Recommendations:

Few studies have described how to overcome these issues. Instead, the research has
focused upon describing the impact of introducing EHRs into a nursing course at the
undergraduate level in terms of: (a) developing nursing informatics competencies,
improving student confidence in using the technology, and developing EHR knowledge
and skills. There is a need for more documented examples of EHR integration into an
undergraduate nursing program, including published works that describe the issues and
challenges encountered by educators. These are important concerns as some
jurisdictions are now requiring entry-level Registered Nurses to develop nursing
informatics competencies and understand how to use information and communication
technologies in health care (BorycKIab et al, 2015).

Electronic health record (EHR) systems have the potential to transform the health care
system from a mostly paper-based industry to one that utilizes clinical and other pieces
of information to assist providers in delivering higher quality of care to their patients. The
Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009,
which is part of the American Recovery and Reinvestment Act (ARRA) (aka “stimulus
package”), was signed into law with an explicit purpose of incentivizing providers (eg,
hospitals and physicians) to adopt EHR systems. However, given that a bare-bone EHR
system provides only partial benefits to patients and society,6 the HITECH Act requires
that providers adopt EHRs and utilize them in a “meaningful” way, which includes using
certain EHR functionalities associated with error reduction and cost containment
(Collum & Menachemi, 2012)

In the post-implementation stage, the following trends emerged: (Lippincott 2016)

4. After using the revised EHR system for a while, nurses learned how to report usage
problems and obtain responses, resulting in system compliance with their specific
documentation needs on patient care. When nurses were getting used to the EHR
system, they hoped that the system could link with other hospital information systems or
databases for data transmission or retrieval to speed up the documentation process.

5. Once nurses mastered data entry, they learned the benefits of EHR in time saving
and documentation. They realized that the time saved by using EHRs could help them
to get off work on time. They also found the electronic notes to be easier to read and
understand than hand-written ones.

6. Some nurses expressed concerns about unrealistic expectations and goals for the
future.  Because the EHR had been implemented for a while, nurses were expected to
learn from the technology and report the problem correctly when interacting with IT staff.
It was their hope that the next time a new system is being considered, more staff
members will be able to assist with the chaotic process.

Transitioning to an EHR requires careful consideration from numerous departments

throughout the hospital. Examining the experiences of these nurses might help you
avoid problems of your own in the present or future.

Several EMR/EHR-related enhancements to medical competencies have been

suggested. 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. 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”.

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. 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 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.

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.

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. 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. 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. 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 withthe 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.
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. In a meta-analysis of video tutorials, Höffler & Leutner 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.
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.