Abstract
A group of informatics experts in simulation, biomedical informatics, patient safety, medical education, and human factors gathered at Corbett, Oregon on April 30 and May 1, 2015. Their objective: to create a consensus statement on best practices for the use of electronic health record (EHR) simulations in education and training, to improve patient safety, and to outline a strategy for future EHR simulation work. A qualitative approach was utilized to analyze data from the conference and generate recommendations in five major categories: (1) Safety, (2) Education and Training, (3) People and Organizations, (4) Usability and Design, and (5) Sociotechnical Aspects.
Introduction
EHR adoption has increased dramatically in the last decade, primarily as a consequence of the Health Information Technology for Clinical and Economic Health (HITECH) Act of 20091. The widespread implementation of EHRs has resulted in both benefits and unintended consequences, with the latter linked to the potential of causing significant adverse outcomes and patient harm, in part due to poor implementation strategies and EHR customization as well as lack of user training2.
There has been a growing realization that improving EHR use may reduce some of these issues, and EHR development, implementation and training have been identified as key areas of research to improve healthcare quality and safety3. With this aim in mind, simulation activities, particularly high-fidelity, EHR-specific simulation training, afford an attractive potential solution that directly addresses some of these issues due to the fact that they can create realistic, reproducible environments without any chance of patient risk4.
In contrast to a majority of simulation-centric research activities in which the EHR was a tool used by participants as they completed the activity, our prior research has utilized the EHR as the focus of the simulation5, 6, 7. We have also developed a model for collaborative intelligent case and simulation design to facilitate EHR training8, 9. Having worked on an EHR safety simulation project funded by AHRQ for almost three years, our research team was about to embark on a second project, and the timing was right to gain input from experts regarding the way forward. In order to achieve this, a conference was organized.
Methods
A. Goals of the Conference
The main goals of the conference were to 1) develop a consensus statement on best practices for the use of EHR simulation in education and training, as well as utilizing the EHR to improve patient safety, and 2) outline a strategy for future EHR safety simulation work. The objective was to develop a consensus statement utilizing the input of expert representatives who would bring multiple perspectives to bear, thus providing guidance for practice in the specific area of EHR simulation10.
A team of Oregon Health & Science University (OHSU) investigators organized the conference, played a supporting role during the two days when events were ongoing, and subsequently analyzed the data. An experienced facilitator (JA) managed the large group discussions. Small group discussions were led by a volunteer expert (VM, JG, JA) with a research team member assisting.
The agenda was developed so that an international group of experts in simulation, informatics, patient safety, medical education, and human factors (representing each of the five perspectives we hoped to capture) could first assess the state of the art in EHR safety simulation and then recommend a path forward. After reviewing what the
OHSU team had learned during the three years of their research project, the group discussed each of the specific thematic questions detailed in the “Conference Activities” section below from multiple perspectives. Discussions occurred in both large as well as small group formats, and conclusions were reached.
B. Pre-Conference Activities: Planning
Six months prior to the conference, potential participants were identified through literature searches, citation analysis, and by the purposive identification of known experts in the field. Categories of representatives included experts in simulation, critical care clinicians, experts in EHR safety, EHR usability experts and representatives of EHR vendors (see Appendix for a list of participants and their affiliations). Geographic and gender diversity was desired as well as representation from different healthcare systems (university-based healthcare systems, community medical centers, and federal institutions) as well as different EHR types (commercial and home-grown clinical information systems). Many of these attendees were able to represent more than one of the stakeholder groups involved in either EHR usability, ICU management, or simulation.
Participants were provided a number of papers, as well as a copy of the grant used to support the conference, as background material so that a certain level of shared knowledge could be assumed. The plan was to maximize onsite time to enable the sharing of expertise and experiences, generate narratives, and develop consensus statements. Attendees were asked to come prepared to discuss the role simulation could play in understanding and optimizing EHR use and design. In addition, participants were asked to provide insight for future directions and research questions to better develop the role for simulation in clinical informatics.
C. Conference Activities: Discussion
After an initial orientation, participants were tasked with answering the question “what have we learned about simulation for improving EHR safety?” Subsequent to an initial large group discussion on findings and the state of the art, participants broke into three groups, each of which addressed the question “how can we best use simulation to improve EHR safety?” Each group subsequently reported back to the large group.
