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.

The First Approved HISP comes to Arizona

Arizona Health-e Connection recently announced the selection of the first health information service provider (HISP) for Arizona. This is exciting news because this is the first step that will enable use of the Direct Project specification. Direct enables secure exchange of health information using a "push" type mechanism much like email. Unlike typical email secure transmission utilizes encryption of messages through use of cryptographic protocols that are powered by digital certificates. The protocols are very similar to online banking and online purchasing services over the Internet, two examples with which we are all familiar. The HISP is needed to provision health care providers with special health care email addresses and provide and manage the digital certificates. The digital certificates are issued by a certificate authority and are needed for trusted identification of the endpoints of the information exchange pair as well as for use in the encryption/decryption process. The selected vendor, GSI Health will also offer a provider directory (needed to obtain health email addresses and digital certificate information needed to communicate with others) and a web portal (software as a service) to enable participation in HIE for those who use EHRs where Direct is not included as a native service and even those for clinicians without EHRs. The basic service is very affordable at $45 annually for the digital certificate and $15 monthly for HIE access using the available portal. Check out the GSI web site for fees associated with EHR interfaces.

The benefits of using Direct are several. Information exchange using interoperable standards facilitate continuity of care, especially when transitions of care are needed and different providers are involved. Examples are discharge of a patient from a hospital with subsequent care by the primary care physician/clinician (PCP), referral from a PCP to a specialist, and transfer of a patient from an inpatient facility to a long term care setting. Other uses include reporting of clinical quality measures, communication with disease registries, public health reporting, and syndromic surveillance. Educated readers will note that many of these tasks are required in Meaningful Use Stage 1 or are included in the two Notices of Proposed Rule Making (NPRM) for Meaningful Use Stage 2. Some have criticized the Direct Project for not having all the bells and whistles of more robust information. Nevertheless, it is a potential game-changer for freeing up the flow of clinical information between authorized clinicians. Now let's review some of the barriers to use of Direct.

Probably the most significant barrier is the resistance to sharing information. Many clinicians and health organizations view patient data as a personal possession. They refuse to consider that the data belongs to the patient and that sharing of data is essential to provide the best possible medical care. Another barrier is that we are at a point where the technology for information exchange is not wide-spread. Think of the similar problem faced by early adopters of the fax machine. For electronic information exchange to make sense, we must of trusted partners who are willing to exchange information and have the necessary technology to do so. The greater the number of partners, the greater the value of the capability. The workflows to incorporate Direct in routine clinical care need to be developed and promulgated. Most vendors do not support Direct natively in their EHR systems. This will need to change in the next two years, unless a major change is made to the NPRM to preclude the proposed standards for interoperability and EHR certification, including the prescription for information transport via Direct. Many EHR vendors also need to work harder to enable preparation of summary documents (CCD) that facilitate transmission of essential clinical information between clinicians (in stage 2 this will need to comply with the consolidated CDA standard.) Finally, many state public health agencies are not prepared for the changing rules and will need to move forward rapidly to enable receipt of information from clinicians via Direct.

These are exciting times. Rapidly changing technology will eventually enable clinicians to provide higher quality medical care for reduced cost. Finally, it is important to remember that Direct is just one hammer in an arsenal of tools that will be available to help achieve the health care goals of the US.

EHR Implementation: Go-Live Week

I recently wrote about my experiences during training to use the EHR to be implemented at the hospital where I practice. That training has been put to practical use this week after Go-Live started in the early hours of Tuesday. Here are some thoughts about my early experiences. Admittedly, I am just one physician in a large organization and my use of the system to date has primarily been in an orthopedic outpatient clinic.


I want to start out with positive comments because I am wired to be critical rather than complimentary. We have had on site-support by engineers and other experts from the vendor, in addition to the local implementation team members. These folks were flown out to Yuma to help us over the "speed bumps" of early implementation, as it was couched by our CEO. The few vendor experts I have encountered have been quite impressive. They are knowledgeable about the software and seem to have efficiently connected with the local team to help solve problems. To their credit, they have been able to fix the majority of issues that have been raised in a most expeditious fashion. Although they were not experts in all modules of the enterprise software, they seemed to have sufficient breadth of knowledge to address almost every issue I had or knew who to go to for appropriate help. Also, their priority has clearly been to provide the one-on-one support that is so valuable at this point in an implementation. None of the pre-go-live activities was able to adequately simulate the daily record keeping needs of a busy clinician.


Now for my usual negative, critical, (?constructive) comments. Even though I have been told that every Go-Live is chaotic, I think many of the problems I have had this week were preventable. Stephen Covey in his The 7 Habits of Highly Effective People advises us to start with the end in mind. So in my opinion "the start" was not completed very effectively. One lesson learned from prior EHR implementations has shown that needs assessment is a very important step. In talking with the clinic staff, I have come to the conclusion that this assessment was carried out in a superficial fashion. Secondly, perhaps the biggest challenge in implementing EHRs is adapting the software to local clinical workflows. This requires in-depth understanding of current workflows and a clear concept of how this will change with EHR adoption. The workflow assessment for our clinic was too simplistic and in many was did not depend on actual, in-person, observation of existing workflows. You might refer to a couple of my previous posts in which I discussed workflow. Finally, I don't think the timeline for implementation allowed enough time for pre-go-live testing of the production environment. I am guessing that a lot of the glitches we have seen this week probably could have been discovered and corrected by following checklists developed based on lessons learned from prior implementations of this vendor's software.


Overall, I think that Go-Live week went about as well as could be expected. I have been impressed with the professionalism of the support team and their ability to rapidly resolve issues that have come up without needing to resort to a lot of administrative overhead. I look forward to developing proficiency and optimizing the EHR capabilities to improve my ability to deliver high quality patient care.