Simplified Medical Record Template Compared to Traditional EMR in Simulation-Based Medical Education
Authors
Martin Leisin, MS, CHSOS1; Lorena Navarro, MSHS, CHSE, RN BSN1; Pascual E. Reyes, BMS1; Jordan B. Coulston, MD1; James A. Lindgren, MD, CHSE, FAAP, FACP1
1University of Arizona, Center for Simulation and Innovation, Phoenix, Arizona
Conflict of Interest Statement
The authors declare no conflict of interest.
Corresponding Author
Martin Leisin, MS, CHSOS, University of Arizona, Center for Simulation and Innovation, Phoenix, AZ
(Email: mleisin@arizona.edu)
Brief Description
Electronic Medical Records (EMR) have become critical in healthcare. Their streamlined workflows, improved documentation, and communication among interprofessional teams have brought more efficient and safer patient care. Integrating EMR into medical education creates some challenges. EMR adoption barriers include accession and maintenance costs (Kim et al., 2019). Other barriers may include time constraints, cost of software licensure and complexity of setup/support needed for use. In addition, learners who visit diverse training sites may encounter multiple EMR solutions with different communication boundaries (Kim et al., 2019). This makes selecting one solution for a training environment difficult. We address these challenges by proposing a simplified medical record template solution that is tailored for medical education. The solution uses a whiteboard approach with a custom template and video capture software. This system enables learners to practice documentation, order entry, and decision-making efficiently. It also supplies a written record to improve communication and debriefing between educators and learners. The solution does lack some features available within computer based EMR systems, such as integrated laboratory and imaging. Nevertheless, the fact that it requires almost no training to use and provides a quick, dynamic and trackable experience more than makes up for its limitations. We further submit that this simplified medical record option prepares learners with skills that can translate into future EMR systems they will encounter during their healthcare training and practice.
Introduction
In today’s clinical world, the EMR functions as a shared store of medical information. It allows the compilation of pertinent patient data to serve as a critical thinking tool (Shala et al., 2021). However, even with all its benefits, the EMR has its share of limitations and challenges. Unfortunately, learners throughout healthcare systems, have limited access to EMR systems in hospitals to be able to gain competency in this skill before entering the workforce. Their ability to use these clinical systems remains low and requires timely training and system exposure to gain competency (Herrmann-Werner et al., 2019). The cost, time and resources needed for training, customization, as well as the “risk” of having access to live ordering and documentation, are all barriers encountered by these healthcare learners. According to Herrmann-Werner et al., the EMR benefits in medical education are significantly lowered due to a lack of live EMR documentation, leading to loss of information within the healthcare team (2019).
EMR systems ease communication and coordination of patient care amongst the diverse but integrated healthcare teams of today’s clinical environment. Ultimately, having medical learners learn how to organize their ideas and clearly communicate these to other members of the healthcare team allows for more coordinated and better continuity of care. According to Manca, there is improved communication between family physicians, other healthcare providers and patients in areas utilizing an effective EMR system (2015).
EMR System Integration into Simulation
Challenges in integrating EMR into the simulation environment include the cost of the hardware and software required for use. Data volume, compatibility, as well as the amount of time required for data input and customization of the platform are further problems. Hospitals have health information professionals (HIP) employed full-time to help their system succeed. This is an expense not available to most simulation centers as well as the lack of funding for technology purchasing (Chung & Cho, 2017). Further, the amount of training needed to teach a student and instructor to use the system competes for time for educational activities that are already stretched by duty hour limits and competing educational demands. In discussing our proposed solution, we focus on cost, training time constraints, and complexity in customization.
Cost
The cost of EMR software can run into the hundreds of thousands of dollars or more, depending on features, functionalities, number of users and vendor pricing structure (Fleming et al., 2011). Hardware, database configuration, network setup, and user training add to this already costly system. Instructional EMR systems are expensive and can range from $3,000 start up price but add up to $30,000 in annual maintenance fees per license (Lucas, 2010). Educational needs assessments and learning objectives should guide the type of system required. The exact configuration tailored to meet these needs then determines the final cost to implement. This involves a complicated number of parameters and can be difficult to estimate.
Time Constraints for Use in Training
Users within the simulation environment, including students, faculty, and full-time staff, need to understand and navigate the integrated EMR features effectively. Training and familiarization sessions are necessary to ensure that users can utilize the EMR integration to its fullest potential, while keeping their psychological safety and learning as top priority. There is a fixed cost in time and finances to complete this training and this competes with the time and finances required for the other aspects of running effective simulation events. Training for learners would need to occur before the simulation took place and individual assigned logins would need to be distributed. Learning objectives would need to be aligned with the EMR activity and full-time staff and faculty would need to be well versed in the instructional EMR system to improve the overall evaluation of the learner for this skill. It is essential that the healthcare learners’ education be supported by academia and all practice settings to assure their competency and success in the workforce (Lucas, 2010).