Next, the group engaged in a large group discussion centered around the theme “what is the role of the EHR in collaborative rounding?”, followed by small group discussions to answer the question “how can we best use the EHR for communicative activities (rounding, signoffs, consultations)?’ After reporting out to the large group, we held an informal evening reception to expound on the most provocative topics of the day.
The second day began with a large group brainstorming session designed to answer the question “how can we ensure scalability of EHR simulation beyond the ICU to multiple locations and for multiple disciplines?” We ended with a prioritization exercise to identify the most important strategies for moving forward.
D. Post-Conference Activities: Analysis
The research team debriefed at the end of each day of the conference and in the days immediately afterwards. As the qualitative analysis progressed, the team met several times in the months after the conference to discuss insights and construct a consensus of expert considerations.
A total of 1,738 minutes of audio were recorded and transcribed into 25 individual transcripts. Five hundred and sixty-two pages of transcripts were qualitatively analyzed utilizing computer assisted qualitative data analysis software (NVivo, QSR International, Melbourne, Australia). Statements were coded by topic and cluster analysis diagrams employing Jaccard’s coefficient similarity metric were generated to ensure consistent coding between members of the research team. Utilizing a grounded theory approach, the research team identified five major themes: (1) Safety, (2) Education and Training, (3) People and Organizations, (4) Usability and Design, and (5) Sociotechnical Aspects.
Results
Theme: Safety
The expert group addressed issues surrounding EHR safety and the lack of effective tools to address this. One prevailing sentiment was that errors were ubiquitous and universal.
“EHR patient safety technology-based errors, they’re pretty much the same kind of errors around the world.”
It was felt the generation and perception of errors had changed substantially since the advent of the EHR, and that simulation was a prime tool to address safety issues. There is also a paucity of strong epidemiologic data on EHR errors and the true frequency of those reported; the dependence of incident reports probably vastly underestimates the frequency and nature of the spectrum of EHR use errors.
Additionally, significant silos exist within hospital systems between personnel undertaking safety, quality and informatics projects. Simulation can serve as a means to help identify errors in EHR system design and use. Specifically, including informatics expertise in EHR simulation activities could potentially help to identify and correct safety issues, especially those related to errors generated from the use of copy-and-paste techniques, voice recognition, and team-based workflows.
Vendors could also utilize EHR simulations to deliver products that enhance patient safety. Participants felt that the development of specific EHR safety-related standards might provide significant impetus for vendors to incorporate more safety-specific features within their products.
“Vendors want standards because somebody else sets them. It doesn’t favor one vendor over another, and the nice thing is, they don’t have to be responsible for it.”
Experts also emphasized the need to look at more than just the design of the EHR and data structure when identifying potential hazards to patient safety. How the EHR is used and by whom are also critical factors.
“…if you’re talking about HIT safety, you can’t approach this as a technical problem alone.”
Theme: Education and Training
The conference emphasized the need to utilize simulation for the purposes of research and education. As the healthcare industry has embraced widespread EHR use, training requirements have shifted away from current models of point-and-click usage to the need for scenario and case-based instruction.
It was also felt that the EHR should be used in simulations in a way that replicates real-world clinical scenarios, with attention to reproducing both realistic workflows as well as the ability to replicate the cognitive complexity of clinical decision-making.
“If the EHR is a tool to help delivery of care, you need to be able to practice using that tool with the functionality you expect it to be used within the real clinical setting. And unless you practice using it that way, you’re never going to know.”
Experts discussed ways to effectively use simulation to improve EHR design as well as optimize the use of the EHR in actual practice. They also discussed utilizing simulation to better train different types of clinicians. This resulted in an examination of the EHR functionality needed to achieve learning objectives.
“There’s a whole series of. strategies how to integrate the EHR into simulations depending on the learning objective. That’s training that I think the vendors could be able to supply to their trainers as well that’s not even part of the normal training.”
It was felt that simulation-centric EHR training could be used to identify weaknesses of the system and in user practices, to train for common or rare events, and for formative or summative assessment. Simulations could be used to foster lifelong learning, both in individual and team environments.
“The purpose of simulation is to train people to work together with technology in an environment.”
The expert group also appreciated the need to conduct simulations in an interprofessional environment, utilizing levels of complexity that would replicate team-based healthcare delivery, medical student and resident training, and also assist in training other members of the clinical team such as medical assistants, scribes, pharmacists, and nurses.
