Introduction
According to the International Diabetes Federation, diabetes is one of the most challenging health problems in the twenty-first century.1 Currently, there are big, persistent gaps between the evidence-based guidelines for diabetes care and actual clinical practice around the world,2 including Canada.3
Almost 80% of diabetes care is provided in primary care by primary care physicians (PCPs).3 To bridge the gaps between current practices and optimal standards, the redesign of primary care has been proposed4 using the chronic care model (CCM).5 The CCM is ‘the best known and most influential’ organisational model for chronic care.6 The overall aim of the CCM is to develop well-informed, activated patients interacting with a practice team that is proactive and prepared for them with the end goal of improving outcomes. The CCM has been adopted and adapted for use in different countries, such as the UK, Denmark, Russia, China, Australia, New Zealand and Canada.7 The CCM includes six elements that are inter-related and designed to strengthen the patient-provider relationship and improve health outcomes: (1) delivery systems design, (2) self-management support, (3) decision support, (4) clinical information systems, (5) the community and (6) health systems. According to the CCM, clinical information systems such as an electronic medical record (EMR), and electronic health record (EHR) are often used interchangeably. In Canada, where this study has been conducted, an EMR is a health record under the custodianship of PCPs, whereas an EHR is used in secondary and tertiary care (hospital) settings. They can play a key role in facilitating improved capture, organisation and presentation of patient information. For diabetes care, EMRs can help PCPs to (1) identify patients with diabetes, (2) assess whether a patient is due for recommended tests or screening procedures and (3) determine which patients have not achieved evidence-based clinical goals for key measures.8
In general, current EMR use by PCPs is suboptimal, especially for supporting chronic care in Canada and the USA.9 10 Previous research highlights the need to support PCPs in the advanced use of their EMRs for diabetes care.11 12 This is referred to as ‘value-adding use’ and includes additional use by the user to increase output or effectiveness.13 The literature widely suggests that end-user-support (EUS) is a critical success factor for increasing value-adding EMR use.14 15 EUS is defined as ‘any information or activity that is intended to help physicians solve problems with, and better utilise, the system’.16 However, many PCPs receive little effective17 or adequate EUS,17 18 especially following the implementation of an EMR. In particular, post-implementation EMR training is an important form of EUS that the majority of PCPs currently lack, especially for using advanced features such as creating recalls/reminders and reports.19–21 Training provides end-users with ‘the conceptual and procedural knowledge necessary to put the technology to effective use’.22
The literature on educational interventions for information systems identifies seven methods of software training: (1) tutorial, (2) course/lecture/seminar, (3) computer-aided instruction, (4) interactive training manual, (5) resident expert, (6) help component and (7) external training.23
In the 1990's, video tutorials were introduced as a new type of tutorial for training end users of information systems. Video tutorials are visual demonstrations of how to accomplish tasks using software,24 and are a simple, affordable tool to produce authentic, situated and motivational instructional material.25 The benefits of video tutorials for learning include: (1) The development of a better mental model of the software26, (2) Faster initial learning and better comfort than using static versions of instructions25 and (3) Increased control and autonomy.25
However, the limitations of using video tutorials include the ‘mimicry model’ (ie, memorising and copying steps without internalising the task)27 28 and lack of an inferential step, which may lower retention of information. Despite these challenges, video tutorials can reduce cognitive processing and allow users to immediately practice the skills they have acquired.25 They may also serve as a cost-effective and scalable tool for software vendors and institutions to provide training to end-users.
In the context of training medical residents and nursing students on EMRs, He et al from the University of Massachusetts (USA) had used two video tutorials in EHR training for nursing students.29 The authors identified several changes to improve their video tutorials (eg, including hands-on practices and review questions with answers). In another study, Thiyagarajan et al30 from Eastern Virginia Medical School (USA) examined the use of EHR video tutorials to orient medical students to the EHR.30 Using retrospective chart review, the authors found that there was a significant improvement in completion of the past medical history and smoking status fields in the EHR after three video tutorials were introduced, although it was not possible to link the post-implementation charts with the medical students who had watched the video tutorials.30 Similarly, Zoghbi et al31 conducted a pre-post study to examine the effects of video tutorials on EMR use for a group of general surgery residents at the Perelman School of Medicine, University of Pennsylvania (USA). The study found statistically significant positive effects of the video tutorials on residents' confidence in carrying out EMR tasks, clinical scores on emergency simulations, as well as decreasing their time required to perform essential EMR tasks without the video tutorial training. However, primary research studies on the use of video tutorials for EHR/EMR training of practicing PCPs or other practicing physicians have not been published to date. Further, to our knowledge, research examining the use of EMR video tutorials has not been published to date outside of the USA. This study adds to this literature by examining the impact of video tutorials on PCPs’ use of advanced EMR features for diabetes care as a continuing medical education-like intervention; it also studies the use of video tutorials by PCPs in Canada. The study addressed the following research questions:
To what extent does a CCM-based video tutorials demonstrate the potential to improve type 1 and type 2 diabetes care processes, including (a) use of a diabetes registry, (b) use of diabetes recalls/reminders, (c) ordering/viewing a patient's haemoglobin A1c every 3 to 6 months and (d) recording a patient's blood pressure every 3 to 6 months?
To what extent do individual PCP characteristics relate to EMR use for diabetes care?