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How to implement the electronic health record in undergraduate nursing education


Information literacy, evidence-based practice (EBP), and informatics are fundamental to delivering culturally competent, safe patient care. Yet most nursing schools continue to educate students in traditional ways; only a minority integrate high-fidelity simulations, require evidence-based literature to support nursing interventions, identify the five core competencies for healthcare professions delineated by the Institute of Medicine (IOM), and incorporate the electronic health record (EHR) to stimulate critical thinking and decision making. The Health Information Technology Act (2009) requires all healthcare facilities to fully adopt EHRs by 2014. This will change how nurses practice, underscoring the importance of teaching students about informatics and the other topics and skills they need to provide high-quality care.

EHR defined

EHR refers to software used by healthcare delivery systems. Cerner Corporation, a supplier of healthcare information technology solutions, designed the Academic Education Solution (AES) for integration in interdisciplinary healthcare curricula. AES is a living health record tailored for teaching. Integrating AES across nursing curricula provides an appropriate environment for teaching students about EBP, standardized nursing language, and the IOM’s core competencies, while giving them the experience of an informatics-intensive healthcare environment.

In 2008, Indiana University-Purdue University Fort Wayne (IPFW), a state-assisted university with undergraduate enrollments of 450 baccalaureate and 75 graduate students, joined the consortium of 22 nursing programs using the AES EHR. Integrating AES leverages a data-driven teaching curriculum as a foundation of evidence-based clinical practice. It also supports informatics, basic evidence-based research, and unidisciplinary and interdisciplinary education goals.

Stepped implementation

Nursing schools in the consortium are at various stages of implementing AES into the curricula. IPFW has gained valuable insights from schools with more experience. Implementation at IPFW was planned in a step-by-step process beginning December 2008, with the entire faculty participating in a 2-day orientation. For most faculty members, the orientation was overwhelming. They were relieved integration would be implemented one course at a time rather than all at once, but concerned they might not remember how to navigate the AES EHR. Some feared they lacked the time to learn how to use the technology, let alone integrate it into their courses. Clearly, not all were excited about the prospects of AES, and some resisted it.

Two entry-level nursing courses (nursing fundamentals and essential clinical skills [ECS]) were chosen as venues for starting to expose students to the AES EHR, with the goal of infusing health information technology throughout the curriculum. Faculty members leading these courses were asked to attempt one simple exercise in each course that would include the AES. One of the two lead faculty members resisted, believing the software would distract students from learning about patient care. Fortunately, a graduate assistant working with her advocated for the technology and was able to integrate it effectively into the laboratory sessions of the ECS course. In the end, the resistant faculty member changed her views and became a vocal proponent of integrating this tool throughout the curriculum.

Lessons learned: First semester

In the first semester of integration, students in the ECS laboratory sessions used AES to document completion of wound care and medication administration check-off requirements. During check-offs, documentation was done on a tablet personal computer (PC). Faculty and graduate assistants reported that using the AES for the check-off assignment enhanced students’ learning experience by allowing integration of dynamic scenarios that included medication errors—which challenged them to use critical-thinking skills. Graduate assistants created case-study patients to provide variety, and rotated these among students completing the check-off assignments. Medications were added to the patient record for each student, and students documented within the AES based on the written scenario presented during the laboratory session. Allergies were added to provide an additional way to assess critical thinking during medication check-off. (See Medication check-off using the AESby clicking the PDF icon above).

Troubleshooting technical problems

A few usability problems arose, aside from training students and faculty how to log into the system. Some problems were related to hardware and networking. Users found it hard to enter information into the PC using the stylet, and reported that the keyboard seemed to disappear from the computer’s desktop. Graduate assistants had difficulty locating the desktop keyboard and were forced to reboot the computer. However, this problem was resolved with enhanced training and practice with the PCs. Also, the wireless connection in the nursing skills laboratory wasn’t reliable; when disruptions occurred, several desktop computers in the nursing skills laboratory were used as backups. About half the graduate assistants reported they didn’t have a good experience with students using the AES to document medication check-offs due to these technical problems.

Fictitious case study

AES was used to supplement lectures in the ECS and nursing fundamentals courses through an evolving case study that centered on a fictitious elderly patient. The case study helped students think critically in clinical situations, including where to look for pertinent clinical data and how to make decisions related to that information. Using this patient scenario provided continuity throughout the semester across the two entry-level courses. (See AES record for a fictitious patient by clicking the PDF icon above.)

AES also allowed sharing of the patient record among students and instructors, which anchored the lectures, demonstrations, and clinical skills check-offs. What’s more, it enabled students to review patient documentation independently outside the classroom. This experience led faculty to create additional case studies within the AES EHR for use in large classrooms, to inspire student conversation and capture the dynamics of novice decision making.

