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. 2025 May 22;2024:1079–1088.

Lessons Learned from OpenEMR Implementation in Graduate Health Informatics Curriculum

Keerthika Sunchu 1, Megha M Moncy 1, Saptarshi Purkayastha 1, Cathy R Fulton 1
PMCID: PMC12099383  PMID: 40417551

Abstract

This study examines the integration of OpenEMR, a Meaningful Use-certified open-source electronic health record (EHR) system, into a Health Informatics curriculum. The primary objective was to address the disparity between theoretical knowledge and practical application in health informatics education. The implementation process revealed several significant challenges, including unintended system modifications that compromised functionality, data entry errors that impacted usability, and technical issues that impeded accessibility. To mitigate these challenges, a series of interventions were implemented. These included backend modifications to enhance data entry accuracy, usability improvements such as limiting open tabs to facilitate navigation, and the implementation ofproactive measures to expedite the resolution of technical issues. The experiences gained from this integration process highlight three critical aspects of health informatics education: the significance of practical proficiency in EHR systems, the necessity for user-centric interface design, and the importance of adaptability and problem-solving skills. The study proposes several future directions for research and practice. These include fostering global collaboration, developing standardized curricula for EHR education, and establishing robust mechanisms for continuous assessment and improvement. The findings underscore the pivotal role of integrating hands-on EHR experience into health informatics education, emphasizing its potential to equip students with the essential competencies required to navigate the complex and dynamic healthcare landscape.

Introduction

The adoption of electronic health record (EHR) systems has revolutionized the healthcare industry, transitioning from predominantly paper-based practices to a model where clinical information and data helps providers deliver improved quality of care to patients [1]. In the United States, the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH Act) provided more than 19 billion dollars to encourage the adoption and use of information technology in healthcare settings [2]. By 2015, almost every hospital (96%) had adopted certified EHR technology, marking a nine-fold increase compared to 2008, before the implementation of the HITECH Act [3].

Despite the widespread adoption of EHRs, student learner access to these systems has decreased [4, 5]. To bridge the gap between the lack of EHR training and the need for EHR exposure, educators have constructed EHR simulators [6] or employed sandbox or training/testing environments of commercial EHRs [7, 8, 9, 10]. While these solutions provide some level of EHR training, they often lack substantial curricular support, educational content, and practical, hands-on experience [11].

The demand for skills in information technology systems has risen steadily due to continuous advancements in technology and its application [12]. Consequently, academic institutions have been developing innovative and dynamic information technology (IT) courses to meet the industry’s evolving needs [13, 14]. In the healthcare field, the utilization of technology and appropriate skills has skyrocketed in recent decades [15]. To address the growing demand for workers who understand the unique blend of IT and healthcare, academic institutions across the country are developing new specialized curricula focused on this intersection [16, 17, 18].

Modern education has shifted from learning outcomes to practice-oriented competencies [19]. The Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM), the accrediting body for Health Information Management (HIM), Health Informatics (HI), and BioHealth Informatics programs, emphasizes a competency-based curriculum. Jobs in HI in the twenty-first century require a diverse set of skills, including systems analysis, data warehousing, and reporting, onboarding new clinical information systems, gaining insights from EHRs through analytics tools and methods, building and maintaining hierarchical and relational databases, writing Structured Query Language (SQL) to organize and retrieve information, and extracting and querying healthcare data with analytics software [20, 21].

Although HI is an interdisciplinary field that offers various paths to different careers and covers a wide range of topics, the specific skill sets required by employers vary due to the rapid pace of technological developments [22, 15, 18]. Moreover, the skills required of health informaticians differ considerably depending on the position [23], and health informatics students need to acquire skills and competencies that are relevant to their professional experience and future careers [24]. Several health informatics graduates are now acquiring skills training on the job rather than during their formal education, highlighting the need for new models of skills acquisition [25, 24, 26].

