From Prototype to Production: Lessons Learned ...

From Prototype to Production: Lessons Learned from the Evolution of an EHR Educational Portal Elizabeth M. Borycki, RN, PhD1, Brian Armstrong, MSc (candidate)1 Andre W. Kushniruk, MSc, PhD1, 1 School of Health Information Science, University of Victoria, Victoria, British Columbia, Canada Abstract The use of electronic health records is rapidly increasing. However, the integration of this technology into the education of health professionals and health informaticians has largely remained to be explored. In this paper we describe an approach to providing remote access to electronic health records for use in health professional and health informatics education at the undergraduate and graduate levels. The University of Victoria EHR Educational Portal was designed by the authors to allow for remote Web-based access by students to a range of systems hosted on the portal. Architectural considerations and the evolution of the portal structure from prototype to production system are described. The paper also describes our initial applications of the approach in integrating EHRs into nursing, medical and health informatics educational programs. Introduction With the emergence and widespread adoption of electronic health records (EHRs) globally, there are increasing pressures for educational institutions to educate health professionals about EHRs. Yet, in countries such as Canada there are few opportunities for health professionals such as physicians, nurses, pharmacists, occupational therapists, social workers, physiotherapists, other allied health professionals, and health informaticians to learn about differing EHRs in the classroom or in clinical practice settings such as hospitals, clinics, physician offices and home care settings during their education. The purpose of this paper is to describe a methodology for developing and transitioning from a prototype EHR portal system, where differing EHR training systems are deployed, to a full production EHR training portal where health professional students can access differing EHRs as part of their discipline specific, health professional, educational programs. In this paper we provide an overview of a methodology for deploying an EHR portal that offers students opportunities to learn about and work with differing EHR’s including electronic medical records (EMRs), electronic patient records (EPRs) and personal health

records (PHRs) anytime and anyplace in a “safe” simulated virtual environment (i.e., where no real or live patient data is used). This allows health professional students to learn about EHRs and learn how to use differing EHRs with differing design metaphors in the classroom setting and prior to entering clinical practice. Use of EHRs in Health Professional Education According to recent reviews of the literature, the use of information technology in medical curricula and, the use of electronic health records in medical education has been limited [1,2]. Much of the published literature has focused upon evaluating physician use of conventional medical information online (e.g. journal articles and text books) and the development and description of medical informatics competencies. Very little research has been conducted examining how to best incorporate medical informatics competencies into medical school curriculums for the purpose of helping clinicians to acquire EHR related skills. A review of nurse educational research involving technology reveals similar findings [3]. Although some nursing programs have been able to successfully integrate EHRs into their nursing curriculum, few nursing programs have integrated multiple EHRs with differing design metaphors (using only one type of EHR) into their nursing curricula. This is different from the real-world practice experiences of physicians and nurses after graduation from their respective disciplinary programs. Physicians and nurses may use many differing EHRs (e.g. electronic medical records, electronic patient records) over the course of a typical day and over the course of a career. Physicians and nurses may also use many EHR vendor products over the course of their careers. For individuals who are studying health informatics, there are few opportunities to use, develop, test and evaluate differing EHRs over the course of their undergraduate and graduate education experiences [4]. These findings are also representative of the experiences of other allied health professionals (including occupational therapy, physiotherapy,

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pharmacy and respiratory therapy), who have few opportunities to use EHRs in the classroom setting prior to working in the real-world. Therefore, health professional students may not have the opportunity to learn about and develop an understanding of the: (1) theoretical underpinnings of the EHR, (2) the components of the EHR, (3) how the components of the EHR are integrated and work together to support continuity of care, (4) how the EHR functions and (5) the importance of the EHR as a tool that can support health professional decision making. The experiences of health professional students are unlike the experiences of engineering, computer science and business students in the academic setting. Students from the above mentioned disciplines have the opportunity to work with the electronic tools of their profession during their undergraduate and graduate education, before entering the workplace and having to work with real-world data - where the costs associated with making an error are increased. In summary, currently in North America there are limited opportunities for health professionals to use EHRs in the academic setting in their undergraduate and graduate educational programs. Along these lines, there is a need to incorporate many differing EHRs or mulitple EPRs, EMRs and PHRs and their components into health professional educational programs. Biomedical and Health Informatician Shortages: Implications for EHR Education in Academic Settings There may be a number of reasons for their being a lack of EHR integration into health professional undergraduate and graduate educational programs. One of the most significant of these reasons is the shortage of health informaticians in North America. The American Medical Informatics Association in 2005 (AMIA) estimated there was a need for 10,000 health and biomedical informaticians by the year 2010 [5]. These estimates have risen significantly with the introduction of the U.S. federal government’s economic stimulus package which plans for all hospitals and physician offices to have electronic records. The U.S. government has estimated that an additional 212,000 health informatics positions would be created if there was a significant move to electronic records by physician offices and other health care organizations as a part of the stimulus package [6]. In Canada the situation is much the same. Roach and Covvey estimate that there are currently 10,000 individuals who are working in health information systems roles in