“…you can’t really separate the technology from the environment in which you’re training and you can’t separate the interprofessional team-based education from the technology use.”
The group placed emphasis on the post-simulation debriefing process, and on developing incentives for participation in simulation-based training such as continuing medical education (CME) credits.
It was also felt essential that simulation activities involve clinicians from environments that do not possess the ability to conduct simulations. This could be achieved by using a central simulation center that would act as a resource for multiple organizations and clinicians.
Theme: People and Organizations
Participants noted that the current EHR design paradigm still does not match the reality of how EHRs are used by healthcare professionals. Care is delivered by interdisciplinary and interprofessional teams of clinicians; however, EHRs are still designed with the individual user in mind.
“The EHR is designed for a single person when really it should be designed for the team.”
In addition, healthcare professionals serving in different roles use the EHR differently, and often visualize data on EHR screens that display information featuring distinctly different designs.
“…it’s important that simulations can really show how important these different views are, how important the trade-offs between safety and efficiency are.”
While the EHR might be useful in team-based clinical care, its limitations also need to be recognized by end users as well as information system designers.
“The EHR can be a part of the team, but we need to realize what it can and what it cannot also do.”
The experts felt that the EHR might play a crucial role in inculcating a culture of systems-based practice.
“…[the EHR] teaches each member of the team how to interact with each other member of the team and how they can work together to better accomplish the goals than they would individually.”
Theme: Usability and Design
EHR system usability and interface design were regarded as key factors in facilitating EHR education and training, and were also seen as crucial elements in ensuring patient safety.
Several factors that have been well described in the literature, such as cognitive overload and user distraction, continue to be a source of EHR-related errors, which suggests that despite attempts to improve EHR interface design and usability, EHR features may still contribute to errors. There is a delicate balance between features which add value and those that distract from completing necessary tasks.
“I will argue that we still have tons of medication errors, even though we have all the alerts that come in the system.”
It was expressed that EHRs need to better support team-based communication and decision-making, and facilitate group decision-making during group rounding.
“…there are a set of tasks that the team assembles to do. And the first tasks have been done by the computer, then you wouldn’t need that team to be there. So it’s all the things that they’re doing that they must converse about that are independent of whatever the computer does. It may be the computer gets smarter and their job gets smaller, but the question is how do you support whatever happens in there.”
While EHR safety features such as alerts are intended to facilitate collaborative clinical care, they can sometimes impede team-based work.
“If an alert comes up and you’re trying to do something, an alert comes up and then I got to deal with that, it stops the conversation.”
Experts grappled with how the user interface should be optimally designed to support education, training, and safety, while still affording for variability in individual users’ performance. One source of inconsistency which may negatively impact patient care is the process of entering data into the EHR. The reliability of data stored within the EHR is affected by the disconnect between the perception of the real-time nature of EHR data and the reality of EHR data entry, which is often delayed due to fragmented clinical workflows. Furthermore, the differences in how each provider uses the data also factors into the overall usability of the system. Incorporating an EHR design model that would account for variability in user tendencies (such as differences in information-finding behavior) could also be a useful EHR feature.
“… each different type of provider uses the data differently, they go to different areas, they look for different things, so we need to build the EHRs so it actually works with whatever the workflow design.”
Participants expressed dissatisfaction over the incongruence between the vendors’ values that guide EHR design (“they’re designing it for efficiency”) and the users’ values that govern EHR usage (“for safety”).
There was extensive discussion about the potential role of simulation in helping guide EHR design to enhance usability. Participants described the potential for developing and deploying a common, standard, simulated patient record that could be EHR-agnostic and contribute to training in different clinical and technological environments.
One major area of unrealized potential for the EHR that was discussed was its role in facilitating handoffs. It was felt that EHR interfaces could be better designed to facilitate provider handoffs that occur not only in person but also remotely (via phone). Clinical decision support tools could be developed to help prioritize the data to convey urgency or clinical severity.
“If we had a decision support tool that helped us synthesize the information better, that’s fantastic. That really helps. If we had a decision support tool that then prioritized it [data]… then all of a sudden you’d have an automatically generated handoff, prioritized handoff note, that actually made sense because it used the same rules to generate itself as the decision process…”
A particular EHR feature that could be helpful to facilitate group communication would be to enable collective situational awareness by sharing EHR screens. This could help others understand what information a user is drawing from to make a decision or to ask a question.
