When learning a healthcare speciality, whether it be nursing, medicine, physiotherapy, pharmacy and more, how often are you taught about medical records? Not very much as common practice is you find out ‘on the job’. A major reason for this is that every hospital, clinic and health site may do things differently.
Paper and pen are easy to use and facilitate, additionally, writing does actually improve memory retention. However, not every health workers’ writing is clear and not every storage facility and the logistics around paper-based medical records are sufficient. Hence, electronic health records are becoming the norm and for many new graduates, they always have been.
Coming back to my point, how much were you taught about record-keeping during your training years? A new study by Akshay Rajaram and colleagues, based in Ontario, Canada looked at multiple research papers, as part of a systematic review, to get a greater understanding of training around Electronic Health Records (EHRs). No surprise to see all the studies had a practical element to their training, yet, what was fascinating is that many did not cover data visualization and the use of the data itself. This is a huge, critical gap that must be filled, otherwise, there is no real advantage in an EHR if the data cannot be used appropriately due to the absence of training.
Overall the authors call for this gap to be closed. It should be done so rapidly, as EHRs are now in every major hospital in North America and Europe. Smaller sites vary as does the compatibility between EHRs, therefore the training must not only be at the training level but also at the employment level, i.e as part of your induction. EHRs are becoming more accessible, with some very good open-source providers, such as Open EMR. This is essential, especially in low resource settings where financial support is minimal or non-existent. Just because you have the software does not mean the system is fixed, you still need to provide the training and the more that can be done before students become professionals, the better.