Electronic Health Records in Pharmacy Skills-based Curricula

Use of EHRs in Pharmacy Education

There is significant variation in how schools and colleges of pharmacy are integrating academic EHRs into their curricula, as well as what skills are taught and assessed using EHRs. VanLangen and colleagues surveyed all accredited US pharmacy schools in 2017 and found that 37 of 59 responding schools were using EHRs in the didactic curriculum. Roughly half of respondents stated this use occurred in patient care laboratory courses, with collection and documentation of patient information being the most common activities performed and assessed. Approximately one third of schools had students use EHRs for medication order entry/verification, medication reconciliation, and errors and omissions activities.⁷ The uses described by VanLangen are supported by several studies describing EHRs in skills-based curricula (Table 1).^8-12 On an international level, recent survey findings from the International Pharmaceutical Federation (FIP) Digital Health in Pharmacy Education Report found that 53% of responding academic institutions from around the world were covering EHRs in some form within the curriculum and 25% of respondents were interested in incorporating EHR education into their curriculum. The survey provided limited information about the methods or depth of coverage.¹

There is a paucity of literature discussing trends with regards to educational EHR adoption, as well as guidance on what skills are essential. The studies referenced in Table 1 used different EHRs, activities, and assessments. This variation makes it difficult to define best practices for EHR use in curricula, as well as to determine what EHR skills most pharmacy graduates possess. Academic EHRs have been adopted in many pharmacy programs, but the method and scope of incorporation is unclear. Evaluating published literature to determine best practices for incorporation of EHR skills into curricula is limited by the lack of consensus on which EHR skills and objectives should be evaluated. Consensus on the core EHR skills and competencies students should possess is needed. There are many areas across the pharmacy curricula in which the EHR can be incorporated. Courses focusing on skills development (eg, “skills labs”) and the Pharmacists Patient Care Process (PPCP) are ideal settings for the EHR to be used for education and assessment of students’ abilities given how closely they relate to practice, and will be the focus in this article. Faculty teaching these courses are key to leading establishment of a consensus on this topic.

Incorporation of Electronic Health Records Use Into Educational Standards

The Accreditation Council for Pharmacy Education (ACPE) Standards 2016 mentions the importance of student competence in using health care technology, contemporary skill development, and utilization of current educational technology.¹³ Appendix 1 of the ACPE standards refers to use of EHRs within two different content areas. Within the section on Health Informatics, the learning expectations state that pharmacy graduates should explore technology-based communication tools, as well as design and use EHRs to provide patient care. Daily use of EHRs for patient care is only a small component of this much broader competency that encompasses a wide range of applications of digital health technology which are outside the scope of this article. Electronic health records are also briefly mentioned within the learning expectations for Medication Dispensing, Distribution, and Administration.¹³ The North American Pharmacist Licensure Examination (NAPLEX) Competency Statements effective January 2021 outline in Area 1 of the blueprint that pharmacy graduates should be able to obtain, interpret, and assess data from medical records.¹⁴ Additionally within the recent (FIP) Digital Health in Pharmacy Education Report, the need for more established standards and formalized education and training of pharmacy students in digital health were included in the key messages.¹

When comparing pharmacy educational standards related to EHR, medical, nursing, and physician assistant standards vary in their incorporation of EHR skills and/or digital health education. The most recent Liaison Committee on Medical Education (LCME) Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the MD Degree, do not specifically mention digital health technologies or EHR skills.¹⁵ In an article in the Journal of the American Medical Informatics Association, Takesue and colleagues discuss the need to better prepare medical students for practice by teaching core EHR competencies; however, these competencies do not exist within medical education standards of practice.¹⁶ In comparison, the Commission on Collegiate Nursing Education (CCNE) Standards for Accreditation of Baccalaureate and Graduate Nursing Programs address digital health technology more extensively than does medicine or pharmacy. The Essentials of Baccalaureate Education for Professional Nursing provides 12 skills outcomes within Essential IV: Information Management and Application of Patient Care Technology that help link the use of digital technology to patient care, listing EHR/physician order entry as sample content.¹⁷ In addition, The Essentials of Master’s Education in Nursing provides five broad areas within Essential V: Informatics and Health Care Technologies, with “Facilitation and use of electronic health records to improve patient care” as one of the five broad areas to encompass.¹⁸ The Accreditation Review Commission on Education for the Physician Assistant standards effective as of September 2020 specifically mentions establishing a strong foundation in health information technology during the program curriculum, but lacks specific guidance.¹⁹ The degree to which health education programs incorporate digital health technology outcomes and standards is widely variable not only between schools within one profession but also between health programs. Specific competencies, example tasks/activities, and national consensus on how to ensure students are achieving these standards may assist institutions in selecting an academic EHR platform and designing their skills-based curricula with that platform. Pharmacy education has an opportunity to lead by developing national guidance on incorporating EHRs into curricula and contributing to educational standards related to EHR skills.

