Clinical Practice in Pediatric Psychology 2015, Vol. 3, No. 2, 179 –181
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COMMENTARY
Electronic Health Records: A Graduate Student’s Experience Claire E. Wallace
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Case Western Reserve University Navigating the use of an Electronic Health Record (EHR) system can be a challenging undertaking for health care providers transitioning from paper documentation systems. As EHR systems are becoming more commonplace, today’s graduate students are often introduced to patient recordkeeping in an electronic format. The challenges for trainees are somewhat different than for established psychologists, as trainees are learning basic principles of confidentiality and documentation in systems that document their every move and are sensitive to error. This commentary serves as a narrative of learning EHR systems from the graduate trainee’s perspective and offers suggestions to trainees and trainers alike to help facilitate the learning process. Keywords: confidentiality, electronic health records, student training
This commentary aims to give an account of learning Electronic Health Records (EHRs) from a trainee’s perspective, incorporating experience with EHRs at different training sites. The author is currently a fourth-year psychology trainee in a clinical psychology doctoral program, and training to date has taken place in schools, hospitals, and training clinics. EHR Training
releases of information or how to transport client notes to supervision sessions. In other cases, supervisors only address issues of confidentiality if the trainee experiences difficulties or asks specific questions. Another complication for graduate students learning an EHR is adjusting to new expectations and procedures that differ by supervisor and by site. Most trainees go through this process on a yearly basis, adapting to writing styles of supervisors and documenting differently depending on the site or the purpose of the documentation. Adjusting to a new supervisor’s style while learning to use an EHR and learning about site-specific procedures becomes complicated. Throughout a student’s training, supervisors differ in the kind of documentation they require. Trainees’ early session notes tend to be detailed and lengthy, offering thorough descriptions of events reported by patients in session. When using an EHR, trainees learn that documentation is often accessible by providers outside mental health. Documentation must be adjusted to fit another setting. Trainees learning an EHR system are in an often-difficult position of learning how to use the EHR while simultaneously learning about confidentiality related issues in the EHR, all while adjusting to a new supervisor in a new setting. I used an EHR at two different hospitals with different approaches to training. In the first setting, my training consisted of a daylong seminar
The EHR provides interprofessional communication and access to patient information that exceeds traditional paper documentation; however, along with it comes with more responsibility to ensure that sensitive patient information remains confidential. The issue of confidentiality in an EHR is more complicated than with paper documentation. Early in graduate training, students learn basic principles of confidentiality: only discuss details of cases with supervisors, keep identifying information locked away, review mandatory reporting rules with all patients. In some cases, supervisors closely monitor patient contact and directly instruct trainees in how to obtain
Correspondence concerning this article should be addressed to Claire E. Wallace, Department of Psychological Sciences, Case Western Reserve University, Cleveland, OH 44106-7123. E-mail:
[email protected] 179
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WALLACE
where I sat alongside doctors, nurses, and other hospital staff, each with vastly different training needs. I received no training specific to documenting mental health notes. I learned on my own by asking clarification from psychologists, social workers, and secretaries on staff. Unfortunately, some privacy and confidentiality issues were discussed only after I made mistakes. For example, I learned after sending several therapy notes to my supervisor that the level of detail I provided about the content of the patient encounter and my impressions of the encounter was too much information for the EHR. In one instance, I recorded in my note an observation that the conflict between parents was a primary contributor to the child’s distress. I learned from the angry father at our next session that a pediatrician had inadvertently shared my observation with the parents. My next practicum placement used the same EHR as the first; however, the training approach was much different. Training was conducted by one of the department’s supervising psychologists in a small group with other psychology trainees. During training, issues of confidentiality were discussed and we were made aware of all the providers who had access to our notes. We learned about features specific to mental health encounters, such as the capability to mark some sections of notes as “sensitive,” which limited access to only mental health providers in the department. Trainees were provided with instructions written for mental health providers and tip sheets for navigating the system. We also received contact information for a staff member who could assist with treatment plans, a particularly tricky part of the system for trainees. Individualized training specific to mental health encounters allows trainees to process the details of confidentiality when using an EHR. For example, how does one protect a child’s private disclosures from the parent if the parent has access to therapy notes? Which aspects of the patient’s medical record can be shared with a noncustodial parent or a stepparent? Lessons Learned Transitioning to using an EHR requires extensive and ongoing on-the-job training; it also can increase awareness of the nuances of confidentiality and interprofessional communication. Using an EHR system can be a valuable
