Athletic Training Students’ Use of Health Information Technology Professional Behaviors During Clinical Experiences

Design

This study was part of a larger investigation to understand the nature and extent of patient care opportunities that exist for professional ATSs during clinical experiences.^14,15 To collect data for this study, we used a panel design across multiple sites to track various characteristics of the PEs ATSs engaged in during their scheduled clinical experiences. The data for each unique PE were captured via the Case Logs module feature of the E*Value software (MedHub) by professional ATSs across 12 institutions during the span of 1.5 academic years. We received institutional research board approval from the sponsoring institutions before data collection. When necessitated, institutional review board approval was also received from the individual participating programs.

Participants

We recruited program administrators of CAATE-accredited professional athletic training programs to participate in this study. To be eligible to participate, programs must (1) have used the E*Value platform for PE tracking programmatically for at least 1 year before this study, (2) require students to record the PEs they engage in during scheduled clinical experiences in the Case Logs modules of E*Value, and (3) have a 3-year Board of Certification exam aggregate first-time pass rate greater than 85%. During recruitment, 12 of the 15 programs that met all study criteria agreed to participate for the duration of the study. Since data collection of this study occurred while professional programs were beginning to transition to the graduate level, 5 participating programs were at the undergraduate level, while 7 were at the graduate level. A total of 363 professional ATSs from the 12 participating programs were enrolled in this study. One member of the research team conducted virtual training sessions with the students and program administrators of each participating program before data collection. The virtual training sessions focused on a detailed review of the Case Log Module feature in E*Value, operational definitions for all variables, strategies for timely data entry, and an opportunity for administrators and students to ask clarifying questions. Additional details about recruitment, training, and characteristics of the participating programs have been published elsewhere.^14,15

Instrumentation

Due to the frequency of use by several professional athletic training programs, we selected the Case Logs Module within the E*Value platform as the mechanism to collect data for this study. For each PE, students were required to record several characteristics about (1) the PE itself, (2) their role during the PE, and (3) the core competency–related professional behaviors they engaged in during the PE. Specific details about the characteristics recorded for each PE have been published elsewhere.^14,15 For this study, we assessed the HIT-related professional behaviors to determine which PE variables were more likely to contribute to a student’s involvement with HIT. The specific professional behaviors associated with HIT that students were asked to record are available in Table 1.

Table 1Professional Behaviors of Health Information Technology

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Procedures

To ensure data collection procedures were well established and the data collected were of high quality, only 3 of the 12 participating programs collected data during the spring 2018 semester. After a quality control assessment, the remaining 9 programs began data collection at the beginning of the fall 2018 semester. All 12 programs required students to track all PEs they engaged with during their scheduled clinical experiences for the full 2018–2019 academic year. During data collection, program administrators downloaded the data entered from E*Value every other week and securely transferred it to the research team. The research team reviewed the data shared by the program administrators biweekly to ensure data quality was maintained. Data collection concluded after the spring 2019 semester, and each program received a participation honorarium.

Data Analysis

Since no major changes were made to the data collection procedures, the data submitted by the 3 programs that participated during the spring 2018 semester were included in the full dataset for analysis. We examined all data using SPSS (version 27; IBM Corp). Students’ professional behaviors associated with HIT during PEs were compiled using descriptive statistics, including frequencies, means, and standard deviations. We calculated relative risk ratios (RRs) to determine the likelihood that students included any of the professional behaviors associated with HIT during each PE. Generalized estimating equation (GEE) models with Poisson distributions and robust covariance estimators were used for these analyses. The results are expressed as a proportionate difference relative to the reference category. For example, the finding that students were more likely to use information from an electronic health/medical record (EHR/EMR) to assist with clinical decision-making during encounters of 16 to 30 minutes (RR = 1.52) compared with PEs of 1 to 15 minutes means that the 16- to 30-minute encounters were associated with a 52% increased likelihood of using EHR/EMR information relative to those lasting 1 to 15 minutes.

Potential predictor variables for analysis comprised several PE characteristics, including clinical site type (college or university, high school, clinic, or other), length of encounters (1 minute to >60 minutes), and student role (observed the PE, assisted their preceptor with the PE, or performed the PE under preceptor supervision).^14,15 For all HIT-related professional behaviors that students included during PEs, we used an analogous GEE approach to examine the association of PE characteristics on the composite opportunities (ranging from none of the behaviors to all of the behaviors, 0–2 behaviors). Only those predictors that significantly contributed to the equation were included in the final model. Pairwise comparisons were also subjected to sequential Bonferroni corrections. We established an a priori significance level of 0.05 for all analyses.