Complexity of Customization
Customizing a simulated patient chart that properly aligns with a specific simulation scenario requires advanced knowledge of the EMR system and time to create. Some systems require real-time entry to have the simulated time match the clinical scenario. This is where realism and time constraints can become an issue, especially if the learner, faculty, or full-time staffer has a time constraint. Simulation environments rely on quick access to accurate information for effective analysis and decision-making in a designated time frame. Therefore, it is essential to address quality issues and ensure that the integrated EMR data is reliable and complete. Adequate support needs to be given to the instructional EMR system for appropriate skill transfer and application to occur. This gap is difficult to bridge as technology rapidly advances in the healthcare field (Lucas, 2010).
Though EMR integration into healthcare academia is challenging, Mollart, et al. suggests an adjustment in teaching loads to better accommodate learning for new technologies (2020). We considered implementing improvements in communication and thought processes to take priority in a medical learner’s skill before taking on the technology portion. This allowed us to come up with a simulated instructional EMR system with removed challenges, lowered costs, and improved ease of customization. This simulated EMR system is customized for medical learners but can definitely be molded to fit other healthcare disciplines.
Methods
To determine the content needed to create a simulated medical record solution for our center, our curricular co-directors reviewed learning objectives established by the College of Medicine’s curriculum committee. Key elements were distilled to create a simple documentation format. The components of a standard history and physical, along with the ability to generate a differential diagnosis were considered important. In addition, order entry for both diagnostic and therapeutic interventions were prioritized. Finally, the ability to document a plan for treatment and disposition were needed. The SOAP Note (Subjective, Objective, Assessment and Plan) method (Podder et. al., 2022) was reviewed as providing many of these components, however, it lacked order entry. We determined that creating a custom template incorporating these elements would work best for our purposes. The sections in the template correspond to the Subjective (historical data), Objective (vital signs, physical exam and applicable diagnostic data), Differential Diagnosis, Diagnostic Orders, Therapeutic Orders, Assessment and Plan elements. With the limited amount of time available to run our simulation scenarios, we wanted a quick and straightforward way to implement the template. Since the simulation rooms already had white boards available, we determined that a magnetic overlay printed with sections would be easy to incorporate (see Figure 1).
We generated a graphic representation of our template according to the specified criteria (Subjective, Objective, Problem List/Differential Diagnosis, Diagnostic Orders, Therapeutic Orders, Disposition/Plan). These criteria are adaptable to fit the requirements of other health professional disciplines. Subsequently, we engaged a vendor, Visual Workplace Inc. in Byron Center, MI, to produce our template on transparent plastic with magnetic backing. The template was then attached to a whiteboard in each one of our simulation training rooms. Since our simulation instructors are normally located within a control room during simulation sessions, we needed a way for them to easily view the content written by the learners. We also wanted a way to save the information to allow for review in debriefing.
The Kaptivo® whiteboard capture system was identified as being cost effective and easy to incorporate into our existing equipment (Lifesize Austin, TX). The Kaptivo® system consists of a telescoping camera mount, that when coupled with a proprietary network integrated encoder, will record and digitize any writing onto the surface of the template/whiteboard (See Figure 2.1 and 2.2). The content is captured and presented on a computer monitor, accessible through a shared hyperlink, this can enable simultaneous viewing on multiple devices (See Figures 3.1, 3.2 and 3.3). Using appropriate network permissions, the content can also be viewed remotely over an internet connection. Using a sharing link, a learner participating in a simulation session remotely can view the digital whiteboard for real-time collaboration. The Kaptivo® software solution allows users to print out a copy of the board contents as well as to save the content as a pdf. Optical Character Recognition (OCR) software within Kaptivo® can also convert handwritten notes into printed text if desired. Text can also be translated into other languages.'
Total production cost per room for our simple medical record solution (consisting of a magnetic steel whiteboard, custom printed magnetic overlay template and Kaptivo® camera) are as follows:
For setup, the camera was added to the university network allowing access from any browser. Other local configurations are available if network restrictions are in place. Our I.T. department and simulation technicians were able to easily complete the installation once the hardware and software was acquired.