opportunity for trainees to practice communicating with other health care providers, a task made less daunting under the guidance of supervision. What follows are recommendations for trainees and trainers that may make EHR training smoother and more productive for both parties. Recommendations for Trainees First, avoid making assumptions, as incorrect assumptions could lead to poor patient care. Ask supervisors or other providers as many questions as necessary to ensure that documentation and access to information are appropriate. For example, clarify the following: Is the correct title being used in the signature? Is the EHR set up to allow supervisors to review trainee notes before they become accessible to other providers? What aspects of a patient’s medical history are appropriate for trainee viewing? It can be difficult to navigate what information trainees are allowed to access, and this accessibility can vary from site to site. These basics of privacy and confidentiality are being learned in a high-stakes system that is prone to human error. When in doubt, ask for clarification. Second, writing EHR notes is much different than writing notes in a department clinic or even a community mental health center. During graduate school, focus is typically placed on learning to write psychotherapy notes; thus, many students do not know the difference between a psychotherapy note and a progress note. A progress note lists brief information related to diagnosis, interventions administered, progress toward treatment goals, and next steps in treatment (Steinfeld & Keyes, 2011). A psychotherapy note may include more sensitive information such as the therapist’s impressions and details of patient history or emotional functioning that patients prefer to keep private (Richards, 2009). Especially in settings where any provider can access treatment notes, details should be provided carefully and sparingly (Nielsen, Baum, & Soares, 2013). Further, every EHR entry should be carefully proofread for errors. Trainee notes become a permanent part of patient medical records just as physician notes, so trainees should take extra care to ensure spelling, gender pronouns, and other patient information is accurate in every note.
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ELECTRONIC HEALTH RECORDS
Third, trainees are responsible for their own actions, and they have a responsibility to practice and advocate for patient privacy and confidentiality. Although supervision is a vital aspect of training, not every student action can be overseen. Trainees have the responsibility, for example, of logging out of the record system each time they step away from a computer and blocking the screen from patient view if other patient names are visible while scheduling. Trainees can also help protect patients by holding each other accountable. Recommendations for Trainers The most valuable training in EHRs I received was delivered by mental health professionals who were familiar with using the EHR system for mental health purposes. An orientation to EHRs that includes written notes for trainees to reference as they navigate the system is hugely helpful and can reduce trainee error. A note or “tip sheet” may include locations within the EHR to find useful information (e.g., growth chart, letters, patient contact information), common smart phrases, and steps for documenting patient encounters (e.g., progress note, diagnosis, billing, routing note to supervisor). Providing a tip sheet specific to mental health encounters allows trainees to become familiar with important aspects of the system that may not be highlighted in a general EHR training module. Introduction to the EHR system by mental health professionals also opened the door for important conversations about privacy and documentation. Trainees received additional indepth exposure to nuances in patient confidentiality and ethical issues that are brought to light with electronic documentation. Helpful discus-
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sions touched on issues such as confidentiality in nonintact families, types of information to exchange in coordinating treatment among disciplines, and specific information trainees are permitted, or not permitted, to access. Trainers may consider taking EHR instruction as an opportunity to expand trainees’ knowledge and understanding of ethics in practice. In addition, trainers should be aware of how they communicate with students about EHR issues. Utilization of EHRs should certainly to be taken seriously, but communication that feels punitive or overly harsh in nature may prevent trainees from asking questions or admitting potential errors when they occur. Coming alongside students in the training experience facilitates the kind of openness and communication that are vital to the successful learning of EHR systems. References Nielsen, B. A., Baum, R. A., & Soares, N. S. (2013). Navigating ethical issues with electronic health records in developmental-behavioral pediatric practice. Journal of Developmental and Behavioral Pediatrics, 34, 45–51. http://dx.doi.org/ 10.1097/DBP.0b013e3182773d8e Richards, M. M. (2009). Electronic medical records: Confidentiality issues in the time of HIPPA. Professional Psychology: Research and Practice, 40, 550 –556. http://dx.doi.org/10.1037/a0016853 Steinfeld, B. I., & Keyes, J. A. (2011). Electronic medical records in a multidisciplinary health care setting: A clinical perspective. Professional Psychology: Research and Practice, 42, 426 – 432. http://dx.doi.org/10.1037/a0025674 Received April 1, 2015 Revision received April 6, 2015 Accepted April 7, 2015 䡲
