Lit review on emr training

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Blended Learning with Electronic Medical Records
Action Research
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 (EMR). 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 clinics 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 patients will be made for a healthier patient (CMS.gov 2017). On top

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of 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.
EMR Training.
Will adding an electronic medical form increase student engagement with patients seen in
their clinical practicum rotation? Several clinics complain students are not retaining medical
history taking skill when set in front a computer versus the paper chart. The student is not able to
engage with their patient during the exam, because they are too focused on a computer screen.
There is more concern on what the computer EMR system is prompting or which drop down to
use. Such negative perception not only comes from the clinic but by their patients as well,
patient perceives the student as undertrained and losses confidence in the general care they are
receiving. When a patient feels the health care provider is only reading the scripted statement
prompted or checking the necessary boxes required by the EMR system template. A trickling
down effect can occur, when technology detracts from the patient experience. (Lovett, 2014).
The unhappy patient will spread the word on their perception of poor standard of care they
received when talking to family, friends, and neighbors. The patient complains to their insurance
providers in patient satisfaction survey. This can be detrimental to the clinic’s reputation, growth
potential and financial wellbeing with the decrease in new and established patient appointments
and insurance reimbursement. The most concerning effect is the patient’s eye care being lost due

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to an unhappy experience. The number one concern for ophthalmic health care providers is to
preserve and save sight, if the patient is not happy with care and refuse future care all is lost.
The Journal of Patient Safety only last year stated that preventable medical errors are the
third leading cause of death in the United States, behind only heart disease and cancer. With
more than 10,000 serious complications are due to medical errors and annual cost in the U.S. is
an estimated $1 trillion dollars. (Oshiro, 2017). These statistics are sadly staggering facts, since
they can easily be prevented and erased with right education and proper training of health care
providers.
Many EMR formats also take the critical thinking away from the provider, the
ophthalmic provider needs to understand and apply the eight elements required for a history of
present illness and chief complaint. These important items are essential in history taking to offer
the physician a starting point in diagnosing and treating the patient. As well as in the coding and
billing for reimbursement. Insurance payments require at least five of these elements for each
full exam.
The EMR trainers/instructors need to keep in mind what elements involved are important.
Training considerations are timing, learning environment, learning theory and proficiency
assessment. (Pantaleoni, Stevens, Mailes, Goad, and Longhurst, 2015). 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). Students will have ten weeks a total
of 30 hours of EMR training during the semester before attending their clinic practicum rotation.
Learning environment will be classroom for instruction and development and lab exam rooms
for application. Adult learning theory will apply with coursework deliver in multiple learning

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styles. Careful planning will be incorporated so that training will be understood by all types of
learners. (Pantaleoni, et al., 2015). At the end of training, each student will develop their own
electronic format.
Exam-based and demonstration-based assessments will be used to determine proficiency in
training. Exam-based will assess the students understanding the knowledge of medical history
taking and the ocular exam. While the demonstration-based assessment will continue, as in the
past, on a 1:1 ratio with an instructor. In the past, the student charts a full ocular medical exam
using paper format. The paper chart will be substituted to the electronic format presented in lab.
Collection of data on EMR training.
The student must exhibit critical thinking in decision making, skills in managing
independent learning, time, communication skills and adaptability to change. The research data
will be collected by using mixed methods of qualitative and quantitative. Qualitative methods
will consist of student’s observation and journals. Student survey, exams, demonstrations in lab
and clinic weekly and exit evaluations will provide quantitative information. Student will
complete a journal after their first clinic rotation on their EMR experience and will continue
journal writing through the two-year program.
The student must demonstrate efficient and accurate charting for the final exam to enter a
clinical practicum rotation. After successfully completion of final exam, the student will be given
Weekly evaluations by their clinic preceptor and coordinator with a final exit report at the end of
term. The Weekly and Exit reports will be submit for review at the end of each semester. At the
end of each term the student will complete a student survey on the student learning outcomes
including EMR training.

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Conclusion on EMR Training for San Jacinto Students.
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 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

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framework for comparing the lecture-centered class to the flipped class is provided by Bloom’s
Taxonomy (Honeycutt, 2013)
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 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 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

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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.
A study on the value of clinical teachers for EMR implementations and conversions at
Stanford Children’s Hospital. First year medical students were selected to complete EMR
training gave their trainers a 3.93 on a 4-point Likert scale for both mastery of material and
communication skills. (Stevens, Pantaleonie, Longhurst, 2015). The trainers for the study were
fourth year students who had been credentials as EMR trainers. Some of first year medical
students were so impressed with the training, they commented it was the highlight of their
training and some developed an interest in pursuing a career in medical informatics. (Stevens, et
al., 2015) The report from this case study will aid San Jacinto Eye Care in developing a starrier
EMR training for students before entering the clinic by having credentialed trainers/instructors,
proper learning environment with computers and EMR formats, timely training sessions and
lastly proper assessment tools.
Educating the student in the use of electronic medical records can relieve some of the
burden on the clinical staff as well as the student. The clinical staff can concentrate on the
student developing skills in performing an ocular exam and less on computer skills. It will also
relieve student anxiety on learning a computer format versus just paper charting. And thus, give
the student time to concentrate on mastering ocular medical exam skills while increasing their
engagement with the patient instead of a computer screen.

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