EHRs, big data take medical curriculum to school

The future of medical school is — almost — here.

More and more, technology is shaping what medical schools teach, how professors teach it and how students learn.  

"There are not a lot of microscopes anymore," laughed Morgan Passiment, director of healthcare affairs for the Association of American Medical Colleges. Cadavers could soon be on their way out too, in favor of virtual anatomy. Instead, schools are beginning to incorporate EHRs, simulation, data analytics and new instructional approaches inspired by mHealth and telemedicine.

Medical school students now need to learn more technology-based skills, which require new settings and strategies that break from the traditional lecture hall environment. The challenge medical schools face is in preparing students for roles that continue to shift as care models and technologies change.

"This is a new era for medical education and it parallels the changes that are happening in our healthcare delivery system," says Marc Triola, MD, associate dean of educational informatics and the director of the Institute for Innovations in Medical Education at NYU School of Medicine.

But curriculum evolves slowly, Ms. Passiment says. Changes are typically reviewed and formalized every eight to 10 years.

"We knew there was a consensus out there for what had to change, but it wasn't happening," says Susan Skochelak, MD, AMA vice president of medical education and director of the AMA Center for Transforming Medical Education.

That's why the AMA decided in 2013 to launch its Accelerating Change in Medical Education Program, which awarded $11 million in grant funding to 11 medical schools. When the AMA put out a request for applications, nearly 85 percent of American medical schools responded, according to Dr. Skochelak.

"People want to teach IT, but they don't have the resources or don't know how to teach it," she says.

The 11 chosen schools were tasked to form a consortium and develop new curricula and learning strategies to share with other institutions around the country. Through 2018, the 11 selected universities, including Indiana University School of Medicine, NYU School of Medicine and Vanderbilt University School of Medicine, will be in the implementation stages of their individual curriculum projects.

The AMA's program isn't the only initiative focused on updating medical school curriculum. The ONC sponsors a Curriculum Development Centers Program, for example, which has awarded schools like Oregon Health and Science University with $2.7 million to overhaul curriculum and include new emphases, like EHRs.

While there is still not consistent integration of health IT across medical schools, pockets are diving into technology-based curricula, according to Ms. Passiment.

"The challenge we have right now is helping our learners understand the role technology can play in healthcare, and focusing on care outcomes, not on technology. Technology is a tool," says Ms. Passiment.

The disappearing paper trail

Just as hospitals strive to integrate EHRs as a tool for improved patient care, many medical schools still grapple with how to best integrate EHRs into curriculum, Dr. Skochelak says. Some universities continue to teach old-school paper record-keeping first, while others debate the use of templates. Meanwhile, at the residency level, students are missing the opportunity to use EHRs due to lack of training or HIPAA restrictions, she says.

"The challenge for educators at the beginning level and at the medical school level is we don't know the methods or the pedagogy that work best," says Dr. Skochelak.

IU School of Medicine, based in Indianapolis, is working to develop better methods and pedagogy to incorporate the EHR in a learning environment. It received a $1 million Accelerating Change in Medical Education grant from the AMA for its proposal to develop a virtual health system and teaching EHR, which would let future physicians practice clinical decision making in a realistic environment.

"I want our medical students to understand this. If I just put them in a lecture hall and talk at them, they won't get it," says Sara Jo Grethlein, MD, associate dean for undergraduate medical education and professor of clinical medicine in the division of hematology and oncology at IU School of Medicine.

"It's not just about [the students]; they have a place in a big, complex system, and they need to learn how to function and how they are assessed in that system, so they can thrive in that system," she says.

IU worked with the Indianapolis-based Regenstrief Insitute, an informatics research organization, and with the support of Eskenazi Hospital in Indianapolis it launched a fully functional teaching version of its EHR a year into the implementation stages of the grant. The tEHR uses real, carefully de-identified patient data from roughly 10,000 patient charts, down to the written notes.

The tEHR stands alone, unconnected to the hospital system, so students are free to write in orders and notes in a simulated environment where it can't hurt anybody, Dr. Grethlein says.

Second-year students at IU will soon start using the tEHR. They will receive 12 sessions across the year learning about systems-based practice and big data, according to Dr. Grethlein.

Now officials are developing activity-based assignments for third-year students to incorporate into their rotation schedules. For example, students could be assigned a hypothetical patient in the tEHR with cholecystitis, or a "hot gallbladder", who received gallbladder surgery. The student will then be asked to go into the tEHR, look at the labs and imaging tests performed during the patient stay and justify each of them, Dr. Grethlein says. If they cannot do so, she says, they must find out how much money was wasted on unnecessary tests.

The ideas behind the tEHR are not entirely new — Dr. Grethlein says she used to have students write down tests that weren't justified on index cards — but, "it's just a slicker, higher-tech way of doing the same thing."

The most important part is showing students how to use the EHR as a tool to better understand their role in providing care.

"It's not just how you put in notes or orders, it's how you use it as a tool to answer clinical questions and design intervention," says Dr. Skochelak.

Getting a hold of big data

To use EHRs as a tool, it is increasingly important for physicians to understand how to make data from EHRs and other sources actionable at the point of care.