“If you got to design the EHR, it’s got to be designed in the understanding it’s part of a team environment and the person operating the keyboard may not be the person who is actually making the decisions and they might not even be seeing the right screen.”
Theme: Sociotechnical Aspects
The expert group felt that the use of EHR simulations in health care was best described within the context of a sociotechnical framework as an interaction among technology, organizations, and individuals. EHR technology is facilitating changes in how clinicians work, and changes in clinician training and work patterns are in turn changing how the EHR is used. We examined this in four contexts: interdisciplinary rounding in an inpatient setting, handoffs, working with a consultant, and providing team-based care in an outpatient setting.
As a consequence of the ubiquitous use of the EHR, the roles of team members have changed while engaging in interdisciplinary rounds.
“. once upon a time the role of the resident was to gather the data, and the attending to provide expert knowledge… Now the resident goes to the EHR where the data is already gathered, and they are doing more of a curation role… The attending’s role is becoming first of all a verification role… Is the right data being gathered and then are they applying it correctly.”
Our experts believed simulation can help develop workflows and processes that balance this shift in clinician roles. The interaction among people in a zero-risk simulation environment can potentially help build interpersonal relationships and assist in the development of trust among clinical care team members. It can also foster systems thinking that allow individuals to better interact with other members of the team and work together to better accomplish group goals.
“…Simulation offers the opportunity I think not only to break down the traditional barriers that exist for data but the traditional barriers that exist for roles.”
There is also a potential for simulation to assist in improving EHR design to better support rounding processes. EHRs have fundamentally changed the way clinicians interact with information. Simulation may help examine this paradigm shift and allow researchers to test new ways that data can be represented to clinicians. Simulation may also help clinicians discover hitherto unidentified errors, and improve safety by preventing patient harm. This requires the acquisition of appropriate tools, both technological as well as cognitive, to facilitate the process.
“This model of simulation training can be extended to a more ideal EHR design with the understanding it is part of a team environment…”
Participants also felt a need to use simulation to test and improve EHRs as part of the collaborative process, especially with respect to consultations, the nature and scope of which have also changed as a consequence of widespread EHR use.
“You don’t physically send your patient. You just simply send a message saying ‘Dr. X, I've got this patient I'm concerned about, could you take a look at their chart and give me a recommendation.’ … is it actually a very exhaustive process for the specialist to actually identify their role”
The experts also highlighted new trends that are developing in the use of the EHR to support team-based primary care.
“[In primary care] we don’t round on the patients of the day, we round on 5,000 patients all week. We use population health and reporting tools, but the same paradigm of communication is needed. We need to identify the gaps in care, we need to do something about it, and we need to let the person who is going to carry it out and the patient know about it. So that whole communication tools is needed in different views.”
Interprofessional simulation allows team-based activities to be evaluated, thus promoting improvements at both the individual as well as the group level. It was noted that the EHR was a tool that merely supported clinical workflows and processes, as opposed to defining the activities themselves.
“… decision-making is one team process or function…EHR doesn’t support rounds, it supports the processes and functions…”
Discussion
EHRs were primarily developed to improve workflow efficiency and capture billing in an optimal fashion, and while the explosive increase in EHR implementation has seen unprecedented growth in EHR use within the clinical environment for clinical decision-making, this phenomenon has not been accompanied by an equivalent growth in ensuring patient safety.
“.the vendors are not designing their systems for safety. First, they’re designing them for efficiency and billing, also we’ve got to have a huge paradigm shift that they’re not interested in at all because the people that are buying their systems are chief financial officers, not doctors.”
Recommendation: Simulations should be used to design systems and protocols explicitly to improve usability and patient safety.
Participants clearly felt that EHR safety could be promoted by the use of simulations. Simulations are likely to have a significant salutary effect on team-based care, and utilizing the EHR within simulations in a manner that mirrors real-life clinical scenarios allows the reproduction and modeling of cognitive burden and uncertainty in a way that replicates real-life conditions. Simulations can also assist in optimizing EHR design and functionality; however this advanced use of simulation in health care will also require an equivalent paradigm shift in operational culture.
