Building an EMR Sandbox Medical Schools Can Play In. Please follow the link and introduce yourself:

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1 Building an EMR Sandbox Medical Schools Can Play In Please follow the link and introduce yourself:

2 Building an EMR Sandbox Medical Schools Can Play In Welcome, Introduction and Context [...15:15] AFMC ehealth Initiative Pierre Beaupré Infoway ehealth Initiative Rashaad Bhyat What is an EMR Sandbox? [ 15:25] Group Discussion Potential Components of Sandbox Environments

3 AFMC - Infoway Physician in Training: e-health Curriculum and e-learning Project Projet AFMC - Inforoute sur les programmes éducatifs de cybersanté et le cyberapprentissage à l'intention des médecins en formation

4 AFMC-Infoway Project Goal / But du projet AFMC-Infoway Bring together champions at Canadian faculties of medicine to strengthen e-health in undergraduate medical education. Réunir des champions des facultés de médecine canadiennes en vue de renforcer le volet portant sur la cybersanté dans le cadre des études médicales prédoctorales.

5 Leadership Committee / comité de leadership Université Laval D r Pierre Beaupré Canada Health Infoway Dr. Rashaad Bhyat Northern Ontario School of Medicine Dr. Rachel Ellaway Memorial University Dr. Gerard Farrell AFMC Mr. Irving Gold University of Alberta Dr. Rob Hayward University of British Columbia Dr. Kendall Ho Dalhousie University Dr. Katrina Hurley University of Manitoba Dr. Judith Littleford Northern Ontario School of Medicine Dr. Greg Ross Canada Health Infoway Dr. Jennifer Zelmer

6 Building a Network of Champions / Construire un résaux de champions Facilitated national engagement of clinical educators, academic leaders, and learners on e-health Favoriser et appuyer l'engagement national de la part des enseignants cliniques, des cadres universitaires et des apprenants en matière de cybersanté. AFMC - Infoway Physician in Training e-health Curriculum & e-learning on CHEC-CESC

7 We request your leadership / Nous profitons donc de l occasion pour faire appel à votre leadership Medical education, to be truly aligned with the needs of Canadians, must adapt, and adapt quickly to major changes in clinical practice catalyzed by e-health technologies. «Afin de parvenir à véritablement s harmoniser avec les besoins des Canadiens, la formation médicale doit s adapter rapidement aux principaux changements dans la pratique clinique provoqués par les technologies de la cybersanté.»

8 Creating National Learning Outcomes and Competencies / Susciter des résultats d apprentisage et des compétences à l échelle nationale Members of the leadership committee have begun the process of developing national learning outcomes and competencies, and a common lexicon for e-health, drawing heavily on stakeholder input. Les membres du Comité de leadership ont commencé à élaborer des conclusions et des compétences au niveau national ainsi qu un lexique commun regroupant des termes propres à la cybersanté en s appuyant fortement sur les commentaires des intervenants.

9 CHEC-CESC Virtual Patient Challenge / Défi Patients virtuels de la CHEC-CESC 2012 à l'intention des étudiants en médecine 1 st / re place Drs. Calvin Ke, Terence Yung, David Harris, University of British Columbia Faculty Advisor / Conseiller académique : Dr. Roger Wong Case / Cas : Unforeseen Circumstances 2nd / e place Caitlin Cahill, McGill University Faculty Advisor / Conseiller académique : Dr. David Fleiszer Case / Cas : An Abdominal Brief 3 rd / e place Ayesha Malik, University of Toronto Faculty Advisors / Conseillers académiques : Drs. Kiran Virdy & Marcus Law Case / Cas : A fatigued figure

10 AFMC- Infoway, e-health Award Prix en cybersanté de l'afmc-inforoute 2013 Recognize a faculty member that has demonstrated exceptional leadership and commitment to e-health Récompensez le leadership et l engagement exceptionnels en leadership et en cybersanté dans le cadre de l enseignement médical au Canada. Award Recipient /la lauréate du prix : Dr. Candace Gibson, Western University

