During the last decade, the use of electronic health records (EHRs) has risen sharply across the world.1,2 The Health Information Technology or HITECH Act of 2009 provided more than 19 billion dollars to stimulate the adoption and use of information technology in health care settings in the United States.3 There was a six-fold increase in the number of US hospitals with basic EHRs between 2009 and 2014 (12.2% vs. 75.5%, respectively).4 Although the use of EHRs has risen significantly, these electronic systems have not been fully incorporated into health care–related educational programs.2,5–8 It is important to incorporate technologies that will be used in real-world settings into educational clinical simulations to better prepare students for clinical practice and promote patient safety. There is evidence to suggest that by reducing the incidence of unintended consequences caused by improper information technology use, improvement in desired outcomes may ensue.9,10 In addition, this will teach students how to more efficiently incorporate patient interactions with the use of technology.9,10
Historically, clinical documentation practices were paper-based and taught primarily during clinical experiences under the guidance of a mentor.1,6,11 Electronic health record documentation can be harder to teach to students because it requires a more in-depth orientation on how to use the electronic documentation system and because health care organizations often give students limited or no access to the documentation system.6 An educational EHR is very similar to a standard EHR but is modified to support functionalities for educational activities. Currently, clinical simulations that incorporate educational EHRs are more likely to use it as a passive source of information and not as an interactive device for both data entry (ie, documentation generation) and information retrieval.2,5,6 Students must also learn to maintain interpersonal communication skills with the patient while documenting in the EHR to maintain an optimal clinician/client relationship.1 Educational EHRs that can be incorporated into currently existing clinical simulation training are being developed to fill this gap.5
While employers expect new graduates to be competent in information technology use upon graduation, students are often not given the necessary educational opportunities to gain this competence.9,10 The purpose of this literature review is to summarize the current state-of-the-science on the use of EHRs in clinical simulations for the purpose of guiding future educational and research practices. This review will not cover the use of EHR simulation by current healthcare professionals because they have different simulation goals and EHR functionality requirements that would be beyond the scope of this review. This review will include a discussion on the benefits and disadvantages of using educational EHRs, barriers and facilitators to implementing educational EHRs, and best practices for incorporating educational EHRs into current educational curriculums.
In December 2016, the databases PubMed and CINAHL were searched for peer-reviewed publications using the following pairs of keywords: (a) electronic health record and simulation and (b) electronic medical record and simulation. No time restrictions for publication dates were used because of the limited amount of literature pertaining to EHRs used in educational settings. Inclusion criteria included any publication that mentioned the use of EHRs in a health professional education setting. Exclusion criteria included non-English articles and publications discussing the use of educational EHR simulations specific to clinicians who were not students. A total of 1572 articles were identified in the initial search and were evaluated on their titles and abstracts (Fig. 1). All of the articles that met the search criteria (N = 15) were electronically retrieved and NVivo qualitative data analysis software, Version 10 (QSR International Pty Ltd, Doncester, Victoria, Australia) was used to assist with conducting the literature review. NVivo is a software tool that assists the user in manually processing qualitative information electronically, as opposed to using paper-based notes.
The articles in this review (N = 15) included a variety of professions, study designs, and geographical locations with the publication dates ranging from 2007 to 2016 (Table 1). The professions represented in the publications included physician residents/medical students (n = 4), nursing students (n =7), pharmacy students (n = 2), and an interdisciplinary team of both medical and nursing students (n = 2). The study designs involved case studies (n = 7), descriptive studies using preimplementation/postimplementation measurements (n = 5), qualitative studies (n = 2), and a nonrandomized controlled trial (n =1). The geographical settings of the studies were diverse and included the United States (n = 10), Canada (n = 2), the United Kingdom (n = 1), Taiwan (n =1), and Israel (n = 1). The specific commercially available EHR systems mentioned in this literature review include Cerner Academic Solution,12 the training environment for EPIC,7,8 Docucare by Lippincott,15 and SimChart by Elsevier.17 Three of the articles discuss self-developed EHRs.7,8,18
Overview of the Literature
This literature review revealed several important themes related to using clinical simulations with educational EHRs. The themes that emerged during this literature review include the following: (a) importance of educational EHR simulation training; (b) properties of ideal educational EHRs; (c) benefits and disadvantages of using educational EHRs; (d) facilitators and barriers for implementing educational EHRs; and (e) best practices for incorporating educational EHRs into pre-existing educational simulations. There were no reports found in the literature about using a training domain EHR in educational settings.
