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A Novel Approach to Supporting Relationship-Centered Care Through Electronic Health Record Ergonomic Training in Preclerkship Medical Education

Silverman, Howard MD, MS; Ho, Yun-Xian PhD; Kaib, Susan MD; Ellis, Wendy Danto DHEd, MC; Moffitt, Marícela P. MD, MPH; Chen, Qingxia PhD; Nian, Hui; Gadd, Cynthia S. PhD

Author Information
doi: 10.1097/ACM.0000000000000297



Collaborative use of the electronic health record (EHR) by patients and physicians can contribute to improved quality of care, enhance the decision-making process, empower patients to participate in their own care, and increase the patient-centeredness of interactions.1,2 However, the EHR is perceived by some to be a “third party to a conversation” between a patient and a physician, whereby the EHR forms its own identity and both physicians and patients project their perceptions onto this identity.3,4 Some have suggested that medical training needs to address the addition of the EHR into the physician–patient relationship in order to fully realize the benefits of EHRs5,6 and that the effective use of computers in clinician–patient communication may largely depend on clinicians being trained with baseline skills in EHR use.7

Since its inception in 2007, the University of Arizona College of Medicine–Phoenix (COM-P) curriculum has included significant instruction in biomedical informatics across all four years of the medical school curriculum.8 Born into the computing age, current medical students are generally at ease with the use of computers; however, we wondered whether additional EHR training would advantage them in using computers in clinical encounters in a relationship-enhancing fashion.

Although many studies have focused on the effects of EHR use on physician–patient relations, few studies have directly examined the integration of relationship-centered EHR training in undergraduate medical education to promote these relations. The purpose of this study was to evaluate the hypothesis that an educational intervention for second-year medical students improves their ability to use the EHR in a way that enhances, rather than detracts from, patient–provider interaction (“EHR ergonomics”) during a standardized patient (SP) encounter.


We performed a comparative study at COM-P of three convenience samples of second-year medical students to examine the effect of EHR ergonomic training on their ability to use the EHR in a relationship-enhancing fashion during required SP encounters. All COM-P students are required to complete SP encounters as part of a Doctoring course in their preclerkship years during which they learn history taking, physical examination, presentation, and clinical reasoning skills. This study was done in collaboration with researchers at Vanderbilt University, and the institutional review boards at the University of Arizona and Vanderbilt University approved all study procedures.

EHR ergonomic training content was incorporated into each of four Doctoring SP encounters (DS1, DS2, DS3, and DS4) scheduled from February through March 2012, and survey items related to EHR ergonomics were included in the assessment materials for each of these sessions. This interval was selected because it immediately preceded the onset of the participants’ clerkship experiences. During the study period, students received one of three different levels of exposure to EHR systems and ergonomic training based on their preassigned Doctoring session schedule (students [n = 40] were randomly assigned for the entire academic year to Tuesday [n = 13], Wednesday [n = 12], or Thursday [n = 15] afternoon groups). All students received a two-hour basic EHR navigation training session at the beginning of the study period. During this initial training session, students completed a presurvey that collected information about participants’ demographics and computer use, and they completed a postsurvey after the series of Doctoring sessions (see Supplemental Digital Appendix 1,

The Tuesday Doctoring students received only the initial basic EHR training with no additional ergonomic training, and no EHR was available for use during their SP encounters (Control I). Wednesday students received only basic EHR training and no ergonomic training and were expected to use the EHR available to them during SP encounters (Control II). Thursday students received both basic EHR training and additional ergonomic training and were expected to use the EHR available to them during SP encounters (Treatment).

