Medical Student Use of Electronic Health Records to Track Former Patients

Medical students are increasingly using electronic health records (EHRs) in training. One educational application of EHRs involves tracking former patients after they have left one’s direct care.¹ By providing longitudinal access to future clinical data, EHRs allow students to audit their diagnostic impressions and observe patient outcomes.²

Despite its potential educational value, to our knowledge, little has been written about tracking former patients, and its prevalence is unknown. Some medical students track patients, but this activity is generally extracurricular and it is unclear why they do it.¹ Furthermore, tracking former patients raises ethical questions about the appropriate use of protected health information.^1,3

We conducted a survey to estimate the prevalence of tracking former patients by medical students at our institution. Secondary aims were to examine the perceived value of and ethical concerns associated with such tracking.

We surveyed fourth-year medical students at an academic health center on August 9, 2013. Fourth-year students were selected because they had completed 48 weeks of clinical clerkships in their third year of medical school, giving them time to establish a pattern of EHR use. The survey was administered in paper format at a mandatory class at the start of the academic year. As participation was voluntary and anonymous, the students did not provide consent. No incentives were offered. Students had received no prior guidance on tracking patients via the EHR.

We developed a preliminary, nonvalidated survey consisting of 7 questions about tracking patients and whether it raised any ethical concerns, with space for free-text responses. Questions were informed by a literature review.¹ Approval of the survey was waived by the Northwestern University Feinberg School of Medicine Institutional Review Board. We manually calculated descriptive statistics to estimate proportions and 95% CIs.

A total of 103 of 169 students (60.9%) completed the survey. Of the respondents, 99 (96.1%; 95% CI, 90%-98%) affirmed use of EHRs to track former patients. Of those who track former patients, 92 students (92.9%; 95% CI, 88%-98%) found it beneficial from an educational perspective. Reasons students cited for tracking patients are displayed in the Figure, and methods they used to learn how to track patients are displayed in the Table. Most students indicated that they track patients to confirm diagnoses and follow up on their progress, and 54 students (52.4%) learned to track patients on their own.

Of the 99 respondents who track patients, 17 (17.2%; 95% CI, 9%-24%) had ethical concerns about it. Their primary concern was that it may not be appropriate to access patient records when they are no longer directly involved in the care of those patients.

Nearly all respondents reported tracking former patients in the EHR. Although we had no data to guide our expectations, this result was surprising, especially since tracking patients occurs in the absence of institutional direction. And while our data are confined to a single institution, evidence suggests that tracking patients occurs at other institutions.¹

Less surprising was that nearly all respondents found tracking patients to be educationally beneficial. Tracking demonstrates self-directed learning and curiosity about patient outcomes, qualities that can improve clinical reasoning.^4,5

Although these results may be interpreted positively, they do not tell the whole story. Only a few respondents expressed concerns about the ethics of tracking patients, and almost half did not distinguish between tracking for education (to confirm diagnosis or follow treatment) and tracking out of curiosity about patients, an action that may not represent appropriate use of EHRs.⁶ These results suggest that students may benefit from guidance on tracking former patients in an ethically appropriate manner. There are limitations to this study, including small sample size, lack of a validated survey tool, and potential nonresponse bias even with a response rate of 60.9%.

Results of this survey suggest that tracking patients is a potentially valuable and widely practiced educational activity. However, it is associated with ethical problems that students may not appreciate, and it is unclear how patients view this activity. This topic merits exploration to understand how to optimize tracking for education while protecting patient privacy.

Corresponding Author: Gregory E. Brisson, MD, Northwestern University Feinberg School of Medicine, 1333 W Belmont, Ste 200, Chicago, IL 60657 (gbrisson@nm.org).

Published Online: July 25, 2016. doi:10.1001/jamainternmed.2016.3878.

Author Contributions: Drs Brisson and Tyler had full access to all the data in the study and take full responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Both authors.

Acquisition, analysis, or interpretation of data: Both authors.

Drafting of the manuscript: Both authors.

Critical revision of the manuscript for important intellectual content: Both authors.

Statistical analysis: Both authors.

Administrative, technical, or material support: Tyler.

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the members of the Northwestern Memorial Hospital Medical Ethics Committee, in particular Cynthia Barnard, MBA, MSJS, and Kathy Neely, MD, for their guidance and feedback on this topic. They were not compensated for their contribution.