There is a lot of disEHRandSim'cussion recently about incorporating electronic health record (EHR) into simulations. Which vendor? Which product? What features are needed? The disturbing thing about most of these discussions in my mind is that no one is talking about what they are trying to accomplish with the inclusion of electronic health records into the simulation environment.

What is the purpose of the EHR in it in a simulation? Is it simply to provide realism? If so, is the EHR that is implemented likely to be the one in the practice environment experienced by the student? Because if not, it is missing the mark likely adding confusion as well as increasing the orientation time necessary for a given simulation. Is the EHR supposed to provide crucial information that will help make healthcare decision during the simulation encounter? Is the entire simulation designed around an efficient query for specific information of a patient’s history? Are entries in the EHR made by the participants of simulation going to be analyzed for knowledge or critical thinking regarding a case? There are so many possibilities! I would argue however that integrating the EHR into the simulation simply for reality will likely be a colossal waste of time.

Much like any other component included in simulation the EHR should be included thoughtfully and carefully driven by needs analysis based on the learning objectives of the educational encounter. EHR technology can be overwhelming by itself to understand and navigate, combined with the fact that there are many different types of systems for different practice environments make it unwieldy to become expert in all brands, systems or examples.

Similarly, it if you have successful implementation of the EHR into your simulations I would recommend that you carefully decide for each and every simulating counter whether you need to include it or not. Again, this decision should rest upon the learning objectives and the intended educational outcomes of the event. Interacting with the EHR can be a time-consuming, frustrating part of the delivery of healthcare and it is up to the creator of the educational encounter to determine the usefulness and necessity of such integration.

The thoughtful use of EHR into select simulated encounters can significantly lead to increased observations of critical thought process, attention to detail, as well as overall understanding of the depth and breadth of understanding of a given case. Additionally it could serve as another avenue for assessment. If the integration of the EHR is predicated around these efforts and clearly the addition of the EHR component is both worthwhile and necessary. Additionally, simulations involving workflow and human factors can possibly benefit from such integration knowing that in today’s delivery of healthcare the interaction with the EHR is a daily reality.

I must close however with reminding the simulation community it is not our job to re-create reality, it is our job to create an innovative educational encounter from which we can form opinions to engage in discussions to help healthcare providers on their quest towards excellence.


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  1. Penni Sadlon

    Thank you Dr. Phrampus for this article. I must wholeheartedly agree with the perspectives you have given. Our SON simualtion program uses a home-grown EHR in special circumstances IF it adds to the overall objectives of the simulation. I took a word template and created EHRs for each simulated patient (with custom QR code patient identifiers).. The records can be navigated by thumbnails to gain further insight into the case. The EHR is introduced in a beginning class, and then used throughout the program. The purpose in my mind, which serves our objectives, is to get students accustomed to thinking about what information is pertinent to the case in that moment. Beginning students use the EHR for a medication administration simulation. Advanced practice students use the EHR to determine background data, current orders, and diagnostic results. Finally, if faculty are interested in documentation competencies, then students can fill out a nursing note, or provider consultation and “save as” a copy to forward on to their professors. So far this has worked for our program. What is missing is “real-time” download of new order, lab results,etc. However, our simulations really don’t last long enough for that to be a crucial skill, and students get that at their clinical practice sites. Finally, we are a low-resouce program, so anything we can do for “labor-only” costs meets our current situation.
    Best Regards,
    Penni Sadlon BSN, RN
    Simulation Coordinator
    Rhode Island College School of Nursing
    600 Mount Pleasant Avenue
    Providence, RI 02908

  2. Paul, I like that you get to the crux of the EHR in simulation question. I suppose what surprises me is how often “objectives” are not fully considered when choosing any technology for instruction/learning purposes. The business community rarely considers an investment unless it has developed clearly defined objectives: rationale is procurement for the stated reasons for doing so. For those that know me, know that I am pretty active on the various simulation community forums. Also, as a representative for a “for-profit” company I get asked what I think the best available simulation AV software. It still comes down to what a simulation program is trying to achieve through such software. While money is often a driving force in these decisions, many of those searching for a solution (regardless of the simulation or instructional technology). Certainly saving money is high on the list of primary objectives when exploring solutions, but should it be? If a less expensive solution causes one to rationalize that some objectives that were priorities before they learned the price are no longer priority objectives when the price has become clear. Many times a simulation program begins the search for a solution even before they have a budget to purchase, which I find perfectly satisfactory. However, what I find particularly unfortunate is how many programs fund major purchases. Money is left over from an account and it must be spent before the end of the week, or a grant that was sought as much as a year before it is awarded remains a secret, and again the simulation program must make a very quick decision on spending a lot of money. I suggest that it is in the best interest of any program, especially a simulation program to consider the following:
    —Do a gap analysis. What are the missing pieces in your program? What are the tripping points in the program that could be smoothed out through the purchase of a solution?
    —Define objectives for a solution purchase. Will one vendor or product meet all of the objectives, or will it require multiple providers.
    —Prioritize objectives. List objectives in order, with the highest priorities listed first.
    —Identify Dependencies. Is one or more priorities dependent on other priorities being met first? If so, ensure that you don’t have a cart in front of the horse. Move dependencies to a higher place in the priority list than those priorities that depend on them.
    —Organize objectives so that they are achieved in phases; starting with objectives that form dependencies for objectives lower in the list.
    —Research solutions on the market. As part of the research, seek out subject matter experts who are knowledgeable about the full spectrum of solutions available on the market, any standards that have been established, etc.
    —Create a budget for each phase to be rolled out and periodically update the budget and quotes in case money becomes available. Typically, unexpected funds have to be spent quickly and so there isn’t much time to do the foot work required to make an informed purchase decision.

    Formalize your preparation in the form of a project business plan. This will accomplish two things: (1) You will be better prepared when a surprise grant or unspent budget become available to you. (2) Administrators will place your plan ahead of those who do not have one and are scrambling to answer the call “We have $xxx,xxx to spend, who should we call first?” I don’t know about you, but I want to be their first call.

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