11 CCME 2013 AFMC-Canada Health Infoway Workshop Dr. Rashaad Bhyat Clinical Leader, Canada Health Infoway Canadian Conference on Medical Education 2013 Quebec City, April 22, 2013

12 Clinical Adoption Clinical value through ICT 12

13 Clinical Engagement Framework Link with leaders Clinical Council Reference Groups Advocate for clinical value & engage with projects Direct care providers Peer Networks E-prescribing HSU Arch/Deploy Blueprint 2015 The next generation AFMC, AFPC, CASN initiatives

14 Infoway s Clinicians in Training Objectives To ensure that clinicians in training are ready to practice in, and gain value from, an ICT-enabled environment when they graduate To integrate concepts and expectations related to the use of ICT in practice into the curricula design/ educational processes of the Faculties of Medicine, Nursing and Pharmacy

15 National Physician Survey 2010 Results FP/GP Residents & Medical Students Almost 7 out of 10 (69.4%) Family Medicine residents across Canada report having received training in the use of ICT for clinical purposes during their residency training. 62% of medical students report that the availability of relevant patient information at the point of care is a factor in having a satisfying and successful medical practice. 53% of medical students report that the availability of electronic health records is also a factor in having a satisfying and successful medical practice. 15

16 EMR Adoption Data Commonwealth Fund Survey % of physicians using EMRs in Canada (compare to 37% in 09) 14% report they can electronically exchange patient summaries and test results with doctors outside their own practice Participate in an upcoming webinar Pan-Canadian EMR Benefits Evaluation study Novel national baseline study Report (April 22) and link to webinar (April 23) at (events, upcoming events) 16

17 Clinician Education Campaign

18 Step 2 & 3 Top 5 Benefit Areas for Clinicians 1.Timely access to information 2.Decision support and workflow 3.Collaboration and communication 4.Improved efficiency and avoided duplication 5.Information management and education 18

19 Educational resource toolkit components Orientation guide Animated videos The Plan The Benefits Peer videos What Clinicians are Saying Demonstration Videos Supporting documents FAQs, PPT template, Article template Accessing the toolkit Contact to become a Clinical Champion.

20 Contact Information Dr. Rashaad Bhyat Or

21 Thank you

22 Building an EMR Sandbox Medical Schools Can Play In Welcome, Introduction and Context [...15:15] AFMC ehealth Initiative Pierre Beaupré Infoway ehealth Initiative Rashaad Bhyat What is an EMR Sandbox? [ 15:25] Group Discussion Potential Components of Sandbox Environments

23 Small Group Activity Please continue to Sandbox Definition:

24 XXR? Computer-based Patient Record (CPR) Electronic Medical Record (EMR) Electronic Patient Record (EPR) Electronic Health Record (EHR) Personal Health Record (PHR) Continuity of Care Record (CCR) Computer Life Record (CLR) Consumer Health Record (CHR) National Care Record (NCR) Patient Medical Record (PMR) Integrated Electronic Health Record (iehr) Electronic Health Record Solution/System (EHRS) Etc.

25 ehealth Context Electronic Health Record (EHR) Client-centred longitudinal collection of personal health data supporting multiple providers across the continuum of care with appropriate information securely delivered to authorized individuals. [patient-centric] Electronic Medical Record (EMR) Record of clinical encounters maintained by the caregiver in an electronic system for reference and updating by the custodian. [provider-centric] Clinical Information System (CIS) Computerized system that collects, stores, manipulates and presents information supporting the delivery of interventions (e.g. ECG repository) or services (e.g. admission-dischargetransfer system). [institution-centric]

26 ehealth Context Personal Health Record (PHR) Consumer-oriented diary of personal health information and goals supporting personal health education, management and communication. [consumer-centric] Digital Health Records (ehealth) Convergence of EHR, EMR, CIS, PHR in wide-area shared health information repositories with role-optimized interfaces. [holistic]

27 EHR Solution The EHR Solution is a combination of people, organizational entities, business processes, systems, technology and standards that interact and exchange clinical data to provide high quality and effective healthcare. 27

