EMR Innovations in Eye Care lit review

Running head: BLENDED LEARNING WITH ELECTRONIC MEDICAL RECORDS
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Blended Learning with Electronic Medical Records
Laura Cole
Lamar University

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Our country is in a crisis for qualified medical personnel. With the increasing numbers of
baby-boomers entering their “golden years”, they are not only requiring medical care but
demanding excellent care. We as educators in higher education and technical programs need to
produce a higher quality professional in a short amount of time. This is where higher education
institutions need to develop and implement disruptive innovations in teaching and learning on a
fast track. “Employers say ironically they cannot find the right person to fill jobs even through
the country is facing its highest unemployment rate” (Christensen, Horn, Caldera & Soares,
2011). Some disruptive innovations discussed in this paper are blended learning with electronic
medical records. The role of the instructor is meeting student learning outcomes for an
ophthalmic medical personnel (OMP) career path; to provide a quality OMP in an increasingly
high demanding industry and implementation of electronic medical records system will be
examined. The changing environment regarding medical record reforms needs to be addressed in
training programs of OMPs. Starting the EMR training the first semester will meet student
learning variances and the increasing need for fast track workforce pathways. The training before
the student reaches their clinical practicum the second semester will enhance the first weeks of
the practicum. The instructor needs to develop and implement disruptive innovations to prompt
student learning in EMR systems and data entry. These innovations may come by changes in
how course material is delivered to the students with a blended concept, an online component.
Changing the traditional paper chart into an electronic chart with the added face /face exam. The
EMR innovation the instructor and program must decide is the type of EMR training is the best
for student learning outcomes, financial aspect, and meets eye care industry’s demands.

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Review of the Literature
On February 17, 2009, the American Recovery and Reinvestment Act of 2009 (ARRA)
and part of ARRA is the Health IT for Economic and Clinical Health Act (HITECH) was enacted
establishing incentive and mandate for all health-care providers to initiate an electronic medical
record (EMR) or electronic health record (EHR). EMRs are systems to store patient information
as did the paper chart. But the EMR systems enable the exchange of information between health
care providers, assists for health care professionals in decision-making and safety protection for
patients (Lambooij and Koster, 2016) The ARRA started a whirlwind of activity in medical
offices and data systems. All medical clincs began looking for the correct system to meet their
needs, purchasing of computers, program system itself, training staff and converting over from
paper to electronic. What reasons did the government and Center for Medicare and Medicaid
(CMS) give for requiring electronic medical / health records? A few reasons are reducing the
incidence of medical mistakes due to misinterpretation of handwritten notes, orders for labs,
other diagnostic testing, and prescriptions. EMR would improve the clarity and accuracy of
medical records. EMR would speed up the health information on referrals, which could reduce
duplication of test that would delay treatment. Not only would referrals appear faster but the
transfer of records across the globe, as patients are becoming more mobile in where they travel
and live. Trackability and traceability are easier and more efficient with logins verses the
forgotten handwritten initials or signature. Research information can be shared faster and more
efficiently. Another important goal of EMR is improvements in patient education. The patient
who understands their own medical history are compliant and proactive in their own care.
Research shows educated patient will be made for a healthier patient (CMS.gov 2017). On top of

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the whirlwind are the penalties for non-compliance for Medicare reimbursements will be reduced
by 1% each year starting in 2015 to a full 5% by 2019 (HealthIT.gov)
Transition from paper to electronic medical recording
A successful migration to electronic charting from the paper in the class lab has a mirage
of concerns. Several decisions had to be made in health care facilities. There are no one-size fits
all EMR system available. The ophthalmology verses optometry practice involves different
information and then each ophthalmology specialties needs their own information. A cornea
specialist requires different exam screens than the retina specialist or even the general
ophthalmologist. Along with the difference in the clinical practice, what type of patients are
being seen will determine which charts are converted over into the EMR system (Dinh, Kennedy,
Perkins, Peterson, Warner, and Washington).
Typically, the health care provided logins into EMR system using one screen and then is
required to maneuver through several screens to view the patient full chart, reason for visit,
signs/symptoms, medications and all additional information necessitated by meaningful use.
Those questions consist of smoking, drug use, do you drive, any falls and do your safe at home
and do you have thoughts of hurting yourself. And depending on the system, the health care
provider may have to view and enter data on two screens for medications. All the literature
points to prescriptions as one of the main motivations of EMR being pushed to all clinical
settings.
Not only does the health care system needs to train its employees in the use of an
electronic system, but how to protect the privacy of patient’s records. Privacy in the healthcare
atmosphere refers to the ability of individuals to prevent certain disclosure of personal health

