Can an Electronic Health Record be Also an Achievable and

Sustainable Vehicle for Clinical Staff Training?

The Importance of e-Learning in Medical Education Accomplished in a Real

Operational Hospital Context



G. Lissoni

, S. Merli

, S. Orlando

, P. Vanelli

, C. Savi

, A. Mascheroni

, G. Orsi

C. Antona

, G. Rizzardini

and G. Orlando

Laserbiomed s.r.l., Milan, Italy

Infectious Diseases I, Dep Infectious Diseases, L Sacco University Hospital, Milan, Italy

Information Support System,

L Sacco University Hospital, Milan, Italy

Cardiosurgery, Dep of Cardiosurgery, L Sacco University Hospital, Milan, Italy

Intensive Care Unit, Dep of Cardiosurgery, L Sacco University Hospital, Milan, Italy

STD Unit, Dep Infectious Diseases, L Sacco University Hospital, Milan, Italy

Keywords: Electronic Health Record (EHR), Health Care Associated Infections (HAIs), Remote Infectious Diseases

Consultations (RIDC).

Abstract: The health care associated infections (HAIs) are growing all over the world. The development of a

customized web-technology for Electronic Health Record (EHR) is aimed to answer to the growing need for

expert Remote Infectious Diseases Consultations (RIDC) in high-risk settings lacking of Infectious Diseases

(ID) specialists and as a tool for the ID students. The outcome measures to evaluate efficacy and efficiency

of the web-platform developed for this purposes are the satisfaction of specialists involved; number of

RIDC performed compared to historical data; number of bed-side consultancies needed for the insufficiency

of web-based data; time spared in avoiding staff movement. In 12 months 18 simulation tests, 19 RIDC and

52 EHR access have been performed for patients admitted in the Cardiac Surgery Unit (L Sacco University

Hospital, Milan – Italy). The mean time from the web-call and the RIDC was 2 hours (range 2 min – 16

hours). The major limit of the system is the time for web-form filling for clinical case presentation. Several

severe infectious diseases case management histories are already stored for ID students learning. After this

first phase considerable structural adjustment are currently under revision.

1 INTRODUCTION

Infectious diseases represent now, more than ever,

an important part of healthcare activities involving

all clinical and surgical wards.

In recent years the problem of nosocomial

infectious diseases or “health care associated

infections" (HAIs) has proliferated into a public

healthcare priority, both in terms of the adverse

consequences to health and to the impact on

organizational and financial resources. They affect

an estimated 1.7 million hospitalizations in the

United States each year, they increase patient

morbidity and risk of mortality, the cost of

treatment, and they extend hospitalization time

(Eber, 2010; Lanini, 2009; Klevens, 2007).

This proliferation has been observed as a steady

increase in the emergence and diffusion of severe

diseases from multi-drug-resistant pathogen and

often attributable to the indiscriminate use of anti-

infective drugs (antibiotics, antifungals, antivirals)

(Mauldin, 2010; Graves, 2010).

Currently, Infectious Diseases’ specialists (ID

specialists) – present only in a limited number of

general hospitals - are involved in the management

of complex patients hospitalized in high-risk

environments such as; surgical wards, intensive and

post-operative care units, patients exposed to organ

transplantation, onco-hematology patients, etc. Due

to their limited numbers, ID specialists currently

398

Lissoni G., Orlando G., Merli S., Mascheroni A., Orlando S., Vanelli P., Savi C., Antona C., Orsi G. and Rizzardini G..

Can an Electronic Health Record be Also an Achievable and Sustainable Vehicle for Clinical Staff Training? - The Importance of e-Learning in Medical

Education Accomplished in a Real Operational Hospital Context.

DOI: 10.5220/0004936103980403

In Proceedings of the 6th International Conference on Computer Supported Education (CSEDU-2014), pages 398-403

ISBN: 978-989-758-020-8

 2014 SCITEPRESS (Science and Technology Publications, Lda.)

work in both their designated hospital and also as

external consultants in hospitals where the

institutional figure of the ID specialist is missing.

Consequently, the organization of consultations

activities from experienced professionals has

become increasingly difficult as demands and needs

invariably grow. Moreover, these activities often

terminate as “on and off” performances which,

unfortunately, cannot be shared with colleagues in

order to promote the enhancement of clinical

protocols of intervention on the patient side.

2 A NEW CONCEPT OF

REMOTE MEDICAL ADVICE

AND E-LEARNING

To address these needs, within the Infectious

Diseases (ID) Department of the Teaching Hospital

“L. Sacco” in Milan (Italy), an Electronic Health

Record (EHR) system was implemented. The

implemented system provides the electronic delivery

of remote infectious disease consultations (RIDC) to

facilitate the diagnostic and therapeutic process in

the hospital’s operational units where an ID

specialist is not directly available.

