Simulation in the EHR

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Electronic Health Record (EHR) simulations use realistic patient charts created and maintained in training environments to allow users to experiment with different EHR tools to accomplish a set of tasks without altering real patient data. Clinical simulations have been used in medical education to teach technical skills,[1][2][3] critical thinking and team-building in emergency situations,[4][5] and to research the impact of multimedia on clinical-decision making in test conditions.[6] Simulation can identify usability problems and direct EHR design. Additionally, competency in the many uses of the electronic health record represents a cornerstone of physician education necessary to function effectively in modern clinical environments.[7] Thus, simulation in the EHR can help characterize users’ approach to a system and educate users on the effective use of the EHR when accomplishing common clinical tasks.

Key Elements

EHR simulations must capture the reality of not only the large amount of information frequently present in electronic charts, but also the distribution of that information across multiple activities and screens, as well as the need to amalgamate data to accomplish tasks. For many educational goals, simulated patient charts require:

  • Clinical notes
  • Laboratory values
  • Orders
  • Medication administration record
  • Flowsheets (vital signs, growth parameters, vent settings, etc.)
  • Past medical history
  • Prior to admission medications

Additionally, educational simulations should specify learning objectives, key safety issues, and evaluation rubrics, as seen in an example of a simulated neonate with hyperbilirubinemia with evidence of sepsis.[8]

Simulated patients must also be created in EHR environments that are stable, refresh daily (such that patient data that is designed to be “today” does not migrate into the past), and allow for copies that users can manipulate without destroying the initial file.

User Training

Safety Issues

EHR simulations aimed at promoting patient safety by training physicians to use the EHR to recognize safety concerns often model cases on common, easily-missed diagnoses as well as errors noted in morbidity & mortality reports or root-cause analyses.[9] In a study of two simulated cases in the medical intensive care unit at Oregon Health Sciences University, users improved recognition of patient safety issues on repeat testing with a new case, suggesting that EHR simulation is an effective tool for teaching EHR safety behaviors.[10] Physicians, nurses, and pharmacists also detect different safety issues from each other, often using different EHR screens.[11] EHR simulations have also been used as an educational tool for medical students in order to each chronic disease management (See Simulated Electronic Health Record (Sim-EHR) Curriculum: Teaching EHR Skills and Use of the EHR for Disease Management and Prevention)[12] and to integrate into traditional clinical simulation education.[13]

Provider Efficiency

Simulation can also be used to promote tools that increase provider efficiency. For example, at the University of Arkansas Medical Sciences, 293 physicians and 94 nurses participated in simulation training after standard EHR training in anticipation of a new EHR implementation across several outpatient clinics. Participants noted significant improvements in self-efficacy ratings after simulation training as compared to after standard EHR training from the vendor.[14]

User Characterization

EHR simulation has also been used to define users’ workflow patterns when accomplishing common tasks. Doberne et al using commercial eye tracking software during a simulated case found distinct patterns among physicians when composing admission notes where some physicians had higher click frequency and screen fragmentation while others focused for longer periods of time on one screen at a time. Nonetheless, these two groups had similar total time required to compose the note and similar note quality at the end of the exercise.[15] This variation was again demonstrated by March et al, who found wide differences in intern progress notes despite being presented with standardized information, and that this could lead to consequences in key quality measures such as missing deep venous thrombosis prophylaxis medications.[16]

Acceptance of Workflows and Decision Support

Simulation in the EHR may also be used to introduce new workflows or decision support to define problem areas early before implementation into production environments. This has been used to iteratively improve nursing workflow in charting of vital signs and intake/output in a simulated hospital.[17] Similarly, the acceptance and non-acceptance of clinical decision support alerts and suggestions can be studied in a simulated environment and polished prior to general implementation.[18]

Future Directions

As more institutions attempt to integrate EHR simulation into medical education, decision support design, and research efforts, the ability to share simulated patients would have great benefits. This approach would take advantage of the portability and scalability of electronic simulated patients through libraries of downloadable patient data. For example in Epic® the Scotty Teleporter Tool could allow for export and import of simulated patient data through .ept masterfiles that can then be customized within each institution for their own learning objectives. Centralizing these efforts would

Related Articles


  1. Lee K-H, Ahn J-H, Jung RB, et al. Evaluation of a novel simulation method of teaching B-lines: hand ultrasound with a wet foam dressing material. Clin Exp Emerg Med 2015; 2: 89–94.
  2. Chaer RA, DeRubertis BG, Lin SC, et al. Simulation improves resident performance in catheter-based intervention: results of a randomized, controlled study. Ann Surg 2006; 244: 343–352.
  3. Nilsson C, Sorensen JL, Konge L, et al. Simulation-based camera navigation training in laparoscopy—a randomized trial. Surg Endosc 2016; published online Oct 21. DOI:10.1007/s00464-016-5210-5.
  4. Lemke DS, Fielder EK, Hsu DC, Doughty CB. Improved Team Performance During Pediatric Resuscitations After Rapid Cycle Deliberate Practice Compared With Traditional Debriefing: A Pilot Study. Pediatr Emerg Care 2016; : 1.
  5. Willie C, Chen F, Joyner BL, Blasius K. Using high-fidelity simulation for critical event training. Med Educ 2016; 50: 1161–2.
  6. Chang TP, Schrager SM, Rake AJ, Chan MW, Pham PK, Christman G. The effect of multimedia replacing text in resident clinical decision-making assessment. Adv Health Sci Educ 2016; published online Oct 17. DOI:10.1007/s10459-016-9719-0.
  7. Hersh WR, Gorman P, Biagioli F, Mohan V, Gold J, Mejicano G. Beyond information retrieval and electronic health record use: competencies in clinical informatics for medical education. Adv Med Educ Pract 2014; : 205.
  8. Orenstein EW, Rasooly I, Phillips W, et al. Developing an Informatics Curriculum: Using Electronic Health Record (EHR) Simulations to Improve Pediatric Residents’ Efficiency and Attention to Patient Safety. Presented at the Learning Technology Symposium of th Association of Pediatric Program Directors Meeting, Spring 2016. New Orleans, LA.
  9. March CA, Steiger D, Scholl G, Mohan V, Hersh WR, Gold JA. Use of simulation to assess electronic health record safety in the intensive care unit: a pilot study. BMJ Open 2013; 3: e002549.
  10. Stephenson L, Gorsuch A, Hersh WR, Mohan V, Gold JA. Participation in EHR based simulation improves recognition of patient safety issues. BMC Med Educ 2014; 14: 224–31.
  11. Sakata KK, Stephenson LS, Mulanax A, et al. Professional and interprofessional differences in electronic health records use and recognition of safety issues in critically ill patients. J Interprof Care 2016; 30: 636–42.
  12. Milano CE, Hardman JA, Plesiu A, Rdesinski RE, Biagioli FE. Simulated Electronic Health Record (Sim-EHR) Curriculum: Teaching EHR Skills and Use of the EHR for Disease Management and Prevention. Acad Med 2014; 89: 399–403.
  13. Shachak A, Elamrousy S, Borycki EM, et al. Towards Educational Electronic Health Records (EHRs): A Design Process for Integrating EHRs, Simulation, and Video Tutorials. Stud Health Technol Inform. 2016;228:624-8.
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Submitted by Evan Orenstein