Despite the widely recognized potential benefits of utilizing EHRs in educational settings, their adoption is accompanied by various obstacles. This article explores the unforeseen challenges encountered and the lessons learned from implementing a popular Meaning Use-certified open-source EHR, OpenEMR, in a graduate Health Informatics (HI) program. In the following sections, we will discuss the methodology employed, the results obtained, and the implications of our findings for the future of EHR integration in health informatics education.

Methodology

We describe our case study methodology aimed to provide students with practical experience in using and customizing an EHR system, thereby enhancing their understanding of EHR functionalities, data structures, and interoperability. The curriculum was designed and implemented by faculty instructors, involving a collaborative process that included consultation with department heads. This study was conducted over two academic years, from 2022 to 2024, providing a comprehensive evaluation period for the OpenEMR implementation. The study involved over 350 graduate students enrolled in the HI program at Indiana University (IUI). The implementation of OpenEMR was carried out in three phases:

  1. Installation and Configuration: In this phase, the OpenEMR system was installed on a dedicated server, and the necessary configurations were made to ensure smooth operation. This included setting up user accounts, defining roles and permissions, and configuring the system to meet the specific requirements of the HI curriculum.

  2. Curriculum Integration: The second phase involved integrating OpenEMR into the existing HI curriculum. This was achieved by developing a series of hands-on exercises and projects that required students to interact with the EHR system. These exercises covered various aspects of EHR functionality, such as patient registration, clinical documentation, order entry, and billing. Students were also tasked with customizing the EHR system to meet specific requirements, such as creating custom templates and reports.

  3. Evaluation and Feedback: The final phase of the study involved evaluating the effectiveness of the OpenEMR implementation in terms of student learning outcomes and gathering feedback from students and faculty. This was accomplished through a combination of surveys, classroom and online task observations, and analysis of student performance on EHR-related assignments and projects.

Throughout the case study, qualitative and quantitative data were collected to assess the impact of the OpenEMR implementation on student learning and to identify any challenges or barriers encountered during the process. The data collected included student feedback, faculty observations, and academic performance related to EHR-based assignments and projects. Institutional Review Board (IRB) #22576 approval was obtained prior to collecting and analyzing student data, ensuring ethical compliance throughout the research process. This comprehensive approach to data collection allowed for a thorough evaluation of the OpenEMR implementation’s effectiveness in enhancing student learning outcomes and identifying areas for improvement in the curriculum.

Implementation Objectives

The insufficient hands-on experience with EHRs during medical education, or informatics training without seeing EHR internals, poses significant challenges for students transitioning to real-world practice. The shift from traditional paper records to electronic formats has unintentionally limited students’ access to patient records, resulting in a lack of essential skills required for residency and future medical practice. Similar efforts are ongoing in clinical training [27, 28, 11], but it is important to distinguish that our effort here is specific to informatics competencies in EHRs. Consequently, individuals often spend considerable time adapting to EHRs, contributing to varied and suboptimal practices, which may compromise healthcare quality and patient safety [29]. Various challenges, such as legal restrictions, logistical barriers, and disparities in EHR systems across institutions, even EHR accessibility [30], hinder students’ access [4].

Proficiency in EHRs integrated into medical curricula can effectively address these challenges and enhance students’ readiness for the intricacies of clinical practice. Therefore, our primary objectives in developing and utilizing an educational EHR within Health Informatics courses are as follows:

  1. Providing students with practical exposure to EHRs to improve technical proficiency, ensuring they can navigate and utilize EMR systems effectively [31].

  2. Cultivating a positive attitude towards EHRs, encouraging students to recognize the benefits, practical applications, and advantages of integrating electronic health records in healthcare settings [31].

  3. Facilitating behavioral changes by encouraging students to apply acquired knowledge and skills in real-world scenarios, leading to improved documentation practices and increased efficiency in healthcare workflows [31].

  4. Equipping students with the knowledge and skills needed to adapt to potential organizational changes related to the implementation and utilization of EHR systems [31].

  5. Emphasizing the importance of EHR training in contributing to patient safety, minimizing errors, and ultimately improving the overall patient health and well-being [31].