28 Two Case Experiences [ 15:55] UofA Rob Hayward UBC UVic André Kushniruk, Elizabeth Borycki Issues and Challenges [ 16:15] Group Discussion Building an EMR Sandbox Medical Schools Can Play In Requirements for valuable, viable and sharable ehealth Sandbox Environments Opportunity for a Common Platform [ 16:25]

29 EHR - Alberta Netcare Province-wide, all Albertans All clinicians and trainees EMR CIS eclinician ehealth Context - UofA Zone-wide, provincial goal Ambulatory care, expanding to continuum of care PHR MyHealth Untethered Personal Health Portal deployed Personal Health Record deploying

30 3-year Sandbox Journey PHR in pre-clinical curriculum EHR Sandbox in bridge from pre-clinical clinical EMR Sandbox in pre-clinical PBL curriculum EMR Simulator in second year curriculum

31 Personal Health Record Intent (CanMeds Expert, Communicator, Advocate, Scholar) Introduction to health literacy Critical appraisal of consumer health information Confront different advice from multiple sources Empathize with consumer health information challenges Intervention Case of the Week (required online exercise) linked to MyHealth.Alberta.ca, reporting any delta from what was taught in clinical approach lecture [All students get MyHealth HealthVault PHR accounts to create a personal health record]

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33 Experience Personal Health Record Re-articulating curriculum content as consumer health advocacy. Contribution to improvement of a provincial public asset Government product availability expectations vs delivery (3+ years late for PHR) Learnings Untapped potential for health literacy, patient advocacy Possible better leverage if built in to early critical appraisal teaching Faculty need support teaching about health literacy Vulnerability to large provincial/political initiatives

34 Electronic Health Record Intent (CanMeds Communicator, Manager) Privacy awareness training Expose implicit decision-support Develop clinical information retrieval and appraisal skills Intervention All second year students provided with security fobs, controlled access to provincial systems, starting with EHR sandbox. Find clinical information as part of required Case of the Week. Examine about common information distortions that can occur in digital health information systems.

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36 Experience Electronic Health Record Unanticipated security/access challenges Sandbox data lacks clinical credibility, unable to populate with realistic clinical data sets Privacy/utility tension Learnings Danger of depending upon over-stretched and out-sourced public information services End-of-second-year effect Move EHR exposure to Link Block and go direct to full EHR

37 Electronic Medical Record Intent (CanMeds Communicator, Manager) Enhance and diversify discovery learning (PBL) Improve clinical authenticity of case-based instruction Explore effects of digital records on clinical problem solving Intervention First year Cardiology Discovery Learning case rendered as virtual patient in full-function EMR All clinical evidence acquired from EMR Focus on interpretation of clinical evidence, effects of clinical data presentation, question-answer coupling.

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39 Experience Electronic Medical Record Learner enthusiasm, non-intimidation, seeking more Variety and authenticity in PBL Value in acclimatization; anticipatory clerkship anxiety Faculty anxiety Learnings Authoring clinically rich and authentic virtual patients Focusing learners on a small subset of product features Faculty needs more support/training: missed ehealth learning opportunity Tension between objectives, content and process

40 EMR Simulator Intent (CanMeds Communicator, Manager) Ability to focus learner experience Abstraction of specific ehealth skills (documentation, dataexploration, order-entry) Overcome need for EMR training Intervention All second year students complete Oncology Case of the Week in virtual patient with an EMR simulator Beyond screenshots: EMR activities with high-fidelity recording of information behaviors, feedback and comparison to experienced clinician behaviors.

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42 Promise: 3-year Sandbox Journey Benefits of a disruptive intervention Learner enthusiasm First attention to important competencies Challenge: Faculty health information literacy Authoring virtual patients for ehealth Sandboxes Dependence on external entities Vendor and sponsor agendas

43 Two Case Experiences [ 15:55] UofA Medical School Rob Hayward UBC Medical Schools André Kushniruk, Elizabeth Borycki Issues and Challenges [ 16:15] Group Discussion Building an EMR Sandbox Medical Schools Can Play In Requirements for valuable, viable and sharable ehealth Sandbox Environments Opportunity for a Common Platform [ 16:25]

