EHR project communications and an opportunity missed.

I often sit at home during the evening I wonder how they could get it so wrong. As my father frequently says-"There's always something." The outstanding feature of the communications plan for our EHR project is that there doesn't seem to be one. It isn't as if best practices for communication in project management circles are unknown or hard to locate in publications. Ready for my short laundry list?

Icons show up suddenly in our EHR without written explanation or training on appropriate use. Single-sign on is being implemented in stages apparently. Many clinicians were never informed of this or even know what it is while others are already using badges to login to the system. I just noticed today that new hardware has been installed on the ward workstations. When I call the help desk to open a ticket for help in our EHR the request seems to go into a maw, never to be implemented or addressed. Order sets seem to be modified willy-nilly, wiping out user defined preferences and frequently removing functionality that is need for good patient care and safety. I'm just getting started but I'm relative certain that this sounds familiar to many of you.

So is there a solution? At my institution, I fear not. I have been offering my opinions about communication for over six years but I always seem to be beating my head against a brick wall. The best way to address this problem is to begin at the beginning. Every HIT project should have a well-defined communication plan. The plan should follow SMART principles. Multiple stakeholders should be considered in creating the plan and their input should be incorporated into the design. Communication should be bi-directional, comprehensive, and utilize multiple modalities to distribute important information. Finally, this should be a written plan that is periodically updated as communication needs and technology change.

By the way, last month we passed an important milestone-one year since the EHR went live. One might have expected a major celebration for this substantial achievement. Instead, there was almost no discussion of the event by administration, hospital staff, clinicians, or the community. I think this was an opportunity lost.

Electronic Prescription of Controlled Substances in Arizona

One of the blog posts that has recently been most popular was from last April on the electronic prescription of controlled substances. Now it is nearly a year later. So what has been happening in Arizona? Unfortunately, I was busy doing clinical work so I missed a recent committee meeting but I have access to a final draft of a proposed electronic prescription of controlled substance (EPCS) program for Arizona.

The interim final rule by the FDA was published in 2010. I suspect adoption has been slow for any of a number of reasons. IT departments in hospitals and clinician practices are overloaded trying to comply with requirements for the various flavors of Meaningful Use. The complexity of Stage I requirements has steadily grown as they depend on the year when attestation first takes place and ongoing annual compliance. Stage II of Meaningful Use with its new requirements, especially for information exchange /consumer engagement, kicks off this October. Also, planning for the change over from ICD-9 to ICD-10 is also requiring increasing attention.

Provider electronic prescription systems need substantial overhaul in order to comply with FDA requirements. Prescribing workflows that include utilization of the required digital certificates are still being developed. Vendors are busy modifying and testing their systems to enable Meaningful Use compliance. Furthermore, the requirements of Meaningful Use do not include EPCS so there is little incentive to expend resources on this capability.

Finally, there are a number of burdens on pharmacies. Their computer systems need to be upgraded in able to accept and manage EPCS. Other than clinician and customer demand, they have few incentives to do this. Pharmacies are also responsible for arranging third party audits of their controlled substance prescribing systems. The infrastructure needed to perform these audits needs to be developed. Unanswered is how the associated costs will be shared.

Under state leadership and stakeholder involvement, Arizona is poised to move forward on EPCS. The approach will be multi-pronged. Initially, an environmental assessment will be undertaken to study clinician and pharmacy readiness. Next, a limited pilot program at 5 sites will be funded using state resources to develop EPCS capabilities. Educational outreach will be undertaken to spread knowledge on availability of EPCS and answer questions about program requirements. Outcomes will be closely monitored and reported back to organizers. Ultimately, lessons learned will be used to encourage and facilitate EPCS throughout the state.

What will be hot in HIT in 2013? My thoughts.

Meaningful Use: Health IT departments will be dealing with every stage of Meaningful Use. Those who haven't attested for stage 1 will be considering whether to move ahead. They will need to calculate what will be needed to be successful. Those who have already earned their first incentive payments will need to track their annual performance on Meaningful Use and Clinical Quality Measures to continue to be eligible. Meaningful Use Stage 2 regulations have been completed. Offices and organizations will need to look ahead to become thoroughly familiar with the requirements. Software upgrades will probably be necessary to keep up with the escalating requirements. For example, availability of a patient portal will be almost indispensable. Also, arrangements will need to be in place to enable health information exchange with outside organizations whether this is via Direct or a more full-blown HIE mechanism. Finally, it will be important to monitor the on-going discussions concerning stage 3 in the Federal Advisory Committees on Health IT throughout the coming year. Preliminary plans for stage 3 have already been published but I am sure there will be some changes before the final regulations are set.

