Different electronic medical record systems (EMR) have established themselves as part of the Finnish health care service provision. There is a need to ensure health care professionals’ competence and training for such systems. The MEDigi project, aimed to modernize and harmonize the Finnish basic medical education, recognized EMR systems as a key competence area for medical professionals in eHealth topics. The project also led to the development of a new eHealth course and an EMR simulation environment targeted for medical students based on the Esko EMR system already in production use.
A new simulation environment was developed in cooperation with the Faculty of Medicine at University of Oulu and Esko Systems Ltd. The simulation environment was implemented as an optional exercise in a cross-institutional web-based course teaching eHealth topics to medical students in the spring 2023. Students’ experiences with the simulation environment and associated exercise were collected with a feedback survey using 5- and 10-point Likert scales.
An EMR simulation environment “TrainingEsko” was successfully implemented into the “Basics in eHealth for Medical Students” course. Up to 11 medical students took part in the exercise, of which two participated in the associated feedback survey. They expressed satisfaction with the performance of the simulation environment and the associated exercise.
Our initial experiences with the EMR simulation environment give support for the further use of the EMR simulation environment in future course implementations. According to the feedback the students found the environment effective and the exercises beneficial for learning about EMR systems.
1 Introduction
Reflecting the increasing digitalization of societies and health care, the International Medical Informatics Association (IMIA) published the second revision of the Recommendations on Biomedical and Health Informatics (BMHI) Education in 2023, suggesting the introduction of BMHI core principles, and fundamentals of other BMHI knowledge domains, in all health care profession curriculums, as a separate or integrated subject [1].
In Finland, efforts have been made to modernize basic medical education. One notable initiative was the national MEDigi project (2018–2021), funded by the Finnish Ministry of Education and Culture [2]. The project aimed to modernize and digitize the teaching of medicine and dentistry in Finland as well as to ensure that students possess a high-level competence in using electronic health care tools. This was achieved by establishing nationwide eHealth key competence themes. These areas of competence included topics such as electronic medical record systems (EMR), electronic databases, and clinical decision support systems [3].
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Additionally, the MEDigi project aimed to promote flexible studying, cross-institutional learning, and other forms of educational cooperation [2]. During the project, a new course titled “Basics in eHealth for Medical Students” was introduced in spring 2021 [4]. The course provides students with an overview of the position of eHealth and telemedicine solutions within the Finnish health care information system. It also familiarizes them with the terminology of information and communication technology (ICT) in health care and offers insights into future health ICT trends. The course, offered to medical students at all Finnish medical campuses, was the first nationwide cross-institutional medical course in Finland. The implementation of the course has been continued even after the end of the project, and on average, 15 students from different universities have completed the course as part of their optional studies yearly.
1.1 Electronic Medical Records and Education
The terms electronic patient record (EPR), electronic medical record (EMR), and electronic health record (EHR) are often used interchangeably. However, some definitions restrict EPR and EMR to a single health care organization, while EHR is more comprehensive, extending across organizational borders [5]. All these terms describe the collection of medical and health-related data on an individual, generated and managed primarily by health care professionals.
Finland has been among the leading countries in electronic medical data management. EMRs had been implemented in all Finnish public health care provider organizations by 2007 [6], and another milestone was reached by 2015, with widespread integration of Kanta services into the public health care sector’s record systems [7]. The Kanta services introduced the national e-prescription service, which became mandatory for all public health care provider organizations since 2017, the Patient Data Repository for central archiving and sharing of patient data between health care organizations, and the citizen health portal “My Kanta”, which provides citizens with secure access to their own health data and the option to control the sharing of their health data between different organizations [8].
With the introduction of Kanta services in Finland, distinguishing between EMRs and EHRs has become more challenging. In this paper, we use the terms electronic medical record (EMR), and EMR systems to denote the primary systems within a single health care organization to store and manage patient data, regardless of Patient Data Repository integration.
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Despite the widespread implementation of digital tools in clinical practice, 57% of Finnish medical doctors, who graduated between 2007 and 2016, felt that their training in these tools during basic medical education was inadequate [9]. Studies have indicated that longer extracurricular EHR experience correlates with higher confidence levels in using EHRs among the students [10]. A scoping review found that simulation training positively impacted the skills, attitudes, knowledge, and satisfaction of health profession students [11]. Moreover, simulated training in using EHRs can enhance medical students’ knowledge and awareness of the limitations of these systems [12]. A review of current literature on EMR training among health professionals and health profession students highlighted Academic Electronic Medical Records (AEMRs) and EMR simulation as the most prevalent methods in EMR education [13].