An additional enhancement we are currently pursuing is to add an extra encoder to our video capture system. This will allow the whiteboard notes to be incorporated along with other video windows into our simulation recordings. This will ensure that all patient interactions, vital sign monitor/changes and whiteboard medical records will be captured and rendered onto one multi-view screen. This in turn will make review, debriefing and assessment as user friendly as possible
Results
The implementation of our medical record solution has helped guide our learners through a standard patient interaction. It provides a template for the acquisition of pertinent history and physical exam findings. We are finding that students are capturing better histories and physical exam findings. Furthermore, the use of the system provides a place for real-time order entry of diagnostic and/or therapeutic interventions. This has allowed our interprofessional providers (e.g. nurse presence or other allied health) in our simulations to require orders to be written, before carrying out the directives. This mirrors a real clinical environment and reinforces good practice. The template has also guided the generation of a differential diagnosis. This has helped uncover the thought process of the learners as they progress through the simulation scenario. Finally, by requiring an assessment and plan, the simulated EMR guides the learners to decide on a proper disposition and any necessary consultations needed to treat the patient.
Cost
As shown above, the cost for implementing our simple medical record system is very low compared to a bonified electronic medical record. This makes it attainable for most simulation centers.
Time Constraints for Use in Training
The Kaptivo® whiteboard does not require the amount of time for set-up or implementation training that a standard EMR needs. This simulated EMR system was introduced, and expectations were reviewed with our learners during a student pre-brief before the simulation took place. Medical learners were allowed to see the template and ask questions regarding their expectation in use and thought process assessment. Our full-time staff and faculty were introduced to the simulated EMR system in faculty preparation sessions and staff training. The estimated time for this was 15 minutes for staff and educators and about 5-10 minutes for learners during their first exposure.
Complexity of Customization
Our simple Kaptivo® whiteboard medical record is a set template. As such, it does not allow customization once the template elements are chosen. Individual simulation programs can alter the template structure as needed to better fit their needs prior to production of the overlay. We utilize computers with simple files that our interprofessional staff members open to provide the stimuli required for cases (labs, ECG, imaging, etc.). This allows customization to a degree, although it is not integrated into our medical record solution.
Our experience since implementing this system has found that our teams of learners communicate better by having a single point of documentation/order reference. The team leaders delegate a team member to scribe the documentation and order entry. By having this information easily viewable, our educators are better able to follow the clinical scenario unfold and the thought process of the learners for later debriefing. With the ability to take a snapshot of the information documented during simulation, the educator can target critical teaching points. Learners can use the provided feedback to better improve their documenting methods in preparation for when introduced to hospital EHR systems during clinical rotations or graduate medical education (GME).
Overall, the solution has supplied a pivotal advancement in our simulation activities. Prior to use, critical elements such as checking allergies before administering medications have, at times, been missed. Now learners and interprofessional providers can refer to the “chart” to see if there are contraindications and to make sure that desired orders are documented and communicated with the entire team in the room.
Assessment Instruments
To evaluate the subjective effectiveness of the white board template in our simulation we created a questionnaire for our students and faculty using a 5-point Likert scale (See Figure 4.1 and Figure 4.2). Questionnaires were distributed using a QR code and submitted anonymously to our simulation students and faculty.
We conducted surveys of our learners (N=19) and educators (N=9) and the results show that a majority of students found the simple Kaptivo® whiteboard medical record was: easy to use (84%), helped them organize their clinical notes (74%) and helped avoid missing important information (58%). Most students would choose to always and often use the solution versus an untemplated white board (84%). Most of our faculty surveyed indicated that they: would have students use the simple medical record (89%) of the time, versus the previous practice of a blank white board. Most of the faculty respondents (89%) agreed that the template provides a good tool to teach the medical record and helps students organize their clinical notes (See Figure 5.1 and 5.2).
Discussion
The incorporation of our simple Kaptivo® whiteboard medical record has led to a dynamic and immersive learning experience for both our learners, educators, and simulation staff. By providing learners with a platform to practice entering orders and to document patient information, learners have the potential to gain experience and critical thinking skills that can be seamlessly translated to other traditional electronic EMR systems in the future. This practice not only aids in sharpening learner communication, but it also helps them gain a deeper understanding of healthcare-related decision making in a team-oriented environment.
With all the positive aspects of implementing our simulated EMR solution, we have also seen certain limitations. The solution does not replicate the complexity of a traditional EMR system. It lacks alerts and parameters that would normally help to keep the patient safe, such as flagging inappropriate dosing of medications. Nevertheless, with its limitations, our system has proven to be an effective approach to a simulated patient record which can be captured electronically and incorporated into a video capture system.
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