Tapering down of ONC financial support for HIT programs: The HITECH Act provided federal funding for many ONC initiatives. With the current fiscal crisis and spending cuts likely in the future, many of the activities sponsored by ONC will necessarily need to be scaled back. Already at the last meeting of the HIT Standards Committee in December Doug Fridsma discussed the new directions for the Standards and Interoperability Framework with much of the activity being transferred to the private sector. Support for other programs such as the Regional Extension Centers, Health Information Exchange state grants, Workforce development, Beacon Communities, and SHARPS grants face the end of their promised funding. Continued operation of these programs after the next year or so is doubtful. Progress on achieving major federal HIT policy goals will depend upon developing new sources of funding for these vital programs.

Health Information Exchange: Progress on achieving wide-spread health information is reaching a critical mass. Stage 2 of Meaningful Use mandates the use of HIE technology to qualify for incentive payments. State and private initiatives are becoming more mature. In some regions of the country, full-blown HIE is a daily reality. For many communities however, HIE is still a distant goal. My opinion is that Direct, even with its many limitations, offers the most satisfactory short-term option for many eligible providers and hospitals. Infra-structure, technology, and standards adoption are hurdles remaining to be overcome. To gain and maintain consumer trust, much progress still needs to be made on the policy, people, and technology fronts to address unresolved issues related to patient consent. A number of competing transport standards vie for more wide-spread adoption. And few of the larger HIEs have solved the conundrum of grant-free sustainability. A cultural transformation must occur for individuals and organizations in the health care system of the US to fully embrace the value of data sharing. Furthermore, they must be willing to pay for the capability.

ICD-10: Planning and training for implementation in 2014. This is a tough one because of previous uncertainty and future unknowns. We do know that implementation in the U.S. of ICD-10 was postponed from October 1, 2013 for one year to 2014 as announced by Health and Human Services Secretary Sebelius . We also know that the U.S. is one of the last major countries to introduce ICD-10 (ICD-10 was approved in 1990!) Recently there has even been some talk of skipping ICD-10 entirely and going with ICD-11 instead. The final revision version is due in 2015. A significant problem is that changes in the diagnosis coding system affect almost every clinical software application. Upgrading software to comply with ICD-10 requires substantial time, effort, and expense. Training will need to permeate through almost every level in the U.S. health care system. Moreover, false steps in adoption have the potential for substantial clinical and financial impact. I empathize with the organizations that are trying to dance to this confusing lead.

Mobile Health: This is an easy pick. Mobile health has been making headlines for several years and the momentum just seems to be growing. Smart phones, tablets, and small laptops are leaders of the pack. Almost every major vendor is designing mobile friendly applications for their EHR software. Mobile devices in concert with wireless-enabled products are poised to revolutionize remote monitoring of such things as weight, blood sugars, oxygen saturation, exercise, pacemaker function and others. Continuity of care is enhanced when home health caregivers use mobile computing to review and document in a patient's EHR. Innovative uses for mobile devices are being developed at an accelerated pace. But mobile devices bring with them new risks. They are easily lost or stolen and are one of the major sources of data breaches. Users may not be well-versed in the special security risks associated with use of their personally owned devices. Organizations face substantial challenges in centrally managing the security risks of these personal devices. There are satisfactory solutions available such as protecting the devices with strong passwords, encryption of personal health information, user training, and remote wipe technology. Security policies should be reviewed to assure that mobile device use is addressed. And the annual security risk assessment required by HIPAA would be incomplete if mobile technology is not considered.

Social Media: I am not a participant in social media, other than email and this blog, so that makes me both a dinosaur and a non-expert on the subject. You won't find me on Facebook and I would not be caught tweeting. Nevertheless, I think that the tide of the current social media blitz will continue to rise. The health care industry has jumped on the social media bandwagon. Many organizations are using it for advertising and self-promotion. Potentially, social media is a good method to distribute patient specific education materials and provide resources for self-management of chronic diseases. Patients will look to social media for links to clinical trials and other medical research information. Increasingly social media outlets will be used to collect and disseminate consumer feedback on the performance of individual providers and health care organizations. That is sure to keep many clinicians on their best customer relationship behavior and it may even help improve the quality of medical care in the U.S.

