Establishing electronic health record competency testing for first-year residents

Area of Science:

• Medical Education
• Health Informatics
• Clinical Skills Training

Background:

• Electronic health records (EHRs) are widely used in healthcare.
• The proficiency of residents in utilizing EHR systems for essential tasks remains unclear.

Purpose of the Study:

• To evaluate the electronic health record (EHR) skills of first-year residents.
• To identify specific EHR tasks where residents may require additional training and support.

Main Methods:

• Incoming residents underwent mandatory EHR training prior to clinical rotations.
• An assessment tool was developed to evaluate 19 distinct EHR tasks.
• Senior residents evaluated interns using a standardized assessment template.

Main Results:

• Residents demonstrated competence in most ambulatory EHR skills (70%-100%).
• Key areas needing improvement included creating result notes (25%), medication reconciliation (15%), and accessing historical results (15%).
• Most inpatient EHR skills were mastered (63%-100%), with needs identified in placing discharge referral orders (34%), flow sheet data interpretation (21%), and discharge summary completion (21%).

Conclusions:

• Findings offer insights for EHR training programs to refine curricula.
• Institutions can better target training interventions toward specific skill deficits and at-risk resident groups.
• Optimizing EHR training can enhance resident performance and patient care.