However EHRs do have the potential to significantly improve safety. In order to achieve this goal, participants felt that a cultural paradigm shift in EHR training was also required.
“So the EHR can facilitate a lot of these[safety-related] things through check-listed tools, but you have to have the appropriate culture change and training to go along with it, as well as a needs assessment, to make sure that you’re creating the right tool.”
Recommendation: Simulations should be central to clinician training and used to improve clinical team communication
Currently simulations are used to some extent in clinician training, but their role is marginal; a paradigm shift that brings simulation front and center in the process of clinician training is also warranted. The emphasis in this new model of training needs to be on the delivery of team-based care, with an equivalent stress on team-based, information-driven decision-making.
“…if you could change the paradigm of the simulation so that it is case-based instead of all of us… in a classroom setting. Just turn it around so that we are all part of a team and attacking the same problem, and that’s our [EHR] training.”
Recommendation: Simulations should be part of a sociotechnical solution involving a broad spectrum of stakeholders and organizations.
The effectiveness of the EHR within the context of communication was a theme that arose commonly during deliberations by the participants. Simulation offers the potential of improving communication processes through training and ideas for improved design, although the process will require the involvement of people with multiple skill sets.
“We need to break down these silos, and that includes involving people who understand the many factors, quality, and informatics. Most of the training activities focus on the EHR as a tool, but that doesn’t mean you still don’t need people who understand that tool and [the need to] get the information out.”
The interdisciplinary nature of the expert participants in the conference allowed them to examine potential solutions from an equally interdisciplinary perspective.
In order to achieve this goal, participants believed that it would be necessary to reach beyond the leaders of healthcare systems to engage diverse stakeholders including informaticians, quality improvement groups, EHR vendors, standards organizations, and payors.
“…we have multiple major stakeholders here within this group. We have industry, we have informaticians, we have clinical champions, quality, safety, and education leaders…What does each group need to bring to the table for each of these domains so that we make sure we keep it inclusive, so this doesn’t become just purely something in the value for the informatician or the hospital QI specialist or the hospital trainer?”
Recommendation: Simulations should be part of a comprehensive incentive program to promote patient safety.
How can we implement this new model of clinician training? The solution might perhaps require us to define a combination of incentives and penalties - incentives to achieve significant milestones in improving patient safety, and penalties when patient harm cannot be sufficiently eradicated.
“Incentives and penalties work together, you get the political will there, get the leadership to do it, and I think you can do it again and create a market. Vendors aren’t going to do this. If they are going to do it, it’s not because it’s the right thing. They are going to do it for an incentive.”
Of course, any incentive program to promote patient safety utilizing simulations would require the commitment of substantial resources, both to build the technical framework and infrastructure and to develop training and evaluation programs to engage end-users. Since lapses in patient safety are typically associated with costs, both with respect to the care subsequently delivered as well as the costs due to medicolegal repercussions, it might benefit both the risk management and medical malpractice community, as well as health insurance providers to bring resources to bear in order to facilitate the use of simulations to promote patient safety.
“So this…suggestion you made about the medical malpractice companies sponsoring this in some way sounds like the most reasonable approach, and maybe a coalition of vendors and the actual health insurance companies because they’re also going to benefit from fewer use of resources, and fewer costs…I just don’t see the EMR vendors doing this unless somebody’s going to step up and pay for it, you know, and I think that those two groups are going to benefit the most.”
Conclusion
The conference brought together authorities from different disciplines with extensive expertise in simulation, biomedical informatics, patient safety, medical education, and human factors. Their deliberations during the two day meeting were extensive and fruitful. Using a grounded theory approach, data analysis revealed five broad themes that could effectively be used to inform the deployment of simulations to improve clinical education, training, and patient safety.
The themes developed in this paper are intended to act as a framework to develop a comprehensive simulation plan, and assist in decision-making that will place simulation within an appropriate context, and assign a role for simulation-related activities within the infrastructure developed and utilized by organizations to educate and train clinicians and other EHR end-users.
More importantly, the themes also help to underscore the importance of using simulations in today’s clinical environment, where the old paradigm of how end users engage with the EHR is rapidly changing not only because of advances in technologies and alterations in clinical workflows, but also notably because of the inexorable advent of the data-driven age of healthcare delivery.