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information to others (Rohstein, 2007). And the privacy of medical records is enforced by the
Health Insurance and Portability Accountability Act of 1996. The new EMR user must learn not
only the skill of data enter while evaluating the patient, how to protect that information. Not
sharing logins and passwords, leaving a patient’s information up on the computer unattended at
the nurses’ station or exam room.
A transition from EMR to EMR Systems.
Parting ways with your EMR to start-up with a new system. The literature reviews
reasons for the break-up as lack of satisfactory support from the vendor, workflow inefficiencies,
and clinic needs changing. More health care providers are deciding it’s time to change to a new
EMR/EHT system. Based on a survey four years ago of 17,000 EHR users about one-quarter of
surveyed stated they were unsatisfied with their current system and were concerning changing
(Schaeffer, 2013). A larger ophthalmology group in Houston is only recently changed vendors
and will go live with their system next week. This group had been with previous EMR vendor for
close to ten years and cited dissatisfied vendor support as the reason for changing. More of the
literature claims the changing needs of clinical practices, small groups that have grown out of
their current system and need more than the current vendor can provide (Kirschenbaum, 2012).
Other key points of usability problems can be characterized as violations of
naturalness, consistency, prevention of errors, lowering the cognitive load, customization
principles, feedback, effective interaction, use of language, and information presentation
(Zahabi, Kaber, Swangner, 2015).
Changing EMR vendors should take as much thought and research of options as it
took to make the decision to leave paper charts. Jumping from one to another requires the same

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amount of transitional time as it did when changing from paper. The clinic should learn from the
mistakes made with the old vendor so not to make the same wrong decisions on the new system.
If the change is due to functionally, the clinic should make sure they happy with the
new template data system. Do not go to a template that requires more screens to view if that’s the
current problem or doesn’t follow naturally with specialty clinic of use. This may include the
language and or drop-downs that are used by the template.
The clinic needs to keep in mind what elements are involved in EMR training. The
clinic managers take in the consideration of over-time pay for additional training hours’ verses
closing the office for a day of training. And will the clinic need to reduce or rearrange the clinic
load to manage the lag time due to the learning curves involved in the re-training? Many medical
providers are hiring scribes to relieve the physician from the tasks of typing in the patient exam
information. This will add to the cost of EMR implementation but to some physicians, it is well
worth the expense, so they concentration on patient care and not the EMR computer screen
(Hilton, 2017). All providers at Casey Eye Institute are required to undergo 15 hours of training
before using the EHR system within the Oregon Health & Science University (Chiang, Read-
Brown, Tu, Dongseok, Sanders, Hwang, Bailey, Karr, Cottle, Morrison, Wilson, and Yackel,
(2013).
Also, it is might not be kosher for the clinic to hire the vendor’s valuable information
technology (IT) employee for their own. Such action may cause the vendor relented in future
service.
The literature describes sticky situations that can evolve in changing vendors. As
reported by the Milwaukee Journal Sentinel in 2013, the Milwaukee Health Services were
without 40,000 patient records for several weeks. This accrued after the end of the contract and

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dispute on vendor requesting more money to release the records to the health services and their
new vendor (Boulton, 2013).
Patient Education and Safety with EMR.
One the goals of ARRA and HITECH is to increase patient education in their own
health issues. As the literature discusses patient self-management system is used to manage their
own health conditions and their everyday life with the use of information and communication
technology (ICT). A study conductive in self-management of type 2 diabetes, indicated by high
blood glucose and accounts for 90% of diabetics (Gardsten, Mortberg, Blomqvist, 2017).
Diabetes is a global health epidemic and places high demands on health care. It involves the
primary care physician, dermatology, endocrinologist, cardiologist, neurologist, ophthalmologist,
dietician and pharmacist to care for these patients. Educating the diabetic patient using ICT can
relieve some of the burdens on the health care. Self-management requires the patient to have
critical thinking in decision making, skills in managing daily activities such as diet, exercise,
skin care, monitoring blood sugar levels and taking medications (Moser, van der Bruggen,
Widdershoven, 2006) The findings in the literature shows the ICT self-management service
needs to offer the following; different communication channels, exchange experiences, written
and visual individualized information (Gardsten, et al.,2017).
EMRs offer the patients access to their own records where they can review medication
information, physician notes, referrals, lab and x-ray reports. In large medical groups, the patient
can up-date and include their own notes before their visit. Allowing patients to type in their own
information in the clinic note may facilitate communication of concerns on the visit (Anderson,
Jackson, Oster, Peacock, Walker, Chen, Elmore 2017). This study is suggesting that health care