Given the importance of EMR systems as a key competence area for medical professionals in eHealth topics, we set out to pilot an electronic medical record simulation environment in the “Basics in eHealth for Medical Students” course during its third iteration in 2023.
1.2 Objectives
Our objectives were:
1.
To develop and implement an EMR simulation environment called “TrainingEsko”, and the associated Moodle exercise targeted at training medical students in the principals and use of EMR systems, and
2.
To gain initial user feedback about the environment and exercise for further development and improvement.
2 Materials and Methods
2.1 Electronic Medical Record System Esko
The “Esko” medical record system, developed by Esko Systems Ltd, is a browser-based modular system comprising of the core system with individual proprietary modules (e.g. Medication and Unit Situation Picture) and external integrations, such as LIS (laboratory information system) and RIS (radiology information system). First introduced in the Oulu University Hospital in 1996, the system has since been in use in specialized health care in four hospital districts. Esko has been among the highest rated systems in national usability studies both among physicians and registered nurses, especially for its ease of use and the technical functionality and stability [14, 15]. The system’s logical, easy to use interface and browser-based accessibility commended its use as the basis for a simulation environment in basic medical education.
2.2 Development and Piloting of the EMR Simulation Environment
The TrainingEsko simulation environment was developed in cooperation with the Faculty of Medicine at University of Oulu and the system producer Esko Systems Ltd, during the MEDigi project. After the end of the MEDigi project, the development was continued by the Medical Faculty and the system provider, and the system was introduced to students through a remote connection with the help of the ICT specialists from the Oulu University Hospital, their service supplier Istekki Ltd, and University of Oulu. The simulation environment and associated exercise were implemented in a web-based course aimed at teaching eHealth topics to medical students, titled “Basics in eHealth for Medical Students”, during the spring semester in 2023. The course was held in English and hosted on the Moodle learning platform. It was offered to all Finnish medical students as an optional course. As the simulation environment and exercises were in a pilot phase, they were an optional part of the course. Despite the course been held in English, the EMR simulation exercise was in Finnish due to the language restrictions of the system. Medical students were invited to participate in the pilot and associated feedback survey in a Moodle platform. The survey was conducted via Webropol survey tool to collect preliminary user experiences about the system and its implementation anonymously.
Student experiences with the exercise were surveyed using 5- and 10-point Likert scales in the survey. Students assessed their self-perceived competence on the subject themes on a scale from 0 (No competence) to 10 (Excellent competence) both before and after the exercise. The usefulness of the EMR simulation environment for independent learning was evaluated on a scale from 0 (Not useful) to 10 (Extremely useful), and students’ readiness and eagerness to use the system in other courses were measured on a scale from 0 (None) to 10 (As much as possible). The construction and implementation of the exercise and its components were assessed using positive statements about each part of the exercise, and a 5-point Likert scale ranging from 1 (Strongly disagree) to 5 (Strongly agree). The perceived level of difficulty of each part of the exercise was rated on a scale from 1 (Too easy) to 5 (Too difficult). In addition, students’ years of study as well as previous EMR experience were collected using a multi-choice question format.
We report the results of the feedback, and our experiences with the development of an EMR simulation environment and its implementation in an optional course as part of basic medical education.
2.3 Ethical Statement
The survey was conducted in accordance with the instructions of the Finnish Advisory Board on Research Integrity, and in compliance with EU data protection regulations as well as the established research practices of the University of Oulu and the Faculty of Medicine. Thus, no approval from the ethics committee was required. Full consideration was given to matters related to data protection in accordance with the ethical principles applicable to research subjects. The participation in the exercise and the feedback survey was voluntary and students were asked for their consent to collect and use data for the purpose of an academic paper. The students were informed of the purpose of the survey, their right to withdraw from it and prohibit the use of their data at any time. No incentives were offered for participation.
