5 Things You Need to Know About Electronic Health Records in Medical Education - Part 2


by SimGHOSTS Board member, Dr. Scott Crawford 


In my previous entry about electronic health records (5 Things You Need to Know About Electronic Health Records in Medical Education - Part 1), I described the origins, goals, and impact that electronic health records have had in the delivery of medicine. I then described how provider training and use of simulation can help with their integration and use. 


Further Background

The recent article about electronic health records, “The Upgrade” written by Atul Gawande that appeared in the New Yorker November 12, 2018, described the difficulties encountered by health care professionals who use electronic health records and the various services and innovations being looked at to combat these encumbrances. He reported on the “Brittleness of Bureaucracy,”[i]  where beautiful ideas and carefully planned innovation in system design eventually crumble as accommodations and advancement finally lead to system slowing and difficulty in adoption and use. This concept has been understood for decades in software design and has even been termed “The Tar Pit”[ii]  when attempts to increase function and accommodate multiple users in a diverse audience finally lead to an overall decrease in usability. Many consider the growth of potential features and the desire to capture information using health records to be an example of this type of obfuscation that comes from attempts to accommodate all possible users. While to health care administrators, providing standardization and mandated care plans can improve safety, in theory, the burden to those forced to use the system may seem unacceptable and has even been implicated in burnout and loss of workforce. The remainder of this blog will describe innovations and considerations on how to improve upon this problem.



To combat brittleness we must adapt and innovate. The proposed characteristics to achieve this adaptability, according to Dr. Gawande, are “mutation” and “selection.” Just as Darwin proposed as the basis for species adaptation, these concepts, when applied together in systems engineering, can allow for sustained improvement. Innovative thinkers can work to adapt, innovate, or even redesign systems to make them again function according to their intended purpose. Those systems that work well are “selected,” while those that do not will require a new “mutation” before being trialed again.

While this change can only occur on a small scale within large enterprise-level systems, innovation and adaptation can and should occur. The first of the five goals for “Meaningful Use” of electronic health records, as outlined by the Centers for Medicare & Medicaid Services (CMS), is: Improving quality, safety, efficiency, and reducing health disparities. One method that health care organizations are using to achieve this is through specialty specific adaptation of systems. Creating customized order sets and changing the appearance and flow of the type of information contained is one method to achieve this. When performed in collaboration with providers, it has the potential to increase support of and improve the utility for those using the system. Many hospitals and health care systems have small teams to specifically tailor systems in this manner. These types of adaptations must be carefully pursued and trialed to ensure they meet the need and don’t simply add to the complexity or brittleness of the system. One method to ensure the aims are met is to take iterative changes in system redesign and stage them in simulation to see the application of theory to practice. This is exactly the approach used by Texas Tech University Health Sciences Center El Paso when it was found that the system for documenting health visits did little to help providers in meeting the American College of Obstetrics and Gynecology (ACOG) guidelines for maternal screening. The revised flow and format for information was trialed in simulation before moving into clinical practice.

One of the standards of accreditation by the Society for Simulation in Healthcare (SSH) is “Systems Integration.” This standard requires the integration of health care simulation to support and improve the delivery of health care. What better way to support improved health care delivery than by impacting the safety and efficiency of health care providers by working to design the tool that providers use most in daily practice to communicate the care provided and receive useful and timely reminders about how to better render care to the patients that they see? Beyond using simulation to improve and integrate into existing health care systems, I discussed in the previous article that prior training and years of experience may have more to do with efficiency of documentation than any specific design. So how do we train using EHRs in simulation?


EHR Tools in Simulation

A 2018 article reviewing electronic health record needs for training described both the ideal features of an educational EHR, and the benefits of training with one.[iii]  In this article, the authors report 14 features of an ideal educational EHR. Some features are unique to the training environment and thus would not be present in an existing clinical application, but overlaps should be expected as well. Clearly usability and aesthetics are important for either, but I found that five major themes were present in the list of features for an ideal educational EHR. Out of the 14 items listed in the article, five common themes and overlaps with the concepts of meaningful use are highlighted below.

  1. Clinical decision tools and instructional software should be built into the system to assist the learner with delivery of care and use of the system, even in a simulated environment.
  2.           • (Improving the quality and efficiency of education)
  3. Allow review of learner use and performance over a set of learning cases
  4.           • (Engage educators with their learners’ use and performance)
  5. Have similar interface features for skill transfer between education and real EHR system.
  6.           • (Coordination of training from simulation to clinical practice)
  7. Modifiable by end-user to support variable training environments and cases that can evolve over time, and work on multiple platforms.
  8.           • (Customizable system to improve education for each population in health care)
  9. Be separate from existing EHR data to ensure safety, privacy and protection.
  10.           • (Protection of health information)

Not surprisingly these common themes mirror the goals put forth under meaningful use for the adoption and use of EHRs in regular practice. So we know what the ideal features should look like, how do we get one?


Use Within Simulation

While specific programs exist with the intent to train the use of electronic health records in simulated practice, there is not a yet a clear perfect system. Systems like Neehr Perfect, now called ehr go, boast use for training for multiple disciplines, but have a per student use fee, may not be well suited for all types of planned simulation, and the version trialed in 2017 was not able to release data over time to simulate an evolving case.

Some groups use existing EHR systems, or at least their “sandbox” training environments, but the ability to stagger the release of information is also not possible. Depending on the software vendor, they may limit user access for students and often will intermittently wipe the data to return to a default set of patients and parameters.