The innovative component of this portal (Rossi,

2006) enables it to be used, if required, as an

educational database of clinical case studies. From

this repository, clinical case studies can be readily

made available to practitioners and trainee doctors,

as well as to a collaborative working environment

where professionals from different disciplines can

exchange views and feedback on various ID issues.

This system is based on a web-platform that not

only permits remote reporting of online

consultations on real patients, but also represents an

innovative model of e-learning in medical education.

This is because access to this consultancy system

has been extended to medical specialists who, in

accordance with criteria of efficiency, effectiveness

and respect for patient privacy and internal

guidelines, can study which therapeutic approaches

have been adopted by more experienced colleagues

when dealing with diseases involving different

clinical disciplines.

2.1 Project’s Purposes

The project kick-off was in November 2011 and has

a duration of 3 years (so it is a work in progress) but

is relevant to providing answers to 3 main issues:

1. The continuing increase in demand for ID

specialist consultations by physicians who

work in environments with a high risk of

nosocomial infectious diseases in hospitals that

do not have an internal service for infectious

diseases;

2. The need to optimize the time required to

perform the ID consultations and

troubleshooting the infectious criticalities in

high-risk patients;

3. Provide an adequate technological setting,

working as a clinical database that facilitates

distance learning for professionals. In other

words, a real portal for the study and

evaluation of complex and up to the minute

clinical cases.

2.2 Project’s Timeline and Methods of

Results’ Analysis

From the operational point of view the project steps

performed can be thus summarized as follows:

- Analytical phase: data analysis needed to develop

a platform for ID online consultations;

- Development of the online platform with the

help of one of the hospital’s principal supplier:

definition and customization of pages and online

algorithms using active interaction and collaboration

among IT analysts and developers and ID specialists

in order to test all along the processes and the

effectiveness of the product under development;

- Partners’ engagement: contacts with other

operational units to identify partners interested in

participating actively in the first experimental phase,

sharing the aims of the project and interactions

during the development of the platform. In the pilot

project the inpatient operational unit chosen was

Cardiac Surgery and Post Operative Intensive Care

Units of L. Sacco University Hospital;

- Integration with other hospital applications

already in use: meetings between the providers of

the online consultations platform and the hospital’s

IT technicians for the necessary integrations, for

example the evaluation of laboratory tests results,

radiology images and reports and anatomic

pathology reports;

- Evaluation of operational procedures: simulated

tests for RIDC calls to verify the accuracy of the

logical processes that underpin the ability to make

effective consultations, the completeness of the

information collected, the information flow, the

possibility to manage emergency/urgent situations,

the adaptation of privacy rules, data security and

integration with the Lombardy regional platform;

- Staff training and education: for ID consultants

CananElectronicHealthRecordbeAlsoanAchievableandSustainableVehicleforClinicalStaffTraining?-The

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and for partners who use the EHR platform;

- Experimental phase: real RIDC activities carried

out with the identified technological partner;

- Portal access given to physicians specializing in

ID and professionals of other departments

(appropriately selected by the Board of Medical

Directors) for the evaluation of real clinical cases;

- Check and audit: periodically audits were made

during the period of use of the platform, required by

the medical staff involved (ID physicians and

colleagues who demand online consultations) for the

adaptation of the operational processes useful to

improve the efficiency and quality of the

consultations, the learning process and the training

of medical staff with respect to the changes from

time to time set up;

- Final assessment (November, 2014) will

encompass: analysis of the consistency of the

product implemented and fulfillment of initial

requirements, the ergonomics of the product, level of

achievement of the objectives.

- Further new developments: possible new

developments and any changes to be made for a

possible extension of the consultation service from

the operational units involved during the

experimental stage to other departments of the same

hospital or, in the eventuality, other external

hospitals.

The outcome measures to evaluate efficacy and

efficiency of the web-platform developed for this

purposes are:

- The satisfaction of specialists involved (measure

of efficacy). This parameter will be evaluated

through the analysis of the customer satisfaction

form filled both by the ID specialists and by the

hearth surgeons at the end of each consultation;



- The number of RIDC performed compared to

historical data of bed-side consultation process

(measure of efficacy);

- The number of bed-side consultancies needed for

the insufficiency of web-based data (measure of

efficiency);

- The time spared in staff movement avoiding

(measure of efficiency). This measure will be

evaluated simulating several distances between the

ID specialist’ hospital and the hospital which asks

for the ID consultation.

