and Stacey J. Jones, DNP, FNP-BC
Gardner, C. and Jones, S. (June 2012). Utilization of academic electronic medical records in undergraduate nursing education. Online Journal of Nursing Informatics (OJNI), vol. 16 (2), Available at http://ojni.org/issues/?p=1702
The profession of nursing and nursing education is “radically transforming” to meet the newly evolving expectations of the nursing workforce. Informatics and electronic medical records must be used to prepare nursing graduates for professional practice. Federal mandates and professional organizations are driving the adoption of electronic medical records in clinical practice. Academic electronic medical records are fully functional systems through which students can navigate technology and document and plan patient care in a simulated format. The academic electronic medical record allows students to apply skills and knowledge obtained during their educational experience and aids in the development of critical thinking skills. Competencies have been developed for the novice or beginning nurse and should serve as a guide to nurse educators in the development of nursing curriculum. Nursing faculty have been identified as the major barrier to the integration of the academic electronic medical record into nursing curriculum.
Keywords: academic electronic medical records, competencies, barriers, facilitators, and faculty development
The profession of nursing is “radically transforming” in response to the rapidly changing context of the current health care environment (Benner, Sutphen, Leonard, & Day, 2010). Changes in science, technology, and the health care system as a whole have major implications on the expectations of nurses in relation to the provision of safe, quality patient care. In order to meet the newly evolving expectations of the nursing workforce, nursing education must also be transformed. Faculty commitment to integration of informatics and electronic medical records (EMR) throughout the curriculum is essential in preparing nursing graduates to meet the needs of health care consumers.
In 2004 the federal government, under the direction of President George W. Bush, set a goal for the nation that healthcare providers would utilize EMR for the majority of citizens by the year 2014 (The National Alliance for Health Information Technology, 2008). Subsequently, the American Recovery and Reinvestment Act (ARRA) of 2009 allocated $19.2 billion for implementation of health information technology into clinical practice. The Health Information Technology for Economic and Clinical Health (HITECH) act is the portion of the ARRA that provides the United States Department of Health and Human Services with the power to facilitate promotion and utilization of health information technology usage through government programs. These government programs are focused on improving health care quality, safety and efficiency (United States Department of Health and Human Services [USDHHS], 2012). Most recently federal agencies have moved from encouraging simple utilization of electronic medical record systems to instituting actual “meaningful use” of system capabilities. Additionally, The HITECH Act provides funding for incentive payments through the Centers for Medicare and Medicaid Services (CMS) to eligible health professionals and hospitals that demonstrate meaningful use (Centers for Medicare and Medicaid Services [CMS], 2012). CMS (2012) also stipulates that by 2015 those professionals and hospitals not demonstrating meaningful use will have adjustments to reimbursement payments in the form of penalties. In light of new federal mandates, nursing graduates will be expected to be proficient in computerized documentation and in the navigation of a computerized EMR when entering the workforce.
In addition to federal mandates, private and public leaders in the fields of health care, nursing, and nursing education also emphasize the importance of integrating health information technology and EMR into nursing practice. The Institute of Medicine (2003) endorses the utilization of informatics as one of the five competencies required of all healthcare providers. The National League for Nursing (NLN, 2008) recommends that nursing faculty should participate in programs to further faculty development in informatics and incorporate informatics into all levels of the curriculum. The American Association of Colleges of Nurses (AACN, 2008) identifies information management and the application of technology in patient care as an essential element of baccalaureate education. Curriculum content to meet this expectation includes the use of EMR, decision support tools, and databases to meet the complex needs of patients in the modern healthcare system. The Quality and Safety Education for Nurses (QSEN, 2011) has identified informatics as an area of competency necessary for the provision of safe, quality care to patients. Documentation and planning of patient care through an EMR is a pertinent skill necessary in achieving this competency.
According to the Technology Informatics Guiding Education Reform (TIGER) initiative, the nursing profession has been slow to incorporate information technology into formal nursing education and nursing practice. The TIGER initiative provides guidelines for nursing leadership to follow when integrating information technology into nursing education and mandates that all nursing students and practicing nurses should be equipped with the skills necessary to practice in the technology-driven world of health care (Hebda & Calderone, 2010; Technology Informatics Guiding Education Reform [TIGER], 2008). In order for schools to meet the expectations of accrediting bodies and in order to prepare students to meet the expectations of the current health care system, nursing schools and faculty must be committed to integrating health care informatics into nursing curriculum.
Accreditation is a voluntary process in which schools of higher education participate in order to ensure the delivery of quality educational programs to students and to foster the improvement of academic programs. Accrediting bodies are non-governmental entities that outline specific standards for schools of higher education. The accreditation process involves self-evaluation by the school and recommendations made by on-site peer reviewers aimed at improving the delivery of education in programs. The National League for Nursing Accrediting Commission (NLNAC) and the Commission on Collegiate Nursing Education (CCNE) are the two main accrediting bodies that govern schools of nursing in the United States (Commission on Collegiate Nursing Education [CCNE], 2009; National League for Nursing Accrediting Commission [NLNAC], 2008).
