Daniel B. Evans

The Patient Centered Medical Home as Curricular Model: Perceived Impact of the “Education-Centered Medical Home”

BackgroundThe patient-centered medical home (PCMH) model aims to provide patient-centered care, lower costs, and improve health outcomes. Medical students have not been meaningfully integrated in this model.AimTo test the feasibility of a longitudinal clerkship based on PCMH principles and anchored by PCMH educational objectives.SettingTwo community-based family medicine clinics, one academic internal medicine clinic, and one pediatric clinic affiliated with an urban medical school.Participants56 medical student volunteers.Program DescriptionWe embedded student teams in existing faculty practices and recruited a high-risk patient panel for each team. Clinical education occurred through a traditional clinic preceptor model and was augmented by 3rd and 4th year students directly observing 1st and 2nd year students. Didactic content included monthly Grand Rounds conferences.Program EvaluationStudents attended 699 clinics, recruited 273 continuity patients, and participated in 9 Grand Rounds conferences. Student confidence with PCMH principles increased and attitudes regarding continuity were highly positive. “Continuity,” “early clinical exposure,” and “peer teaching” were the most powerful themes expressed by students. Faculty response to the pilot was highly positive.DiscussionAn Education-Centered Medical Home (ECMH) is feasible and is highly rated by students and faculty. Expansion of this model is underway.

Four-Year Educational and Patient Care Outcomes of a Team-Based Primary Care Longitudinal Clerkship.

Background Longitudinal clerkships show promise in improving undergraduate primary care education. This study examines the Education-Centered Medical Home (ECMH), a longitudinal clerkship embedding teams of students across all four years into primary care clinics to provide patient care and serve as health coaches for high-risk patients. Method All students graduating in 2015 were surveyed to assess attitudes, experiences, and preferences regarding primary care education. ECMH students were compared with students receiving their primary care training in a traditional curriculum (TC) using paired measures of comparison. To assess the impact of the ECMH on patient care quality, authors performed a detailed chart review at one site. Results Seventy-six percent of eligible students participated in the study. ECMH students (n = 69) and TC students (n = 68) had similar baseline academic performance and career interests. ECMH students reported more continuity-of-care experiences, higher satisfaction with their primary care learning climate (86% versus 61% in the EMCH and TC cohorts, respectively), more confidence in their quality improvement skills, and scored higher on measures of perceived patient centeredness. Students from both groups recommended the ECMH (91% and 57%, respectively). Student involvement at one ECMH site was correlated with increased patient contacts and improved delivery of recommended preventive care. Conclusions Incorporating students longitudinally into primary care clinics is highly rated by students. The ECMH model led to improved continuity, improved perceptions of the learning climate, and higher patient centeredness. Preliminary data suggest that students add value and improve patient outcomes during longitudinal clinical experiences.

Medical students' observations, practices, and attitudes regarding electronic health record documentation.

Background: Medical students are increasingly documenting their patient notes in electronic health records (EHRs). Documentation short-cuts, such as copy–paste and templates, have raised concern among clinician-educators because they may perpetuate redundant, inaccurate, or even plagiarized notes. Little is known about medical students’ experiences with copy-paste, templates and other “efficiency tools” in EHRs. Purposes: We sought to understand medical students’ observations, practices, and attitudes regarding electronic documentation efficiency tools. Methods: We surveyed 3rd-year medical students at one medical school. We asked about efficiency tools including copy–paste, templates, auto-inserted data, and “scribing” (documentation under a supervisors name). Results: Overall, 123 of 163 students (75%) responded; almost all frequently use an EHR for documentation. Eighty-six percent (102/119) reported at least sometimes observing residents copying data from other providers’ notes and 60% (70/116) reported observing attending physicians doing so. Most students (95%, 113/119) reported copying from their own previous notes, and 22% (26/119) reported copying from residents. Only 10% (12/119) indicated that copying from other providers is acceptable, whereas 83% (98/118) believe copying from their own notes is acceptable. Most students use templates and auto-inserted data; 43% (51/120) reported documenting while signed in under an attendings name. Greater use of documentation efficiency tools is associated with plans to enter a procedural specialty and with lack of awareness of the medical school copy–paste policy. Conclusions: Students frequently use a range of efficiency tools to document in the electronic health record, most commonly copying their own notes. Although the vast majority of students believe it is unacceptable to copy–paste from other providers, most have observed clinical supervisors doing so.

Educating future physicians to track health care quality: feasibility and perceived impact of a health care quality report card for medical students.

Purpose Quality improvement (QI) requires measurement, but medical schools rarely provide opportunities for students to measure their patient outcomes. The authors tested the feasibility and perceived impact of a quality metric report card as part of an Education-Centered Medical Home longitudinal curriculum. Method Student teams were embedded into faculty practices and assigned a panel of patients to follow longitudinally. Students performed retrospective chart reviews and reported deidentified data on 30 nationally endorsed QI metrics for their assigned patients. Scorecards were created for each clinic team. Students completed pre/post surveys on self-perceived QI skills. Results A total of 405 of their patients’ charts were abstracted by 149 students (76% response rate; mean 2.7 charts/student). Median abstraction time was 21.8 (range: 13.1–37.1) minutes. Abstracted data confirmed that the students had successfully recruited a “high-risk” patient panel. Initial performance on abstracted quality measures ranged from 100% adherence on the use of beta-blockers in postmyocardial infarction patients to 24% on documentation of dilated diabetic eye exams. After the chart abstraction assignment, grand rounds, and background readings, student self-assessment of their perceived QI skills significantly increased for all metrics, though it remained low. Conclusions Creation of an actionable health care quality report card as part of an ambulatory longitudinal experience is feasible, and it improves student perception of QI skills. Future research will aim to use statistical process control methods to track health care quality prospectively as our students use their scorecards to drive clinic-level improvement efforts.

The patient-centered medical home as a curricular model: Medical students need an "educational home"

huge increases in medical knowledge, technology and specialization in recent decades have interacted with a now nearchaotic system of health care delivery, magnifying the challenges facing medical education.... Those who teach medical students and residents must choose whether to continue in the direction established over a hundred years ago or take a fundamentally different course, guided by contemporary innovation and new understanding about how people learn.2