Use of simulation to assess electronic health record safety in the intensive care unit: a pilot study

Abstract

ObjectiveTo establish the role of high-fidelity simulation training to test the efficacy and safety of the electronic health record (EHR)–user interface within the intensive care unit (ICU) environment.DesignProspective pilot study.SettingMedical ICU in an academic medical centre.ParticipantsPostgraduate medical trainees.InterventionsA 5-day-simulated ICU patient was developed in the EHR including labs, hourly vitals, medication administration, ventilator settings, nursing and notes. Fourteen medical issues requiring recognition and subsequent changes in management were included. Issues were chosen based on their frequency of occurrence within the ICU and their ability to test different aspects of the EHR–user interface. ICU residents, blinded to the presence of medical errors within the case, were provided a sign-out and given 10 min to review the case in the EHR. They then presented the case with their management suggestions to an attending physician. Participants were graded on the number of issues identified. All participants were provided with immediate feedback upon completion of the simulation.Primary and secondary outcomesTo determine the frequency of error recognition in an EHR simulation. To determine factors associated with improved performance in the simulation.Results38 participants including 9 interns, 10 residents and 19 fellows were tested. The average error recognition rate was 41% (range 6–73%), which increased slightly with the level of training (35%, 41% and 50% for interns, residents, and fellows, respectively). Over-sedation was the least-recognised error (16%); poor glycemic control was most often recognised (68%). Only 32% of the participants recognised inappropriate antibiotic dosing. Performance correlated with the total number of screens used (p=0.03).ConclusionsDespite development of comprehensive EHRs, there remain significant gaps in identifying dangerous medical management issues. This gap remains despite high levels of medical training, suggesting that EHR-specific training may be beneficial. Simulation provides a novel tool in order to both identify these gaps as well as foster EHR-specific training.

Use of Electronic Health Record Simulation to Understand the Accuracy of Intern Progress Notes

“…Finally, our sample encompasses only interns, although training level had little impact on the recognition of safety issues in our prior study. 10 …”

“…6 For simulations, we utilized workstations identical to the stations found in the hospital, but we ran a simulation version of Epic, as previously described. 10 Briefly, this version was cloned from the production environment and populated with our high-fidelity simulation case while maintaining all unique log-in and user customizations utilized in the clinical environment.…”

Professional and interprofessional differences in electronic health records use and recognition of safety issues in critically ill patients

“…Simulation-based training is a powerful tool that can be used to assess EHR usability and recognition of safety issues in critically ill patients without affording unnecessary risk whilst improving diagnostic accuracy (BenAssuli, Sagi, Leshno, Ironi, & Ziv, 2015;March et al, 2013;Weller, Nestel, Marshall, Brooks, & Conn, 2012). With reforms in medical education, there has been increasing emphasis on simulation training as it has been shown to increase knowledge and skills in invasive procedures as well as communication in a realistic environment (Wayne, Barsuk, O'Leary, Fudala, & McGaghie, 2008;Wayne, Didwania et al, 2008;Zendejas, Brydges, Wang, & Cook, 2013).…”

“…Specifically, our group has employed high-fidelity EHRbased simulation to understand physician clinical decision-making and recognition of patient safety issues in critically ill patients (March et al, 2013). To accomplish this, we created a clone of our institution's EHR environment (EpicCare, Epic Systems, Inc., Madison, WI, USA) which contained full functionality and all user-specific customisations.…”

“…One of our previously validated cases which we employed in this study is a 74-year-old woman who is admitted with septic shock, acute renal failure, and acute respiratory distress syndrome. A total of 14 safety issues were built into the case and were categorised into 3 groups: (1) dangerous trends in the patient's condition, (2) medication errors, and (3) failure to adhere to critical care best practices (March et al, 2013;Stephenson et al, 2014). The goal of this study was to utilise a high-fidelity EHR-based simulation to understand the workflow of the different members of the interprofessional ICU rounding team and the ability of team members from each professional group to recognise safety issues in a critically ill patient.…”