To combat some of these difficulties, many programs have tried to create simple systems to mimic the function of an EHR. These systems may include drop down lists, free-text order boxes, or even a text-editor interface where students can type information in the form of a clinical note or assessment, but do not garner the full look and feel of an EHR system.

Another option harking to the concept of mutation and selection may be a home built system like that, termed VICT-EHR, presented by Ronald Streetman and James McTiernan from the University of Michigan at the 2018 SimGHOSTS event in Memphis Tennessee.[iv]  This innovative group had been working at their home institution over the past several years to combat the issue of needing a simulated electronic health record for use in their simulation center. They did so by creating one. This relied on dedication from their team of healthcare simulation technology specialists and guidance from clinical faculty. The product was reportedly created in intermittent downtime over a several year period and utilized web based script written in HTML and PHP. While only tantalized by the concept at the event, it was clear that innovation is not only possible, it is inevitable. Systems will continue to be created to address this training need and will be best served by being adaptable to meet specific needs of educators, just as EHRs are being improved to meet the specific needs of clinicians in practice.


Final Thoughts

A whopping $19 billion dollars was invested to advance the use of electronic health systems as a component of the 2009 American Recovery and Reinvestment Act.[v]  Support and expansion of use for existing systems will continue and each health care system/region will continue to make adaptations to improve the way that care is accessed, shared, and delivered. The concepts behind EHR use are actually embraced by most providers, although a financial incentive is now also tied to their use. In one study that used the Technology Acceptance Model to examine the factors affecting use of an electronic health record, actual use was highly correlated with the perceived usefulness of the system, but perceived ease of use had no apparent direct influence actual use of the system by physicians.[vi] The same article suggests that involving physicians in the selection and development of an EHR improves perceived ease of use.

Some regions are using EHRs to help improve patient care across regions. Not uncommonly, and often partially related to the doctor patient disconnect caused by electronic health records, a patient will present to a second health care facility shortly after being seen for the same or similar complaint elsewhere. This repeat visit is often manifested because there was limited face-to-face interaction with the previous provider. A description of the previous interaction is frequently described by the patient stating “they didn’t do anything for me.” Too commonly, especially in emergency department practice, health care providers will perform a barrage of tests and studies to look for dangerous causes of symptoms but not find a definitive cause. In these instances, follow-up with other practitioners and additional non-emergent testing may be indicated. The solution is twofold. One, providers should be conscious of the perceived disconnect and make extra efforts to describe what was done and what additional steps may be required to prevent duplicate visits. Two, healthcare directors and providers could work with regional health care agencies to allow access to studies performed at outside facilities to improve regional delivery of care. Due to HIPAA privacy protection and the propriety of results within a hospital or health care network, the records and results from a previous visit at a hospital across town will not be available to a second provider. Larger systems are able to combat this by collectively controlling and housing all records in a single location for a geographic region. A similar system is possible and has been shown useful by coordinating a regional provider accessible database where all labs, results, and studies are uploaded to a central web accessible database. Systems that allow this type of information exchange have been established recently across several municipalities; Denver, Colorado and El Paso, Texas are two such examples.[vii viii]   Systems like the Paso del Norte Health Information Exchange (PHIX) collect data from unique EHRs, but utilize the international database standard of each, known as Health Level 7 (HL7), to link common information. This has allowed similar information to be shared and easily accessed in this region.

Larger regional or national adoption could have the opportunity to enhance delivery of care if a common system were developed. Similarly and related to education, common training platforms could be designed within simulation to allow national benchmarking of student performance to a network of others. Common and standardized educational platforms such as those developed by New York University under the titles Wise-Oncall and Night-Oncall could allow standardized training and benchmarking for care documentation. The system currently used for documentation for Wise-Oncall, however, is reported as a simple word processing document. With careful implementation, standardized training like this has the possibility to provide valid assessment of the readiness of medical students to perform tasks expected of interns after graduation from medical school.

Although standardization for EHR systems is likely an impossible reality, we within simulation could still push to develop a common, sharable, and still configurable system to allow training on effective use of EHR systems for providers before entering practice. Even if using existing EHR systems, simulation could be an effective testing ground to gather provider input and improve the way systems are designed and implemented.[ix]

[i] Spencer, M. (2015). Brittleness and Bureaucracy: Software as a Material for Science. Perspectives on Science, 23(4), 466-484.

[ii] Brooks, F. P. (1975). The mythical man-month.

[iii] Wilbanks, B. A., Watts, P. I., & Epps, C. A. (2018). Electronic Health Records in Simulation Education: Literature Review and Synthesis. Simulation in Healthcare, 13(4), 261-267.

[iv] Streetman, R. McTiernan, & Turkelson, C. (2018) DIY Simulated Patient Electronic Health Record: An Introduction. Presentation at 2018 SimGHOSTS USA, Memphis, Tennessee.

[v] Blumenthal, D. (2009). Stimulating the adoption of health information technology. New England journal of medicine, 360(15), 1477-1479.

[vi] Morton, M. E., & Wiedenbeck, S. (2009). A framework for predicting EHR adoption attitudes: a physician survey. Perspectives in Health Information Management/AHIMA, American Health Information Management Association, 6 (Fall).

[vii] Colorado Regional Health Information Organization, http://www.corhio.org/

[viii] Paso Del Norte Health Information Exchange, http://phixnetwork.org/

[ix] Kalet, A., Zabar, S., Szyld, D., Yavner, S. D., Song, H., Nick, M. W., ... & Eliasz, K. L. (2017). A simulated “Night-onCall” to assess and address the readiness-for-internship of transitioning medical students. Advances in Simulation, 2(1), 13.