"The analytics piece, just like the EHR, becomes the tool and mechanism to provide care. Many schools are headed in this direction, however, I don't believe it is consistent across medical education," says Ms. Passiment with the AAMC.

Clinical informatics became a certified subspecialty only a few years ago, in September 2011. It emphasizes data management to help improve how providers, patients and trainees use the information to improve overall health.

"There is a real challenge in getting people to fill the applied analytics positions in healthcare because you have to have some understanding and background in healthcare as well as analytics," says Ms. Passiment. Giving all future physicians some training in the data analytics portion of informatics could help address this challenge.

NYU School of Medicine, which also received Accelerating Change in Medical Education funding, is working to add data analytics into its traditional doctoring course, called "Practice of Medicine."

"NYU is using big data," says Dr. Skochelak with the AMA. "And I mean big data."

Big as in 5 million de-identified patient records. NYU students are learning to approach big clinical data sets and analyze them to measure providers' performance. They're challenged to think critically about healthcare and ask their own questions of the data, which is compiled from a publically available database called SPARCS, or the Statewide Planning and Research Cooperative System. Launched in 1979, the New York State database houses hospital admission and discharge information, patient diagnoses, treatments and charges, and outpatient services information. NYU combined this with CDC nutrition surveys and NYU Langone Medical Center's own patient data, providing students with access to millions of de-identified records.

The big data then becomes a learning tool. For example, in a pilot class NYU launched last summer, students were asked, "What do you think is the most likely reason a person is hospitalized in the state of New York?"

Most guessed chest pain or pneumonia, Dr. Skochelak says. They were surprised to learn the number one reason for hospitalization in New York is actually childbirth. They were even more surprised when they saw the fluctuation in cost for this service across the state. Delivering a baby costs $2,000 to $3,000 in rural areas, but up to $22,000 in Manhattan, Dr. Skochelak says. Students are challenged to think about why this discrepancy exists and track their own patient and population management activities and queries.

"What our students love most about this is the fact that it's real," says Dr. Triola. "It's not a textbook exercise; it's real clinical data. It's the environment students will be training in and potentially working in."

By October 2014, administrators were so impressed by the pilot they wanted the whole class to have the lesson, Dr. Skochelak says. It is now a core part of the medical curriculum and the entire first year class has taken the course, entitled "Healthcare by the Numbers."

Adding data analytics to the curriculum helps move NYU toward competency-based education, Dr. Triola says. It helps students acquire the tools they need to continue to learn throughout their careers. So, even though medical students are now tackling data analytics and other IT skills in addition to anatomy and biochemistry, Dr. Triola doesn't believe medical school needs to be longer.

"What I do think we need to do is begin using some of these technologies to make medical education more of a continuum," he says.

Applying IT to learning processes

Nashville-based Vanderbilt University School of Medicine did just that, by not only incorporating technology into what professors teach, but also into how students learn.

Vanderbilt calls it Curriculum 2.0.

The new curriculum applies not only to clinical outcomes or patient records, but to students and their learning trajectories. It documents achievements, competencies, faculty ratings and assessments in a portfolio for each student. It is also populated with hospital notes students enter in the EMR during their clerkships, automatically capturing their panel of patients, so they can use it as a teaching space.

Vanderbilt provides each student with a portfolio coach, who they keep throughout their time in school. Students are scheduled to periodically meet with their coaches to talk about their progress and performance.

"It allows us to ask students, 'How can we help you be the very best that you can be?' For high performers, we can ask, 'Given where you are, what else can you do?'" says Kim Lomis, MD, associate dean of undergraduate medical education and associate professor of surgery at Vanderbilt.

The advantage of this system is that it allows students to progress through medical school in a flexible way, Dr. Skochelak notes. Students advance through competencies based on performance, rather than time. This works well for some students who may need more — or less — time in medical school. Physical therapists who decide to go back to medical school, for example, could potentially acquire all the necessary competencies in a time frame shorter than the traditional four-year period, she says.

More importantly, it helps ensure students are building skills like communication, skills that could potentially fall through the cracks in a lecture hall-structured, knowledge-based curriculum, according to Dr. Lomis.  

"It's very much in the spirit of patient safety. It's making sure people are prepared for the roles they're going into," she says.

Vanderbilt's Curriculum 2.0 is more focused on team-based, active learning and puts students into the workplace sooner, Dr. Lomis says. Instead of the traditional two years of basic science, students go into clinics in their second year and the school weaves the remaining science courses through all four years.

"The new curriculum is not only focusing on content, but also on teaching students how they will learn throughout their whole career," she says.

* * *

Technology and technology-based learning strategies are helping medical schools like IU, NYU and Vanderbilt shift into collaborative, interactive learning environments, which may be better suited for a new generation of physicians.

"Students are used to a much more networked, engaged sharing environment and healthcare is not yet like that," says Ms. Passiment. "It's a much more structured tech environment. It's clunky for a lot of learners. It's challenged them to create their own workaround, which allows us to see what the next generation of care will look like."


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