The NLNAC (2008) has established five standards of accreditation for schools of nursing that measure the quality of nursing education. These standards evaluate the individual areas of mission and administrative capacity; faculty and staff; students; curriculum; and resources. Student and faculty utilization of technology is addressed by three of the five standards. Standard Three: Students focuses on student development, including technological resources and support availability. More specifically, Standard Four: Curriculum outlines the necessity of advancing technology competencies and exposing students to the best practices to promote safe and effective client care throughout the curriculum. Standard Five: Resources focuses on selection and maintenance of current learning resources and technology to promote student success (NLNAC, 2008).
Technology usage is also emphasized in the standards outlined by the CCNE (2009) during the accreditation process. CCNE standards serve as a broad guideline for institutions and outline the expectation of the use of “innovated teaching and learning strategies” throughout the curriculum to improve and enhance student learning. Additionally, through the accreditation process, schools should be able to document the availability of technology for students. The utilization of technology is outlined in two of the four CCNE standards. In Standard II Program Quality: Institutional Commitment and Resources, technology is considered an academic support service to ensure the attainment of student learning outcomes. Standard III Program Quality: Curriculum and Teaching Learning Practices specifically states simulated learning experiences as appropriate teaching-learning strategies to meet the needs and expectations of the community of interest (CCNE, 2009). In order to meet outlined accreditation expectations, schools of nursing need to utilize simulated technology that is current and relevant to nursing practice.
With electronic medical record systems being one of the most widely utilized forms of health information technology, students should be exposed to computerized documentation systems during their formal nursing educational experiences. Upon graduation, students must be proficient in the computerized documentation of nursing activities performed during patient care. Johnson and Bushey (2011) define the academic EMR as a secure computerized system, used in an educational setting, that contains the capabilities and functionality required of EMR systems being utilized in clinical practice. Through the use of academic EMR, students benefit from learning opportunities in areas such as navigation of technology, patient assessment, decision making, and documentation proficiency (Johnson & Bushey, 2011). Integration of academic EMR into nursing curriculum helps create a technology-rich learning environment for students, exposing them to evidence-based practice, standardized nursing language, and informatics competencies (Meyer, Sternberger, & Toscos, 2011).
There is increasing importance being placed on the adoption of EMR in clinical practice (TIGER, 2008). Nurses who are not capable of communicating within an EMR will be at a significant disadvantage in upcoming years. Staggers, Gassert, and Curran (2001, p. 306) define nursing informatics competencies as the “integration of knowledge, skills, and attitudes in the performance of various nursing informatics activities within prescribed levels of nursing practice.” Specific competencies for four levels of nurses (beginning, experienced, informatics nurse specialist, and informatics innovator) were identified. The beginning nurse should have the fundamental knowledge and computer skills to utilize existing information technology in patient care (Staggers et al., 2001, 2002). Specific competencies and skills that are expected of the beginning nurse include searching for patient information, communication, data access, documentation, decision support, patient education, and patient monitoring (Stagger et al., 2001, 2002). In addition to recognition of the impact nursing data can have on improvement of practice, new graduates should be able to identify the limitations of computerized documentation systems in relation to program design and computer capacity. Beginning nurse graduates should be knowledgeable regarding ethical use of the computer system and privacy and security issues that accompany computer use. Students should be instructed on ethical issues such as maintaining password security, preventing unauthorized access of patient records, and ensuring patient confidentiality (Ornes & Gassert, 2007; Staggers et al., 2001).
The work of Staggers et al. (2001, 2002) served as the basis for the further refinement of standards by the American Nurses Association (ANA). The ANA categorizes competencies into three broad areas: computer literacy, information literacy, and professional development/leadership (American Nurses Association [ANA], 2008). Based on an extensive review of literature, the TIGER (2008) initiative also defined competency standards through the TIGER Informatics Competencies Collaborative (TICC). The TICC developed a model of informatics competencies including basic computer competencies, information literacy, and information management. The underlying theme of all of the competency sets is the preparation of the graduate to have a novice or beginning level of knowledge regarding the utilization of electronic medical records in patient care. These competencies should be used during implementation of the academic EMR to prepare graduates for expectations in the workforce.