44 Andre Kushniruk, PhD, Professor Elizabeth Borycki PhD, Associate Professor School of Health Information Science University of Victoria, Victoria, British Columbia

45 Will streamline healthcare with electronic access to health data, value added features decision support, surveillance systems, interchange of health data across regions, provincially and nationally However, there are adoption issues Adoption by physicians and other health care providers needs to be increased in Canada Usability problems Efforts at system selection and integration can be problematic Education and its role in adoption has remained to be fully explored (Borycki et al., 2009)

46 Students may not see or work with EHRs in their undergraduate academic training programs EHR is not well integrated into medical, nursing and other allied health professional curricula Graduates in many programs are likely to have not seen (i.e. had hands-on exposure to) with a variety of EHRs by time of graduation Consequently will not understand advantages, disadvantages, how to use EHR to improve practice (Borycki et al., 2009; Otto & Kushniruk, 2009)

47 How Can We Improve Adoption Using Education and Training? We can increase adoption by: exposing students and practitioners to EHRs through hands on access, through remote, widespread and easy access working systems Enabling students, practitioners and managers to distinguish between systems and see how they can be used in their practice and educational settings Increasing understanding of use of systems, decisionmaking knowledge This will result in: Reduced financial and human resources burden on universities, colleges and regional health authorities for e-health application education and training (Borycki et al., 2009; Otto & Kushniruk, 2009; Kushniruk et al., 2010)

48 An Extensible Solution Development of a server and portal that allows students and practitioners in 2008: - Funded by BC Ministry of Health To let students remotely access and interact with real EHR software (from anywhere and anytime) To obtain the latest information about EHRs and actually try them out in their educational or clinical practice settings To learn about the use of the EHR Educational modules focused around EHR and related e-health applications (Borycki et al, 2009; Kushniruk et al, 2010; Kushniruk et al., 2012)

49 Users of the Portal Health professional students Medical, nursing, pharmacy, nutrition, physiotherapy, social work, health services and information science Potentially thousands of students Practicing professionals wanting continuing education Managers and decision makers Health professionals selecting amongst available EHR systems (Borycki et al., 2009; Kushniruk et al., 2010; Kushniruk et al 2012)

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51 Medical Education Portal EMR (designed as educational EMR by two of our M.Sc. Students Ron Joe, M.D. and Tony Otto, M.D.) and integrated with medical curricula Used in pilot with all 4 th year medical students in December (over 240 students and faculty) Island Medical Program, UBC main campus and UNBC (collaborators: Drs. R. Sidhu, K. Ho, F. Black, B. Armstrong) Medical cases previously accessed on paper made accessible using the EMR to students during an educational module Allowed medical students to experience EMR first hand Initial EMR used for this project was installed on the EHR Educational Portal

52 Health Informatics Education Used by over 100 health informatics students in design and testing of a Web-accessible international EMR for pediatric cancer care - POND (in collaboration with St. Judes Research Hospital, Memphis) Accessed from anywhere in the world Served as centerpiece of courses on electronic health records at UVic Nursing Education Was used over several years in the education of hundreds of nursing students throughout the province of BC and across Canada (e.g. Quebec) On-campus and distance education program

53 The portal allowed access to several open source EMRs Was extended to access to Veteran s Affairs OpenVISTA Was extended to access OpenMRS and several personal health record systems These applications were used by medical, nursing, health informatics students Used in on-campus and distance education across Canada

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64 A Continuum for Considering Integration of EHR into Health Professional Education Loose Coupling Tight Coupling Practicum training by healthcare organization (e.g. hospital) Standalone unit about the EHR in a class Integration of EHR into key points in the curriculum Full integration of EHR into labs, lectures and tests Kushniruk et al., 2010

65 UBC/UVic Extensions and Collaborative Work in Integrating EHRs into Medical Education Investigators: Elizabeth Borycki Andre Kushniruk Kendall Ho