Prior to strengthening the language in educational standards, national consensus is needed across pharmacy education on what skills a pharmacy graduate should possess related to EHRs. Faculty focused on skills-based courses are key leaders in the development and strengthening of educational standards surrounding use of the EHR through task forces or workgroups within major pharmacy organizations. Through the work of these groups, consensus could be developed to determine what skills are the most important to be connected to the EHR. As core skills related to the EHR are developed, these skills can be mapped to existing entrustable professional activities (EPAs), pre-APPE domains, standards, and the PPCP. This roadmap could serve as a way to assess how skills in the EHR connect with current or new standards and identify gaps where new language is needed. A position paper including the perspectives of leaders in skills-based courses across several institutions on these topics is needed.

Pontefract and colleagues have described competencies and learning outcomes that all health care professionals, including pharmacists, would need to thrive in the digital setting. The agreed upon competency domains included digital health, accessing data, communication, generating data, multidisciplinary working, and monitoring and audit.²⁰ Although specific competencies for EHRs do not currently exist in pharmacy education in the United States, the addition of more specific language in the new version of the ACPE Standards or guidance document could be helpful. Specifics could also be added to Standard 10.8 Pharmacists’ Patient Care Process (PPCP), which describes the skills needed to provide patient-centered care, and to the section on pre-APPE domains, which explains the skills students are expected to have prior to participating in APPEs.^13,21,22 A possible additional EPA centered on pharmacy informatics could include EHR skills as a component that would benefit both learners and their patients.²³

There are skills and abilities already laid out in the standards that can be taught and assessed within the EHR, for example, collecting patient information, performing medication reconciliation, practicing order verification, or completing documentation. Many of these activities can be created outside of the academic EHR to teach and assess these skills (ie, using patient cases presented in a word-processed document); however, in practice the ability to perform those skills within the EHR are necessary. There are also skills that are related to how one uses the EHR, like efficiency, clinical decision support, maintaining good communication while using an EHR, or data query targeted to impact population health. Consensus from faculty teaching in skills-based courses is needed in both areas. Example activities/skills within the EHR are provided in Table 2 and can serve as a starting point for a wider discussion.

Integration of The EHR Into Skills-Based Curricula

After developing consensus on EHR skills and mapping for pharmacy graduates, individual schools and colleges of pharmacy will need to ensure that skills, learning activities, and assessments align with the consensus at a national level. Each pharmacy school faces unique challenges and has unique strengths, and there will be variation in the depth and breadth to which an EHR curriculum can be implemented at a school. Skills-based courses should aim to incorporate the EHR into all steps of the PPCP and into all activities where EHR is used in practice. Objective structured clinical examinations (OSCEs) and clinical skills assessments that serve as milestone assessments to pass a course or move on to APPEs are often integrated into skills-based courses. Assessment of students’ skills should be incorporated into these examinations for all activities for which an EHR would be used in practice. Increased integration of the EHR across various skills will help students recognize how integral the EHR is for pharmacy practice, increase students’ comfort level with and navigation skills within the EHR, and possibly increase their APPE readiness.

As schools begin to think more in depth about EHR curriculum development in skills-based courses, a variety of stakeholders should be included. Input and involvement from faculty, preceptors, students, and affiliated health care partners is key to creating a curriculum that represents a broad range of practice settings. Faculty focused on skills-based teaching should be leaders on teams developing the EHR curriculum. Focus groups and surveys to gather baseline data from students, faculty, and preceptors on EHR experiences and current abilities of students can help inform development of curricula. A team representing the groups mentioned may use this data and work with the school’s curriculum committee to develop institution-specific objectives for an EHR curriculum, a map of the different activities in their curriculum, a timeline, and the skills assessments that link back to national standards. Programs will need to determine what is the best process for them, but consideration should be given to introducing EHRs in the first professional year and, ideally, prior to introductory pharmacy practice experiences (IPPEs) in which EHRs will be encountered. Currently there is little information in the published literature regarding translating simulated EHR activities in the classroom to their use in patient care. Most of the literature available in this area examines student self-perceptions of their skills and readiness to use EHRs rather than providing more objective measures. Evaluating student performance using the EHR on APPEs, following exposure to an EHR curriculum in the didactic setting, will be an important measure of success.

Integration of the EHR into skills-based courses and curricula is not without barriers. Survey findings from the FIP Digital Health in Pharmacy Education Report identified the top three challenges faced by pharmacy schools that resulted in them not providing digital health education: lack of experts to facilitate learning experience (83%), lack of resources (79%), and lack of guidance (59%).¹

The cost of access to an educational EHR, fees, technology infrastructure requirements and support, and faculty and staff training specific to the chosen educational EHR can be significant. In addition, students’ EHR skills must be developed over several years and reinforced through experiential experiences. An assessment of potential barriers and a discussion of strategies to overcome these barriers is a critical step in implementation of an EHR curricula.