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put self-care back into the patient's hands, which will make patients more compliant and
hopefully healthier.
The safety issues take on several meanings; safety in prescribing medication, orders
for labs and diagnostic tests. Clarity of orders and patient notes from the physician to the
diagnostic testing area will decrease time but more importantly improve patient’s standard of
care.
Trackability is a safety issue. The EMR tracks the health care provider giving the care
with the login and tracks what was performed and given to the patient. This increases reliability
of patient care and information given by the health care professional. The EMR will trace logins
and will not forget to sign the chart at the end of care as with paper.
Tracing and tracking can also be used in research to track patients with diabetic
retinopathy. Making it easier and accessibly to generate a report on all patients seen that week,
month or year with diabetic retinopathy. The report can track the appointments, treatments,
surgeries and results of treatments and / or surgeries. These reports can help determine which
plan of action is best for future treatments as well as the progress of current patients. The reports
can be shared within the clinic group as well as with colleagues across the globe for discussion,
updates and treatment plans. Placing the patient’s medical history and information in an
electronic database can also be expedited to another location for routine and emergency care.
Conclusion on EMR Training for San Jacinto Students.
Decision making in information technology (IT) is described and lead by three main
categories by the literature. First, foundation services available such as network connections,
storage and back-up services. Secondly, mission-unique services that include special hardware to

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view diagnostic testing and billing information. And thirdly, innovation services cover the ability
to change with future needs and technology (Spallek, Johnson, Kerr,and Rankin 2013). The
study conductive by the Dr. Spallek group, summarized the monetary impact regarding Health IT
infrastructure. The study includes four dental schools; two purchased an EHR package while the
other two developed their own EHR system. The study showed the cost of the custom created
EHR solution was five times greater than a purchased package and IT support.
The San Jacinto college eye care program will consider the study by Dr. Spallek while
also considering that only mock patients are used instead of seeing real patients as in the dental
schools. The cost to the college for an EMR data system, IT support with computers or use of
textbooks and E.H.R. tutor which are not eye care specific verses developing San Jacinto College
eye care’s own electronic charting system.
Putting the learning in blending EMR training, the instructor designs the blended EMR
portion of the course by using Dr. Shibley’s three step approach. 1. Establish clear learning goals
for the topic. 2. Design activities to help students meet the learning goals. 3. Sort the activities
into two categories: outline and face to face (Shibley, 2011). The instructor can leave more time
in the face to face class time, by placing low level content like EMR definitions, abbreviations
and data enter on-line giving more time in class for higher level activities. (Shibley, 2011). This
releases time for individual tutoring between the instructor and student on higher critical thinking
course material. As well as, preparing the student beforehand the material expected of them for
that next class time. The use of EMR database can be used in several ways. Used at the
beginning of class, students and instructor discuss as a group what they didn’t understand with
material covered at home. The EMR database is used in class for critical thinking on case reports
of patient’s history, signs / symptoms and ocular pathology. And final electronic system would

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give review and feedback on student putting the puzzle together in taking a medical history and
performing the appropriate tests to match the medical ocular history. (Weimer, 2012).
A blend learning environment is disrupting the traditional lecture in class with
assignment done at home. Instructors are blending the model giving students the lecture
materials for homework then applying the material in class. Or another way of describing it is
shifting from an instructional-centered learning to a student-centered learning environment
(Honeycutt & Garrett, 2013). Just like the blended learning model where lower level information
is given for homework and higher level work is completed in the instructional time. The
framework for comparing the lecture-centered class to the flipped class is provided by Bloom’s
Taxonomy (Honeycutt, 2013)
Disruptive innovation in higher education has brought on the revolution of online distant
learning courses. This emerging innovation allows from a break from the policies that focus on
credit hours and seat time to one that ties advancement to competency and mastery (Christensen,
Horn, Caldera, Soares, 2011). With the increase demand by medical and other industries for
quality employees, community and technical intuitions are rethinking their roles in providing the
much-needed employee. These institutions are developing pathways for the student to stay on
track for either that certificate or associate degree. These pathways are mapped out for the
student for each term. And only gives a slight leave way for core courses for the degree seeker
(Bailey, Smith Jaggars, Jenkins, 2015). These fast track certificates are setup to furnish relief to
under staffed industries. This disruption is pushing students into finding a career path sooner
than later. And to eliminate the associate degree in general studies that may or may not transfer
to a four-year university. Many states are compelling community colleges into building and
pushing these fast track career pathways. By reducing some associate degrees to 60 hours and