Documenting the PE in an Electronic Records System

Length of encounter (χ²[4] = 38.1, P < .001), student role (χ²[2] = 16.9, P < .001), and clinical site type (χ²[3] = 8.1, P = .04) were associated with whether the student documented information obtained from the PE in an EHR/EMR. When compared with PEs of 1 to 15 minutes (n = 18 017 PEs), students engaging in PEs of 16 to 30 minutes (n = 8819 PEs; RR = 1.30; 95% CI = 1.17, 1.44; P < .001), PEs of 31 to 45 minutes (n = 2327 PEs; RR = 1.64; 95% CI = 1.37, 1.94; P < .001), PEs of 46 to 60 minutes (n = 903 PEs; RR = 1.53; 95% CI = 1.29, 1.80; P < .001), and PEs longer than 60 minutes (n = 452 PEs; RR = 1.35; 95% CI = 1.02, 1.79; P = .03) were more likely to document information obtained from the PE in an EHR/EMR. Students who performed the PE (n = 21 798 PEs) under the supervision of their preceptor (RR = 1.46; 95% CI = 1.21, 1.75; P < .001) or assisted their preceptor during the PE (n = 5051 PEs; RR = 1.24; 95% CI = 1.05, 1.46; P < .01) were more likely to document information obtained from the PE in an EHR/EMR than students who observed their preceptor completing the PE (n = 3669 PEs). Students participating in clinical experiences in the high school setting (n = 8307 PEs; RR = 0.75; 95% CI = 0.60, 0.92; P = .007) were less likely to document information obtained from the PE in an EHR/EMR than students participating in clinical experiences in the college or university setting (n = 20 016 PEs).

Using Information From an Electronic Records System

Students’ use of information from an EHR/EMR to assist with the clinical decision-making process during PEs was associated with length of encounter (χ²[4] = 19.8, P = .001) and clinical site type (χ²[3] = 30.5, P = < .001). Students were more likely to use of information from an EHR/EMR to assist with the clinical decision-making process when the length of the encounter was 16 to 30 minutes (RR = 1.52; 95% CI = 1.17, 1.96; P = .002), PEs of 31 to 45 minutes (RR = 2.54; 95% CI = 1.58, 4.06; P < .001), PEs of 46 to 60 minutes (RR = 2.05; 95% CI = 1.42, 2.93; P < .001), or longer than 60 minutes (RR = 2.79; 95% CI = 1.53, 5.08; P = .001) than PEs that were 1 to 15 minutes. Regarding clinical site type, students were more likely to use information from an EHR/EMR to assist with the clinical decision-making process in the clinic setting (RR = 3.20; 95% CI = 2.10, 4.87; P < .001) than the college or university setting.

Implemented No HIT Behaviors

The likelihood that students implemented no professional behaviors related to HIT was associated with student role (χ²[2] = 12.8, P = .002), clinical site type (χ²[3] = 17.4, P = .001), and length of encounter (χ²[4] = 34.2, P < .001). Students who performed the PE (RR = 0.88; 95% CI = 0.81, 0.94; P < .001) or assisted their preceptor with the PE (RR = 0.93; 95% CI = 0.87, 0.99; P = .02) were less likely to implement no HIT behaviors than those who observed their preceptor performing the PE. Students participating in clinical experiences in the high school setting (RR = 1.13; 95% CI = 1.03, 1.22; P = .005) or other setting (n = 587 PEs; RR = 1.69; 95% CI = 1.24, 2.31; P = .001) were more likely to implement no HIT behaviors than students participating in clinical experiences in the college or university setting. When compared with PEs of 1 to 15 minutes, students were less likely to implement no HIT-related professional behaviors during PEs of 16 to 30 minutes (RR = 0.88; 95% CI = 0.83, 0.92; P < .001), PEs of 31 to 45 minutes (RR = 0.73; 95% CI = 0.63, 0.83; P < .001), PEs of 46 to 60 minutes (RR = 0.77; 95% CI = 0.68, 0.85; P = .001), or PEs longer than 60 minutes (RR = 0.82; 95% CI = 0.69, 0.96; P = .02).