Results

Challenges Encountered

The implementation of OpenEMR web instances in various health informatics courses revealed several challenges that highlight the need for students to develop key competencies in this field:

  1. In the Clinical Decision Support System (CDSS) class, student modification of another student’s Clinical Decision Rules (CDR) disrupted the entire OpenEMR instance. This incident necessitated instance recreation and the recreation of new student accounts, highlighting the importance of students understanding the technical aspects and consequences of their actions within health informatics tools.

  2. During a Clinical Information Systems (CIS) class quiz, student data entry errors, such as entering excessively large numbers in the vitals form and inputting lengthy texts instead of numeric values in the CDR rules, caused complications in the OpenEMR instance and posed grading challenges for Teaching Assistants (TAs). These instances underscore the significance of input validation (See Figure 1) and the rationale behind fields and their purpose within the EHR.

  3. A mix-up occurred in the vitals form, where the units for height and weight were inadvertently switched. This challenge, arising from rule misconfigurations and instances where units were incorrectly assigned, underscores the need to commit to continuous learning in health informatics. Professionals in this domain must stay updated on the latest advancements and best practices to prevent and address such issues effectively, ensuring the accuracy and integrity of patient data.

  4. Initial implementations included both Clinician and Physician roles, but difficulties with the prescription-editing tool (See Figure 2) led to the decision to retain only the Physician role. This role adjustment highlights the need for a clearer understanding of roles and privileges in a role-based access control architecture of the EHR [32]. Emphasis on competencies in planning, executing, and evaluating health informatics projects would contribute to more efficient and error-resistant implementations.

  5. An excessive number of open tabs led to difficulties in managing and navigating the interface (See Figure 3), prompting a limit of three tabs to prevent confusion. This challenge emphasizes the importance of designing user-friendly interfaces and systems to enhance adoption and satisfaction among healthcare professionals.

  6. Minor issues arose during the implementation of OpenEMR, such as students encountering difficulties accessing the system due to VPN issues or forgetting their usernames and passwords. Consequently, TAs and professors received numerous emails seeking assistance. These issues, related to VPN connectivity, forgotten credentials, and other technical problems, increased the volume of support emails. This experience highlights the importance of effective communication skills for health informatics professionals, who must be adept at communicating with diverse stakeholders, including students, to address challenges and provide timely assistance.

  7. Previously, inputting vitals required navigating through the patient and encounter modules, which proved time-consuming. To address this inefficiency, we implemented an edit option for vitals directly in the patient dashboard, resulting in significant time savings. This enhancement demonstrates our commitment to improving efficiency and user experience, aligning with the competency of system optimization. By continually refining our processes and systems, we ensure that our healthcare workflows evolve to effectively meet changing needs, ultimately benefiting healthcare providers and patients alike.

Figure 1:

Figure 1:

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Vitals Form with Clear Instructions

Figure 2:

Figure 2:

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Edit Option for Prescriptions

Figure 3:

Figure 3:

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Excessive Number of Open Tabs

Insights and Adaptations

Integrating EHRs into undergraduate and graduate courses offers significant advantages, but ensuring a seamless learning experience requires continuous efforts to address user challenges. Our implementation journey has been characterized by a dedication to learning and adaptation, with the goal of meeting the specific needs of both students and instructors.

One notable challenge we faced was related to data entry errors. Students inputting excessively large numbers in vitals forms and using lengthy text instead of values in Clinical Decision Support System (CDSS) rules created difficulties in accessing vital information and grading by Teaching Assistants. To address this issue, we implemented backend modifications, such as introducing placeholder text (“enter a number”) in input boxes and restricting alphabetic characters for numerical fields (see Figure 4). Furthermore, for CDSS rules, measures were put in place to ensure that only valid values could be entered, thereby enhancing data integrity and facilitating efficient grading processes.

Figure 4:

Figure 4:

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CDR Reminder Intervals Form with Clear Instructions

Improving navigation and resolving technical issues were also crucial to enhancing the user experience. By limiting the number of open tabs, we helped students maintain focus, while pre-assignment tutoring sessions provided deeper insights into tasks and effective system navigation. The introduction of peer tutoring further strengthened the collaborative learning environment, fostering ongoing support and peer-to-peer learning.