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stacking courses are a few disruptive innovations used by community colleges to nudge a student
into a successfully completion (Bailey, et al., 2015).
The economic impact of disruptive innovations in higher education is out for the jury to
decide and analysis is still being quantified. Today the community college state funding is
dependent on completers of certificates and degrees and enrollment number in the course. An
example is requiring twenty–twenty-five students for an online course to be full before the next
section can be opened and then paying the instructor per student up to thirteen. The future of
higher education will essential move toward more disruptive innovations such as: 1. Not focus
on degree attainment as the role of measurement of success. 2. Remove barriers that judge
institutions based on their inputs such as credit hours, student-faculty ratios 3. Fund higher
education with the aim of increasing quality and decreasing cost (Christensen, et al, 2011).
Another disruptive innovation is altering the clinic and classroom appearance. Moving
from desk and chairs facing the front of the room and teacher, to a full equipment exam room,
including computer with a EMR system with a mock patient verses having a manila folder, paper
form and pen to complete the exam on the mock patient. The students engage in study stations
with a partner who is the mock patient as well as self-study stations. The students are learning by
doing the work in the lab stations. At the end of a set time, the instructor has the students rotate
into the next lab station with a new mock patient. (Horn & Staker, 2015). The two person and
team groups allows the student the opportunity to teach and learn from each other. This method
allows the instructor to give guidance and tutoring of the material instead of demanding the
education through lecture. This reinforcement of the material from the project or assignment will
give the student self-worth, increase self-esteem and thus retention of the material. The student
learns by teaching self and others. The ability to review and receive feedback at the end of the

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day, awards the student with instant gratification for a job well done. We as educators are putting
the learning back into the student hands (Horn & Staker, 2015). This type EMR training gives
the student confidence in taking a medical history, socializes with the patient, while entering the
data electronical. It is important that the student remembers to interact with the patient and not
the EMR device whether it be a desktop, laptop computer or Ipad. The student will increase their
knowledge about ocular and systemic medications by adding the element of electronic
prescribing as well as enhance the ability to understand the mechanics of glasses and / or a
contact lens prescription. The student will be able to understand extra testing an ophthalmologist
might order outside the clinic such as labs for blood-ups, and MRI’s. With the implementation of
EMR, the student will see patient’s work-up from others in the class as the patient comes back
for follow-up visit. At which time the student will be able to read and follow the instructions /
orders given for that day’s exam from the previous notes.
Let’s get the eye care technology students trained in EMR sooner than later to aid the
clinical practicum experience for the student while given must need support to the clinical staff.

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References
Abramson, E.L., Patel, V., Malhortra, S., Pfoh, E.R., Nena Osorio, S., Cheriff, A.,
Kaushal, R., (2012), Physician experiences transitioning between an older version newer
electronic health records for electronic prescribing. International Journal of Medical Informatic,
81, P. 539-548
Anderson, M.O., Jackson, S.L., Oster, N. V., Peacock, S., Walker, J.D., Chen, G.Y.,
Elmore, J.G., (2017), Patients typing their own visit agendas into an electronic medical record:
Pilot in a safety-net clinic. Annals of Family Medicine, Retrieved from www.annfammed.org.
Bailey, T. R., Smith-Jaggars, S., Jenkins, D., (2015), Redesigning America’s Community
Colleges. President and Fellows of Harvard College, Library of Congress Cataloging-in-
Publications Data
Boulton, G., (2013), Community health center battles for patient records. Retrieved from
the Milwaukee-Wisconsin Journal Sentinel
Chiang, M. F., Read-Brown, S., Tu, D.C., Dongseok, C., Sanders, D.S., Hwang, T.S.,
Bailey, S., Karr, D.J., Cottle, E., Morrison, J.C. Wilson, D.J., and Yackel, T.R., (2013),
Evaluation of electronic health record implementation in Ophthalmology at an academic medical
center. (An American Ophthalmology Society Thesis), Trans Am Ophthalmol Soc.2103; 111,
70-92, Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3797873/
Christensen, C.M., Horn, M.B., Caldera, L., Soares, L., (February 011), Disrupting
College, How Disruptive Innovation Can Deliver Quality and Affordability to Postsecondary
Education. Retrieved from www.americanprocess.org
Dinh, A.K., Kennedy, M.S., Perkins, S.G., Peterson, L.L., Warner, D., and Washington,
L.,(2010),
Journal of American Health Information Management Association, 81, no.11, P. 60-64
Gardsten,C., Mortberg, C., and Blomqvist, K., (2017), Designing an ICT self-
management service: suggestions from persons with type 2 diabetes. Springelink.com Open
Access

