October 2018

A Targeted Approach to EHR Training Improves Success Rates
By Lisa A. Eramo, MA
For The Record
Vol. 30 No. 9 P. 22

A prominent cancer center invokes simulation training, one of the ways organizations are attempting to make transitions as smooth as possible.

Imagine a physician walking into an exam room where a volunteer patient awaits while an EHR trainer silently watches them navigate the entire visit using a new record-keeping system. This hands-on simulated learning environment is exactly what more than 1,850 clinical providers at MD Anderson Cancer Center in Houston experienced as the organization transitioned from a best-of-breed EHR to an integrated system in March 2016.

"What we were trying to do is practice what it was going to be like the first time providers went into the room with a patient and had to use the new EHR," says Craig Owen, interim CIO at MD Anderson. "How were they going to interact with the patient and the new system? We go through similar simulations with life safety training, so we thought, 'Why can't we leverage something like this for EHR training?'"

Leveraging Simulation Training
An EHR conversion or implementation is a large undertaking. The experience can be daunting for any provider trying to assess and diagnose patients while also documenting in a new system, Owen says. Simulation training can mitigate some of this anxiety. At MD Anderson, the goal of EHR simulation training was to promote a positive patient experience during and after this major transition while also helping providers feel confident in using the new system.

Providers at MD Anderson participated in 20 to 24 hours of mandatory classroom training before they completed two mandatory one-hour sessions of simulation training. During the simulation training, patient volunteers followed scripts prompting them to say certain things that would test providers' knowledge of the new EHR. For example, patients deliberately forgot to tell the physician about a medication so he or she had to backtrack in the workflow to document correctly.

An EHR trainer in the simulation room evaluated physicians as they used the system. The trainer provided this feedback to a different individual who subsequently worked one-on-one with physicians to personalize the EHR so it met their needs more effectively, Owen says.

Volunteer patients completed a survey which evaluated physicians on their bedside manner when using the EHR. They answered questions such as: Did the provider look at you while using the EHR? Did you feel as though the provider cared about you? Did you have a good experience?

To provide the training, MD Anderson converted 25 infusion rooms into ambulatory clinic space complete with medical equipment, exam tables, and supplies. These rooms, which had been set to go under construction, served as the simulation training space for approximately five months.

"You have to look at the investment," Owen says. "What's going to help you have a safe and positive patient and provider experience at go-live and beyond? In the grand scheme of things, I think simulation training is a small investment to help ensure success."

In addition to EHR simulation training, there are other ways in which HIM leaders can advocate for best practices that lead to the safe and successful adoption of EHRs. Consider the following 10 strategies.

Make Training Mandatory
EHR training is no different than training on a new device for a surgical procedure, says Zack Tisch, PMP, consulting services executive at Pivot Point Consulting. "If someone is going to use the system and provide patient care, they need to be trained," he says.

Jeannine M. Arnold, RN, solution director at CTG Healthcare Solutions, agrees. "Some organizations say if you don't have training, you don't have access to the EHR at go-live and you won't be able to take care of your patients," she says.

Nonemployed physicians can be challenging because they sometimes resist training, Arnold says. To overcome this hurdle, she recommends placing every provider's name on a big poster in the cafeteria. As providers attend EHR training, check off their names. This calls attention to those who don't attend the training.

Some organizations make the decision to pay all nonemployed physicians to attend EHR training, Arnold adds.

One potential exception to the mandatory training rule are physicians who have already used the same EHR at another facility and who can demonstrate proficiency, Tisch says. Some organizations choose to allow these physicians to attend an abbreviated training that focuses solely on organization-specific workflows, he adds.

Look for Budget-Friendly, Efficient Options
In addition to classroom training, consider webinars, e-learning, or self-study packets that employees can read or watch during downtime at their own workstations to learn system basics, says Becky Manne, vice president of training and activation at Optimum Healthcare IT. Use practice sessions for hands-on experience with the EHR based on what employees have already learned on their own. This avoids days-long classroom training that often makes productivity come to a standstill, she says.

Some organizations choose to pay employees overtime for their time spent outside of work hours learning the EHR, Manne says. This eliminates the need to pay for temporary employees while staff attend lengthy classroom training. "It all depends on what the budget will tolerate," she says.

Focus Training on End-User Needs and Workflows
Although EHR vendors provide basic training, this education usually isn't tailored to the specific needs of the organization, including its unique workflows, Tisch says.

In addition, it's easy to make assumptions because there's often no documentation to support each workflow (eg, this individual performs these tasks using these specific steps). Employees often perform tasks that go beyond what's required in their job descriptions. These are training aspects that can be overlooked, Manne says.

For example, a nurse who isn't technically required to schedule patients may perform the scheduling function on the fourth Saturday of every month because the scheduler is out of the office. Or a nurse may handle admissions at night because the unit clerk doesn't work that shift.

"It's about knowing what questions to ask so the right training is given to the right person for everything that they do," Manne says.

Arnold agrees, citing the examples of a security guard who performs registration when the night clerk goes on a break or a nurse who primarily works in the emergency department but floats to the medical/surgical floor a few times a month as needed. "It's never a one size fits all. Each end user has unique needs," she says.

