The literature on EMRs was mostly about the use of the system; only few studies discussed EMRs in terms of resident education [1, 21]. This study explored the dimensions and items within the EMRs conducted by residents from various departments. The checklist in this study could be used as a fundamental requirement in residency. The results indicated that residents showed diverse performance. Overall performance was rated as fair to good. This result was consistent with previous studies which indicated that residents demonstrated inconsistencies between their medical knowledge and their clinical encounters, leading to limited performance in EMRs [4, 9, 12].
Of the six dimensions, the weakest dimension was the weekly summary, followed by the progress note, problem lists, overall performance, admission note, and discharge note. Returning to the checklist for the weekly summary and progress note, the assessment for these two dimensions emphasized that residents should avoid overuse of copy-and-paste and should revise patients’ daily changes and summarize daily information logically. For example, the format of the progress note was subjective-objective-assessment-plan (SOAP), but we found that duplication often occurred in the subjective, which led to low scores in this dimension. Instead of renewing daily examination results, some residents would copy admission notes to progress notes.
From an educational perspective, residents tried to apply medical knowledge to practice-based encounters to identify problems, establish diagnosis, and summarize the report in narrative or chronological order. However, in the current EMR system, information is often presented in a segment, splitting data from multiple screens and modules in various formats. As there are massive amounts of data in EMR systems, residents needed to put more effort into refining everyday changes and selecting useful data to complete a precise and concise MR. Discharge notes in the inpatient record consisting of a summary with clearly written orders and feedback from attending physicians were well developed. Conversely, the weaker performing dimensions, the weekly summary and progress notes, required careful clinical reasoning elements including collecting the patient’s story and screening data to judge critical writing points.
With the judgment based on medical knowledge and patient-care professionalism, a resident could then gain accurate diagnosis and create an illness script, thus conducting high quality EMRs [4]. However, the massive amount of data in the EMR system may hinder the clinical reasoning process of constructing the EMR de novo or receiving essential feedback from residents’ advisors or colleagues. This situation indicated that residents might ignore the inter-connection among dimensions within EMRs, which leads to a long but pointless record. In the United States, only 24% of healthcare organizations establish regulations to limit the use of duplication in EMRs. Additionally, more than 60% of residents duplicate data without confirming its accuracy, and this leads to 2-3% of inappropriate diagnosis [22]. Moreover, when residents solely relied on copy-and paste from previous records or templates in EMR system, the feedback was likely not meaningful because the records were not created through doctor-thinking but through computer program-thinking [1].
We proposed that in such clinical reasoning processes, the competencies of medical knowledge, interpersonal communication skills, and system-based practice might be required [3]. The finding was also in line with a previous study which demonstrated that the effective use of EMRs requires narrative elements, data elements, and system elements combined in the context of patient care [5]. In other words, the quality of EMRs, the core competencies, and the clinical reasoning skills are closely interconnected in resident education.
We also found difference among groups. Performance varied depending on the unique affordances and workload in each department. Surgery gained the lowest scores among the five groups. They performed well solely on Item 12, which was the particular record for operation. This could be a result of the specific culture of Surgery; for example, heavy workload, time pressure, insufficient information from interview, lack of feedback, and the focus on surgical skills training. As such, residents in Surgery require extra opportunities to learn clinical reasoning processes and chronological descriptions of the EMR system, rather than overly relying on templates and the copy-and-paste strategy.
Conclusively, meaningful experiences using the EMR system should be consistently implemented in clinical training and the integration of the EMR system and core competencies should be rigorously designed and assessed. Enhancing EMR as a meaningful tool could benefit not only the level of clinical skills of residents but also their attitudes toward clinical reasoning and professionalism [6,17].
Pedagogical suggestion
Previous study suggested that EMRs can affect how residents develop clinical reasoning skills and document strategies [5]. Stephens, Gimbel, and Pangaro (2011) proposed a specific educational approach to clinical documentation called the Reporter–Interpreter–Manager–Educator scheme, which structures the introduction, expectations, and assessment of medical record writing skills throughout the medical education process. We further suggest two key points for EMRs teaching in resident education. First, in spite of the convenience of the EMR system, EMR should avoid duplications and offer additional and concise information through careful judgement of past and future plans. The avoidance of duplication should be a key point in resident education [23].
The overuse of duplication also indicates the gap in clinical communication. For example, review of system (ROS) provides a complete list, other than chief complaints and present illnesses, and helps doctors make clinical decisions [24]. In this study, the findings show that our residents may lack a comprehensive review of patients. It seems that the EMR has not demonstrated a positive impact on communication [23, 25]. In the era of specialized divisions in medicine, a comprehensive review is particularly necessary because it may affect more than 10% of final clinical diagnoses [26]. An EMR system may enhance the ability of physicians to complete information tasks but can also make it more difficult to focus attention on other aspects of patient communication.
Some suggestions are given to mitigate EMRs’ negative educational impact [23]. First, a meeting of residents, attending physicians, and other healthcare providers can be held for real and interprofessional communication. After that, doctor-patient communication can be followed so as to fulfill patients’ courses based on doctors’ narratives. Second, residents can be trained to interact with patients before directly reviewing EMRs [14]. Third, a systematic coaching program may be helpful for integrating important elements and strategies as a whole-package course, and thus clinical teachers can train residents effectively.
Limitation
This study contributes to resident education in the era of EMR, but there are some limitations. First, although the sample in this study contained residents from various departments, it only included 7-10% of the residents in our hospital. Additionally, the inpatient record checklist was created for clinical assessment. The design process relied on medical experts’ discussions and the literature review. In future studies, we will expand the sample size to other hospitals and examine reliability and validity to promote generalization. Second, departments have created medical record templates based on their unique culture and needs long before this study. Although the Quality Center announced the assessment standards before the competition, it was not easy for every department to transform the templates in such a short time. This might lead to a bias that the departments that carefully used the checklist achieved great performance. Third, residents from different departments experience unique work requirements and clinical cultures, and thus this study compared the five groups instead of comparing group members with each other. Conclusively, despite the limitations, this study provides new insights into resident education and offers directions for future studies on EMR.
