Resident physician interactions with the EHR are plentiful.
With data indicating that first-year residents spend considerably more time in physician workrooms than at the bedside, an effective and efficient approach to working with the EHR can help a successful transition to residency. A recent AMA webinar for incoming interns offered some do’s and don’ts for resident EHR usage.
You are likely to have some experience working in the EHR as a medical student, but electronic health record systems can differ and the pace of your day is far more frenzied as a PGY-1.
“Don’t expect to be proficient in all aspects of your EMR from day one,” said Haidn Foster, MD, an AMA member and internal medicine resident at Penn State Health.
“The EMR used by my current hospital system is different from the one I used in medical school. And because my first rotation in residency was in the ICU, I was worried that I’d be starting on one of the most challenging rotations in the hospital while learning how to navigate a completely new electronic medical record. Even if you'll be using the same EMR in residency as you did in medical school, you will ultimately have to interact with the EMR in a more fast-paced, intensive way than you did as a student.
“Trust in the process,” Foster said. “You’ll quickly learn the essentials of working in your particular EMR; the shortcuts and power user tips will come with experience.”
The way you interact with the EHR early on is likely to stick with you throughout your entire career.
“Residency in general, and internship specifically, is where you will form habits that are going to be durable for your professional career,” said Sanjay Desai, MD, the AMA’s chief academic officer and group vice president of medical education. “How you write notes is one of those habits. You will see as you go further and further along into your career—one of the problems that we'll notice is when somebody copy-and-pastes something that's old or inaccurate. That it is hard to recover from—those things, and those habits.
“It's so important in my view for you, at this stage when you first start, to make sure if you use copy-paste, whatever you forward that you go through it yourself and you take ownership of everything that is written there,” Dr. Desai added. “Ensure that this is not old information, that the plan is actually an updated plan, that the exam is actually an updated exam.”
It isn’t applicable to every resident, but if you are working or rotating in an outpatient setting, it’s vital to stay on top of your inbox.
“It's easy to get behind on your messages, especially on demanding inpatient rotations. Remember that, at the end of the day, thorough and timely responses to those messages are also an important part of patient care,” Dr. Foster said. It’s vital, he added, to “take a couple of minutes every day to check in on your inbox.”
A checklist can go a long way toward ensuring notes in the EHR are entered thoroughly.
“Having your own routine of a checklist that you go through will help so much, because you know you won't miss anything,” said Mohammad Ibrahim, DO, a second-year family medicine resident at Trinity Health Michigan. “You always go from vitals, to labs, to images, to micro, to pathology or whatever your checklist is. But if you do that systematically and you do that every single time, you'll never miss anything, and your presentations will be great—and then your notes will be great. It's a huge snowball effect.”
Dr. Foster touted speech-recognition programs for helping him save time by dictating his notes.
“If your EMR has the capability to dictate notes, figure out how to use it,” he said. “It's a tremendous timesaver, and you can always edit as you go. Plus, it’s a great wellness tip to keep your hands healthy from the repetitive strain of typing notes all day.”
EHR use for new residents is addressed in the AMA's book, Facilitating Effective Transitions Along the Medical Education Continuum, which is available for free from the AMA's website. (Registration required.)