We proactively addressed technical challenges, such as VPN issues and forgotten credentials, to enhance accessibility and minimize disruptions to the learning process. System inconsistencies, like a mix-up in the units for height and weight within the vitals form, were swiftly rectified through backend modifications, ensuring data accuracy and consistency. Our commitment to continuous improvement is exemplified by establishing a dedicated development environment. This separate web instance allows us to test new features and address potential issues before deployment, minimizing the risk of disruptions to the live learning environment. Regular backups and updates ensure that new instances are equipped with the latest patches, incorporating all previously addressed issues and enhancements.

Open communication and adaptation are fundamental to our approach. Assigning OpenEMR specialists to the Clinical Information Systems (CIS) class facilitated direct access for students to address their queries and concerns. By actively listening to feedback from students, administrators, and tutors, we continuously refine our methods and identify areas for improvement. Recognizing the diverse needs of different courses, we provide dedicated web instances for each class, tailoring the learning experience to align with specific course requirements. This customized approach ensures that students receive targeted instruction and practice using the EHR system in a manner directly relevant to their academic pursuits.

Although our initial implementation presented challenges, continuous adaptation and dedication to user experience have transformed it into a valuable and effective learning tool. The lessons learned throughout this process underscore the importance of ongoing user feedback, proactive problem-solving, and a commitment to ensuring a smooth and enriching learning experience for all stakeholders involved in the educational journey.

Discussion

Our experience integrating OpenEMR in Health Informatics courses aligns with prior research highlighting the importance of hands-on EHR training in healthcare education [4, 5, 11]. However, our findings also highlight unique challenges and insights that contribute to the growing body of knowledge in this field.

One of the most significant challenges we encountered revolved around maintaining data integrity, a concern previously identified in the literature [33]. Students unintentionally introduced errors through incorrect data entry, such as inputting excessively large values for vitals or lengthy text in clinical decision support rules. This issue underscores the need for robust data validation and user training, as emphasized by previous studies [34, 35]. Our experience highlights the importance of fostering not just theoretical knowledge but also practical proficiency, ensuring that students are well-equipped to handle real-world scenarios where precision and accuracy are paramount.

The user experience challenges we faced, such as managing an excessive number of open tabs and encountering technical glitches like forgotten passwords, are consistent with prior research emphasizing the importance of user-friendly interface design in healthcare information systems [36]. Our findings suggest that students can develop basic IT troubleshooting skills as they learn to navigate these challenges, a competency identified as crucial for health informatics professionals [37].

The issue of inadvertent modifications to clinical decision rules, which disrupted the entire system, is a novel finding that has not been extensively explored in previous studies. This underscores the potential consequences of a lack of understanding of the technical aspects of EHR systems. It highlights the need for students to develop a comprehensive understanding of system functionalities and the potential repercussions of their actions to ensure the safe and effective use of EHRs.

Despite these challenges, our experience aligns with prior research that emphasizes the value of hands-on EHR training in equipping students with a robust skillset [7, 8, 9, 10]. Students gained practical proficiency in navigating and utilizing the EHR system, addressed data entry mistakes, adapted to system changes, and maneuvered through the complexities of the software. These findings support the notion that practical experience with EHRs fosters problem-solving abilities, critical thinking, and effective communication skills [38, 39]. The unexpected challenges encountered during the implementation provided students with a more comprehensive and practical understanding of health informatics, highlighting the importance of continuous adaptation and problem-solving in the ever-evolving landscape of healthcare technology.

Future Directions

Building upon the lessons learned from our OpenEMR implementation and insights from extant literature, we propose several avenues for enhancing the educational EHR environment in future initiatives. A primary focus is the promotion of global collaboration through institutional partnerships. By facilitating knowledge exchange, sharing best practices, and incorporating diverse perspectives, we aim to enrich the learning experience and prepare students for the increasingly globalized nature of healthcare informatics.

