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Towards Educational Electronic Health Records (Ehrs): a Design Process for Integrating Ehrs, Simulation, and Video Tutorials

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Towards Educational Electronic Health Records (Ehrs): a Design Process for Integrating Ehrs, Simulation, and Video Tutorials 624 Exploring Complexity in Health: An Interdisciplinary Systems Approach A. Hoerbst et al. (Eds.) © 2016 European Federation for Medical Informatics (EFMI) and IOS Press. This article is published online with Open Access by IOS Press and distributed under the terms of the Creative Commons Attribution Non-Commercial License 4.0 (CC BY-NC 4.0). doi:10.3233/978-1-61499-678-1-624 Towards Educational Electronic Health Records (EHRs): A Design Process for Integrating EHRs, Simulation, and Video Tutorials Aviv SHACHAKa,1, Samer ELAMROUSYa, Elizabeth M. BORYCKIb, Sharon DOMBc and Andre W. KUSHNIRUKb a Institute of Health Policy, Management and Evaluation, University of Toronto, Canada b School of Health Information Science, University of Victoria, Canada c Department of Family and Community Medicine, Sunnybrook Health Sciences Centre Abstract. Electronic health records (EHRs) are becoming ubiquitous in healthcare practice. However, their use in medical education has been slower to catch on and a new category of EHRs is beginning to emerge known as eduEHRs. These systems allow learners to explore and experiment with EHRs in the context of medical education. However, current eduEHRs have limitations, such as a lack of dynamic interaction built-in that would mimic real-world use of these tools. To overcome this, the integration of eduEHRs with software and tools such as video simulations and tutorials has considerable promise. In this paper we describe a new design process for integrating EHRs, simulations, and video tutorials. Keywords. electronic health record (EHR), virtual patient simulation, health professions’ education 1. Introduction Electronic health records (EHRs) and electronic medical records (EMRs)2 have become ubiquitous and are now being used in many countries and health care organizations. Although these systems are in daily use in healthcare, they have not been fully integrated into medical education [1-3]. The exposure of medical students to EHRs has varied from very little to attempts to integrate the technology tightly into courses. Along these lines, educational EHRs (eduEHRs) are now being developed to allow for greater use of the technology in teaching medical students [6-9]. To date, there have been a number of published papers documenting the effects of eduEHRs upon competency development and learners’ satisfaction as part of a course on EHRs or EMRs [6-9]. However, there remain a number of issues with current eduEHRs, including need for better patient case authoring, the need for improved 1 Corresponding Author: [email protected] 2 The terms EHR and EMR are often used interchangeably. While EHR refers to interoperable systems, which integrate data from multiple health care organizations, EMRs usually are local applications with limited integrative capability A. Shachak et al. / Towards Educational Electronic Health Records (EHRs) 625 integration with other course tools and software, and the need to provide students with the opportunity to experience the dynamic nature of eduEHRs in the classroom [6-9]. Therefore, the purpose of this paper is to describe an approach to making the student experience more dynamic through the integration of educational content using simulation and video tutorials directly into eduEHRs. We describe our approach and process in this work and illustrate how this approach is undertaken using a case from the Association of Faculties of Medicine of Canada (AFMC) and Canada Health Inforway (Infoway) Virtual Patient Challenge. 2. Literature Review Several EMR/EHR-related enhancements to medical competencies have been suggested [1]. Nevertheless, integration of electronic records into health professions’ education has been relatively slow. Students’ access to EHRs/EMRs varies, depending on profession, institution, and stage in program [2-4]. Even when students do get access to electronic records in real-world settings, their performance varies. For example, a US study, which assessed medical student’s performance of various tasks concluded that “The mere presence of an EMR will not improve practice quality and will not necessarily make the educational experience better or more efficient” [5]. To address these issues, researchers have attempted to develop EHRs that would also educate health professional students. Initial work in this area involved creating EHR simulators that could be used in the classroom [6]. This work identified that students found the opportunity to learn about EHRs in a classroom context to be satisfying, and of importance as they transition to independent practice after graduation [7]. In addition, studies