3 Results
3.1 Design and Implementation of the Electronic Medical Record Simulation Environment TrainingEsko
The Esko simulation environment “TrainingEsko” is a separate instance of the core Esko medical record system. Intended for educational and training purposes, the TrainingEsko includes functionalities such as medical history, progression and discharge notes, medication, and key certificate forms. Importantly, as an independent system, Training-Esko is not connected to the production version of Esko and does not contain any real patient data; instead, it features entirely fictional patient profiles. The simulation environment is hosted on secure servers, and students can access the simulation environment in a browser on their own computers, using personal Oulu University login ID to open a secure connection. Access to the system is granted only to the students enrolled in the course and only for the duration of the course. Login to the simulated EMR system itself uses login information intended for this purpose only. Personal login information to the production system is never used with the simulation system.
As a pilot feature, the simulation environment was introduced as an optional additional exercise designed to teach the anatomy and use of EMR systems. The exercise comprised of Moodle H5P-activity with branching scenarios and practical tasks per-formed in the EMR simulation environment. The H5P-activity in Moodle, with slide shows and interactive imagery, provided students with written instructions for navigating the exercise and managing the simulation environment. It presented activating questions from various viewpoints on the subjects for student contemplation. Screenshots of the training environment, equipped with interactive “hotspots” that opened additional information in floating windows, offered a practical method for presenting visual and dynamic instructions on the structure and use of the simulation environment. For this exercise, we created an imaginary patient case in the simulation environment, featuring a senior patient with a history of hypertension, heart infarction, and atrial fibrillation, along with appropriate medications.
The related learning exercise was divided into three parts, which students could perform separately and in the order of their choosing, although the numbered order was encouraged (see Fig. 1). Part 1, titled “Relevance and anatomy of EMRs”, focused on the general structure and functions of EMRs using TrainingEsko as an example. It covered what information EMRs contain, and how this information is stored and organized. Students were instructed to navigate in the system and familiarize themselves with the general structures of EMRs by searching and opening the medical record of the fictional patient using a personal identity code (see Fig. 2–3).
Fig. 1.
Screenshot of student’s view in the Moodle activity with branching scenarios. First three options direct to parts 1–3 of the exercise, and the last option to the feedback survey and used sources. English translations by authors.
Fig. 2.
Screenshot of student’s view in TrainingEsko, as they search for the fictional patient’s records. System language Finnish, English translations provided by authors.
Fig. 3.
Screenshot of the Moodle activity from part 1 of the exercise. After instructing the students to practice navigating the system themselves, screenshots of the respective views of the system with interactive hotspots (green plus signs) were used to educate students on different aspects of the system. English translation by authors.
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Part 2, “Patient record and note entering”, dealt with the medical record of an individual, exploring the differences between structured and unstructured medical data, as well as aspects of data security. As practical tasks, students reviewed the patient history and practiced note entering in the simulation environment (see Fig. 4). Part 3, “EMR and tools of care: medications”, focused on the management of medication data. This section discussed the benefits and risks associated with electronic medication lists, and relevant clinical decision support tools, such as drug interaction warning systems. Students engaged in different types of medication orders, which also demonstrated various levels of drug interaction warnings (see Fig. 5).
Fig. 4.
Screenshot from Moodle for the part 2 of the exercise, in which students are instructed how to enter notes into the patient record. English translations by authors.
Fig. 5.
Screenshot of the student’s view in TrainingEsko as they practice entering medication orders in part 3 of the exercise. Following the instructions will result in a demonstration of several medical interaction warnings due to the patient’s existing medication. System language Finnish, English translations provided by authors.
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3.2 Initial User Experiences Based on the Feedback Survey
Of the course-enrolled students, 11 students had interacted with the Moodle activity of the exercise. Two first-year medical students completed at least one part of the exercise and took the feedback survey. Neither had previous experience in relevant working field nor previous experience with EMR systems.
The students’ self-estimated competence in the respective course subject themes (“Electronic Health Records”, “Components to EPR/EHR”, and “Health Information Exchange and Kanta”) varied from 4 and 8 before the exercise. After the exercise, the estimated confidence ranged from 6 to 7, meaning one of the students estimated their confidence lower by at least 1 point. The usefulness of Training Esko was evaluated ranging from 5 to 9, and the students’ readiness and eagerness to use the system in other courses varied from 5 to 8.