Despite the established need for academic EMR, many schools of nursing have been unable to integrate a system into the curriculum. Nursing faculty have been identified as a major barrier to adopting academic EMR into the curriculum. Reasons given for failure to adopt academic EMR are that faculty members are often unsure how to integrate information technology into the curriculum and may be unfamiliar with the use of EMR (Flood et al., 2010). A lack of faculty computer skills and discomfort with technology also impede the implementation of an academic EMR. In order for faculty to develop competent computer skills and improve comfort level, additional staff may be required to provide training (Ornes & Gassert, 2007). Limited funding and cost are also barriers to the implementation of an academic EMR (Fetter, 2009a). Also, many different types of EMR are in use in the hospital setting, thus it is impossible to prepare new nursing graduates for each specific documentation system.
Despite these barriers, numerous facilitators exist supporting the need to incorporate academic EMR into the BSN curriculum. While nurses may not be able to learn all possible systems, there are certain minimal skills that should be acquired during formal educational preparation. For example, the ability to document in an electronic medical record is a skill required for most registered nurses (Cheeseman, 2011). Making this process easier, undergraduate students are usually technically proficient and enjoy using technology in the learning process (Kennedy, Pallikkathayil, & Warren, 2009). Students also have access to computer labs, internet, and many have personal computers. Academic EMR are accessible 24 hours a day, 7 days a week to students both on and off campus (Johnson & Bushey, 2011). Using academic EMR as part of the nursing curriculum develops critical thinking skills and helps prepare students to use electronic medical records in practice. Johnson and Bushey (2011) also found that the academic EMR was a valuable resource in preparing students for summer internship experiences.
Information systems, such as electronic medical records, have been found to improve patient safety and decrease medication errors in practice. Implementation of an academic EMR as part of the nursing education program could increase the time spent in direct patient care and decrease the time spent documenting when the student nurse transitions into professional practice (Ornes & Gassert, 2007). The use of evidence-based practice is imperative in providing quality patient care. Students can use academic EMR and other information technology to search for evidence-based guidelines that can be incorporated into patient care (Flood et al., 2010).
Initially faculty and administrators should meet and discuss the commitment of the program to implement and thread technology and simulated documentation throughout the curriculum. Programs should identify specific goals and expected student outcomes in relation to the technology usage. During discussions, program specific facilitators and barriers should be identified and addressed in order to ensure successful implementation. Funding and budgeting concerns should also be addressed early in the planning process, allowing faculty to focus on products that meet the fiscal requirements of the program. During the planning process, programs may also appoint a product-selection steering committee headed by a faculty member with health information technology as a specialty to review academic EMR technology. An employee from the educational facility’s Information Technology (IT) department could assist in the selection of a program that would meet IT requirements. This committee can then make recommendations to the faculty unit as a whole (Gloe, 2010).
Once a program has committed to the implementation of academic EMR, an actual product for purchase must be identified. Faculty and administrators should be knowledgeable about the different types of delivery for academic EMR technology and should choose the most appropriate delivery for the program specific objectives and goals. Presently, there are several different options for schools to consider. Products range from fully-functional academic EMR systems similar to those used in the hospital setting to textbooks with accompanying activities on a software disc. Educational publishing houses are also developing simulated charting programs that allow students to document in a computerized format. Obviously, fully functional programs that allow for a large degree of customization are more expensive than textbooks with accompanying software. Prior to demonstrations, faculty should develop a list of questions guided by program-specific goals (Gloe, 2010). Demonstrations of specific products by vendors should be scheduled so that faculty may attend and make recommendations.
After the demonstration of all products, faculty should make recommendations to the committee regarding selection of the academic EMR. The committee can then review all faculty feedback and make a recommendation that can then be voted upon by faculty. The committee must consider faculty goals and take into consideration fiscal requirements and monetary limitations.
Nursing faculty have been identified as one of the major barriers to implementation of technology and nursing informatics into nursing curriculum. Therefore, the need exists to improve faculty skills and knowledge in relation to understanding informatics competencies required of novice nurses. Nursing faculty should participate in faculty development programs and form partnerships with local vendors and health care delivery systems to improve integration of clinical information systems into nursing education. Each school should designate an informatics champion to help guide faculty in the implementation of instructional teaching strategies to meet the needs of students (NLN, 2008; Hebda & Calderone, 2010). Deans and directors of nursing programs should provide the necessary staff and monetary resources for implementation of an information technology infrastructure. Additionally, nursing faculty should be provided continuing education and professional development opportunities to ensure competence in computer and informatics literacy (NLN, 2008).
In order to facilitate successful implementation of an academic EMR, extensive faculty training should occur prior to student use of the program. Prior to any training, faculty should be individually evaluated regarding information technology competency levels and grouped accordingly. Training can be tailored to the competency levels of faculty. In order to allow for adequate time for faculty preparation, training should be begin four to six months prior to initiation of student usage of the program. A formal orientation of one to two days should be scheduled to train faculty. More informal training can be implemented for faculty members based on individual competencies and needs. In addition to training on actual system usage, faculty should also be educated regarding the benefits of the academic EMR and utilization to improve nursing practice (TIGER, 2008).
