developmental aspect. The RIME scheme, which was developed in
1999, 32 provides a “synthetic” vocabulary of clinical progress of students as they
advance to mastering the Reporter level, then adding Interpreter, Manager, and finally
Educator phases of competence over the subsequent years. The RIME scheme for
evaluation of student electronic medical communications in the context of the ACGME
core competencies is elegantly delineated in a commentary by Stephens et al. 32 Prior to
entering clinical rotations, students should be evaluated on their proficiency with the
basic “reporting” mechanics available in the EHR system. By the end of their clerkship
year, students should be proficient in the “reporter” skills such as data entry, reliability in
completing all sections of a note, and recording their own findings instead of “cutting
and pasting.” By the end of the 4th year of medical school, students should be proficient
in the “interpreter” skills such as creating their own assessment of the patient's condition
and interpreting data. Mastery in the “manager” and “educator” skills will be obtained in
students’ postgraduate education.
Evaluation Methods
How students are evaluated depends in part on the setting in which they are utilizing the
EHR. Students will either interact with the EHR in the workplace in vivo where they have
real responsibility for writing notes or orders, or in vitro in testing or simulated learning
environments where their interactions are outside of an actual patient record. Both
approaches have a role in the educational process—in vitro to prepare students for their
clerkships and to document specific skills prior to graduation. In vivo assessments are
essential to demonstrate the transfer of those skills to actual care, and to also the
ethical behavior that is the cornerstone of practice.
Assessment of knowledge and skills could include examining the ability of a student to
navigate the EHR with regard to note creation, order placement, communication with
other care providers, and use of online tools. Methods for evaluation can include those
traditionally used, such as checklists for content and Likert scales for issues such as
quality and accuracy of data, organization, completeness, and originality of the note.
The electronic nature of the note provides opportunities for the creation of portfolios as
well as improvement in evaluator access to student documentation. Spickard et al have
written of their method of automatic capture of student notes within the inpatient medical
record to a portfolio, with the capacity to e-mail the evaluator when a student completes
a note. They found that teachers reported giving more frequent and detailed feedback
and students reported receiving more feedback on their write-ups. 33
Evaluation Components
Items for assessment in the EHR include all types of notes such as written histories and
physicals, progress notes, discharge notes operative notes, and order entry. The
assessment of student notes includes the layout of the note as well as aspects of the
content. In the context of RIME, Reporter content would include gathering and
documenting findings and expressing them accurately, succinctly and in an organized
fashion. Accuracy should include not only freedom from errors but avoiding cutting and
pasting exam findings, assessments and plans from previous notes, and avoiding
prepopulating note templates with data that are not available at the time of note writing.
Students should avoid plagiarizing other clinician's notes unless they include those
portions within quotations and indicate the source. Cutting and pasting should be
confined to objective findings such as radiology and pathology reports. Content should
also be graded on completeness such as complete characterization of the chief
complaint in the history of present illness and inclusion of all appropriate subsegments
of the note.
“Interpreter” content should include the student's offering an explicit assessment such
as a differential diagnosis for a new problem, or improvement of a prior diagnosis.
“Manager” content should include a diagnostic plan and/or treatment plan. Content
relevant to the Educator phase would include that related to both self-education and that
of the patient. This would include just in time learning such as using tools embedded
within the EHR, use of patient education materials, and documentation of shared
decision making.
Order entry should be graded on completeness and accuracy, including proper drug
dosages and frequency, and patient safety issues such as avoiding drug–drug
interactions or prescribing drugs to which the patient is allergic. Optimally, students
would be able to place orders directly into the EHR and forward them to a resident for
review and cosignature. Difficulties with access to order entry within the EHR and the
lack of capacity for efficient review by residents are significant barriers in many EHR
systems and likely contribute to the aforementioned reduction in order entry by students
using the EHR.
Whether captured in the RIME framework or not, EHR may afford a unique capacity to
evaluate students in some areas of the ACGME core competencies. Professionalism
traits that can be more readily evaluated in the EHR include honesty (not cutting and
pasting) and respect for patients (HIPPA compliance). For the competency of practice-
based learning, there is the ability to electronically measure the student's exposure to
certain conditions and to track quality compliance issues that may aid students’
development of self-evaluation and improvement. Systems-based practice content that
can be evaluated includes the students’ use of clinical decision aids within the EHR in
order to better practice evidence-based medicine as well recognizing and utilizing EHR
tools to avoid errors such as medication reconciliation and medication/allergy
interactions.
Ethical, Legal, and Social Considerations
There are a number of ethical and legal considerations when students use any medical
record, which is a legal document. Medical students are not licensed providers and
cannot write independent orders or prescribe medication without direct supervision.
Instead such student-initiated actions require a cosignature by a credentialed provider.
However, a significant part of the barrier to full student documentation comes from The
Center for Medicare and Medicaid Services (CMS) guidelines, which govern teaching
physician and medical students: 34
Students may document services in the medical record; however, the teaching
physician may only refer to the student's documentation … that is related to the ROS
and/or PFSH. … If the student documents … the teaching physician must verify and
redocument the history of present illness and perform and redocument the physical
examination and medical decision making activities of the service.
This rule has been the reason most often stated by preceptors for not allowing students
to document in their charts. The primary concern of CMS is the billing issue. However,
EHRs provide the opportunity to clearly identify the author of note either by direct
attribution or through an electronic audit trail. In certain limited settings, according to
CMS, medical students may act as scribes, which should be separate from the
educational experience of the student. The AAMC white paper on medical student
documentation in the EHR36 suggests that Medicare frowns on medical students as
scribes. There are a wide variety of practices employed to address the Medicare rules
across the country. Some health systems have created specific policies, and some
leave it up to each service or attending.
Many EHRs use templates for their notes, particularly in an outpatient setting. There is a
danger of leaving normal findings in a prefilled template where items were not in fact
looked for in the patient. Presumably most of the time this is not intentional, but it raises
significant ethical issues. In addition, one of the new challenges created by EHRs is that
they provide the ability to cut and paste medical student documentation into a resident
or attending note. Many EHRs allow the ability for a provider to paste information,
sometimes even whole notes, from a prior visit into a current visit note. This helps to
speed up documentation for information that is still pertinent for the current visit. The
danger, of course, is that the information is not confirmed and erroneous information is
promulgated. In addition, history or physical information that has changed may not be
discovered. This practice, when done by attendings, is also not good role modeling for
students, who should be encouraged to get their own data (history and physical) when
they write notes. Intentional use of medical student notes without redocumentation
would constitute fraud. In addition, students learn very little if they utilize cut and paste
rather than take the pertinent history themselves.
The other legal issue that is cited by local hospital administrators, particularly by
compliance officers, is the worry about increased liability when students document in a
chart. There is not good evidence that student notes do increase this problem, but the
fear is that the student will document erroneous information that is not directly refuted
by the attending, or even that the student will document correct information that was
ignored by the treating team. The premise seems to be that juries will in some
circumstances be persuaded to trust a student's inaccurate entry rather than a licensed
physician's. Convincing the compliance office of the educational importance of student
notes is often a challenge.
There are competing social needs that underlie this article. Schools have responsibility
to graduate students with the expertise and sense of duty in the basics of practice and
who function with some independence during the first postgraduate year. Although ACE
does not dispute the government's role (through CMS) in ensuring quality care and
avoiding billing fraud, we wonder if there is too great a price extracted in the current
regulations that deny students their century-long role of recording their own clinical
findings in the medical record. This is a radical experiment in educational practice.
Educators, deans, and the AAMC have questioned the need, and questioned why the
breaches of traditional supervision by licensed faculty were not seen as exceptions,
rather than the rule.
SUMMARY
To provide the best education for medical students in the electronic era, we propose to
use the following as practice guidelines for medical student documentation in the EHR.
1.Student must document in the patient's chart, and their notes should be reviewed for
content and format.
2.Students must have the opportunity to practice order entry in an EHR—in actual or
simulated patient cases—prior to graduation.
3.Students should be exposed to the utilization of the decision aids that typically accompany
EHRs.
4.Schools must develop a set of medical student competencies related to charting in the
EHR and state how they would evaluate it. This should include specific competencies to
be documented at each stage, and by time of graduation.
In addition, we recommend that accreditation bodies such as the LCME utilize stronger
language in their educational directives standards to ensure compliance with
educational principles. This will guarantee that the necessary training and resources are
available to ensure that medical students have the fundamental skills for lifelong clinical
practice. This article represents a collaborative effort of ACE, and the recommendations
included in the article have been endorsed by the ACE Council.
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BioMed Research International

