Electronic Medical Records (EMR): an Opportunity to Expand
Interprofessional Education and
Advance Case Based Learning
Lisa D. Inge, Elizabeth A. Winans;
Maqual R. Graham, Karen J. Kopacek,
Patricia A. Marken, Maureen A Novak,
Kristin Weitzel
6/13/2012
1.Discuss the educational needs and training required to prepare students and faculty to effectively use an EMR within the classroom or practice setting
2. Demonstrate how multiple commercial EMR systems may be utilized within the curriculum to teach case-based learning, communication skills and allow interprofessional collaboration
3. Review student EMR assessment techniques and perceptions of these teaching methods both in the classroom and clinic setting
4. Evaluate a taped EMR patient interview using one of three rubrics to obtain audience feedback on the activity and/or the assessment itself.
Which of the following best describes your institutional EMR setting?
A. EMRs use is taught in the didactic setting
B. Transitioning to EMR activities
C. Only APPE students use an EMR
D. Multiple experiences in IPPE & APPE
E. No Current EMR activities
Patricia A. Marken, Pharm.D., FCCP, BCPP
Associate Dean for Student Affairs and Professor
Maqual R. Graham, Pharm.D.
Associate Professor
Elizabeth A. Winans, Pharm.D., BCPP
Clinical Associate Professor
University of Missouri-Kansas City
Department of Pharmacy Practice and Administration
• Increasing importance of Health Care
Information Technology (HCIT) in ACPE
Standards and in preparing students for the workforce
• Partnership with Cerner
• UMKC-based HCIT competencies
– Competencies and strategies to develop them across curriculum
• Academic Education Solution (AES)
• Lectures
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• Input, store, retrieve, and analyze electronic health information
• Optimize the medication prescribing/ordering process
• Aid in clinical decision-making
• Automate the medication delivery process
• Facilitate pharmacy management
References:
ACPE Standards 2007, Competencies in Informatics
AMIA Revised Informatics Competency Statements November 29, 2007
CAPE Guidelines 2007
AMIA 2008 Joint Workforce Task Force
• Live version of the Cerner software used in health care institutions modified to support student learning
• Allows for:
– Authentic instructional environment
– Practice using a real EMR and pharmacy information system supported by clinical decision support services
– Track student progress in documentation skills over time
6/13/2012
HCIT skills
 by using AES
AES
 clinical skills
• Students
– Brief videos
– Manuals
– Play patients
– Homework
• Faculty
– Individual meetings regarding instructional goals
– Templates and instructions for case development
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How to:
– Sign on to system
• remembering passwords biggest issues
– Navigate system
– Retrieve and visualize data
– Use data to identify and solve drug related problems
– Enter note
• AES project manager
– Primary contact with Cerner
– Manages student enrollment in AES
– First line trouble shooting
• Cerner staff enters cases
• Pharmacotherapy II and III (PII and PIII)
– Course purpose: to develop student’s ability to assess patients and provide care
– Course objectives (not inclusive):
• Identify medical and drug-related problems
• Design, implement, monitor, evaluate and adjust pharmacy care plans
• HCIT course objective:
– Locate and retrieve information in the EMR system (AES) and utilize it to make patient care decisions
6/13/2012
• Usual lab case completion
– Students work in small groups to complete paper patient cases
• Pertinent patient information is provided as well as some information that is not relevant
• Must identify all medical and drug-related problems as well as recommend therapy
• Documented on the “standard case form” developed for the course
• Lab case completion utilizing the EMR
– Students work in small groups to complete patient cases
• Only Patient’s name and ID are provided
• Students must retrieve pertinent patient information from the EMR to identify problems and recommend therapy
• Documented on the “standard case form” developed for the course
• One to two students/group utilized EMR while others observed
• Utilized to complete four lab experiences
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• Homework
– Mechanism for all students to use the EMR
– Provided students with patient’s name and then asked student to:
• List two dates of hospital admission
• Provide lab value on certain date
• Determine if patient had JVD on admission
• Determine if patient has an allergy and if so, to what drug
• Dose, frequency and stop date of a certain drug
• Homework
• Prior to assignment, students were asked to view two tutorial videos for log-in and navigation
• Other helpful documents were also posted for review by the student
• Because homework was completed at the beginning of Pharmacotherapy II, students were better prepared to complete lab cases
6/13/2012
• Students continued working in groups to complete lab cases utilizing the EMR
– Patient’s name and ID provided
– Students retrieve pertinent patient information from the EMR
– Students identify problems and recommend therapy
– Documented on the “standard case form” developed for the course
– EMR was utilized to complete 6 lab experiences (CVD, CHF,
HAP/CAP, Depression, Dementia/PD and CC)
• Students were encouraged to individually review the patient’s medical prior to completion of the EMR labs in PII
• Students did not have access to patient data prior to the EMR lab in PIII
• Students were frequently reminded that the
PIII Capstone would utilize AES
• Overall, more students engaged in completion of labs
• Capstone Activity
– Culmination of the homework activity and multiple group lab
– Complex patient case developed that incorporated diseases discussed during the two semesters of Pharmacotherapy
– Case completed by each individual student utilizing EMR
• Capstone Activity
– Afforded 1 hour and 15 minutes to complete case
– Following data extraction from the EMR, students were expected to
• Determine the patient’s medical and drug-related problems
• Recommend pharmacologic therapy with justification
• Suggesting appropriate monitoring for drug therapy initiated, changed or discontinued
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• Capstone activity grading rubric
– Modified version of exam case rubric
• Surveys were administered to students enrolled in Pharmacotherapy courses
– Completed at the end of Pharmacotherapy II and III
– Collected during the 2010-2011 and 2011-2012 academic years
• Survey contained 8 questions regarding the student’s perception of utilizing an
EMR for patient case completion
– 5-point Likert scale and free text answers
6/13/2012
• Confidence in utilization of an EMR
• Adequacy of EMR training
• Ability to use the EMR to identify problems and document treatment recommendations
• EMR activity simulates real world practice
• Use of EMR prepares students for experiential learning
• Free text questions
– When using the EMR, what did it teach you that a paper case could not?
