The use of Electronic Medical Records is now standard in clinical practice, but only a few simulation programs integrate its use in a structured way. A recent joint project in Texas shows how filling this gap can improve student preparedness… but not without challenges.
Can a simulation be truly realistic without the use of an electronic health record?
Imagine this scene:
Sara, a second-year student in her nurse practitioner program, enters a simulation room. In front of her is a standardized patient complaining of chest pain. She has a few minutes to take the patient’s medical history, analyze the symptoms, read an ECG, interpret blood tests and formulate a plan of action. But this time there is an added element: everything she needs is contained in an Electronic Medical Records (EMR) identical to the one she will find in a few months’ time in the hospital. Sara nervously scrolls through the screen, looks for the troponin values, consults previous notes, types her observations while interacting with the patient. She is learning to think like a clinician, to document like a professional, to make decisions under pressure.
If we really want the simulation to prepare future healthcare practitioners for real-world clinical encounters, we need to recreate realistic environments that incorporate all the elements that are part of the practice. among these is also the EMR. However, integrating this tool into teaching is not simple.
In nurse practitioner programs, we use simulation to foster critical thinking and prepare students for real patient scenarios they may encounter. To promote patient safety and enhance training, it is important that these simulations use the same tools that the student will use in the clinic and hospital. Electronic Medical Records are universally used to capture patient data and allow the clinicians to review critical information regarding the patient’s health. The addition of informatics components will not only make the encounter more realistic for the student, but also provide instructors the means to evaluate the student’s ability to synthesize patient information and use all available information to formulate an accurate diagnosis and treatment plan. The nurse practitioner program at Lubbock Christian University recently added the use of an EMR to simulation activities and noted various pros and cons.
The challenge in using EMR during simulated patient encounters is finding one that can be tailored to the instructor’s particular needs and is student friendly. Collaborating with Texas Tech University Health Sciences Center Simulation Program, we were able to use a non-production training domain of the EMR used at local hospitals and clinics. Multiple case scenarios were developed that include diagnostic results students could interpret including blood work, EKG, x-rays, spirometry, and urine cultures. Vital signs and chief complaints were tailored to the individual case scenarios and standardized patients were provided a script to follow. Students were allowed a set amount of time to flow between different clinic rooms with different case scenarios in which they interacted with the patients. The students documented in the EMR during the patient interactions and reviewed preloaded diagnostic information to guide formulation of a diagnosis.
Student feedback regarding EMR use was mixed. While it did make the encounter more realistic, some students felt it increased their stress levels having to navigate through the EMR and document during the patient encounters. The instructors liked having the students work through the health history and interpreting diagnostic data in real-time during patient encounters. The main limitation noted was that all diagnostic test results had to be preloaded and viewable in the EMR prior to the patient encounter. This removed the need for students to determine appropriate diagnostic tests to order based on their synthesis of the information they gathered from the patient, thus eliminating one avenue to measure student critical thinking. This is one issue that we will continue to explore and collaborate on a possible solution.
Some tips that may help make the use of an EMR more effective and less stressful during simulation include:
- Begin student training and frequent exposure to the EMR early in the program prior to use in testing situations.
- Initially use the EMR in low stakes simulation activities.
- Pilot new simulations or significant changes prior to implementation.
- Assign a sandbox chart to each student for free exploration and independent practice on their own time.
- Identify EMR power users amongst the faculty who are well trained and versed in the use of the EMR during simulation to assist students.
- Have an Information Technology Specialist available to help with technical issues such as password issues, lockouts, etc.
- Have brief instructor collaborative meetings following any simulation activities to discuss what worked well and what did not.
- Solicit and utilize student feedback to evaluate and enhance the experience.
Introducing any new technology into simulation can be challenging, but it is imperative that simulation activities be as authentic as possible and prepare students for real-world encounters. The extensive use of electronic medical records throughout healthcare requires that nursing students learn to use these tools effectively. EMR use during simulation can really tie everything together for students and allow them to feel submersed in a real-life patient care experience. While you may have challenges to overcome if you add the use of EMR during clinical simulation activities, most can be overcome with careful planning and implementation.
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