In DS1, all students received an exercise to refresh the knowledge and skills learned from the basic EHR training session. Experienced COM-P faculty members fully aware of the objectives of this study (M.M. and S.K.) conducted a “read-only” EHR exercise reviewing vital signs and confirming the medication list with an SP using the EHR for all three groups. In DS2 and DS3, only students in the Treatment group received 15 minutes of EHR ergonomic training at the beginning of each Doctoring session led by two COM-P faculty members (H.S. and W.E.) as detailed in Supplemental Digital Appendix 2 ( and summarized here:

  • In DS2, students were instructed how to introduce the use of the laptop-based EHR into the SP encounter by explaining the benefits of using the EHR. The slight distraction of logging into the EHR was framed to the patient as positive in that the patient’s information was secure within the EHR. A script was provided for use by students and was demonstrated through role-play by the instructors.
  • In DS3, students were instructed on optimizing positioning of the laptop to effectively integrate the EHR into their interactions with the patient such that the patient is actively involved in viewing and reviewing the information on the laptop. This was demonstrated through role-play by instructors.
  • In DS4, students were encouraged to share their experiences from DS2 and DS3. Insights and challenges were discussed, reflected, and problem-solved by the group and the instructors.

All students were asked to perform the standard tasks of reviewing vital signs and confirming a medication list during their SP encounters in all four Doctoring sessions. Customized ergonomic assessment items were created for students, faculty, and SPs to assess the students’ EHR use during SP encounters in the Doctoring sessions (see Supplemental Digital Appendix 3, on the basis of the learning objectives in the educational intervention (see Supplemental Digital Appendix 2, Data from student self-assessments, faculty observation and narrative assessments, and SP ergonomic assessments were collected immediately after each encounter. All SP encounters were video-recorded as part of standard COM-P practice.


To determine whether there were any differences in characteristics among the three study groups (Control I, Control II, and Treatment), we used the Kruskal–Wallis test for continuous variables, Pearson chi-square test for categorical variables, and a likelihood ratio test of proportional odds models for ordinal variables. To examine the overall effect of EHR ergonomic training on students’ self-assessment of their EHR use, we fitted a linear model with the difference of the ergonomic assessment scores reported in the pre- and postsurveys as response, and study group and baseline score were included as independent variables. We also evaluated the effect of each ergonomic training session on EHR use by fitting a generalized least-squares linear model of ergonomic assessment score difference between DS1 and each of the subsequent sessions to adjust for repeated measurements from each student. We included the following variables as covariates in our model: study group, Doctoring session, ergonomic assessment score in DS1, and an interaction term for study group and Doctoring session variables. We used unstructured or compound symmetry covariance structure (determined by likelihood ratio test) to account for within-subject correlation. Scores obtained from the ergonomic assessment items were fitted with separate models, and Wald statistics were used to assess patterns of results. Two-sided P values less than .05 were considered statistically significant. We calculated Cronbach alpha to evaluate the internal consistency of the ergonomic assessment items. All analyses were conducted using R 2.13.1 (R Foundation for Statistical Computing, Vienna, Austria). There were no significant differences in baseline characteristics among the three study groups comprising the 40 students who completed this study, including prior personal use of EHRs (see Table 1).

Table 1:
Baseline Characteristics of 40 Second-Year Medical Student Participants by Study Group in a Study of the Effect of Electronic Health Record Ergonomics Training on Performance During Standardized Patient Encounters, University of Arizona College of Medicine–Phoenix, 2012

The mean scores of each of our five ergonomic assessment items in the pre- and postsurveys are presented in Figure 1. We found a significant difference between the pre- and postsurvey scores compared across the three study groups for all ergonomic student self-assessment items (P < .005, Table 2), indicating that EHR use improved with EHR ergonomic training. The five ergonomic assessment items used in this study showed high internal consistency; Cronbach alphas were 0.81, 0.90, 0.88, 0.94, 0.98, and 0.97 when evaluated for the presurvey, postsurvey, and each of the four Doctoring sessions, respectively.