Any consultation can be used as teaching

material to analyze the diagnostic work-flow

process, the choice of empirical treatment pending

cultures, the evaluation of the susceptibility test

performed on isolated microorganisms and the

following guided treatment, the timing of dose-

delivery methods for antibiotic / antifungal /

antiviral drugs, for the monitoring of treatment

outcome, for the side and untoward effects, for the

dose adjustments, etc.

2.3 Technological Key Elements

The originality and the strength of this prospective

work is its building process. This is based on the

interaction of technicians and physicians who give

their contribution from different points of view to

identify the most appropriate tool able to reach these

objectives.

Many Italian hospitals are equipped (and many

others are going to equip) with healthcare

information systems oriented to the management of

clinical events.

In particular, in the Lombardy Region, various

Hospital Information Systems (HIS) are evolving

according to the guidelines of SISS (acronym of

“Sistema Informativo Socio Sanitario”, the

Lombardy Healthcare Information System)

(Barbarito, 2012).

SISS can be defined as the set of IT applications

and infrastructures in the Lombardy Region (IT

systems for pharmacies, doctors, hospitals,

Lombardy Region offices, etc.) that contribute to the

provision of healthcare services within the Region.

SISS today consists of a number of systems that

are gradually evolving, according to a specific IT

strategy in e-health matters, in order to put into

practice more widespread and pervasive Information

and Communication Technologies (ICT) for

innovation purposes.

In addition to these considerations, the ID

department protagonist of this paper wanted to add

more value to the EHR currently in use and enforced

its functionalities.

This platform, already capable of managing the

entire care process in a paperless way and of

improving the clinical risk management procedures

compliantly (to Joint Commission International

standards and Italian Legislation), was integrated

with further features that could allow the exchange

of medical and scientific expertise, based on real

clinical cases, with an eye to provide continuing

online education to physicians.

From a technological point of view, a careful

examination of various type of healthcare, scientific

and documentary aspects has led to the

implementation of a real clinical tool accessible via

the web on any terminal or device with a browser

(PC, Tablet-PC, etc.). Connectivity is achieved

regardless of the operating system and functionality

enables doctors and nurses to perform all the tasks

CSEDU2014-6thInternationalConferenceonComputerSupportedEducation

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related to patients care.

To obtain a real paperless solution each clinical

task inserted in the system is digitally signed with

smartcard (as required from the Italian law) and this

permits the definitive replacement of inpatient and

outpatient paper medical records electronically (Lisi

A, 2010; Rossi L, 2006).

The operational workflow commences with the

operator who accesses the portal by typing a URL,

like an ordinary website, but conveniently protected

with personal username and password (fig. 1).

Figure 1: Access to the portal for remote ID consultation.

Each user that has been securely enabled and

assigned to one or more operational units, may log

into the portal and pass a request for a new RIDC to

another unit or department.

Once the patient is correctly identified, users can

proceed and fill out a consultation request (fig. 2)

form which requires some mandatory data such as;

hospital, operational units, specialists needed, for the

remote clinical evaluation, priority (non-urgent,

moderately urgent, absolutely urgent, …) and main

reason for the RIDC.

Figure 2: Form for the consultation request for the patient

“Mario Rossi”.

Due to the configurability of the platform,

information required in the request form is still

modifiable according to need.

Items available for the corresponding pop-up

menu can be customized pursuant to the needs that

may possibly arise during the utilization of the

system.

Physicians can accede to both the list of requests

of consultations already sent to other operational

units and to the list of requests coming from other

units.

A series of filters related to the time period in

which they look for these requests and their status of

implementation (e.g. visits scheduled – executed - in

execution - canceled) are always at the users’

disposal.

2.3.1 Architecture of the EHR

The EHR architecture, configured according to the

requirements that emerged in the initial phase of

analysis, provided for the introduction of three

sections (request for consultation, consultation

assessment, module for documents uploading), each

containing some specific clinical forms.

In the first section "request for consultation"

there is a consultation request form with basic

information such as the reason for the request, the

reason for patient’s admission and so on.

The EHR platform includes a framework where

it is possible to create in an easy way new forms (or

modify forms already existing) with structured data

by linking certain values of particular clinical

interest to specific functions.

In addition to the information inserted in the

clinical form available, the EHR portal enables the

upload of other paper-based data after acquisition

through scanner (e.g. pdf and word documents, jpeg

files, …) and the use of the digital signature

procedure part of the system as previously

described.

Therefore, users may load any external

documentation in order to proceed to a more

comprehensive request/response of consultation.

When applying for a consultation an email

notification is sent to the addressee delivering the

essential information about the request, such as

soliciting physician, his operational unit and priority

of the request.

The doctor addressed with the ID consultation

has access to the form filled out by the colleague (in

the pilot phase, a heart surgeon) and examines the

documentation loaded for the clinical case.