Composite HIT Behaviors

The total number of HIT-related professional behaviors included during a PE were affected by the length of the encounter (χ²[4] = 38.9, P < .001). When compared with PEs of 1 to 15 minutes, students were likely to implement more HIT-related professional behaviors during PEs of 16 to 30 minutes (RR = 1.33; 95% CI = 1.19, 1.48; P < .001), PEs of 31 to 45 minutes (RR = 1.78; 95% CI = 1.43, 2.19; P < .001), PEs of 46 to 60 minutes (RR = 1.61; 95% CI = 1.36, 1.90; P < .001), and PEs longer than 60 minutes (RR = 1.53; 95% CI = 1.10, 2.09; P < .001).

Documenting in an EMR/EHR

Documenting patient care in an EMR or EHR is not only a component of the CAATE curricular content standards for professional athletic training programs, but it is also a recommendation included in the Best Practice Guidelines for Athletic Training Documentation disseminated by the National Athletic Trainers’ Association (NATA).^8,16 For students to become proficient and consistent documenters as they enter clinical practice, it is imperative that they are provided continual opportunities to document actual patient care during clinical experiences. Our findings suggest that nearly two-thirds of all PEs experienced by ATSs during clinical experiences do not allow for any engagement with an electronic patient care documentation system.

Previously, researchers identified some of the barriers that preceptors face in teaching documentation to students within clinical practice.¹⁷ As is common with most tasks associated with athletic training practice, 1 common barrier to teaching this content was time.¹⁷ Our findings indicated that the amount of time spent with the patient was an influencing factor to documenting PEs in an EMR or EHR, with longer PEs resulting in an increased likelihood for this behavior. As most health care documentation does not occur during the patient interaction, we interpret this finding to indicate that longer PEs generate more information that likely warrants documentation.¹⁸ Given that time is a barrier for most ATs’ documentation practices, preceptors face an added time challenge of having to guide students through the documentation practice which may result in several iterations of documentation attempts and revisions.^17,19 When time is limited, this may decrease the likelihood for a preceptor to provide opportunities for students to engage in documentation to facilitate expeditious completion of the requisite task.

Our findings also indicated that students were most likely to document in an EMR or EHR when performing or assisting their preceptors with the PE and were least likely to do so when observing their preceptor perform the PE. The latter finding seems appropriate since the preceptor was performing the encounter; they would be the appropriate person to document it accordingly. However, given that students did not document in an EMR or EHR for 62.8% of their performed PEs, it is unclear who, if anyone, electronically documented those patient interactions.

The only other clinical experience characteristic that influenced documentation in an EMR/EHR by students in our study was clinical setting, with students in secondary school clinical experiences being 25% less likely to document in an EMR/EHR. This finding is not surprising, as previous researchers have identified that ATs in the secondary school setting faced several barriers to documenting patient care, including time, technology issues, and patient volume.^20,21 Preceptors in secondary schools facing such challenges are less likely to have adequate patient care documentation and that subsequently will affect the students’ opportunities.

Another barrier to student documentation previously noted by preceptors is concerns regarding patient privacy protection, which in some cases might be reflected in employer policies regarding student access to EMRs or EHRs.¹⁷ In 2015, the American Medical Association released an executive summary that indicated that medical students were significantly restricted in using EHRs, citing that only 32% of medical students were allowed to view patient records; 41% were allowed to view and document within an EHR; and only 27% could view, write notes, or enter orders within an EHR.^22,23 This could similarly affect ATSs, specifically those associated with hospital or physician practice settings, as the Centers for Medicare & Medicaid Services have explicitly denoted that services provided by students are not reimbursable and therefore have instituted policies about which billable services are permitted to be documented by students.²² It is likely that, as a result of these policies, preceptors in settings that submit for third-party reimbursement are more likely to have rules regarding all health care student documentation within the EMR/EHR, regardless of their role in the patient interaction. Athletic training preceptors have, in some cases, implemented processes by which notes are scribed on paper and then input into the electronic record; however, this practice results in duplication of effort and likely compounds the barrier of time.^17,19

