Nephrology Fellows Recognize Benefits, Flaws of EHRs

Christina Yuan, MD

Results of a survey suggest electronic health records (EHRs) enhance education for those training to become kidney specialists, but the time demands of data and order entry can be a downside.

Christina Yuan, MD, and a team of investigators assessed educational burdens and benefits of EHR use on US nephrology fellows through a survey. Although beneficial, the results pointed to flaws in the systems and their use.

“It is important to ask faculty and trainee physicians how they perceive the effects of the (EHR) on physician education, and to determine what they think is deleterious and what is value-added,” Yuan said in a statement.

Yuan and colleagues who were active clinical faculty familiar with more than 1 EHR drafted the surveys. Questions were based on comments from recent procedural surveys, studies of unintended consequences and effect of the EHR on postgraduate medical education, and question structure of wellness surveys. Positive and negative statements were included, and surveys were anonymous.

The team anonymously surveyed 148 nephrology program directors who they identified from the Public List of Nephrology Specialty Programs from the Accreditation Council for Graduate Medical Education website. The survey was open from January 28-April 5, 2019. The program directors were asked to forward the anonymous fellow survey link and indicate the number of fellows they sent it to.

There were 8 objectives to the survey questions:

1. To determine whether recipients believed the EHR contributed positively or negatively to fellow education and whether such was on the basis of years of nephrology practice or fellowship training year.
2. To determine the perceived positive and negative effects of EHRs.
3. To describe EHR technical problems and whether fellows perceived them differently from faculty and program directors.
4. To determine whether education in nephrology procedures, didactic conferences, patient interactions, and self-directed case-based literature review was perceived as adversely affected by EHR time demands.
5. To determine whether EHR use increased self-reported stress from fellows when seeing outpatients.
6. To determine how much outpatient encounter time was spent by fellows and faculty on EHR data entry.
7. To determine whether completion time contributed to the risk of exceeding work-hours limitations.
8. To determine whether fellows made mistakes in documentation due to “copy forward.”

Among the program directors who received the survey, 22% forwarded them to faculty (n=387) and fellows (n=216; 26% of US nephrology fellows). Responses rates were 25% for faculty and 33% for fellows.

Just more than half of the fellows (51%) agreed or strongly agreed EHRs contributed positively to their education. Positive effects included access flexibility and ease of obtaining laboratory/radiology results. Negative effects included copy-forward errors and excessive, irrelevant documentation.

More than 40% of those surveyed reported EHR function was slow, disrupted, or completely lost monthly. Such respondents were significantly less likely to agree EHRs contribute positively to their education. Completion time demands led to fellow reluctance to do procedures (52%), participate in conferences (57%), prolong patient interactions (74%), and do patient-directed reading (55%).

A majority of fellows (65%) reported often or sometimes exceeding work-hours limits because of documentation time demands. Most faculty (85%) reported often or sometimes observing copy-forward errors.

"Nephrology fellows and faculty who responded to our survey reported that the (EHR) enhances education and patient care by providing efficient and flexible access to patient lab and x-ray results, but the time demands of data and order entry reduces engagement in educational activities, contributes to work-hour violations, and stifles direct patient interaction,” Yuan said.

The study, “The Electronic Medical Record and Nephrology Fellowship Education in the United States,” was published online in the Clinical Journal of American Society of Nephrology.