Simulation in the EHR
Electronic Health Record (EHR) simulations use realistic patient charts created and maintained in training environments to allow users to experiment with different EHR tools to accomplish a set of tasks without altering real patient data. Clinical simulations have been used in medical education to teach technical skills, critical thinking and team-building in emergency situations, and to research the impact of multimedia on clinical-decision making in test conditions. Simulation can identify usability problems and direct EHR design. Additionally, competency in the many uses of the electronic health record represents a cornerstone of physician education necessary to function effectively in modern clinical environments. Thus, simulation in the EHR can help characterize users’ approach to a system and educate users on the effective use of the EHR when accomplishing common clinical tasks.
EHR simulations must capture the reality of not only the large amount of information frequently present in electronic charts, but also the distribution of that information across multiple activities and screens, as well as the need to amalgamate data to accomplish tasks. For many educational goals, simulated patient charts require:
- Clinical notes
- Laboratory values
- Medication administration record
- Flowsheets (vital signs, growth parameters, vent settings, etc.)
- Past medical history
- Prior to admission medications
Additionally, educational simulations should specify learning objectives, key safety issues, and evaluation rubrics, as seen in an example of a simulated neonate with hyperbilirubinemia with evidence of sepsis.
Simulated patients must also be created in EHR environments that are stable, refresh daily (such that patient data that is designed to be “today” does not migrate into the past), and allow for copies that users can manipulate without destroying the initial file.
EHR simulations aimed at promoting patient safety by training physicians to use the EHR to recognize safety concerns often model cases on common, easily-missed diagnoses as well as errors noted in morbidity & mortality reports or root-cause analyses. In a study of two simulated cases in the medical intensive care unit at Oregon Health Sciences University, users improved recognition of patient safety issues on repeat testing with a new case, suggesting that EHR simulation is an effective tool for teaching EHR safety behaviors. Physicians, nurses, and pharmacists also detect different safety issues from each other, often using different EHR screens. EHR simulations have also been used as an educational tool for medical students in order to each chronic disease management (See Simulated Electronic Health Record (Sim-EHR) Curriculum: Teaching EHR Skills and Use of the EHR for Disease Management and Prevention) and to integrate into traditional clinical simulation education.
Simulation can also be used to promote tools that increase provider efficiency. For example, at the University of Arkansas Medical Sciences, 293 physicians and 94 nurses participated in simulation training after standard EHR training in anticipation of a new EHR implementation across several outpatient clinics. Participants noted significant improvements in self-efficacy ratings after simulation training as compared to after standard EHR training from the vendor.
EHR simulation has also been used to define users’ workflow patterns when accomplishing common tasks. Doberne et al using commercial eye tracking software during a simulated case found distinct patterns among physicians when composing admission notes where some physicians had higher click frequency and screen fragmentation while others focused for longer periods of time on one screen at a time. Nonetheless, these two groups had similar total time required to compose the note and similar note quality at the end of the exercise. This variation was again demonstrated by March et al, who found wide differences in intern progress notes despite being presented with standardized information, and that this could lead to consequences in key quality measures such as missing deep venous thrombosis prophylaxis medications.
Acceptance of Workflows and Decision Support
Simulation in the EHR may also be used to introduce new workflows or decision support to define problem areas early before implementation into production environments. This has been used to iteratively improve nursing workflow in charting of vital signs and intake/output in a simulated hospital. Similarly, the acceptance and non-acceptance of clinical decision support alerts and suggestions can be studied in a simulated environment and polished prior to general implementation.
As more institutions attempt to integrate EHR simulation into medical education, decision support design, and research efforts, the ability to share simulated patients would have great benefits. This approach would take advantage of the portability and scalability of electronic simulated patients through libraries of downloadable patient data. For example in Epic® the Scotty Teleporter Tool could allow for export and import of simulated patient data through .ept masterfiles that can then be customized within each institution for their own learning objectives. Centralizing these efforts would
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- Simulated Electronic Health Record (Sim-EHR) Curriculum: Teaching EHR Skills and Use of the EHR for Disease Management and Prevention
- A Novel Approach to Supporting Relationship-Centered Care Through Electronic Health Record Ergonomic Training in Preclerkship Medical Education
- Nurses Readiness and Electronic Health Records
- Heuristic evaluation of eNote: an electronic notes system
- Real alerts and artifact classification in archived multi-signal vital sign monitoring data: implications for mining big data
- Training providers: beyond the basics of electronic health records
- Advanced Proficiency EHR Training: Effect on Physicians’ EHR Efficiency, EHR Satisfaction and Job Satisfaction
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Submitted by Evan Orenstein