Importance of Educational EHR Simulation Training
Clinical documentation needs to be accurate and well organized because it has a direct impact on patient safety and the provision of efficient patient care.10,15,19 The quality of clinical documentation is important because it is used to guide current and future patient care decisions, serves as the legal record of the patient care provided, and is used for financial reimbursement for health care services.10,19 Clinical documentation is the primary tool used to communicate important patient information to the entire interdisciplinary health care team,13 but health care providers are usually not effectively taught how to generate high-quality clinical documentation.10,15
Electronic health records have other functionalities beyond documentation that students must be trained to use.17 Clinical decision support (CDS) tools such as drug reference libraries or evidence-based clinical guidelines can be incorporated into EHR designs.20 Exposing students to CDS tools before beginning clinical rotations can better prepare them to use them to guide patient care decisions.17 Educational EHRs have been used to allow students to apply concepts and knowledge gained from other courses in clinical simulations. For example, the addition of a drug reference library into an educational EHR has been used to allow students to apply knowledge gained from a didactic pharmacology course into a clinical simulation.17
The requirement for competency in information technology is being added to the curriculum of many health professions.2,9,10 Educational EHRs can be implemented and used to improve students' competencies with information technology to meet these new requirements.10 In addition, improving students' understanding of EHR functionality may prevent medical errors.13 Exposing students to best practices for EHRs before participating in clinical settings can better prepare them to more effectively use these systems.17
Properties of Ideal Educational EHRs
The literature identifies many ideal properties of an educational EHR (Table 2). All of the ideal properties of educational EHRs are related to usability or required functionality. Some of the important ideal properties include a usable graphical user interface, the ease of creating and using EHR patient data with clinical simulations, and the fact that an educational EHR is more than a reproduction of an EHR used in real-world settings.
Usability is defined as the extent that information technology is effective and efficient in doing its intended job and also includes how satisfied people are in using the technology.21 A usable educational EHR is one that is interactive and is easy to navigate for both data entry and information retrieval.13 The usability of the graphical user interface is improved if course instructors can add or remove any educational EHR functionality that is not needed for a given clinical simulation because the presence of unneeded functions can distract students from a simulation's specific learning objectives.2 For example, if the goal of a clinical simulation is to introduce new students to EHRs, then it might be distracting to force students to learn every CDS tool available in the system. Instead, letting students focus on simply navigating the graphical user interface to search patient records and document clinical care may be more beneficial.
Both faculty and students must be able to easily use the system. The ability of faculty to easily create and implement EHR patient data with clinical simulations is important because user satisfaction and perceived workload for faculty members determines their acceptance and use of educational EHRs.2 Students must be able to easily use educational EHRs in clinical simulations because if the educational EHR is requiring all of the student's mental efforts, then the student will not achieve the intended objectives of the clinical simulation.13 Faculty and students who are unhappy with the performance of an educational EHR will not want to use them.
Educational EHRs have unique functional requirements that are different from standard EHRs found in clinical settings.13 Some of the functional requirements for educational EHRs include the ability to deactivate or hide unused CDS tools, easily create new EHR patient data to use with clinical simulations, and the need for the educational EHR to provide a brief synopsis of the current clinical simulation. Other useful functions that are only found in educational EHRs is the ability for students to access prebriefing information before the actual clinical simulation and the ability to provide postsimulation quizzes.16 The educational EHR also benefits from having a graphical user interface that faculty can customize to mimic multiple EHR interfaces and better prepare students to use diverse EHR systems.13 Students often obtain clinical experiences at multiple hospitals that use different EHR vendors, and having a customizable educational EHR to train the students could better prepare them to use different EHR systems.13
Benefits and Disadvantages of Using Educational EHRs in Simulations
There are many benefits of using educational EHRs (Table 3). Learning to use an EHR is more effectively taught in clinical simulations because there are numerous contextual factors involved in using an EHR in real-world settings.16 Students will become more proficient if they are trained in a setting that closely mimics the actual environment EHRs are used.16 Educational EHRs can even be used by current healthcare professionals during educational training. If students are properly trained on how to use an EHR, then they are less likely to make a cognitive error in clinical decision-making that results from improper data entry or patient information retrieval.16 Incorporating educational EHRs into clinical simulations can also foster better interdisciplinary communication when used to coordinate activities of multiple health care professions in a single simulation.2,11,13 Another benefit of using educational EHRs is that these can introduce students to the field of informatics.12
A major advantage of educational EHRs is the ability to teach students patient-centered care and disease state management using technology in a safe environment.7,8,11 Clinical simulations combined with educational EHRs promote active learning and the development of higher-level thinking by allowing students to apply the knowledge gained from didactic courses in real-world situations.7 Students can follow the same simulated patients over the course of a single class or over multiple classes so they can observe patient changes over time.7
The major disadvantages of using educational EHRs are the acquisition price and human labor needed to implement and use EHRs. Web site–based educational EHRs require internet connectivity. There are currently only a few open-source educational EHRs available, and the acquisition price for proprietary software vendors can be cost prohibitive.13 The Veterans Health Administration developed an open-source EHR named the Veterans Health Information System Architecture (VistA) (download: http://www.worldvista.org/Software) that has been implemented globally.22 There is a published case report of an educational EHR developed by adapting Google Drive into a simulated EHR by designing spreadsheets that mimic clinical documentation forms.23 The initial acquisition costs of a basic proprietary educational EHR have been reported to cost a minimum of up to US $30,000.14