All in all, 2013 should be an interesting and challenging year for Health IT. I hope you will join me periodically and consider my thoughts on the journey.

EHR Implementation Update at 6 months

Surprisingly, it has already been 6 months since an enterprise EHR was implemented at the hospital where I work. Things should be going smoothly by now, right? I truly wish I could say that were the case. It may be an understatement to say that the EHR project has hit a few speed bumps. I hear that just a few weeks ago the medical executive committee considered a motion to turn off the EHR for 6 months while it is re-engineered to meet the demands of local practice and function in a more user friendly fashion. That must have been a really scary moment for administrators present at the meeting. I never imagined that a recapitulation of what happened at Cedars Sinai years ago would happen in Yuma. Instead of turning the system off, the decision was made to hire more consultants and IT staff to speed the "optimization" of the system. But I assert that the response of medical staff members was totally predictable.

Optimization is the process whereby the EHR is modified after go-live to correct unanticipated user issues. Above, I mentioned that user outcry was predictable. What did I mean? Adoption of an EHR goes through a well-known life cycle that has been validated by years of experience. First, the institution determines its EHR requirements and (often) produces a RFP (request for proposal) to be submitted to a battery of EHR vendors. Then a multidisciplinary committee sifts through the responses, selects a small group of finalists, makes site visits to hospitals where vendor products have been implemented, performs other due diligence activities and makes a final vendor selection. The next step is contracting for the software license and, often, vendor implementation support. Here, the hospital should take legally binding steps to protect its multimillion dollar investment. Once an agreeable contract is reached, the next steps are to refine local user requirements, perform work-flow analysis, set up governance structures to help manage the EHR, and begin implementation of change management strategies. Then the real fun begins.

Design and build of the software is carried out by local and vendor-provided IT staff based on data collected in previous steps. Testing of the software build in a simulated working environment is essential to verify interface function, safety of the build, stability and performance of IT infrastructure, and generally to make sure that everything works as designed. Everyone who will use the EHR must receive general and specialized training before go-live. Go-live is always a high stress time but really should go smoothly if all the preceding steps were done properly. Finally, optimization is really just part of the maintenance that all IT systems require after they are introduced. So where did the processes at my hospital go wrong?

First, I believe that the selection process was as good as it could have been. The selection that was made was the best that was available at the time. I think that many of those involved in the selection process now feel that we did not get the system or design support that we expected, however. I wasn't privy to the specifications and protections for the hospital built into the contract. Certainly, the investment required in post-implementation support is much greater than the administration expected. I hope the hospital was protected by an appropriate service level agreement.

I am disappointed that more user input specific to our local routines and workflow patterns was not incorporated by the design team. My impression has been that the design team did not do their homework. Governance structure for the EHR is still evolving. Even now, it is not designed to efficiently manage user feedback. The CMIO was almost the last IT staff member hired, a year after other major hires. There was little time to build a sense of team membership/ownership. Everything I have ever read has emphasized the importance of physician involvement from the earliest stages of EHR implementation. I think many of the current problems could have been mitigated had a qualified CMIO participated from the start. I made this point to medical staff leaders and administration members during the selection process; the consequences were predictable; and outcome could have been avoided. Communications have been poorly managed. It is hard to know if or when a help desk ticket has been acted upon and what the outcome is. There is no system of publishing institution wide lessons learned with the EHR. A few notes have been posted in physician's lounges and in mini-pamphlets of "tips and tricks." I would have liked to see ticket request information posted on the private intranet of the hospital. I would also have liked to have lessons learned posted to the intranet along with an index to help find information of concern. Finally, I cannot determine if we selected an unsatisfactory system. It does seem to have many inherent deficiencies but some of these may be design and build related. The next few months of EHR IT department work will see optimization steps that will seriously revisit the previous design and build activity, incorporating our nascent governance input. Hopefully, the future EHR will more closely fulfill the needs for functionality and usability our medical staff members demand.