Part 1 of the exercise was assessed by one student, who assessed the Moodle-activity as moderately challenging (4) and the exercise-demanded use of TrainingEsko as suitably challenging (3). Likewise, part 2 of the exercise was assessed by one student, who found both the Moodle activity and the exercise-demanded use of the simulation environment as suitably challenging (3). Unfortunately, neither student filled the survey regarding exercise part 3.
4 Discussion
To our knowledge, this was the first EMR simulation environment piloted for medical education purposes in Finland. Globally, there have been a few initiatives to implement similar solutions in basic medical education, and the response to these initiatives has been mainly positive [12, 16, 17]. Recognized potential challenges include the availability of suitable systems meeting the technical requirements for educational use, the financial and human resources needed for the implementation and maintenance of these systems, resistance from faculty, educators, or students, and the already loaded curriculum of medical studies [12, 18, 19].
We report our experiences of successfully implementing an EMR simulation environment into a Finnish cross-institutional medical online course, and the collected preliminary experiences from students about the system and its use. Though our simulation environment focuses on only one Finnish EMR system, the connected exercise targets to teach about EMR systems, their functions and anatomy, at a universal level. The students who participated in the pilot exercise and the feedback survey expressed satisfaction with the performance of the simulation environment and the associated exercise. Students felt that the tasks supported their learning and perceived the EMR simulation environment as at least moderately useful for independent learning. They indicated readiness and eagerness to implement it in other courses, aligning with results found in literature [20, 21].
An interesting finding was that for at least one student, the self-assessed confidence level in using the EMR system decreased after completing the exercise. This might be attributed to increased awareness of the complexities and demands of recording patient data in EMR systems [22]. The sophistication of current systems may have been unexpected for participants with no prior EMR experience. However, due to the small number of participants, further conclusions on this topic are limited.
Another observation during the project was related to the published literature on EMR training and EMR simulation environments. More studies seemed to involve health care professionals or nursing students with relatively few focusing on undergraduate medical students [13]. This is noteworthy considering that medical students are a significant future user group of EMR systems. While the basic education in digital tools and eHealth was considered insufficient by doctors who graduated before 2016 [9], recent findings suggest that the self-reported competence level of fifth year medical students in Finland is at a good level, though there is room for improvement [23]. Globally, the situation may differ, as indicated by a study from Saudi-Arabia [24]. There is evidence that EMR teaching interventions can enhance students’ competence levels and confidence in their skills [25].
Simulation-based teaching is at its core student-centered in nature, and directs the student to an active role [11]. Students’ motivation can be increased by their learning having a direct transfer effect to the context of working life. More research is needed on the ways in which EMR teaching should be integrated into basic medical education. Developed frameworks, such as the one described by Borycki et al., are helpful for discussing ways and levels of EMR simulation integration [26]. The role of piloting is significant, as the models created with them can help to develop and promote teaching practices. We hope that our model of using a non-production copy of an EMR, combined with the flexibility of established educational environments like Moodle, will provide inspiration to others. However, the variety of technical solutions behind different EMRs may hinder or prevent their use in this manner.
Though the system and the associated exercise we have described demonstrates stand-alone learning, the system could potentially be used to supplement traditional medical education in the future, for example as a platform for clinical course material. Such integration would come with its own benefits, such as natural exposure to EMRs during basic studies while avoiding adding new course content to the curriculum. However, such use of the system could also introduce new requirements insure a smooth and seamless integration with other course education.
Based on the positive results we decided to make part 1 of the EMR simulation environment a compulsory exercise for all students in the “Basics in eHealth for Medical Students” course, with minor modifications, while parts 2 and 3 remained optional. The EMR simulation system was also piloted on a clinical neurology course, receiving generally positive feedback from students. Many noted that the optimal timing for such a system would at the beginning of the clinical phase of their studies. As the “Basics in eHealth for Medical Students” is scheduled for the last year of pre-clinical studies, these comments reinforce our decision to continue implementing EMR simulation in this course.
4.1 Conclusions
According to the feedback, the students found the EMR simulation environment effective and the exercises beneficial for learning about EMR systems. Our experiences provide a solid foundation for the further use of the EMR simulation environment in future course implementations.
Acknowledgments
We would like to thank the students participating in the pilot exercise, Esko Systems Ltd and Oulu University Hospital (OYS) for providing the software environment, and the ICT specialists at Esko Systems Ltd, OYS, Istekki Ltd, and ICT Services of University of Oulu for their contribution and support in implementation of the system in medical education.
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