Review Article | Open Access

Utilisation of Electronic Health Records for

Lesley Dornan,1 Kanokporn Pinyopornpanish,1 Wichuda Jiraporncharoen,1 Ahmar Hashmi,1 Nisachol

2. Material and Methods

2.1. Analytical Framework

2.2. Search Strategy

2.3. Search Outcomes

3.1. Role and Benefits of Electronic Health Records to Public Health

3.2. Success Factors and Potential Barriers

3.2.2. EHR Input Process

3.2.3. EMR Output Process

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14. M. H. Van Velthoven, N. Mastellos, A. Majeed, J. O'Donoghue, and J. Car, “Feasibility

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31. N. H. Rahman, H. Tanaka, S. D. Shin et al., “Emergency medical services key

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37. A. B. Sutiono, A. Qiantori, S. Prasetio et al., “Designing an emergency medical

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Teaching and Learning in Medicine

Perspectives And Editorials

Medical Student Documentation in Electronic

Pages 257-266 | Published online: 10 Jul 2012

Purpose: The electronic health record (EHR) is an important advancement in health

The electronic health record (EHR) is an important advancement in the delivery of

As EHRs become more commonplace, it is incumbent upon medical school leadership

TABLE 1 Alliance for Clinical Education member organizations

2.The evaluation of specific competencies related to documentation.

Documentation in the medical records and writing of physician orders is an essential

TABLE 2 Free EHR systems and associated Web site

As students transition to the traditional inpatient hospital-based and outpatient

TABLE 3 EHR skills expected of a medical school graduate

TABLE 4 Guidelines for introduction of EHR templates for student use

Guidelines for Note Writing