The development of standardized curricula across various programs is another critical objective. While recognizing the potential challenges in achieving consensus, standardization could ensure comprehensive training and consistent acquisition of core competencies essential for future health informatics professionals [40]. However, careful consideration must be given to maintaining flexibility to address institution-specific needs and emerging trends in the field.

To further augment the educational EHR setting, we advocate for increased research opportunities aligned with the growing body of literature in this domain. Engaging students in research projects focused on EHR usability, data quality, and implementation challenges may contribute to advancing knowledge and fostering a culture of inquiry and innovation. Nevertheless, it is imperative to balance these research initiatives with the primary educational objectives and resource constraints.

Continuous assessment and improvement are fundamental to maintaining the relevance and effectiveness of the educational EHR environment. We propose establishing a systematic approach for regularly gathering and analyzing feedback from students, instructors, and industry partners. This feedback will inform ongoing enhancements to the OpenEMR system, ensuring its alignment with the evolving needs of the healthcare industry and technological advancements. However, it is crucial to acknowledge the potential limitations of such feedback mechanisms and supplement them with objective performance metrics and external evaluations.

Through these strategic directions, we aim to create a dynamic and responsive educational EHR environment that addresses current challenges and prepares students for the technology-driven healthcare landscape. Our commitment to fostering continuous innovation and collaboration with global partners reflects our dedication to advancing health informatics education. As we progress with these initiatives, we will continue to build upon existing research and contribute new insights to the growing body of knowledge in health informatics education. By disseminating our experiences, challenges, and successes, we hope to inform and inspire other institutions embarking on similar journeys, ultimately strengthening the global community of health informatics educators and professionals.

Conclusion

Integrating OpenEMR into our Health Informatics courses has provided valuable insights and learning experiences that extend beyond the initial objectives. This case study highlights the importance of hands-on EHR training in preparing students for the challenges and complexities of the healthcare industry. By encountering and addressing real-world issues such as data integrity, user experience, and system modifications, students developed crucial skills in problem-solving, critical thinking, and effective communication.

However, it is important to acknowledge the limitations of this implementation. The specific challenges encountered may not be universally applicable, and the solutions developed may require adaptation in different educational or healthcare contexts. Furthermore, the rapid evolution of healthcare technology necessitates ongoing reassessment and adaptation of the educational EHR environment.

Despite these challenges, the integration of OpenEMR has demonstrated significant potential in enhancing health informatics education. It has provided a platform for practical skills development and fostered a deeper understanding of the complexities inherent in healthcare information systems. The experience has also highlighted areas for improvement and future research, particularly in the realms of user interface design, data standardization, and interoperability.

In conclusion, integrating OpenEMR in our Health Informatics courses has been a transformative journey that has enriched student learning, highlighted the importance of practical skills development, and paved the way for future innovations in health informatics education. As we continue to navigate the challenges and opportunities presented by the ever-evolving healthcare landscape, our commitment to providing comprehensive, hands-on EHR training remains unwavering, ensuring that our students are well-prepared to become leaders and innovators in the field of health informatics.

Acknowledgements

We acknowledge the initiative of Dr. Robert Hoyt, who first inspired us to create an open-source distribution of an educational EHR based on OpenEMR in the LibreHealth community. We acknowledge the invaluable contributions of our teaching assistants, tech staff, and instructors supporting the deployment of the Educational EHR. Additionally, we extend our gratitude to all undergraduate and graduate students for their proactive feedback on the EHR, which has significantly contributed to making it more efficient. We acknowledge the support of the IUPUI STEM Education Innovation & Research Institute’s 2023 seed grant. Special thanks to our research assistants for their dedicated efforts: Swapnil Ramanna, Jahnavi Pinnamraju, Satya Sree Rallabandi, Vamshi Krishna Ayyam, Yuva Ranjith Kumar Edara, Thejomayi Malempati, Manya Pilli, Megha M Moncy, Sahaja Ratna, Manasi Somasundaram, Madhuri Kokkalakonda.

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