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Hilton, L., (2017), Scribes slash EMR burden, Urology Times. Urology Times February
2017, Vol. 45, No 2, Retrieved from www: UrologyTimes.com
Honeycutt, B., Garret, J., (2013), Expanding the Definition of a Flipped Learning
Environment. Excerpted from “The Flipped Approach in a Learner-Centered Class,” Magna
Publication
Honeycutt, B., (2103), Looking for the “Flippable” Moments in Your Class. Reprint from
Faculty Focus, Magna Publications
Honeycutt, B., Egan-Warren, S., (2014), The Flipped Classroom: Tips for Integrating
Moments of Reflection. Reprinted from Faculty Focus, Magna Publications
Horn, M. B., Staker,H., (2015), Blended: Using Disruptive Innovations to Improve
Schools. Published by Jossey-Bass, A Wiley Brand
Jawhari, B., Ludwick, D., Keenan, L., Zakus, D., and Hayward, R.,(2016), Benefits and
challenges of EMR implementations in low resource settings: a state-of-the-art review. Creative
Commons Attribution 4.0 International License, Retrieved from BioMed Central, Open Access
Kirschenbaum, I., (2012), The OMG EMR template book – Orthopaedics. CreateSpace
Independent Publish Platform, Amazon
Lambooij, M.S., and Koster, F., (2016), How organizational escalation prevention
potential affects success of implementation of innovations: electronic medical records in
hospitals. Creative Commons Attribution 4.0 International License, Retrieved from BioMed
Central, Open Access
Ma, C.C., Kuo, K.M., and Alexander, J.W., (2016), A survey-based study of factors that
motivate nurses to protect the privacy of electronic medical records. Creative Commons
Attribution 4.0 International License, Retrieved from BioMed Central, Open Access
Moser, A., van der Bruggen, H., Widdershown, G., (2006), Competency in shaping one’s
own life: autonomy of people with type 2 diabetes mellitus in a nurse-led, shared-care setting; a
qualitative study. Int J Nurse Stud 2006: 43(4), P. 417-27. doi:10.1016/j.ijnurstu.2005.06.003
Rothstein, M.A., (2007), Health privacy in the electronic age. J.LegMed 2007;28 (4); P.
487-501
Schaeffer, J., (2013), Breaking Up (with and EHR) is hard to do. For the Record, Vol.25
No.14 P. 22

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Shibley, I., (2011), Putting the Learning in Blended Learning, Blended and Flipped:
Exploring New Models for Effective Teaching & Learning. Pg 4, Magna Publication
Spallek, H., Johnson, L., Kerr, J., and Rankin, D., (2014), Costs of Health IT: Beginning
to understand the financial impact of a dental school EHR. Journal of Dental Health, Vol. 78,
No. 11, P.1542
Steinbrook, R., (2015), The repeal of medicare’s sustainable growth rate for physician
payment. JAMA, Retrieved from
http://jamanetwork.com/journals/jama/fullarticle/22777734?linkid=14395931
Weimer, M., (2012), Blended Learning: A Way for Dealing with Content, Blended and
Flipped: Exploring New Models for Effective Teaching & Learning. P. 6, Magna Publish
Zahabi, M., Kaber, D.B., Swangnetr, M., (2015), Usability and safety in electronic
medical records interface design: A review of recent literature and guideline formulation. The
Journal of Human Factors and Ergonomics Society, Retrieved from
http://journals.sagepub.com/doi/abs/10.1177/0018720815576827

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