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Using the Electronic Health Record to Identify Educational Gaps for Internal Medicine Interns.

Alvin Rajkomar, Sumant R Ranji, Bradley Sharpe

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|March 7, 2017

Summary

First-year residents gain varied experience with common diagnoses during internal medicine rotations. Automated analysis of clinical notes can help programs assess this inpatient clinical exposure.

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Area of Science:

Medical Education
Internal Medicine
Health Informatics

Background:

Clinical immersion during core rotations is crucial for internal medicine residency.
First-year residents (PGY-1s) need exposure to common diagnoses.

Purpose of the Study:

To quantify the clinical experience of residents with common diagnoses.
To analyze documentation in electronic health records for intern experience assessment.

Main Methods:

Analysis of 53,066 clinical notes from PGY-1, PGY-2, and PGY-3 residents.
Quantification of 'diagnosis-days' based on principal billing diagnoses (ICD-9, CCS).
Assessment of PGY-1 exposure to top diagnoses and diagnostic categories.

Main Results:

Top 10 ICD-9 diagnoses comprised 23% of diagnosis-days; top 10 CCS categories comprised over 40%.
Only 3% of PGY-1s encountered all top 10 ICD-9 diagnoses; 17% encountered all top 10 CCS diagnoses.
Significant variability in exposure: 31% of PGY-1s saw fewer than 5 top ICD-9 diagnoses.

Conclusions:

Inpatient clinical experience varies significantly among first-year residents.
Automated analysis of clinical documentation offers a method to review resident experience.
This approach can aid residency programs in evaluating and enhancing clinical exposure.