Clinical Documentation Challenges

One of the most difficult tasks for EHR software is to capture clinical documentation. For many EHR implementers this is one of the last functions to be "turned on." There is a tremendous diversity in the breadth and depth of clinical notes. This is an area where "one size fits all" solutions usually do not apply. An advantage of EHR adoption purportedly has been reduction in transcription costs. This is achieved by clinical documentation software that eliminates the need for dictation and manual transcription. Often this accomplished through use of templates. Check boxes are filled in by the provider and then the narrative text representing the clinical note is generated by computer to provide a traditional-appearing note. Another method is the use of voice recognition software that in real-time converts voice to written text. As usual, I will relate my own experiences and thoughts:

Templates: I work with another surgeon who does mostly one type of operation over and over. He has a very standardized method with few variations. Previously, he dictated an operative report for each case. This task took at least several minutes of his time. That does no account for the time and expense of transcribing his dictations. I was able to create a template that accommodated almost all of his variations. There was one blank that required free text (the name of the anesthesiologist), two drop-down lists, and 5 fields that need to be completed with a typed number for the size of implants used. The surgeon is now able to complete an accurate operative with the template in about a minute. There is no doubt that this is a more efficient way for him to create his operative reports. In my experience templates work well for generally simple clinical documents where there are a limited number of possible variations.

On the other hand, templates do not work so well for me. I think it is hard to capture the nuances that are so important to recognize and report in clinical medicine. The majority of my surgical practice is individually tailored to each patient. The multiple types of conditions that I see and the complexity of co-morbidities make template-based documentation impractical. The types of procedures I perform are numerous and cannot be distilled down to simple templates. I need a tool like to dictation to complete operative reports for the surgeries I perform and the preparation of clinic notes for the outpatients that I evaluate.

Voice to text. My hospital eliminated most of the transcription department when the EHR went live in May. Dictation is still permitted but transcription has been scheduled to be eliminated by January 2013. Transcribed dictations follow a different work-flow than notes entered directly into the EHR because they must be scanned. The hospital administration decided to license voice recognition software for use by clinicians to assist in their documentation. (Recall that our EHR implementation was a "Big Bang" so transition was from paper to all electronic without phased introduction of functions or any pilot projects.) For some clinicians, voice recognition works well, with acceptable accuracy. For me, the accuracy is somewhere less than 85%. Some of the mistakes that are made result in text that at best has a number of embarrassing errors and at worst is nonsensical even to the creator of the note. Optimization of software by "training" is not feasible. It takes too much time and disrupts workflow when attempted on the fly. The output rate for voice to text during a dictation is unpredictable so that it can sometimes be near real-time but at other times as much as a sentence or 3 are printed after a delay, then all at once. Corrections on the fly completely disrupt productivity. Besides, with all the extra work the EHR engenders, I do not have the time nor is it the best use of my training to function as a copyeditor to fix transcriptions. I hesitate to admit that I am now resorting to typing most of my notes. This, I think, is definitely an unintended negative consequence of the EHR adoption. A solution that I favor is to have the hospital hire transcriptionists to review and edit each report. They would have access to the original voice files to help with the editing/correction task. (By the way, I used an earlier version of the voice recognition software the hospital licenses for a year in my private office during 2005-2006. I abandoned the software because of the unacceptable number of errors in my reports. I was actually "happy" to spend $1,000 a month to hire a skilled transcription service whose work I could rely on to be accurate and provide a professional result.)

One advantage of voice recognition software that I am impressed with is its potential to orchestrate navigation functions by voice commands rather through use of a mouse. Macros can be developed to facilitate tasks such as user logon, application launches, and page navigation among others. Programming can be as simple as recording a sequence of mouse clicks or it may require specialized programming training. Watch for increased use of voice controlled functions by users of HIT devices in the near future. Here is an interesting article I just read as I was preparing this post.

EHR Implementation-My first thoughts

It is time for some reflection about the EHR system I have been using since go-live at the beginning of May. These impressions are uniquely my own but I think they mirror those of many on the medical staff. The most surprising conclusion (though it shouldn't be) is that I am finding that change is especially hard to accept. The question I pose is: Is change hard because it is innately so or were there design, training, and implementation flaws that exacerbated the situation? Introspective IT professionals would be wise to revisit these possibilities on a regular basis.


Going counter to my natural inclination, I will discuss the positives first. One of the most positive elements of the implementation was having well-trained EHR specialists easily available during the first few months of use. These folks, some internal, and some with special training with the EHR, were generally very knowledgeable and could answer most questions. They had access to resources to get quick answers when they were stumped. The hospital administration wisely extended its short-term commitment to keeping these people around when they recognized how much the service was needed even 6 weeks after go-live.

