Audience EMR Poll. Objectives: How Did We Get Here? The EMR Experience at UMKC 6/13/2012

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1 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 Objectives: 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. Audience EMR Poll 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 The EMR Experience at UMKC 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 How Did We Get Here? 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 1

2 UMKC HCIT Competencies 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 What is the Academic Education Solution? 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 What Does It Look Like? What Does It Look Like? Reciprocal Relationship Training Strategies to Use AES 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 2

3 Key Issues in Training Students 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 Resource Issues AES project manager Primary contact with Cerner Manages student enrollment in AES First line trouble shooting Cerner staff enters cases Pharmacotherapy 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 Pharmacotherapy HCIT course objective: Locate and retrieve information in the EMR system (AES) and utilize it to make patient care decisions Pharmacotherapy ( ) 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 Pharmacotherapy ( ) 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 3

4 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 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 4

5 Capstone activity grading rubric Modified version of exam case rubric Student EMR Survey Surveys were administered to students enrolled in Pharmacotherapy courses Completed at the end of Pharmacotherapy II and III Collected during the and 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 Survey Questions 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 Survey Questions 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? General Survey Results PII to PIII General Survey Results 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 29 to 46% to 73% +36 Retrieval/Case 60 to 74% to 97% +14 Completion Documentation 48 to 56% to 88% +49 Simulation 58 to 61% to 82% +7 *Represents those answering agree and strongly agree 5

6 Variance in Survey Results Mixed response between academic years of study: Advantage over paper cases in simulation of information retrieval and documentation by pharmacists Academic Year PII * PIII* Difference % 37% -13% % 74% +7% *Represents those answering agree and strongly agree Variance in Survey Results Preference to use only paper cases Academic Year PII* PIII* Difference % 57% +8% % 26% -3% *Represents those answering agree and strongly agree Explanation of Capstone CAPSTONE SURVEY RESULTS Continuation of Capstone Capstone Promotes Reflection of Abilities 6

7 Capstone Serves as a Bridge to APPE Future Incorporation of EMR at UMKC 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 Summary of UMKC Experience 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 University of Wisconsin-Madison School of Pharmacy 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) Obtaining Medication Histories 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. 7

8 Templates Used in Moodle 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. 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. EHR Communication Project 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 EHR Communication 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 *Morrow et al. Fam Med 2009;41(1): 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 Results EHR Communication Skill Fall 2011 Spring 2012 p value Introduced self to patient before 97.7% 94.4% NS turning on computer Explained use of computer prior to NS start of interview Moved close enough to patient to NS form work triangle Adjusted screen so patient can NS view easily Alerted patient verbally when turning attention to computer Offered to print copy of med list NS 100% 90% 80% 70% 60% 50% 40% 30% 20% Confidence in Obtaining Med History with EMR Extremely confident Very confident Moderately confident Not very confident Not at all confident Avoided periods of extended silence during interview NS 10% p< % Baseline Fall Spring 8

9 University of Florida: Our EPIC experience 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 Program Support 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 EPIC Patient Profile Pharmacy s EMR Training Model 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 Pharmacy s Assessment 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 Pharmacy Student Point Assessment Communication Skills Complete Needs Help Not Done EMR Medical History 13 Points 7 points ± ±14.24 N=276 students Discussed Not Reviewed 9

10 Medicine s Training & Assessment Model 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. Interprofessional Activities Future EPIC Activities Advanced Training Model Pharmacy increased Medicine? HIPPA focused Interprofessional student cases Medicine Pharmacy Dentistry* Physician Assistants* From the Classroom to Clinical Practice 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? 10

11 From the Classroom to Clinical Practice 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? Applied Assessment Video Audience EMR Assessment Poll EMR PATIENT INTERVIEW RUBRIC DISCUSSION What would you assess differently? UF s Assessment Plan Pharmacy Medicine Summary of UF Experiences 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 11

12 UF Acknowledgements: Diane Beck, Pharm.D. Carolyn Stalvey, MD Debbie Wilson, PhD Randy Graff Sara Henning Maria Velazquez, PA Daniel Pollock Questions? 12