“… how we actually engage with the EHR is antiquated…simulations offer an opportunity to test new modalities of engagement with data…”
Acknowledgements
This work was supported by the Agency for Healthcare Research and Quality (AHRQ), grant 1R18HS021637-01. The authors also wish to acknowledge Knewton Sakata, MD for his role in organizing the conference.
Address for Correspondence
Vishnu Mohan, MD, MBI
Department of Medical Informatics and Clinical Epidemiology
Oregon Health & Science University
Mail Code: BICC
3181 S.W. Sam Jackson Park Rd.
Portland, OR 97239-3098
Appendix
Consensus conference participants, their current affiliations, and their roles: Elizabeth Borycki (University of Victoria, Victoria, BC, nurse, informatician, educator and international perspective), Enrico Coiera (Macquarie University, Sydney, NSW, informatician, educator, and international perspective), John Dulcey (Lansdale, PA, physician and clinical systems consultant), R. Scott Evans (University of Utah, Salt Lake City, UT, informatician and educator), Roy Gill (NextGen Healthcare, Horsham, PA, physician and vendor representative), Richard Holden (Indiana University, Indianapolis, IN, human factors engineer and psychologist), Andre Kushniruk (University of Victoria, Victoria, BC, Canada, informatician, educator, and international perspective), Michael Lieberman (Oregon Health & Science University, Portland, OR, physician and clinician leader), Vincent Liu (Kaiser Permanente Northern California Division of Research, Oakland, CA, physician and research leader), Dean Sittig (University of Texas, Houston, TX, informatician and educator), Adam Wright (Harvard Medical School, Cambridge, MA, informatician and educator), Brian Young (Legacy Health, Portland, OR, physician and clinician leader).
Research team members included: Joan Ash, Jeffrey Gold, Vishnu Mohan, Knewton Sakata, Dian Chase, Julie Doberne, Gretchen Scholl, Deborah Woodcock, Karess McGrath and Robert Pranaat.
Views expressed by participants are their own and not necessarily those of agencies or organizations with which they are affiliated.
References
- 1.Blumenthal D. Implementation of the federal health information technology initiative. N Engl J Med. 2011;365:2426–31. doi: 10.1056/NEJMsr1112158. [DOI] [PubMed] [Google Scholar]
- 2.Sittig DF, Ash JS, Zhang J, Osheroff JA, Shabot MM. Lessons from “Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system”. Pediatrics. 2006;118:797–801. doi: 10.1542/peds.2005-3132. [DOI] [PubMed] [Google Scholar]
- 3.Middleton B, Bloomrosen M, Dente MA, et al. Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA. J Am Med Inform Assoc. 2013;20:e2–8. doi: 10.1136/amiajnl-2012-001458. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Rosen KR. The history of medical simulation. J Crit Care. 2008;23:157–66. doi: 10.1016/j.jcrc.2007.12.004. [DOI] [PubMed] [Google Scholar]
- 5.Stephenson LS, Gorsuch A, Hersh WR, Mohan V, Gold JA. Participation in EHR based simulation improves recognition of patient safety issues. BMC Med Educ. 2014 Oct 21;14:224. doi: 10.1186/1472-6920-14-224. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.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(4):e002549. doi: 10.1136/bmjopen-2013-002549. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Gold JA, Tutsch AS, Gorsuch A, Mohan V. Integrating the Electronic Health Record into High-Fidelity, Interprofessional ICU Simulations-A Case Study. J Interprof Care. 2015 Nov;29(6):562–3. doi: 10.3109/13561820.2015.1063482. [DOI] [PubMed] [Google Scholar]
- 8.Mohan V, Gold JA. Collaborative Intelligent Case Design Model To Facilitate Simulated Testing of Clinical Cognitive Load; Workshop on Interactive Systems in Healthcare; 2014. [Google Scholar]
- 9.Mohan V, Scholl G, Gold JA. Intelligent Simulation Model To Facilitate EHR Training; Proceedings of the AMIA Annual Symposium; 2015. [PMC free article] [PubMed] [Google Scholar]
- 10.Ash JS, Stavri PZ, Kuperman GJ. A Consensus Statement on Considerations for a Successful CPOE Implementation. Journal of the American Medical Informatics Association: JAMIA. 2003;10(3):229–234. doi: 10.1197/jamia.M1204. [DOI] [PMC free article] [PubMed] [Google Scholar]