To complete AES integration in the fundamentals course, students documented nursing care in the AES after each clinical experience in long-term care facilities. Because AES is a real EHR, each student enters data using his or her own name as the patient name to avoid including identifying patient information. When the lead course faculty members evaluated the student entries, they found their unfamiliarity with the patient assignments made them unsure if the recorded data were reasonable. So it was decided this task was best suited for clinical instructors familiar with the care assignments.

Student satisfaction with AES varied. Poor evaluations most commonly related to problems logging into the system. In response, video tutorials were made available, stored in a central area and accessed through the course management software used by IPFW.

Lessons learned: Second semester

During the fall semester 2009, AES integration was expanded based on the “add-a-class-each-semester ” plan. As students progressed, AES integration moved with them to the next clinical course. In the first medical-surgical clinicals, students provided care for one or two patients. Clinical instructors had an established paper-based method for evaluating each student’s assessment of the patients they cared for. To make clinical instructors’ jobs easier, the paper-based method was replaced with assignments completed within the AES. While this seemed logical, it required a change in pedagogical approach and workflow. As with EHR integration in clinical settings, the faculty faced challenges transitioning to an electronic environment. Currently, clinical faculty are retooling the curriculum to most effectively exploit AES as a teaching tool.

Benefits to students

In some schools, students participate in clinical rotations in facilities that use Cerner’s AES. This means they can use the same information system for documentation in the clinical environment as they do to complete their academic assignments.

IPFW students don’t use clinical sites with the AES. But the value of using AES isn’t that students learn a specific EHR; it’s that they learn the importance of entering, managing, and using data to produce information and knowledge. Using various types of EHRs is similar to using various types of word-processing software, Internet browsers, or computer operating systems: Once you grasp the principles of each category, you can translate your skills to different software products with a minimal learning curve.

With the 2009 Health Information Technology Act requiring all healthcare pro­viders to use EHRs, new graduates will be exposed to various EHR systems. Integrating the AES into nursing school curricula may better prepare graduates who value the data that will enhance patient comfort or prevent undesirable outcomes. The AES EHR gives nursing schools ease of access and the chance to integrate an active, up-to-date information system across entire undergraduate and graduate curricula. Students must learn how to identify, find, use, and evaluate information to successfully apply evidence-based principles for delivery of culturally competent and safe care. Access to such data as patients’ current vital signs, medication history, and alerts for drug incompatibility can dramatically increase the quality of nursing care. Clear, concise, readily accessible information stimulates critical thinking, resulting in better clinical decisions grounded in evidence-based care.

Selected references

Cerner Corporation. Academic Education Solution.
Accessed March 28, 2011.

Drucker P. The Essential Drucker: The Best of Sixty Years of Peter Drucker’s Essential Writings on Management. New York, NY: Collins Business; 2003.

Finkelman A, Kenner C, Benner P. Teaching IOM: Implications of the Institute of Medicine Reports for Nursing Education. 2nd ed. Silver Spring, MD: American Nurses Association; 2009.

Institute of Medicine. Health Professions Education: A Bridge to Quality. Washington, DC: National Academies Press; 2003.

National League for Nursing. Preparing the Next Generation of Nurses to Practice in a Technology-Rich Environment: An Informatics Agenda. May 9, 2008. Accessed March 28, 2011.

Nurse leaders discuss the nurse’s role in driving technology decisions. Am Nurs Today. 2010;5(1):16-19.

Nursing Informatics: Scope and Standards of Practice. Silver Spring, MD: American Nurses Association; 2008.

Office of the National Coordinator for Health Information Technology. Electronic health records and meaningful use. Accessed March 28, 2011.

Simpson RL. Information technology: building nursing intellectual capital for the information age. Nurs Adm Q. 2007;31(1):84-88.

Skiba D, Connors H, Jeffries P. Information technologies and the transformation of nursing education. Nurs Outlook. 2008;56(5):225-230.

Watson J. Nursing: Human Science and Human Care. A Theory of Nursing. Rev ed. Sudbury, MA: Jones & Bartlett Learning; 2008.

The authors work at Indiana University-Purdue University Fort Wayne in Fort Wayne, Indiana. Linda Meyer is a professor emeritus, Carol Sternberger is a professor of nursing, and Tammy Toscos is a visiting assistant professor.

1 Comment.

  • A lot of Academic EHR Systems, like EHR Tutor, have taken these lessons learned from different schools and added resources for instructors and faculty. For example, sample lesson plans integrating the Academic EHR System, webinars for instructors to gather ideas, critical thinking questions to prompt further thought when using the system, etc. Hopefully schools are finding it much easier to implement these programs now that a few years have passed!

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