Are Electronic Health Records a Barrier to Nurse Practitioner Student Learning?

Article Outline

• Support for EHR in NP Student Learning
• Rationale Against EHR in NP Student Learning
• Reference
• Copyright

Kathleen Woodruff, MS, CRNP, is an instructor at the Johns Hopkins University School of Nursing and practices as an adult nurse practitioner at the Wood Clinic at the Johns Hopkins University Bloomberg School of Public Health. Her primary teaching responsibilities are in the adult and family nurse practitioner programs. She is also a student in the doctor of nursing practice program at the University of Maryland's School of Nursing in Baltimore.

Janet Selway, DNSc, CRNP, is an assistant professor at the University of Delaware's School of Nursing. She currently practices as an adult and pediatric nurse practitioner in an after-hours care center in the greater Baltimore area and is the president-elect of the American College of Nurse Practitioners.

The electronic health record (EHR) has many benefits; reduction of human error, virtual record storage, facilitation of access to data, improved data accuracy, and better patient outcomes are just a few. Disadvantages include threats to privacy, lack of record standardization, loss of human touch, and, in some cases, reduced efficiency. With the ever-growing workload of primary care providers, EHRs are often a welcome time saver for experienced clinicians. What about the inexperienced learner? A recent questionnaire¹ of 2005–2006 third-year medical students' attitudes towards clinical learning using EHR in primary care clinics revealed generally positive attitudes. However, the students reported major concerns about the impact of EHR on their ability to conduct the patient encounter, and 48% said they spent less time looking at the patient. Does EHR have a positive or negative impact on NP student learning?

What do you think? Contact Section Editor Janet Selway at janet.selway@gmail.com if you would like to comment on this matter.

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Support for EHR in NP Student Learning 

Kathleen Woodruff

EHR is an everyday practice management tool that is fast becoming the norm. NP students should learn how to be comfortable with and best use EHR. Most NP students enter graduate school with basic computer skills learned in their undergraduate programs or have experience using EHR programs at their workplaces. Learning an EHR software program should not be a significant challenge. In facilities that allow students to access EHR, faculty or preceptors could arrange for the NP student to get some time with the facility's EHR trainer before spending clinical hours with the preceptor. This will allow the student to focus on clinical skills and reduce preceptor burden. A single day of one-on-one training could prevent days of preceptor-student frustration. If institutional policies do not allow students to access EHR, the preceptor could use simulation by encouraging the student to hand-write a few real-world practice progress notes on actual patients and then provide feedback.

In settings where e-prescribing is the norm, students could practice writing out paper prescriptions for preceptor review. In addition to lengthy academic progress note assignments, NP faculty could have students write on-the-spot, brief, real-world, simulated progress notes and practice prescriptions. These could be submitted for immediate feedback or peer review as a classroom exercise.

Rather than a barrier to learning, EHR enhances student learning. A 2008 study of third-year medical students in a family practice rotation reported that EHR allowed them to improve their documentation and that EHR prompts allowed them to ask more history questions. The incorporation of EHR into healthcare, which has been mandated nationally, cannot be viewed as a detriment to NP student learning but rather an opportunity for faculty and preceptors to create a positive environment for teaching and to actively engage students in learning.

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Rationale Against EHR in NP Student Learning 

Janet Selway

Although the paperless office is the wave of the future, it can create new obstacles to learning for NP students. When preceptors are required to maintain a high patient volume (some with 10-minute appointments), they have little time to teach an NP student basic diagnosis and management skills, let alone how to manage an EHR system specific to the preceptor's practice. Because the preceptor has to rapidly input data into the computer, opportunities for the student to practice history-taking skills may be nonexistent or very limited. When preceptors do allow the students to use the EHR, the students often do not have time to master the software. The computer may become the object of student focus, rather than the actual living, breathing patient in the exam room.

The computer distracts the student, who may miss important patient cues necessary for obtaining an accurate history. Documenting findings on EHR is designed to be a time-saving point-and-click function but does not allow the student an opportunity to learn how to correctly document abnormal physical exam findings. Similarly, electronic prescribing, known to minimize error and increase convenience, limits opportunity for students to become proficient at writing prescriptions.

EHR software programs are not standardized across healthcare systems or individual practices, making it even more difficult for students to apply basic documentation skills as they rotate through a variety of clinical sites. While academic progress note assignments are designed to teach documentation and health assessment skills, they do not teach how to document in the fast-paced real world of today's clinical practice. The future workload of primary care providers is destined to increase, making it more difficult for preceptors to teach well. NP educators must face the challenge of teaching students how to effectively incorporate new record-keeping technology into everyday practice.

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Reference 

1. Rouf E , Chumley HS , Dobbie AE . Electronic health records in outpatient clinics: Perspectives of third year medical students . BMC Medical Education . 2008;8: Available at: www.biomedcentral.com//1472-6920/8/13 Accessed March 16, 2010
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