In this way, the doctor is able to provide a first

in-depth analysis of radiological images, ECG,

photographs of skin lesions, laboratory tests and

other documents as well as the clinical history of the

patient at issue.

CananElectronicHealthRecordbeAlsoanAchievableandSustainableVehicleforClinicalStaffTraining?-The

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After the evaluation of the documentation is

terminated, the consultant (in the pilot phase, the ID

specialist) can respond by filling out a special form

that will include the ID opinion.

The third section "consult assessment" consists

of two forms for the assessment of the completeness

of the case presentation. These forms have been

designed to measure the degree of satisfaction of the

addressed operator with respect to the data provided

by the sender.

Consequently, the ID specialist has the

opportunity to assess the completeness of the

description of the clinical case while the cardiac

surgeon evaluates the response returned from the ID

specialist.

The features developed for the part of the web

platform related to the feedbacks are of great

importance from the educational point of view since

they allow the examination and realization of how a

particular clinical aspect has been addressed by a

senior specialist. This may also represent an

additional means of professional development for

younger colleagues.

The structure of the patient’s "clinical dossier"

allows operators to get a simpler guided navigation,

increasing flexibility, modularity and ease of use of

information made available.

3 PRELIMINARY RESULTS

In 12 months, from the beginning of the simulation

tests of the customized Electronic Health Record

(EHR), 18 simulation tests, 19 Remote Infectious

Diseases Consultations (RIDC) by Infectious

Diseases Specialists of the I Division of the L. Sacco

University Hospital, Milan – Italy have been

performed with 52 accesses to the EHR of patients

admitted in the Cardiac Surgery and Post Operative

Intensive Care Unit of the hospital.

The mean time ranging from the web-call and the

RIDC was 2 hours (range 2 - 960 minutes). A

comparison with the time occurred for the bed-side

consult in the same unit is ongoing: the 94 bed-side

consultations performed between Jun 2013 - Jan

2014 were delivered after a mean of 8.3 hours (range

30 – 1440 minutes). The real Δ-time from the call

and the consultation delivery will be evaluated when

the system will be tested in a really remote setting.

Among the questionnaires made to evaluate the

platform, the major limit arisen of the system

efficacy was the time spent for the completion of

data required to fully-describe the clinical case and

to collect requisite data required to facilitate the

diagnostic and therapeutic process. After this first

phase, several structural adjustment are currently

under revision.

In Table 1 are reported the topics stored since

now as a clinical database which can be used for e-

learning and training of ID students. All the cases

stored represent very important and up-to-date issues

for the management of severe infectious diseases in

high risk patients.

Table 1: Clinical cases stored for e-learning and training

of ID students.

Clinical case N %

Sepsis 5 26.3

Ventilator (VAP) or healthcare

associated (HCAP) pneumonia

4 21.0

Native (NVE) or Prosthetic

(PVE) valve endocarditis

2 10.5

Surgical Site Infection (SSI) 2 10.5

Chronic liver disease 1 5.3

Clostridium difficilis colitis 1 5.3

Other 4 21.1

Total 19 100

4 CONCLUSIONS

This pilot project, currently involving two

operational units within the same hospital, is proving

to be an interesting and intelligent learning

experience for many specialists with different levels

of expertise. The project can easily be extended, not

only to other departments of the hospital, but also to

other hospitals in the area interested in the care of

IDs and nosocomial infections.

Among the benefits gained we are proud to

emphasize the implementation of additional training

content related to ID studies accessible with

simplicity and immediacy, and especially the

possibility of reducing now and again the logistical

and time-management training costs of new

specialists (e.g. avoiding transfers for “face to face”

traditional training, giving the possibility to study

new clinical cases also in non-working hours from

home, etc.).

The project could potentially modify

substantially the specialists consultation process

which is actually based on the movement of

specialized personnel. In perspective it is important

to stress the possibility of extending access to the

portal to a larger number of users and operators

nation-wide with the idea of establishing networks

of ID specialists consultations not only at regional

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level.

So far, the initial goal of the project, which is to

develop a computer technology that would enable

the structuring of case studies by means of

innovative technology-based learning strategies

localized in a real context of patient care, can be said

to be fully achieved.

This is mainly because users’ have taken

advantage of data inserted into the system from the

consultations’ part of a real EHR that is open to

support distance education and exchange of

information, opinions and feedbacks among a

considerable number of professionals.

ACKNOWLEDGEMENTS

This project was funded by Italian Ministry of

Health (project GR-2009-1568943 CUP

E41J110001).

We want to thank every single ID specialist for

the patience, diligence and commitment

demonstrated in order to learn how to use this new

information technology platform.

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