The most positive aspect for the inpatient EHR from my point of view is that I don't have to search the ward looking for a patient's chart. I can assess the record from any computer on the hospital network as well as remotely from home. It is a lot easier to locate incomplete charts that need additional documents or signatures. I have helped develop two operative report templates for a colleague does a few procedures over and over. He can now complete the operative reports just as accurately in about one third the time it would take to dictate. This doesn't work as well for me because I do so many different types of procedures. I will have more to say about my documentation difficulties later.

I have spoken to a few nurses about the system. Their assessments of the EHR seem generally much more positive than that of physicians.

Now I will discuss some of my criticisms. I don't the same as a lot of physicians that I have read about in EHR case studies. For a lot of things I do, I don't feel the EHR is an indispensable step forward and that I would never go back. A lot of my complaints stem from poor overall engineering of the system where usability and attention to clinician workflows could not have been high priorities of the design team. The system is clunky, makes us do things that don't make sense in a way that does not seem natural and that does not follow customs and patterns many have come to expect when using computer systems. A laundry list of my complaints would be too long for this post.

Patient Safety: I have run into the problem many times where a patient's medications cannot be fully documented. Only medications in the EHR data base can be used. That data base is not exhaustive by any means. For example Combivent inhaler is not on the list either generic or by trade name, as far as I can tell. Furthermore, that is no work around to enter a medication not in the data base by free text so that at least it shows even if it is not in structured format. True, you can enter the drug in a patient care note but unless someone searches for and finds this specific note it will not be apparent that the patient is taking the medication. To reiterate, it does not show on the patient's medication list and is not available to the system for clinical decision support when drug-allergy and drug-drug interactions are being checked. Finally, as far as I know, there is no policy that has been promulgated to clinicians to explain how one goes about bringing this to the IT department's attention and correcting the problem.

Order sets available at go-live in no way reflected local preferences. They were company generic sets and had a frustrating number of inadequacies. The third CMIO in 3 years has just started working at the medical center. The governance structure to deal with order set development and maintenance does not yet exist. There is no capability for clinicians to individually modify, amend, or add to the pre-determined list of order sets. Some parameters of existing order sets can be pre-selected and saved as favorites.

Results: Access to laboratory results is essential for patient care. Our system offers several options for locating and reviewing lab results. The trouble is that I am not sure where the best place to look is. Results are presented in directory format that requires one to open sub files to see all the results. I have found that I sometimes miss results that are important to me. I hate to say this but in the old days of paper or with our previous computerized lab reporting system, I could feel secure that I was viewing all the daily labs and cumulative summaries. Now-not so much. I am not alone among clinicians in voicing this concern.

Elements such as setting up in baskets to receive and show results were not configured individually with clinicians. It took me months to learn what I did not know about my personal work space-that I had not been set up to receive results. This was potentially dangerous for my patients and for me. I cannot understand why someone from IT did not sit down with each clinician and go through a checklist of options for how to configure the system to match their preferences. This seems like EHR 101 to me. I am still making discoveries about configuration issues at four months after the initial implementation where significant discrepancies in configuration result in differences in my screen views vs. how others in my same specialty.

Ease of Use/Efficiency of Care: Clinical documentation. The plan was to offer about one third of the medical staff the use of voice recognition (VR) software for dictation, once they completed creation of user files and had training in the use of the software. Many of the hospital transcriptionists were laid off. Some clinicians were expected to develop point and click templates; others were expected to continue to use dictation until the end of the year when dictation would be phased out completely. The number of VR licenses was rapidly increased due to unexpected demand by clinicians. A separate decision was that positions for transcriptionist/editors would not be created. Sole responsibility for accuracy of dictations rests on clinicians and spell check software. At first, I was an enthusiastic supporter of this enterprise version (but not the latest version.) Then I started reading some of my previously created notes. I found the number and types of errors to be unsatisfactory. I tried to solve this by running spell check on every note. This took time but did not significantly increase the accuracy rate. Some of the errors I were such a distortion of what I said that I would not be able to correct them without listening to the original voice file to discover what was really said. I have tried taking the time to train out the errors but this is time-consuming and did not seem to be achieving the desired effect. More and more, I am resorting to typing my notes to achieve the accuracy that I feel is needed for a medical document. It is that or proofread and correct every document. That is not efficient use of my time. Isn't that why voice recorders and transcription systems were developed in the last century in the first place?

