A Novel Approach to Supporting Relationship-Centered Care Through Electronic Health Record Ergonomic Training in Preclerkship Medical Education

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An electronic health record (EHR) is a digital patient chart that consists of the patient’s health information, such as diagnosis, physician encounter, past medical history, medications, patient demographics, laboratory data, radiology imaging, and so on. [1]

This article evaluates the effectiveness of relationship-enhancing EHR ergonomics training in Preclerkship medical education at the University of Arizona College of Medicine - Phoenix (COM-P). [2]


Forty 2nd year medical students at COM-P were sampled during their preclerkship years in 2012. These students were required to have completed the Doctoring course with Standardized Patients (SP), where they were educated on “history taking, physical examination, presentation, and clinical reasoning skills.” The students were randomly separated into three groups, 13 student for Tuesday sessions, 12 students for Wednesday sessions, and 15 students for Thursday sessions. The EHR training sessions were divided into four groups, which were conducted prior to Doctoring SP encounter: DS1 - Two hour basic EHR training and pre-survey; DS2 - Introduction to laptop-based EHR (15 minute session); DS3 - Introduction to laptop positioning optimization (15 minute session); and DS4 - Evaluation of DS2 & DS3. The Groups included: Control I (Tuesday group) - Received DS1, no additional training, and no EHR provided during SP encounter; Control II (Wednesday group) - Received DS1, no additional training, and EHR provided during SP encounter; and Treatment (Thursday group) - Received DS1, DS2, and DS3 with EHR provided during SP encounter. A post-survey was then completed after each SP encounter.


Pre and post-survey by the students indicated that an increment improvement with each subsequence session. DS1 vs DS2 = P< .05, DS1 vs DS3 = P< .01, DS1 vs DS4 = P< .001. Furthermore, using the linear regression model, it was determined that the estimated difference in pre and post-survey improvement between Control I and Control II, in terms of the student’s ability to effectively use the EHR while engaging the patient, was 0.31. While the estimated difference between Control II and Treatment was 1.23.


Utilization of EHRs was more effective in students who received additional training on EHR in a relationship-enhancing way, than in those with basic training. With the healthcare industry rapidly shifting toward EHR adoption, a significant impact towards easier unitization of EHRs can be achieved, if education is initiated at undergraduate or graduate medical academic level.

Though the study highlights the benefits of EHR ergonomics, it is limited in its real world application, in that; the same results may not be achieved in less controlled clinical environments, such as hospitals. In addition, the introduction of multidisciplinary nurses and allied health personnel can further affect the outcome of the study.


This includes: Pre-Survey, Post-Survey, EHR Ergonomic Training Materials, Student EHR Questionnaire, Standardized Patient EHR Questionnaire, Faculty EHR Questionnaire, and Statistical Analysis of EHR Use Improvement. [3]

My Comments

I think this is an interesting approach on educating physicians on relation-centered care via EHR at the earlier stage of their careers. As a nurse, I would also like this approach to be incorporated into the nursing curriculum in academic institutions. As the healthcare industry is being digitized, healthcare professional must at abreast. Therefore, I think an EHR course should be introduced in all healthcare affiliated studies.

As mentioned in the conclusion, the only criticism I have, is the real world application of this study may not yield the same results. I would suggest a similar study be conducted with new graduate nurses in a hospital or clinic setting in collaborating hospital or clinic to monitor the effectiveness of the training with multiple distractions.

Related Articles


  1. HealthIT.gov https://www.healthit.gov/providers-professionals/faqs/what-electronic-health-record-ehr
  2. Silverman, H., Ho, Y-X., Kaib, S., Ellis, W. D., Moffitt, M. P., Chen, Q., Nian, H., & Gadd, C.S. (2014). A novel approach to supporting relationship-centered care through electronic health record ergonomic training in preclerkship medical education. Academic Medicine: Journal of the Associate of American Medical Colleges. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4146679/
  3. Silverman, H. et. al. (2014). file:///C:/Users/lawrence/Downloads/NIHMS584233-supplement-Supplemental_Digital_Content%20(1).pdf