Canada [7]. According to these researchers there is a need for up to 10,000 more health informatics professionals to address Canada’s current health informatics needs. The significant shortage of biomedical and health informatics professionals has had an effect upon the ability of health professional educational programs to incorporate EHRs into health professional curricula. As many health informaticians move to industry positions shortly after graduation there are few available professionals to implement and maintain such systems in the educational setting as the demand for workers in industrial settings is significant and the competition for such skilled workers is intense. At present, as outlined earlier in this section, industry demands for qualified professionals are exceptionally high as many health care organizations are not only operating and updating existing EHRs but they are also implementing new EHR components. Development of the University of Victoria EHR Educational Portal In order for EHRs to be implemented in all health professional educational programs across North America there would be a need for a significant number of health informaticians. In order to address the growing need for health professional training involving EHRs in the academic setting while at the same time recognizing there are few human resources to implement such systems, the authors have developed an innovative method for delivering EHRs to health professional students across wide geographic distances in North America. The University of Victoria (UVic) EHR Educational Portal provides access to differing EHRs, requires few human resources to provide the service and provides remote EHR access over wide geographic distances [3]. The portal has been designed to allow students (both health professional and health informatics students) to have remote Web-based access to a range of EHRs. The portal allows students to explore differing types of EHRs (using dummy patient data) and the systems on the portal can also be formally integrated into the training of medical, nursing and health professional student curricula. To date, the UVic EHR portal has provided health professionals of varying disciplinary backgrounds (i.e. medicine, nursing, health informatics) with access to differing types of electronic records with divergent design metaphors (i.e. Medsphere’s


pre-prototyping stage of the portal through to the production and expansion stages.

Figure 1. The UVic EHR Educational Portal desktop showing the Medsphere’s OpenVistA System as accessed by a student remotely.

OpenVistA CIS, DigitalAnthrologix®, OpenMRS). The portal has supported up to 150 students accessing an EHR at one time with as many as three geographically distant sites accessing a patient case on the EHR at one time over the WWW. Figure 1 shows a screen from the portal where a student has accessed Medsphere’s OpenVistA system through the UVic EHR Portal (in Figure 1, a range of other remotely accessible EHRs are shown on the Portal’s desktop to the left of the Vista screen). In the next section of this paper we will discuss the evolution of the portal and its use for incorporating the EHR into both health professional and health informatics education. Evolution of the Architectural Model The evolution of the architectural model we have developed for deploying EHRs over the WWW has been influenced by the need to provide many different types of students with access to a variety of EHRs over large geographical distances at low cost with low human resource requirements. In Figure 2 the stages (from development to production and expansion) of the evolution of the UVic EHR Educational Portal are displayed. A time period of nearly two years of growth is shown which depicts planning and design/re-design processes with accompanying implementation/re-implementation milestones. Prototyping Stages In the next section of the paper we will discuss our approach to prototype development from the early

Early Pre-prototyping Approximately, two years ago a planning meeting was held to plan out the UVic EHR Educational Portal. During the planning meeting the Portal framework was developed, discussed, and a suggested structure was proposed for the portal. During this time a Pre-Prototype system was built using Microsoft Windows Server 2003 with Terminal Services installed. Within this pre-prototype environment an electronic medical record (EMR) application was installed. The EMR application was reconfigured/recompiled so that many students could access the system at the same time. This approach also allowed for the server to be tested as a standalone system [8]. This preliminary environment was set up and tested. It was known early on that this was a preliminary environment and that it would require reconfiguration so that the server framework would allow for more users to connect and access the EMR software, and to allow for more representative systems to be installed and accessed. Prototyping As the EMR application could be recompiled by the original developers to connect to a database server (Microsoft SQL Server 2005) rather than a local database (Microsoft Access 2003), its software code was modified effectively making it a client-server application. As shown in Figure 2, the application required at minimum two servers to enable this to occur, one for the application (Terminal server) and one for the database (Database server). Production Stage During the Prototyping Stage the current server technology infrastructure was defined, purchased, and set up – and is now defined as the Production Stage. The need to expand beyond the limitations of two servers, and to provide a scalable solution to allow for hundreds of users and multiple curricula to be hosted informed architecture development. The portal architecture had to be flexible and agile in order to meet current and future academic needs as they arose. The implementation of virtualization based upon the Microsoft Windows Server 2008 Hyper-V hypervisor solution [8] ensured that the goal of hosting multiple EHRs independent of hosting OS (Windows, Linux) was technically and realistically feasible. In the Production Stage a larger installed base of applications was defined, which


Figure 2. Evolution of Architectural Framework.