I could go on but I will stop here. IT staff say they are committed to addressing clinician concerns, optimizing the systems, correction errors, and providing on-going user training. That remains to be seen. While I don't think clinicians will reject this system, the successful implementation of our EHR is a work in progress.

EHR/HIT Training-MyThoughts

These are some of my thought about EHR Training. I recently went through clinician specific training to use the EHR being installed in the hospital where I work. I wrote about my experience, which was not very satisfactory. I've had some time to process my impressions and hopefully will put together some useful conclusion in this post.


The training for physicians where I work consisted of two 4-5 hour classroom sessions. The training primarily was a lecture/demonstration format, although participants were assigned some exercises. Printed training aids were limited, poorly edited, had some confusing errors, and were only provided at the time of training, not before. Navigation instructions to accomplish basic tasks were few and often did not follow clinical workflows. My biggest complaint is that the training had few permanent artifacts that could be reviewed later. The sessions were repetitive for the trainers, who became very familiar with the system by conducting numerous classes, but not for the future users who had only one chance to learn information critical to their livelihood and the safety of patients. The result is that the trainers became excellent super-users to help clinicians after go-live but the clinicians were poorly prepared to use the system. This form of training was expensive for the institution because of the need for a large number of trainers and specialized classroom space required for the sessions. The pace was often determined by the trainers rather than the students and could not easily accommodate those with different levels of computer skills. My experience was that when I got stuck at some phase, often I missed a big chunk of training as the class moved ahead without me. Several of the clinicians received pages and phone calls during the classes that either took them out of the sessions or were distracting to other attendees. I'll say it again, there were almost no permanent guides to refer to later during go-live.

I envision a different approach. First and foremost, training should recognize and follow the workflows encountered in real clinical practice. This means that curriculum developers need to have a strong and broad-based clinical background. Next, as a clinician, I want to have the control to learn at my own pace, at a time I find convenient. I would like to be able to review training materials as many times as it takes to learn how perform essential tasks. Furthermore, training that is based on a set of training artifacts can be reused to train new staff members without the need for the institution or vendor to maintain and support a large staff of permanent trainers. Self-directed learning suits the needs of busy clinicians better than the options we were provided. I learned these lessons first hand in my graduate program for a master's degree in medical informatics.


One of the challenges of taking an online degree was the need to learn and rapidly master a variety of new computer applications. Here is a short list of the some of the applications we used at Northwestern when I was a student: WebEx, Backboard, Visio, Microsoft Word, Microsoft Excel, TreeAge, Microsoft Access, Microsoft PowerPoint, Microsoft SQL, Adobe Connect Pro, SimulConsult, and EndNote. One of the more difficult academic assignments was to create a database in Access from a schema we were given, in little over a week. I'd had no prior exposure to MS Access. The teaching assistant for the class created a WebEx recording and demonstrated each of the required tasks in a session that took her only about 45 minutes. I watched the recording a few times. I then broke out the tasks I needed to accomplish and created an index using the time code for the WebEx recording that correlated with the tasks. I used the indexed times to review relevant portions of the session until I could accomplish the tasks myself. This made it relatively easy to complete the assignment even though the software program was completely new to me. It turns out that this was one of the most valuable lessons learned in the graduate program.


The approach I recommend is applicable to many adult learning needs. First, you need to realize that not everyone is a good teacher. To create useful educational materials requires a team of skilled individuals. Curriculum development is a specialized skill set that is an essential element. Once a curriculum has been developed then a scripted teaching plan must be formally written out, much like a screenplay for a TV show or a movie. Those with creative skills to actualize the plan are needed next. This requires skill with special software that that has the ability to record screen movements, webcam output, capture voice over, and insert presentation graphics. Such software is readily available. Some sites even offer many functions at no cost. Indexing capability within the software is a must to make the materials accessible and user- friendly. Additional skills with video and audio editing are helpful as is the ability to utilize web resources such as video streaming optimization, etc. The final product can be distributed as free content on the Web (YouTube, for example), can be sold commercially as a training aid, or be made available over an organization's private Intranet. Realistic training exercises could be developed. Computerized scoring is an available tool.


I realize there are many approaches to teaching EHR use. The technology I have recommended is available now to enable user-friendly training that respects the learning needs and time restrictions of modern clinicians. Taking this approach can also limit training costs and improve the quality of EHR instruction for the sponsoring institution or vendor.