Table 2:
Comparison of Differences in 40 Second-Year Medical Students’ Self-Assessment Scores for Electronic Health Record Ergonomics Before (Pre) and After (Post) Doctoring Sessions for Study Groups in a Study of the Effect of Electronic Health Record Ergonomics Training on Performance During Standardized Patient Encounters, University of Arizona College of Medicine–Phoenix, 2012
Figure 1:
Student, standardized patient (SP), and faculty assessment scores of 40 students’ electronic health record (EHR) use in SP encounters, and students’ pre- and postsurvey scores from an intervention to provide “EHR ergonomics” training during Doctoring sessions, University of Arizona College of Medicine–Phoenix, February to March 2012. Significant increases in scores between the first Doctoring session (DS1) and the comparison sessions (DS2, DS3, and DS4) are indicated by the asterisks just above the corresponding comparison session (* P < .05, ** P < .01, *** P < .001).

Postsurvey responses indicated that compared with participants in the Control II group, students in the Treatment group felt that they were able to use the EHR more effectively to engage with the patient, better articulate the benefits of using EHR, better address patient concerns, more appropriately position the EHR device, and more effectively integrate EHR into the patient encounter. On the other hand, Control I and Control II participants, both of which groups received no ergonomic training in the study, did not exhibit any significant differences between pre- and postsurvey ergonomic assessment scores.

To determine whether ergonomic training yielded incremental improvement in students’ relationship-centered EHR use over multiple sessions, we also collected these same items from students in Control II and Treatment groups as well as from SPs and faculty after each SP encounter for each of the four Doctoring sessions. We defined incremental improvement in EHR use as the difference between ergonomic assessment scores in the first session and each of the subsequent sessions (i.e., DS1 versus DS2, DS1 versus DS3, DS1 versus DS4), as shown in Figure 1 and in Supplemental Digital Appendix 4, A similar pattern emerged across students, faculty, and SPs: The difference in scores for some, but not all, EHR assessment items between DS1 and DS2 was significantly greater for the Treatment than for the Control II group. However, the difference in scores between the DS1 and DS3 for the Treatment group was significantly greater across all five ergonomic assessment items, indicating that a minimum of three ergonomic training sessions were necessary to see overall improvement in EHR use. Additionally, student self-assessments were well corroborated by SP and faculty assessments, suggesting that students’ self-perceptions were consistent with their performance as observed by SPs and faculty during SP encounters.

Next Steps

This study demonstrates that our students who received simple instruction in EHR ergonomics were much better able to use the EHR in a relationship-enhancing fashion compared with their peers who did not receive this training. Given the rapid and widespread deployment of EHRs into clinical settings and the positive potential of collaborative use of the EHR described above, these techniques could positively affect clinician EHR training in undergraduate and graduate medical education. Further studies should be carried out to determine the effect of such training for practicing clinicians, including physicians, nurses, and allied health personnel.

Our approach was limited in several respects. It was carried out in a highly controlled environment focused on the simple task of accessing vital signs and medications in order to study the direct effects of ergonomic training; however, it is not clear whether the beneficial effects of training observed here would translate into other, less controlled and more robust clinical environments. Because our study focused on a preclerkship cohort, it is difficult to know what impact, if any, it will produce as these students move into clerkships, residencies, and practice environments.

There are several areas that merit further study. First, it would be interesting to determine whether EHR ergonomic skills carry forward or grow subsequently as students move through clerkships and residency. A variety of clinical environments, EHR systems, and clinical specialties, including nursing and allied health personnel, should be studied to determine whether effects of preclerkship EHR training are still evident in diverse and complex real-world clinical environments. Refinements to the training content and methods could be informed by “real-world” observations. Second, although the literature suggests that these skills would have a positive impact on patients with regard to shared decision making, other patient outcomes, such as patient satisfaction and compliance, are areas that may warrant further investigation. Similarly, we would recommend further exploration into the effects of EHR ergonomic skills in other areas, including provider satisfaction, efficiency, accuracy, and burnout.

We are not aware of the incorporation of any similar training into medical school or practice environments. As EHR implementation accelerates, our findings suggest that such training may be a valuable addition to existing conventional EHR training programs for all clinicians.

Acknowledgments: The authors wish to thank Lou Clark for her tireless and valuable work in preparing the standardized patients to participate in this study and Liz Williams for skillfully implementing the student assessment tools used to gather data for this study.


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Supplemental Digital Content

© 2014 by the Association of American Medical Colleges