expanded the pool of virtual machines hosting these EHRs. The existing Prototype (Terminal and Database) servers were redesigned and created as virtual machines, and several other terminal servers were created and deployed which leveraged the virtualized server model to allow for hundreds of users to access the Terminal servers simultaneously. This ability to expand to multiple Windows and Linux server-based EHR solutions has given students and educators access to electronic health records in the educational setting and led to the development of a realistic, scalable solution that would meet the challenges and needs of the educational setting. Expansion Stage The future growth of the server architecture will provide for: (1) research and collaboration with other University educational programs, (2) research involving healthcare information technologies, (3) research in deploying new care pathways and clinical decision support systems, and (4) research aimed at clinician involvement in the planning, design, development, and procurement of healthcare

information technologies and solutions. The technology currently in place provides for scaling from the current 28 virtual machines to 56-128 virtual machines (depending on configuration), and will meet the needs of the University of Victoria’s School of Health Information Science, nursing programs, medical schools, and beyond. To date the total investment in hardware has been in the range of $60,000.

Experiences to Date and Lessons Learned One of the first applications of the UVic EHR Educational Portal involved a trial run where 150 nursing students were given login access to the portal in a course on Nursing Trends. The students were asked to access the portal from home and explore the OpenVistA CIS system (by accessing dummy patient data available through the portal). In doing so the students were asked to consider what they felt the impact of such systems would be on nursing practice and were asked to explore a range of system features


on their own. One week later all the students met in a classroom setting to discuss their experience with using an EHR via the portal. Students left the experience with a new understanding of EHRs and we are currently exploring the integration of the EHR into several other nursing classes, including integration into a new joint nursing and health informatics program being developed at the University of Victoria. During this trial, the architecture was able to support simultaneous remote access by the students to the EHR hosted on the portal. In other trials we have integrated use of EHRs available on the portal more tightly into educational curricula. For example, in integrating the portal into medical education, we have experimented with requiring 4th year medical students to access patient cases (discussed during problem based learning sessions) through the portal (rather than reviewing such case information on paper). In doing this, we have focused on educating students about the main features of EHR systems [3]. Initial qualitative evaluation of this experience (involving interviews see [3]) indicated students found the interaction with EHRs useful and a number of students indicated they would have liked to have had such exposure to EHRs right from the beginning of their medical studies. Finally, in a range of trials we have incorporated use of the portal into the education of health informatics students at the University of Victoria. This has involved students accessing systems available on the portal to gain experience with a variety of different types of systems. This has also involved student work in conducting usability analyses of hosted systems and this is currently being expanded for use in a course on healthcare information system analysis and design (where students will access open source systems and gain experience in both customizing the code of such systems and remote hosting of EHRs). In all of the above mentioned trials of the Portal architecture we have found that the approach taken was practical, has allowed for remote access by over 100 simultaneous users and has been scalable and customizable for use in a range of educational projects. From a technical perspective, the move towards an approach involving virtual machines was critical to allowing for continual expansion of the capabilities of the architecture to meet growing and changing educational requirements.

education. The approach has evolved over the past two years from a prototype to a fully operational production system. Current work is underway in “stress testing” the system architecture (using simulations of large numbers of simultaneous users) as well as conducting longitudinal evaluation of the impact of educational EHR exposure on subsequent professional practice. The experiences and results to date indicate that the approach is a promising way of providing a large number of health and health informatics students with access to EHR, in an economical and scalable way (rather than requiring large numbers of health professionals to set up individual systems at many individual training sites). We expect to continue and expand our collaborations involving use of the Portal internationally.

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8. Conclusion The UVic EHR Educational Portal was designed to allow for access to EHRs remotely for integration into health professional and health informatics

References Otto A, Kushniruk A. Incorporation of medical information technology as core components of undergraduate medical education – Time for change! Stud Health Technol and Inform. 2009; 143: 62-67. McGowan JJ, Passiment M, Hoffman HM. Educating medical students as competent users of health information technologies: The MSOP Data. Stud Health Technol Inform. 2007; 129:1414-1418. Borycki, E.M., Kushniruk, A.W., Joe, R., Armstrong, B., Otto, T., Ho, K., Silverman, H., Moreau, J., Frisch, N. The University of Victoria Interdisciplinary Electronic Health Record Educational Portal. Stud Health Techol and Inform. 2009; 143: 49-54. Lyman JA, Cohn W, Knaus W, Einbinder JS. Introducing an academic data warehouse into the undergraduate medical curriculum. Proc AMIA Symp. 2002; 474-478. AMIA, 10,000 trained by 2010. 2005; http://www.amia.org/10X10 Goldman D. Obama’s big idea: Digital health records; http://money.cnn.com/2009/01/12/technology/sti mulus_health_care/index.htm Roach R., Covvey D. Co-operative experience in health informatics. COACH meeting, Toronto, Nov. 2008. Armstrong, B., Kushniruk, A., Joe, R., Borycki, E. Technical and architectural issues in deploying electronic health records (EHRs) over the WWW. Stud Health Techol and Inform. 2009;143:193-8.
