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模拟电子健康记录 (Sim-EHR) 课程:教授 EHR 技能以及使用 EHR 进行疾病管理和预防。

Simulated electronic health record (Sim-EHR) curriculum: teaching EHR skills and use of the EHR for disease management and prevention.

机构信息

Dr. Milano is assistant professor, Department of Family Medicine, Oregon Health & Science University, Portland, Oregon. Dr. Hardman is assistant professor, Department of Medicine, Oregon Health & Science University, Portland, Oregon. Dr. Plesiu is an intern, Kettering Medical Center, Kettering, Ohio. Ms. Rdesinski is a research associate, Department of Family Medicine, Oregon Health & Science University, Portland, Oregon. Dr. Biagioli is associate professor, Department of Family Medicine, Oregon Health & Science University, Portland, Oregon.

出版信息

Acad Med. 2014 Mar;89(3):399-403. doi: 10.1097/ACM.0000000000000149.

Abstract

Electronic health records (EHRs) can improve many aspects of patient care, yet few formal EHR curricula exist to teach optimal use to students and other trainees. The Simulated EHR (Sim-EHR) curriculum was introduced in January 2011 at Oregon Health & Science University (OHSU) to provide learners with a safe hands-on environment in which to apply evidence-based guidelines while learning EHR skills. Using an EHR training platform identical to the OHSU EHR system, learners review and correct a simulated medical chart for a complex virtual patient with chronic diseases and years of fragmented care. They write orders and prescriptions, create an evidence-based plan of care for indicated disease prevention and management, and review their work in a small-group setting. Third-year students complete the Sim-EHR curriculum as part of the required family medicine clerkship; their chart work is assessed using a rubric tied to the curriculum's general and specific objectives. As of January 2014, 406 third-year OHSU medical students, on campus or at remote clerkship sites, and 21 OHSU internal medicine interns had completed simulated charts.In this article, the authors describe the development and implementation of the Sim-EHR curriculum, with a focus on use of the curriculum in the family medicine clerkship. They also share preliminary findings and lessons learned. They suggest that the Sim-EHR curriculum is an effective, interactive method for providing learners with EHR skills education while demonstrating how a well-organized chart helps ensure safe, efficient, and quality patient care.

摘要

电子健康记录 (EHR) 可以改善患者护理的许多方面,但很少有专门的 EHR 课程来教授学生和其他受训人员如何最佳使用 EHR。俄勒冈健康与科学大学 (OHSU) 于 2011 年 1 月推出了模拟电子健康记录 (Sim-EHR) 课程,为学习者提供了一个安全的实践环境,使他们能够在学习 EHR 技能的同时应用循证指南。学习者使用与 OHSU EHR 系统完全相同的 EHR 培训平台,查看和纠正一位患有慢性疾病和多年碎片化治疗的复杂虚拟患者的模拟医疗图表。他们下达医嘱和处方,为指示性疾病的预防和管理制定基于证据的护理计划,并在小组环境中审查他们的工作。三年级学生作为必修家庭医学实习的一部分完成 Sim-EHR 课程;他们的图表工作使用与课程的一般和具体目标相关的评分标准进行评估。截至 2014 年 1 月,已有 406 名 OHSU 医学生(在校或远程实习地点)和 21 名 OHSU 内科住院医师完成了模拟图表。本文作者描述了 Sim-EHR 课程的开发和实施情况,重点介绍了该课程在家庭医学实习中的应用。他们还分享了初步发现和经验教训。他们认为,Sim-EHR 课程是为学习者提供 EHR 技能教育的有效、互动方法,同时展示了一个组织良好的图表如何有助于确保安全、高效和高质量的患者护理。

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