Solutions are needed to support ATS documentation practice during clinical experiences, preferably ones that mitigate barriers such as time, concerns over patient privacy, or limited availability of electronic recordkeeping systems in certain practice settings. Athletic training program administrators should address expectations of documentation with preceptors before assigning students and ensure that documentation of patient care is a planned component of the educational experience. To address some of the patient privacy concerns, athletic training program administrators should first aim to guide students toward compliance with the Health Insurance Portability and Accountability Act (HIPAA) by applying for a National Provider Identifier (NPI).²⁴ However, an NPI alone will not address employer concerns over student EMR/EHR use relative to billable services, nor will it overcome the barriers of time or the lack of available EMR/EHRs in some settings. To improve upon access to electronic records to document patient care regardless of setting policies, athletic training program administrators will likely need to explore the potential for using an academic electronic medical/health record (AEMR/AEHR) for students during clinical rotations. An AEMR/AEHR is an electronic patient record designed solely for academic use to eliminate the barriers of patient care documentation for students.²⁵ Students can document in an AEMR/AEHR independently or alongside their preceptor documenting in an EMR to ensure quality documentation and data entry. Use of such a system would also eliminate some of the barriers unique to the secondary school setting as the student would not be reliant on the preceptors’ documentation to complete their own. Academic electronic medical/health records have been shown to improve documentation skill competency, increase the use of informatics, and improve perceptions of documentation.²⁵ The use of an AEMR would also provide the added benefit of tracking PEs students experience during clinical experiences for programmatic use.

Use of Information From an EMR/EHR

The use of EMR/EHRs should provide increased accessibility to patient data that can then improve clinical decision-making.²⁵ Our findings indicate that student use of information contained in an EMR/EHR was only influenced by 2 variables: the site at which the encounter occurred and the length of the encounter.

Students involved with PEs at a clinic type of site were 220% more likely than those at a college or university site to indicate having used information from the EMR/EHR to assist with clinical decision-making. Clinic-based sites are more likely to have clear guidelines or policies and employer expectations relative to required documentation practices.²⁶ Previously, researchers have determined that employment culture and expectations highly affect documentation practices, with college or universities and secondary schools typically lacking in this structure.^19,21,26

The length of time spent with the patient also influenced the use of information obtained from an EMR/EHR to assist with clinical decision-making with the shortest encounter lengths being the least likely to include this behavior. Encounter lengths longer than 30 minutes were all more than 100% more likely to include this behavior. Most researchers examining documentation practices indicate that time is a barrier to good documentation practices, so it logically follows that the ability to review documented patient data within that documentation would also require additional time.^{17,19,21,26,27} It is also important to note that, specifically for students within a clinical experience, documentation practices of the preceptor before the student’s arrival will influence the availability of patient data in a patient’s file that is available for review and use in clinical decision-making. As researchers have shown that technology, time, and organizational culture are a barrier to patient care documentation in the secondary school and college or university settings, our findings that students are most likely to have the opportunity to review patient data during clinical decision making during longer encounters and during rotations at clinic-type sites are somewhat unsurprising.^21,26,27

Program administrators should seek opportunities to incorporate patient data into assignments and simulations if such opportunities are not as readily available during clinical experience rotations. Researchers have previously identified that preceptors would benefit from additional development in the process of mentoring and modeling documentation practices and patient-data use before supervising students during clinical experiences.¹⁷

Limitations and Future Research

As with all studies, ours is not without limitations. One limitation of the data was that the numbers of responses were not equally distributed across respondent schools, averaging 2543 records per school and ranging from 48 to 7142. Thus, while a GEE approach was used to address correlated error within student respondents, the 12 schools who participated were not equally represented. It is not clear how this affected our estimates of population-average effects. Due to the nature of data collection, we could only collect information of HIT-related professional behaviors that could occur within a PE. It is possible that other HIT-related professional behaviors were performed by our participants during clinical experiences but were not captured in the patient-case logging structure of our data collection. Additionally, we did not triangulate our findings with preceptor behaviors regarding HIT at each clinical site.

Our findings had inverse results relative to use of an EMR/EHR and documentation in an EMR/EHR within the same clinical site types. Future researchers should aim to better understand the influence of clinical site type on students’ EMR/EHR interactions and use. Future researchers should examine HIT behaviors students may engage in that can be included in clinical practice outside of individual PEs, such as examining injury trends across a patient population. Our data collection also relied on honest and accurate reporting of PEs by students. Authors of future studies should aim at triangulating responses with supervising preceptors to ascertain accuracy in reporting. Future researchers should consider examining the feasibility of an AEMR/AEHR to facilitate HIT behaviors among ATSs.