Using the Electronic Health Record to Identify Practice-Based Learning Opportunities

Purpose: Feedback is inextricably linked to the core competency of practice-based learning and improvement (PBLI). Specifically, clinical feedback (or follow-up)—information that can often be found in electronic health records (EHR) related to a patient’s evolving condition—can often point to key areas for improvement.1,2 Even though the Accreditation Council for Graduate Medical Education (ACGME) has called for increased use of EHR to provide individualized data to residents, this type of clinical follow-up data, and its relation to PBLI, is relatively understudied.3 A better understanding of residents’ interest in clinical feedback may enhance the use of EHR for education. The purpose of our study was to characterize why and on which patients residents want clinical feedback and what type of follow-up information they would want included in the clinical feedback. Method: We conducted a cross-sectional survey study of residents in Pediatrics and Internal Medicine (IM) on inpatient rotations during 2020–21. Participating residents completed surveys about their interest in follow-up data about patients. A novelty of this study is that surveys were linked to specific patients whose chart had been opened by the resident in the past 24 hours. Surveys included questions on the role the resident played in the patient’s care, whether they were interested in clinical feedback, and, if so, what type and why they were interested (or in what situations they would be interested). Surveys were sent every other day for 2 weeks (total of 7 survey-days) on up to 10 unique patients. We report on the descriptive statistics and the results from chi-square tests comparing the responses from the cases indicating desire for clinical follow-up versus no desire. Results: 42 participants completed an average of 23 surveys during the 2-week period with 958 total surveys in the analysis. Residents wanted feedback or follow-up on 32% of unique, first-time queried patient encounters (n = 315/958). There was no significant difference between pediatric and IM residents (28.9% [n = 117/405] vs 33.4% [n = 137/410, P = .163]) in the proportion of those wanting clinical feedback. The most cited reasons for wanting follow-up were when the resident made significant decisions for the patient, followed by feeling responsibility/ownership for the patient, and the least cited reasons were when the resident was concerned about vulnerability of the patient/family or the resident had personal attachment to the patient/family. Residents were more interested in feedback on encounters with higher severity of illness scores. The most desired type of follow-up information was “if something significant or unexpected happened,” followed by feedback from a supervisor or colleague on the resident’s clinical management. The least desired type of feedback/follow-up information was information in aggregated quality metrics. Discussion: We identified that residents were interested in follow-up on less than half of their clinical encounters on inpatient rotations suggesting that the PBLI competency is not sufficiently aligned with realities of clinical practice, and residents may not perceive that they can receive meaningful data from every patient encounter. Also, our results suggest that the type of clinical feedback desired needs to be considered for meaningful feedback. Focusing on “unexpected outcomes” or when residents felt responsible for care or were heavily involved in decision making could produce better opportunities for practice-based learning. Alternatively, faculty may need to help residents understand the learning that comes from feedback on a broader population of the patients. Furthermore, future work should investigate residents’ motivation or demotivation for follow-up. Significance: Without more consideration of what residents consider useful data and of how to motivate residents to seek such data, attempts at harnessing EHR for medical education may never reach full potential

Accreditation · Electronic health record · Family medicine · Graduate medical education · Health care · Medical education · MEDLINE · Novelty · Healthcare Systems and Technology · Innovations in Medical Education · Medicine · Nursing · Primary Care and Health Outcomes · Psychology