Many EHR implementations require the continuous availability of information technology staff to provide the initial implementation, on-going maintenance, and technical support.10 Educational EHRs also require a lot of time from faculty who use it because they have to generate the clinical simulations and incorporate them into their curriculum.10 Many faculty will often skip the documentation portion of the simulation if they are behind schedule and need to make room for other activities.8 Using a pre-existing EHR may save money, but clinical EHR systems do not have the functionality for educational settings.8
Facilitators and Barriers for Implementing Educational EHRs
The major facilitators for implementing and using educational EHRs are adequate faculty and student support as well as acceptance. Course coordinators, clinical faculty, and students need adequate training and support to improve the acceptance and use of the new information technology.10 Faculty and students also need to know the relevance and benefits of using educational EHRs to improve their acceptance of it.10 Faculty will become more comfortable with the technology as their experience with it increases, but it is important to monitor faculty acceptance consistently because faculty who are not satisfied with the educational EHR will not use it.12
The barriers of using educational EHRs occur as a result of limited availability of educational EHRs, decreased functionality compared with EHRs in clinical use, high acquisition costs, and the labor needed to implement and use educational EHRs. The required functionality of educational EHRs is markedly different from standard EHRs currently used in clinical settings. Most academic settings that use an educational EHR use software that is an exact copy of the EHR used clinically, and these systems do not always meet the needs of an educational environment.5 Converting a standard EHR into an educational EHR may result in a system that is used as a passive source of information because it does not support dynamic interactions, has limited connectivity with other information management systems, and also has very limited functionality compared with a complete EHR installation because of the lack of integration into other information management systems.5,8,13 Standard EHRs may not have adequate patient case simulation authoring tools to meet the needs of an educational EHR.5,8,13
Best Practices for Incorporating Educational EHRs into Pre-existing Educational Simulations
The literature identifies several best practices for using educational EHRs with clinical simulations. Using an educational EHR with clinical simulations will not automatically improve the quality of the education or make it more efficient.1 See Table 4 for a comprehensive list of best practices to improve the impact on student education. A discussion of faculty support and training during implementing educational EHRs, teaching clinician-patient communication skills, and integrating video tutorials into educational EHRs are presented hereinafter.
Faculty support and training are crucial in a successful educational EHR implementation. Faculty support and training can be accomplished by providing troubleshooting assistance using dedicated informatics personnel and an informatics-teaching assistant available to assist faculty in using educational EHRs in their courses.10 Training sessions that offer practical examples of using the educational EHR can also be first offered to faculty to improve their confidence in using the system. In addition, faculty will need to be taught the importance and benefits of using an educational EHR to improve their acceptance of the technology.10
While the use of EHRs that allow patients to access their personal health records has increased electronic communication between clinicians and patients, the personal interactions during physical encounters have been impersonalized because of the need of the clinician to focus more on documentation generation than human interaction.1 Clinician-based factors that influence interpersonal communications with patients include computer skills mastery and baseline basic communication skills.1 Students can learn to improve both of these factors during simulations that include EHRs. Computer mastery skills that students can practice include EHR navigation skills, use of keyboard shortcuts, and learning to scan the computer screen for information quickly.1 The basic communication skills that students can practice include maintaining eye contact, actively listening to the patient, and learning to balance interacting with the EHR and patient.1 Some other suggestions for students are to read out loud while documenting or share the monitor with the patient so that the patient is an active participant.11
Incorporating video tutorials into educational EHRs can be very beneficial because they can visually explain how to navigate the user interface instead of depending on the student to infer how to navigate from static diagrams or written instructions.5 Instructional videos have been found to be more effective in teaching procedural motor skills than pictures or written instructions, and they are also better at teaching the tacit aspects of software use.5 The video tutorials can be incorporated using hypertext links from within the educational EHR itself or playing the video before the simulation.5 The video tutorials can be made available to the students before the simulation experience via a Web site or e-mail communication.
There were a few limitations to this literature review. The articles were predominately from settings in North America and may not be representative of other regions. In addition, the only professions with published literature on the use of educational EHRs in clinical simulations were medicine, nursing, and pharmacy; consequently, the findings of this literature review may not be representative of other professions. In addition, this review looked at preprofessional students and not practicing clinicians.
The increasing adoption of the EHRs in our current health systems demands new ways of working. Similarly, the rising EHR use requires a new way of educating and preparing future health care professionals. It is important to incorporate EHRs into educational settings to promote patient safety by improving information technology competencies. Traditional paper-based documentation is being replaced by electronically generated records, but students are not being properly trained to use them. Incorporating educational EHRs into clinical simulations is an effective strategy to bridge this gap.
Some of the properties of an ideal educational EHR include usable graphical user interfaces that are easy to modify and easy to configure patient data to assist in realistic clinical simulations. In addition, faculty support, training, and adequate financial support are essential to a successful educational EHR. Faculty must receive both the initial instruction on how to use the educational EHR and then have access to support personnel to help trouble shoot issues that may arise. Since low user satisfaction is a leading cause of failed system implementations, it is important to assess the user satisfaction of both faculty and students.
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