– What percent of lab cases would you like to complete using an EMR?
– Are there other ways to utilize an EMR in
Pharmacotherapy?
• Student abilities and perceptions increased from PII to PIII by:
– EMR navigation
– Data retrieval and case completion
– Documentation in the EMR
– EMR reflects pharmacist responsibility and role in patient care
Navigation
Retrieval/Case
Completion
2010-2011* 2011-2012*
29 to 46% +17 37 to 73%
60 to 74% +14 84 to 97%
Documentation 48 to 56% +8 39 to 88%
Simulation 58 to 61% +3 75 to 82%
+36
+14
+49
+7
*Represents those answering agree and strongly agree
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• Mixed response between academic years of study:
– Advantage over paper cases in simulation of information retrieval and documentation by pharmacists
Academic Year PII *
2010-2011
2011-2012
50%
67%
PIII*
37%
74%
Difference
-13%
+7%
*Represents those answering agree and strongly agree
– Preference to use only paper cases
Academic Year PII*
2010-2011 49%
PIII*
57%
Difference
+8%
2011-2012 29% 26% -3%
*Represents those answering agree and strongly agree
6/13/2012
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• Developed, in part, from answers to free text questions
– Simulation-based learning activities
• TOSCE and OSCE
– Clinical support decision technology
– Increase types and frequency of student documentation
• PRIME-3, QuEST, SOAP note
– Nonprescription and self-care course
6/13/2012
• Three years into implementing HCIT competencies – still a work in progress
• Identify where using AES adds value to education versus a “cool thing to do”
• Start slow and identify early adopters
• Determine frequency of use to maintain skills
• Balance with skills development through
APPE’s
Karen J. Kopacek, R.Ph.
Clinical Associate Professor, Associate Dean of Student Affairs
Andrea Porter, Pharm.D.
Clinical Assistant Professor
Kathryn Hentzen, Pharm.D.
Clinical Instructor
Michael Pitterle, M.S., R.Ph.
Associate Professor, Director of Instructional and
Information Technology
University of Wisconsin- Madison
• Summer 2011:interdisciplinary group formed
(medical, PA, nursing, and pharmacy schools)
• Goal: Collaboration between UW Hospital,
Clinics (UWHC) and EPIC to bring EMR into each classroom
• Plan: Utilize existing developed UWHC patient cases for the new EPIC training, thus focusing students on finding data in the EMR and documenting specific discipline information
– Example: Nursing students would complete a physical exam and record vital signs, pharmacy students would complete medication histories
– All disciplines work together on cases to provide care
(inpatient and ambulatory)
• Students practice taking medication histories in 1 st -year IPPEs and during Pharmacotherapy
Lab activities in 2 nd year.
• Observations made by PGY-1 ambulatory care residents precepting students during summer internship noted that students were:
– competent with obtaining medication histories.
– struggled using an EHR to document information while conducting the interview.
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®
• Student copies template into a new
Word document and records information during consult. The document is saved to the laptop and submitted in Moodle for grading.
6/13/2012
• When EPIC was not available for use in
Pharmacotherapy Lab, the UW SOP IIT
Department created a mock EMR for student use with drug consults to simulate a clinic pharmacy.
• If interested in learning more, contact Mike
Pitterle at mepitterle@ pharmacy.wisc.edu.
• Students completed 1 medication history without using an EHR
• Watched taped example of interview using a computer to document med list
– Assessed performance using new rubric
• Completed two medication histories using laptops and documenting list in Moodle
– Template created in Word
– Peer evaluated using rubric
– Watched first interview and completed selfassessment of performance using rubric
 Introduced self before turning on computer

Explained use of computer prior to start
 Formed work triangle between patient, computer, and pharmacist

Adjusted screen for patient viewing
 Alerted patient when turning attention to computer
 Offered to print copy of med list
• Established rapport with patient
• Used open-ended questions
• Maintained good eye contact during interview
• Allowed patient to speak without interruption
 Avoided extended periods of silence
Rubric uses 5-point scale, ranking performance of each communication skill from strongly disagree to strongly agree
*Morrow et al. Fam Med 2009;41(1):28-33.