helped formulate requirements and improve the system; for example, it was shown that for some educational applications it is best to disable some EHR features that may detract from learning the task at hand [8]. Integrating simulation modules into the EHR may further enhance student learning by providing content in a format that is both fairly realistic and scalable. There has been a lot of work on computer-based simulation recently and particularly virtual patient cases. A recent analysis and classification of articles using the term ‘virtual patients’ has shown that the majority refer to interactive patient scenarios and have been applied mostly to teaching clinical reasoning [10]. Some virtual patient simulations have incorporated health information technology and particularly EHRs or EMRs into the simulation; e.g., the Virtual Patient Challenge promoted by AFMC-Infoway [11]. However, in reviewing the cases submitted to this project, we found out that the majority of them treat the EHR as a passive source of information, which is often presented in screen captures and not as an interactive component of the simulation. Similarly, Bloice et al. [12] found that the use of EHRs in a raw, unformatted, form in virtual patient cases is rare. In our own work, we developed a computer-based simulation named EMR-sim for teaching Family Medicine residents to deal with challenges of using an electronic medical record (EMR) in the clinical encounter [13]. A pilot study of this simulation revealed that computer-based simulation may be an effective tool to teach Family Medicine residents about these issues and that it is acceptable to users [13]. However, this work, too, used still screen shots from the electronic record and participants in the study expressed their desire for interactive representation of the EMR in the simulation. While simulation may provide the context for the learning activity, specific actions and operations with 626 A. Shachak et al. / Towards Educational Electronic Health Records (EHRs) the EHR also need to be learned. Here, researchers have experimented with video tutorials. Video tutorials have been studied since the early 1990’s. They may be especially suitable for learning software applications because they show users directly which elements of the user interface are manipulated and how, rather than require them to infer it from text or static images [14]. Video tutorials also capture the tacit dimensions of software operation such as position of objects, movement, and timing and thus help in creating a mental model of the software [15]. In a meta-analysis of video tutorials, Höffler & Leutner [16] found that animations were more effective than static images, especially when used for conveying procedural-motor knowledge rather than declarative or problem-solving knowledge, and when the animation represented the actual task instead of serving a decorative function only. Others have found that integrating narrated video clips into the software in an unobtrusive manner is an effective way to overcome software learnability barriers [17]. There is considerable potential for linking video tutorials directly into eduEHRs. This would result in an eduEHR system that integrates EHR with simulation and video tutorials, which would overcome limitations of current eduEHRs such as the lack of dynamic cases built into the educational system. Here, we describe a process for integrating EHRs with simulation and video tutorials and illustrate its application using one of the cases from the AFMC-Infoway Virtual Patient Challenge. This study was funded by SIM-one (Ontario Simulation Network) Research and Innovation Grant. 3. Methods We applied a combination of storyboarding and modeling techniques to represent a virtual patient scenario. The storyboard was used to identify points where integration of EHR use, video tutorials, and textual help could be achieved. First, we selected one module from the AFMC-Infoway Virtual Patient Challenge: “Poppy Gone: Prenatal Care”, which deals with common issues in early pregnancy [18]. Similar to most virtual patient simulations, this module focuses on clinical reasoning and uses the EHR as a passive source of information. Next we re-created the storyboard from the computerized simulation and represented it in a flowchart similar to the ones we used for developing our EMR-sim simulation [19]. To better identify points in the scenario at which the EHR is being used, we presented the storyboard in the form of Unified Modeling Language (UML) sequence diagram. Finally, we modified the diagram and story board to make EHR use interactive. 4. Results In the first stage we re-created the scenario’s storyboard from the “Poppy Gone” virtual patient module. We presented the story board in the form of a flow chart that captures the different paths to progress through the scenario and the various elements of the virtual patient module
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