Education Columns

Margot Savoy, MD, MPH; Lisa Maxwell, MD; Mary Stephens, MD, MPH, Christiana Care Family Medicine Residency Program, Wilmington, DE

The Health Information Technology for Economic and Clinical Health Act (HITECH) (2009) and subsequent Meaningful Use requirements have assured that today’s medical student will need to be tomorrow’s technology-savvy physician. Many faculty assume that the younger generation were born with a smartphone in their hands, but it is an error to assume all students enjoy the same comfort level with health information technology (HIT). Students’ self-efficacy and openness to change may impact the ease with which they successfully incorporate HIT into their growing medical identity.¹

Simultaneously with HITECH, the Patient Protection and Affordable Care Act (2010) refocused the nation on the importance of providing evidenced-based prevention and ensuring the health of communities through population-based care. Inadequate undergraduate medical education; inefficient systems unable to identify, contact, track, and educate patients; and competing time demands have all been cited as barriers to providing preventive care.^2,3

Given the rapidly changing health care landscape, educators need efficient and effective curricular elements that also support the overall goal of meeting the patient’s medical needs. Is there a way to easily combine teaching preventive medicine with EMR skills? Yes, and we call it SCOOP: The Student Coordinator of Prevention.

SCOOP is an experience our third-year medical students complete as a part of their 6-week Family Medicine Clerkship. Concentrated prevention education is coupled with hands-on application of prevention, motivational interviewing, counseling, and HIT skills. Students attend a series of small-group interactive didactic lectures. These lectures include presentations with hands-on practice using web-based prevention resources like the USPSTF Guideline website and our electronic medical record. In addition they are provided a reference article collection self-study and a patient education toolkit for use during clinical sessions. Students spend several days as the SCOOP, completing pre-visit SCOOP chart audits for upcoming scheduled patients, updating the EMR with verified information, and conducting patient-centered motivational interviewing-based counseling sessions prior to the provider portion of the patient’s visit.

During a pre-visit SCOOP chart audit, the student identifies the age-specific preventive care recommendations like immunizations, breast cancer screening, cervical cancer screening, colon cancer screening, and current tobacco use for the patient who will be presenting for care using the evidence-based tools introduced in class. The student audits the patient’s electronic medical record for evidence of the preventive service being provided. For example, was a mammogram ordered and a result recorded in the EMR? If the mammogram was ordered and the report scanned into the EMR but no result entered into the master flowsheet that holds all the health record’s data, the student updates the flowsheet. Also, if during the office visit a patient reports having the mammogram done at an outside site, students are able to alert the provider to access the Delaware Health Information Network, our statewide information exchange, to retrieve the report.

Fifty-two students participated in the initial year and in total over 100 students have gone through the curriculum since 2011. Both self-assessed and objective knowledge of preventive care improved. The experience was considered valuable, and students advised it should be kept in the curriculum. Students maintained very positive attitudes toward prevention though we noted a negative trend regarding their individual future practice of preventive care. We suspect this trend may be impacted by many students intending to pursue specialty careers and perceiving prevention as primary care’s responsibility. The curriculum also highlights patient-centered medical home principles including the expanded health professional roles in the team model. We did not observe an impact on self-assessed preventive care skill application, but we suspect this is due to the students’ high pre-curriculum confidence in these skills. While we did not measure comfort or ease of EMR use, there has been a noticeable improvement by precepting faculty and residents in how quickly students become comfortable documenting in our medical record and locating prevention information for patient visits during non-SCOOP care sessions.

Since 2011, more than 1,400 SCOOP chart audits have been performed. A total of 1,335 patients (14% of all patients seen at our office during the curriculum pilot timeframe) were SCOOP chart audited; 459 patients (5%) needed their EMR flowsheet updated for accuracy; and 119 patients (1% of all patients seen at our office) received motivational interview counseling from the SCOOP during their visit. Common reasons for omitting the counseling included patient declination, provider declination (this occurred most often in providers with full schedules running on time who did not want their schedule delayed), late patient arrival (decreasing available time for providing counseling), patient no show or rescheduling, and patient being up to date on included screening recommendations. Improvements to our baseline breast and colon cancer screening rates were minimal (2.7% increase, 1.6% decrease, respectively) in our general practice; however, when separating the medical student clinic patients the change in rates improved (14.99% increase and 11.4% increase, respectively).

By improving our documentation and counseling patients about necessary preventive care, the medical students are creating a significant value-added service. For the patient, an opportunity to review, identify barriers, and be referred for services that can save their lives. For the practice, improving documentation in the EMR and alerting the providers to missing testing allows them to provide improved quality of care while also improving the bottom line by meeting key meaningful use and patient-centered medical home benchmarks. Last, but not least, the student experiences a practical hands-on educational experience with critical skill development in HIT, motivational interviewing, preventive medicine, and primary care.

References

1. Harle CA, Gruber LA, Dewar MA. Factors in medical student beliefs about electronic health record use. Perspectives in Health Information Management 2014;Winter:1-14.

2. Walter U, Flick U, Neuber A, Fischer C, Hussein RJ, Schwartz FW. Putting prevention into practice: qualitative study of factors that inhibit and promote preventive care by general practitioners, with a focus on elderly patients. BMC Fam Pract 2010;11(1):68. [Epub ahead of print]
3. Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999;282(15):1458-65. doi:10.1001/jama.282.15.1458.