Perform an in-depth analysis of the workflow and build EHR training around that analysis, Manne says. When developing workflow-specific training, consider the following questions:

• What daily tasks does this individual perform?
• Does this individual perform any additional tasks during evenings and weekends?
• For the same basic role (eg, nurse), are there different titles (eg, staff nurse vs charge nurse)? If so, do their responsibilities differ? Does the charge nurse run certain reports? Does he or she need access to certain information that might otherwise be restricted in the EHR?

"Training should be 'a day in the life of.' It's running people through their role as it pertains to the patient experience," Manne says.

Engage Superusers From the Start
Best practice is to engage employees—especially superusers—during the design, validation, and testing phases to provide them with a basic familiarity with the system, Tisch says. "When you get to the traditional training period right before the go-live, people already have the basic knowledge," he says. "They've moved past their anxiety. And because you've let them participate in the project, they understand why the system is architected the way it is, and they're ready to do more scenario-based training."

This approach eliminates scenarios in which organizations bring in trainers one or two months before go-live. "They come in, quickly learn what you've set up, and do a 'just-in-time' training," Tisch says. "Instead, think about the 12 or 18 months you might have allocated for the whole project. Where are the touch points and opportunities to help set your training program up for success?"

Think of Training as a Work in Progress
According to Arnold, one of the biggest mistakes organizations make is they develop a training program but don't stay flexible. As employees "test drive" the system, organizations must be willing to adapt and make changes to their training program. For example, if superusers say a particular training video isn't helpful, perhaps the organization can develop a new video or webinar to cover the same material. Organizations need to leave enough time in their EHR rollout to accommodate for these lessons learned, Arnold says.

Tisch agrees. "Think of training as continuous improvement. You constantly need to give people tools and techniques to help them do their work more efficiently," he says, adding that even after a formal training period has ended, organizations should continue to keep employees engaged in the form of bulletins and quick tips about the EHR's features based on feedback about the system.

Distinguish Between New and Existing Hires
Just as training should accommodate end-user needs, it should also differentiate between new and existing hires. Arnold says training for new hires should be built into the orientation process to prevent unsanctioned workarounds that don't follow validated workflows. Some organizations also assign a "buddy" to new hires after they receive training to ensure that they're following protocols and to answer questions as they arise, she adds.

Existing staff may have different needs. For example, they may be stuck on certain workflows, or they may have inherited bad habits that need to be addressed, Tisch says. They may also need workflow crosswalks (ie, here's how we used to do this in the old system, and here's how we do it now), he adds.

In addition, existing staff may need change management support, Arnold says. Trainers must be able to acknowledge that new technology can be daunting at first. They must help employees navigate this uncertainty and provide additional support when needed.

Size Matters
Large organizations usually have more defined roles, which may make training more straightforward, Manne says. "With small organizations, individuals wear many hats," she says. "From a trainer's perspective, you need to be very aware of making sure you cover all of these hats."

However, large organizations have more users who require training. The challenge is that if it takes several months to get everyone through training, those who were trained first may not retain some of the information if they don't actively use it, says Owen, who oversaw training for approximately 15,000 users at MD Anderson. To combat this, large organizations may need additional trainers to train all users closer to the go-live date or provide refresher training on an ongoing basis, he says.

Know Where You'll Provide the Training
In their eagerness to provide high-quality content for EHR training, some organizations overlook the question of where the training will occur. The physical space must be close by, provide enough room to accommodate everyone, and ideally provide individual access to the EHR, Manne says.

Some organizations may be able to convert a space (eg, a surgeon's lounge or a conference room) into a temporary training space. Others may need to look outside the organization at potential training locations. For example, one organization to which Manne provided consulting services used space in a nearby outlet mall.

If a single location doesn't fit the bill—as is often the case for organizations with outlier physician practices—multiple locations may need to be identified, Manne says. "Remember that if you do decentralize the training to make it more conducive for participation, it generally increases the number of trainers you need. This circles back to the budget," she says.

Don't Forget Downtime Training
In the rush to train users on the EHR, organizations may forget that employees also need to know what to do when there's downtime, Manne says.

"Most individuals become very savvy on how to use the technology, but they need education on what to do when that technology isn't present," she says. "There are employees who have never had to document on paper. When you tell them to go into the downtime procedure, they look at you as though they can't take care of the patient because the system is down."

Downtime training should be specific to each type of scenario (eg, downtime due to a power outage, system upgrade, weather-related disaster, or a variety of other reasons), Manne says.

Tie It Back to Patient Care
EHR training needs to feel like patient care training, not system training. "Make it about the patients and less about the technology itself," Tisch says.

Manne agrees, adding that employees should feel confident when they use the EHR. Confidence translates to greater efficiency, which translates to an improved patient experience, she says.

Regardless of the specifics, experts agree that training is a critical aspect of a successful EHR rollout. "Training is a thankless job. If the go-live goes well, then it's because of great build. That's true, but it's also because of great build that was then trained," Manne says.

— Lisa A. Eramo, MA, is a freelance writer and editor in Cranston, Rhode Island, who specializes in HIM, medical coding, and health care regulatory topics.