66 Integrating Electronic Medical Records (EMRs) Into Medical Education UBC/UVic Work Need to introduce medical students to EMRs (and related technologies) in problem-based curriculum, however few examples in Canada TEKTIC pilot project (collaboration with UBC and UVic December 2007) o Introduced all BC 4th year medical students to EMRs (integrated into problem based learning) o o o Case of Tom s back pain delivered to students via an EMR modified for teaching purposes Over 200 medical students and staff from across BC participated and accessed case of the week using the EMR (rather than on paper) Training about EMR and related technology (e.g. coding of patient data, decision support, etc.) integrated within context of problem based learning o Student feedback positive but some indicated they wanted earlier integration into curriculum How do we assess student EMR and IT competencies? (Borycki, Kushniruk, Joe, Armstrong, Ho, Silverman, Otto, 2009; Kushniruk et al., 2012) 66

67 Source: maps.google.com

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69 EMR technology could be practically integrated into a problem-based medical education module. coupling of information technology within a PBL module allowed students to gain knowledge about EMRs Students learned about the biomedical aspects of patient cases with little extra time expenditure. Quantitative Findings Students were asked about their overall experience. Students rated the session favorably (Kushniruk, Borycki, Joe, Otto, Armstrong, Ho, 2012)

70 Qualitative Findings reflected strategies for improving EMR integration into existing curricula. decreasing the amount of didactic information about EMRs increasing the amount of hands-on exposure to EMRs themselves. some students commented that by their fourth year: they would like to have had experience with a range of different systems in particular the specific vendor systems that the provincial government is providing funding for purchasing in their medical practice upon their graduation. students suggested an alternative activity: critiquing the EMR in use reflecting on the benefits offered by this technology. (Kushniruk, Borycki, Joe, Otto, Armstrong, Ho, 2012)

71 Current UBC/UVic Work in EMR Integration into Curriculum Extended previous work to include both introducing students to EMRs and also designing OSCEs for assessing medical student EMR related competencies: o o o Electronic access and retrieval of patient data Use of decision support Interaction with patient while using an EMR o (Borycki, Kushniruk, Khan, Zibrik, Campbell, Ho, 2012) 71

72 Several phases: o o o Interviews with stakeholders about information technology competencies needed (conducted in ) Participatory design focus groups to arrive at design of OSCE test stations to assess EMR competencies (2011 and 2012) Piloting with medical students expected to take place in current academic year

73 Directions UBC/UVic Collaboration on Curriculum Continuing to explore ways of integrating information technologies into medical education training o Including technologies such as electronic medical records, mobile devices and EBM Issue of when and how to integrate information technologies into curriculum being explored Exploring insertion into new curriculum 73

74 There is need for increased exposure of health professional students to EHR (and related technology and e-tools) Allowing flexible access to a range of different real working systems allows both students and working professionals to explore this technology in a safe and user-friendly environment Can be done in their own practice and learning contexts, and can be done remotely making access easy and virtual Other educational resources (e.g. on-line courses) can be integrated with real on-line systems

75 Dr. Elizabeth Borycki Dr. Kendall Ho Dr. Andre Kushniruk

76 Two Case Experiences [ 15:55] UofA Rob Hayward UBC UVic André Kushniruk, Elizabeth Borycki Issues and Challenges [ 16:15] Group Discussion Building an EMR Sandbox Medical Schools Can Play In Requirements for valuable, viable and sharable ehealth Sandbox Environments Opportunity for a Common Platform [ 16:25]

77 Small Group Activity Please continue to Sandbox Desiderata:

78 Two Case Experiences [ 15:55] UofA Rob Hayward UBC UVic André Kushniruk, Elizabeth Borycki Issues and Challenges [ 16:15] Group Discussion Building an EMR Sandbox Medical Schools Can Play In Requirements for valuable, viable and sharable ehealth Sandbox Environments Opportunity for a Common Platform [ 16:25]

79 Individual Activity Please complete last item:

80 Thank you To learn more about the initiative, join the AFMC - Infoway Physician in Training e-health Curriculum & e-learning Community on CHEC-CESC.ca

81 EMR Sandbox Follow-up National EMR Sandbox Workshop interest (Red Laser App)

82 EMR Sandbox Follow-up (Red Laser App) Physician in Training e- Health Curriculum