EHR Training, the Hard Way

My hospital is preparing to go live with a major vendor's EHR system the first of May. Hospital staff and clinicians have been busy going to training to prepare. Most of this post will be about my experiences during this training. Anyone who has read this blog knows that I tend to be on the critical side. Most of my experience has been unpleasant, perhaps because I, more than most other clinicians, know how it should/could be done.

First, you should know that I volunteered to become a physician superuser. Based on my training and preparation to teach a class on EHR adoption at the master's degree level, I had certain preconceived notions about how this would go. I was greatly disappointed to find out that most superusers being trained were not physicians. I was in a class that included no physicians in fact. Most of my fellow students were already familiar with the system because they had been enrolled in earlier courses so they had a head start on me. I was doubly frustrated because I had a lot of difficulty searching for my assigned patients. The search was done on the last name, case sensitive, and grammatically incorrect small case letters for the entire last name. It was hard to get over a life time of capitalizing the first letter of proper names. I am sure my 9th grade English teacher is turning over in her grave even now.


I had a lot of trouble following the training. It did not take me long to realize that the major reason for this was that the training was not following clinical workflow. They might train how to manage orders in the recovery room, then a discharge, and then a history and physical. I have written a post about workflow and my observations about workflow have not changed a bit. It was enlightening to learn that one of the trainers had a background in sales and never worked in a clinical environment. This does not excuse the designers of the training who should have known better. I rightly or wrongly attribute this to lack of provider input. But that ignores the fact that best practices for clinician training are well-recognized and widely promulgated.


Many of the major tasks clinicians do routinely were not covered at all. Basic things like how to order an x-ray (I am an orthopedic surgeon after all) or how to view an x-ray in the new system, how to incorporate dictation into a note ( turns out a few clinicians will use voice recognition, most will use the current dictation system if they choose) or create a hybrid note, how patients will be consented for surgery (an electronic signature device will be used) how to transfer a patient to an outside facility, how to prescribe controlled substances, how to ensure a patient receives an electronic visit summary, how to provide patient education materials, how a clinician handles the patient portal- patient emails, release of lab information, and the list goes on.


Back to being a superuser. I found the plan for training superusers was to have them take the course twice and maybe help out with people having trouble on the second go around. There was no special one-on-one or small group training, and short cuts, tips, in depth training, best practices, etc. were not covered. The executive plan appears to me to have non physician superusers help physicians during the go-live. Given the lack of physicians trained in the role this is inevitable. The question is whether it will work well. There is substantial experience to indicate that there will be a problem. Physicians do better taking advice from physicians. Even experienced nurses or unit clerks really don't know physician workflows and likely are not aware of some special needs of physicians. I will wait and report back on the success of the strategy being implemented.


I had a cloud-based practice management system a number of years back. Training was carried out via live webinars for me and my staff by the vendor's trainers. I set up my scheduling system including role based permissions, appointment types and times with this training alone. Physicians were provided very little training about the schedule function of the new software. I was not even aware of the courses that trained on the scheduling module. I like to make my own appointments when I see a patient after hours, or discharge a patient from the hospital on a weekend. I think this provides better continuity of care at a care transition. With the new system, I will not be able to utilize this functionality-by design. I get upset about such things. I dislike wasted potential to improve care and I don't like being harnessed to a receptionist or medical assistant to carry out essential tasks. It turns out that this enterprise system actually is broken up into a number of silos as far as training goes-inpatient, outpatient, financial, patient portal, administration, etc.


A number of asynchronous learning sessions were offered to doctors. I never heard about them before class even though they were assigned as prerequisites. They were accessed through an employee portal. I had never used the portal because I was not an employee of the hospital and did not have user credentials to get into the system anyway. This oversight was clear up at the end of the first class. I think it happened less frequently for physicians taking classes after me. The e-learning sessions were actually quite helpful. They were produced by the vendor using professional trainers who were experts with the system. Each session covered a vignette, an element of clinician workflow. I liked being able to watch these videos several times. Unfortunately, there were quite a number of e-sessions available. Because of the numbering system for the sessions it was apparent that only a few of the available sessions were assigned for review. Communication for physicians about the menu of available sessions was only available upon request if one figured out there had to be more available somewhere.


Everyone had to pass a test to be able to be cleared to use the system. The first time I took the test I found out I was going to be tested at the end of the course during the final hour of 9 hours of training (after hours and after a full day of work.) The test was given on paper and answers were not discussed. I failed the first time but did not know what I missed. Later, trainers covered all the questions before the test (and gave correct answers) and the test was electronic and provided the correct answers for all questions missed so that when one retook the test it was hard not to pass. I could go on with a few more complaints but I think I'll end with one more thought.


Finally, I found it surprising that there was not a single point of contact for questions about training. I didn't know whom to call for help. The trainers were so focused on their individual areas that they did not have an overview of the whole system. I did find one trainer who was able to answer a laundry list of questions I prepared after my first few classes. I appreciated his help but I was lucky to find him.