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Editor's Note
September 2015

Maximizing the EMR’s Educational Potential

JAMA Intern Med. 2015;175(9):1562-1563. doi:10.1001/jamainternmed.2015.2070

Today, a small but significant amount of our education as house officers comes from pop-up alerts in the electronic medical record (EMR). Medical school lectures shaped our understanding of venous thromboembolism prophylaxis, antibiotic stewardship, and transfusion of blood products. In residency, EMR-based clinical decision support (CDS) tools cement the Padua score, empirical antibiotic choices, and appropriate transfusion thresholds. We contend that involving medical trainees in developing CDS tools will increase their value in academic medical centers.

In this issue of JAMA Internal Medicine, Tapper et al1 report on a CDS intervention at a single academic center where providers frequently drew ceruloplasmin levels during initial evaluation of abnormal liver function tests. This expensive practice runs contrary to American Association for the Study of Liver Disease (AASLD) guidelines.2 The authors created an alert that popped up when ceruloplasmin was ordered describing the rarity of Wilson disease and the situations in which the AASLD recommended testing for it. Their before-and-after analysis demonstrated that all ceruloplasmin orders decreased by half and first-pass ceruloplasmin orders—those ordered at the same time as viral hepatitis serologies—decreased even more substantially.

In a recent systematic review of health information technology (IT) implementation, the Office of the National Coordinator for Health IT highlighted well-implemented CDS tools that reduce cost, length of stay, and mortality.3 However, they also find health IT interventions that are ineffective or even detrimental. Too many pop-ups lead to alert fatigue, which limits CDS efficacy and resident physician sanity.4 Among other worries, some fear that trainees may develop so-called “automation bias” by relying on CDS tools to make decisions, rather than thinking critically and independently.5 It is not yet well understood what aspects of CDS tools increase high-value care, clinical efficiency, and trainee education; pinpointing them is crucial to advance the field.3,5

In academic institutions, educator and trainee collaboration has the potential to strengthen CDS.5 Formal quality improvement curricula for house staff could include succinct teaching about the educational value and pitfalls of CDS. Then, educators and trainees can evaluate their institution’s CDS and advocate for tools that are timely, efficient, educational, and evidence based.

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Article Information

Conflict of Interest Disclosures: None reported.

References
1.
Tapper  EB, Sengupta  N, Lai  M, Horowitz  G.  A decision support tool to reduce overtesting for ceruloplasmin and improve adherence with clinical guidelines [published online June 1, 2015.]. JAMA Intern Med. doi:10.1001/jamainternmed.2015.2062.
2.
Roberts  EA, Schilsky  ML; American Association for Study of Liver Diseases (AASLD).  Diagnosis and treatment of Wilson disease: an update. Hepatology. 2008;47(6):2089-2111.PubMedArticle
3.
Jones  SS, Rudin  RS, Perry  T, Shekelle  PG.  Health information technology: an updated systematic review with a focus on meaningful use. Ann Intern Med. 2014;160(1):48-54.PubMedArticle
4.
Ranji  SR, Rennke  S, Wachter  RM.  Computerised provider order entry combined with clinical decision support systems to improve medication safety: a narrative review. BMJ Qual Saf. 2014;23(9):773-780.PubMedArticle
5.
Tierney  MJ, Pageler  NM, Kahana  M, Pantaleoni  JL, Longhurst  CA.  Medical education in the electronic medical record (EMR) era: benefits, challenges, and future directions. Acad Med. 2013;88(6):748-752.PubMedArticle
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