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    ROCC Member Spotlight: Jeffrey A. Gold, M.D.

    Dr. Jeffrey A. Gold is one of the recipients of the 2013 AAMC/Donaghue Foundation grant Advancing Effectiveness Research and Implementation Science in Our Own Backyards. He is a Professor of Medicine in the Division of Pulmonary Critical Care, and the Department of Medical Informatics and Clinical Epidemiology at Oregon Health and Sciences University (OHSU). He currently serves as the Director of Simulation Services at OHSU, as well as the Program Director for the Pulmonary Critical Care and Critical Care Fellowships. In this role, Dr. Gold integrates electronic health record (EHR) usability, simulation, and medical education across the OHSU HealthCare enterprise. Download Dr. Gold’s ROCC Star profile.

    Briefly describe how your project has utilized simulation exercises as a means to create an environment where learners’ use of electronic health records and communication skills can be captured.

    The biggest innovation was being able to create an exact replica of our hospital’s Electronic Health Record (EHR) and populate it with cases specifically designed to test the user’s ability to extract information and subsequently communicate it. Our simulation instance of the EHR is a virtual “clone” of the actual hospital system containing everyone’s unique customizations including screen layouts and order sets. Further, the cases are able to be temporally shifted forward to the day of testing allowing for real time use of the system. Finally, the EHR is deployed on specially designed mobile computers which contain sophisticated eye and screen tracking software to identify patterns in EHR use associated with optimal data retrieval and communication.
    Once created, we have been able to place our simulated EHR at the center of a simulated instance of Interprofessional ICU rounds. For each simulation, individual team members, Physicians, Nurses and Pharmacists are assessed on their ability to recognize and communicate critical patient safety issues built into the simulated medical record.

    Describe both the level and importance of collaboration between research, education, and the health system in moving this project forward.

    Without collaboration between these 3 areas of our medical center, none of this project would be feasible. The health system controls the EHR and specifically the training instance of the EHR upon which our simulation version is created.  Without their buy-in from the beginning of our work, including staff to help in the creation of training of our cases, none of this would have been possible.

    In terms of education, the main subjects in this study are residents (on the physician side). Without the acceptance and encouragement from our GME leadership to allow participation, again the study would never have begun. Further, as we have been able to establish the value of our simulation instance of the EHR, we have been able to partner with the SOM to integrate this throughout our new Medical School Curriculum.  In doing so, they have provided additional resources to help support personnel used to create and maintain the simulation versions of the EHR.

    Research is the third arm. Unfortunately, it is still difficult to garner resources to conduct this type of research, especially in terms of personnel support. Without financial support from both the Donaghue Foundation and AHRQ, again, this project would not have been feasible.

    Since the beginning of your project, how has your work encouraged the development of new research questions and/or acquisition of new sources of funding?

    The biggest thing is by creating a high fidelity rounding simulation we have been able to create the infrastructure to objectively assess the effectiveness all aspects of data communication during rounds, and create a test-bed to fundamentally redesign the rounding process to best leverage the power of the EHR.  As a result, we have been able to obtain subsequent RO1 funding conduct this additional research.

    Please share any preliminary findings from your research.

    First, we were able to demonstrate that physicians, nurses, and pharmacists have distinctly different patterns of EHR use when independently reviewing the medical record. These different patterns of EHR use led to distinctly different patterns in data gathering and specifically different patterns in recognition of patient safety issues built into the simulated cases. Of greater interest is that there was little overlap between the 3 professional groups suggesting that the safety net of IP rounds may have significant holes leading to a traditional “Swiss cheese model” of information gathering. We have now been able to confirm this in a full ICU rounding simulation where only 2/11 teams have been able to place the correct diagnosis in their differential. More importantly, this simulation has identified an additional set of errors of commission resulting from either missed or inappropriate orders placed into the EHR during the simulation.

    How can other institutions develop a similar infrastructure?

    The big thing is to understand who operates and controls your EHR and EHR training environments.  Sometimes this resides within Information Technology Group (ITG), in other instances through health care operations.  Often it is a hybrid where ITG will maintain the servers while healthcare operations populates and manages the training environments in order to facilitate on-boarding on new personnel.