Integrating and incorporating technology into nursing curriculum should be a priority for nurse educators. During the planning and training phases, faculty should first decide on an implementation strategy beginning with curriculum development. Users of technology must first have a level of comfort and understanding in order to effectively utilize technology to improve patient safety and outcomes (TIGER, 2008). Informatics should be woven throughout the curriculum of a BSN program (Flood, Gassiewicz, & Delpier, 2010). Overall program and individual course objectives should be evaluated and modified to meet Essential IV of the AACN Essentials of Baccalaureate Education that addresses the application of patient care technology (AACN, 2008). As reported by Fetter (2009b), new graduate nurses provided low self-ratings in the areas of electronic care documentation/care planning and valuing informatics knowledge. Candela and Bowles (2008) reported that 76% of recent registered nurse graduate respondents in their study did not feel that they were prepared to access and utilize EMR in patient care. In a national survey of nursing school deans or directors, McNeil, et al. (2005) found that less than half of the respondents reported that they were educating students regarding the ethical use of information systems and electronic-based records in their respective undergraduate nursing programs. Nursing schools must focus on the integration of technology and informatics in order to better prepare graduates for the workforce.
Academic electronic medical records can be integrated into a variety of clinical or classroom settings to help prepare nursing students to enter the workforce (Gloe, 2010). Assignments should be threaded into the curriculum and increase in complexity as the student progresses through the program. The integration of teaching strategies across the curriculum supports the attainment of overall Quality and Safety Education for Nurses (QSEN) competencies, including informatics as a focus area (Barton, Armstrong, Preheim, Gelmon, & Andrus, 2009). Informatics activities should be integrated into clinical and theory nursing courses with defined standards for expected competencies based on the course level and year of the student (Fetter, 2009b). Assignments should meet individual course objectives progressing to attainment of program outcomes (Flood et al., 2010). In order to facilitate success, programs may want to implement academic EMR into the curriculum beginning with entry-level clinical courses and slowly progressing to program-wide implementation.
Simulation of patient care serves to standardize teaching and evaluation in the educational setting. Fetter (2009b) found that students reported a wide variation of information technology resources and training in the clinical setting. Integration of simulated documentation can standardize the information to which students are exposed during their undergraduate preparation. Specific examples of simulation activities utilizing an academic EMR include navigation of an EMR to locate pertinent patient information, documentation of nursing interventions for simulated patient care scenarios, and development of electronic plans of care.
Short-term and long-term evaluation of the academic EMR should be priorities to determine the success of implementation and utilization. Individual student activities should be evaluated for attainment of technology-related course objectives. Specific grading rubrics for each activity should be developed in addition to summative course objective evaluation tools. Long-term evaluation can occur through post-graduation employer and student surveys regarding educational preparation for technology usage in practice. In light of the inclusion of technology into accreditation standards, attainment of accreditation may also be considered a method of long-term evaluation.
In the rapidly changing world of healthcare delivery, nurses play an integral role in the delivery of patient care. National initiatives and private leaders in the field of healthcare are driving the adoption and utilization of technology in the clinical care setting. With the increasing expectations of nurses regarding the use of health information technology, nursing graduates must be highly prepared when entering the workforce. It is the responsibility of nursing programs to prepare graduates for practice in a technology driven health care setting. Accreditation standards are evolving to specifically include and outline technology usage and simulated teaching-learning activities in nursing curriculum. In order to meet these newly evolving standards, programs must be actively integrating these activities into the classroom. Academic electronic medical records assist students in learning skills that are necessary to the provision of safe, quality health care for consumers. Nursing faculty should utilize current competencies to guide the implementation of academic electronic medical records into nursing curriculum in the preparation of graduates for clinical practice.
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Dr. Carrie Lee Gardner is an Assistant Professor with Troy University in southern Alabama. She completed her BSN degree at Auburn University in 1997. In 2000, she completed her MSN Family Nurse Practitioner degree at the University of Alabama at Birmingham. She is certified through the ANCC and the AANP. Dr. Gardner began her career in nursing education in 2007 at Troy University in the BSN nursing program. She received her DNP degree in 2011 from the University of Alabama at Birmingham.
Stacey J. Jones, DNP, FNP-BC
Dr. Stacey J. Jones is an Assistant Professor with Troy University in southern Alabama. She began her career in nursing in 1995 when she graduated from Troy University with her BSN. She completed her MSN as a Family Nurse Practitioner in 2001 from the same university and was ANCC certified as an FNP. In 2001, she began working in a family practice clinic in rural south Alabama. She began her career in nursing education in 2007 with the BSN nursing program at Troy University. Dr. Jones received her DNP from the University of Alabama at Birmingham in 2011.