EHR Communication Skill
Fall 2011
97.7% Introduced self to patient before turning on computer
Explained use of computer prior to start of interview
Moved close enough to patient to form work triangle
Adjusted screen so patient can view easily
Alerted patient verbally when turning attention to computer
Offered to print copy of med list
Avoided periods of extended silence during interview
79.5
100
77.3
58.1
61
88.6
Spring 2012 p value
94.4% NS
88.9
94.5
NS
NS
83.3
88.9
55.5
100
NS
0.034
NS
NS
Confidence in Obtaining Med
History with EMR
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Baseline Fall Spring p<0.001
Extremely confident
Very confident
Moderately confident
Not very confident
Not at all confident
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Lisa D. Inge, Pharm.D., BCPS, BCACP, AAHIVE
Clinical Associate Professor, College of Pharmacy
Maureen Novak, MD
Associate Dean for Medical Education, College of Medicine
Kristin Weitzel, Pharm.D., CDE, FAPhA
Director of Experiential Education, Clinical Associate Professor
College of Pharmacy
• UF multiple hospital model of “EPIC”
• EPIC organization & University support
• Multidiscipline Plan:
– Dentistry, Medicine and Pharmacy
– Interprofessional training & CME
• UF sponsor technology grant
– IT support
– Hardware
– Software
http://jcu-stp-seminar.wikidot.com/john-hurt-2-10-11
• Second year pharmacy students
• Completed at least one standard non-
EMR patient interview prior to event
• OSCE model with EMR:
– Gainesville: Traditional simulation center
– Distance Campus Model (Jacksonville,
Orlando & St. Petersburg): Mimicked simulation with same “patients”
• Medicine & Pharmacy: Same Rubric
• Post activity survey
Limited during initial year:
• Video training with paper case
(EPIC and IT developed)
• Each student received a “practice patient” with an individual password
(IT developed)
• Two Assessed readings: EMR use & communication techniques
• Communication EMR rubric posted
EMR Medical History
Communication
Skills
Complete
Needs
Help
Not Done
Discussed
Not
Reviewed
13 Points
84.20
±
13.59
7 points
N=276 students
88.77
±
14.24
6/13/2012
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• Integrated into “Doctoring” course
• Individual patient data entry & review
• OSCE Assessment for communication and case interventions
– Same rubric as pharmacy (different focus
& point distribution)
• SOAP note writing on rotations
Scenario – Medicine – Rising 3 rd
Year –Discharge Navigator
• Learning Objectives - After this scenario, you will be able to:
– Locate the patient for Discharge
– Locate patient from My Patient list
– Open patient chart
– Complete the Discharge Navigator
– Update problem list
– Complete Med Rec/ Orders
– Write a Discharge summary note using Smart text
– Mark note as requiring a co-sign
• Patient Situation
– It’s now the end of the day and you return to Maureen’s unit to see how she has done today. You anticipate that if she has maintained her oxygen saturation, and is not having any more respiratory distress, that you can discharge her home. You return to her room to see her sitting up, eating dinner and chatting with friends who have come to visit. She is still off oxygen and her o 2 sat is 98%. She tells you that she feels SO much better and that she is only getting the albuterol every 4 hours as currently scheduled. You tell her that you feel she is safe to go home, but must follow-up at the student health clinic tomorrow. She is extremely happy and promises she will go there tomorrow. You tell her you must work on her discharge paperwork, but that she should be ready to go within the next hour. You leave the room and proceed to a computer station.
–
•
• Advanced Training Model
– Pharmacy increased
– Medicine ?
• HIPPA focused
• Interprofessional student cases
– Medicine
– Pharmacy
– Dentistry*
– Physician Assistants*
• Student use of EPIC on APPEs
– Adult Med, Critical Care, Advanced
Hospital, Ambulatory Care
• Benefits
– Student integration into site
• Pharmacy activities and systems
• Interprofessional practice
– Increased efficiency?
6/13/2012
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• Barriers
– Student access to EPIC in clinical practice
– Learning curve
• Student feedback
• Implications for future
– How does this impact our training model?
– What are we missing in the educational process?
6/13/2012
What would you assess differently?
Pharmacy Medicine
• More classroom activities are needed
– HIPPA, access pathways & communication techniques in addition to straight data entry
• Interprofessional activities are necessary and practical
• EMR Impact on student APPE require further investigation
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• Diane Beck, Pharm.D.
• Carolyn Stalvey, MD
• Debbie Wilson, PhD
• Randy Graff
• Sara Henning
• Maria Velazquez, PA
• Daniel Pollock
6/13/2012
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