In the first part of this series, we took a look, from a case-based perspective, at some of the general complexities and challenges faced in implementing a new Electronic Medical Record System. In part two, I want to drill down a bit more to look at some of the barriers and challenges that clinicians and trainers encounter as they try to learn and use an EMR. I will also offer up some suggestions, as a jumping-off place for considering solutions.
As previously discussed, I had an opportunity earlier this year to actually "swim in the soup" as an EMR trainer for a new hospital. This hospital was started by a local healthcare organization in a bold move to provide integrated inpatient/outpatient care as well as a state-of-the-art, patient-centered hospital in our community. The first article discusses how the hospital (the inpatient side) ended up with a different EMR system than the outpatient side. In this article I want to examine from instructional design and critical theory standpoints how trainers, clinicians, and ultimately the patients themselves are surviving and coping on the EMR frontier.
Theoretically one benefit of the EMR is to make medical information more accessible to those who need it most. Ironically it may introduce new challenges to accessibility. Several years before building their new hospital, the local outpatient care organization joined a larger network of hospitals in the region. While this alliance created new opportunities, it also added another layer of standardization to the local organization with respect to licensing requirements and the Joint Commission (JCAHO). As a result the new hospital went with the EMR (Cerner) used by the other hospitals in the network. The local outpatient side stayed with Epic. Additionally the new hospital used a later version of Cerner than the older hospitals in the network.
While EMR training at the hospital has been largely effective, staff and trainers have encountered disconnects in our new frontier. One disconnect revolved around the EMR manual(s). Picture, if you will, a continuum with training by function at one end and training by process at the other. Training by function referrs to sequencing the content to be learned by the basic functionality of the EMR software, usually as laid out in a software manual. Training by process referrs to a more "situated learning" approach, sequencing content to be taught by work flow or "day in the life" of various clincian roles. Generally speaking, trainers who came from a clinical background leaned more toward teaching by process, while trainers from professional training, adult education, IT, and traditional education backgrounds were more familiar with teaching by function. In actuality, trainers experimented with a blend of approaches, particularly as classes decreased in size. The logistics of bringing a huge influx of staff on-board during hospital start-up required classes that were large and more generalized. Training was instructor-lead and occurred in 8 hour blocks in classrooms and computer labs. After going live, the flow of incoming staff tapered off and training became more individualized and flexible in schedule - with trainers providing "at the elbow" support and instruction to clinicians.
Because the hospitals in the network had standardized on the EMR (more or less), the local organization did not have control over their training manual even though their new hospital broke new ground in conception and design and had also implemented a newer version of Cerner. The manual's copyright remained with the parent organization. The process to update the manual was a committee-reviewed, hierarchically-negotiated process at the highest levels, while the need to update, refine, and retrain new procedures occurred almost daily in our new frontier. Our education department was quite resourceful, inventive, and effective in designing and delivering retraining to the units. The problem came with getting these same changes into the manual for new employee orientation. While manuals are usually out of date the minute they go into print (especially in the world of technology), they can still be a valuable tool for the instructor, the learner, and the organization. At the least, manuals help trainers keep "on the same page" about the content to be covered, whether they train by process or by function, thus ensuring more consistency for learners overall. (After all, learners do need to be able to speak the same language after they emerge from training.) Additionally many learners find that underlining key points, jotting notes on the pages, and reviewing/rereading the text constitute an effective strategy for reinforcing retention and filling in gaps in understanding that may occur during initial instruction.
In our case new employers were provided with manuals at the onset of training. These manuals had to be ordered from the parent organization and were a significant training expense. Therefore, learners were asked not to mark in them and to hand them back at the end of training. The manuals weren't necessarily up to date with the training software or with current procedures. All that aside, I noted that many new clinicians were reluctant to relinquish their manual at the end of the training. Their manual was their security blanket, depending on where they were in their experience with the EMR and computers in general. It was also a way that empowered them to teach themselves - one of the fundamental precepts of adult education theory. New employees were given the URL of the most recent PDF version of the manual during orientation, but for many, access to print from home was problematic, and opportunities to print at the new hospital were relatively inaccessible during the orientation period.
Some quick suggestions regarding the manual - since the local organization was pioneering a new hospital in conception and design, and had implemented a newer version of the EMR, they should logically be given more control of their teaching manual. This would allow them to quickly integrate changes and to print "throwaway" copies that clinicians could write in and keep. To ensure each group of incoming employees receives the most up to date version, manuals should be printed locally at the time of each orientation, which takes place every two weeks. The manuals themselves should contain the URL of the latest, most current PDF version. Clinicians should be able to reach this URL from any location or computer whether at home or at work.
In my opinion, a software simulation package would be the tool of choice in teaching an EMR, and the larger healthcare network and the vendors had the wisdom and foresight to implement one. Along with the manual, the new hospital shared a simulation tool with the rest of the hospitals in the network. A workbook bridged between the simulation tool and the instruction manual, but given the rapid nature of change on the new frontier, the three were often out of sync. The simulation tool mirrored the locations for the entire healthcare network - but also provided imaginary "training units" for each hospital. Because of HIPPA privacy rules, the simulation software contained no real data, only test patients assigned to the training units. Unfortunately, the patient names, demographics, and medical data resembled "leftover test data" created by programmers more than they did realistic medical cases. As a result, test patient data did not complement the situated learning approach being pursued by many of the trainers. Many of the experienced trainers became adept in setting up their own realistic teaching scenarios with the test data. This required obtaining access to a number of different clinician roles (physician, pharmacist, nurse, etc.) which required a different log-in for each role. Allowing new clinicians to practice, experiment, and familiarize themselves in the train domain on their own (after a training session), was problematic, because they might choose a patient who was currently being utilized by another trainer for another class. While simultaneous electronic access to a patient is normal in a production situation where different clinicians (pharmacy, nursing, physical therapy) need to enter orders and chart results, unintentional simultaneous access in the learning environment can be quite confusing to both learners and trainers. This difficulty of providing additional practice time to new clinicians is unfortunate, because many wanted to become more familiar with various charting forms before they "hit the floor" - and none wanted to appear to fumble in front of a patient (or their colleagues).
The simulation software, referred to as "the train domain," was actually a clone of the production software - only several versions back, and had to accommodate the fact that different hospitals in the network were using different versions of Cerner. Synchronizing the train domain with the most common production features across the healthcare network required long build times that took the better part of a weekend to finish, and sometimes the better part of the following week to troubleshoot. Consequently synchronization only took place bimonthly. The test data in the train domain reset itself every night, a fact which had advantages and disadvantages. Advantages were that each new day dawned with a clean slate and students and trainers got plenty of practice and review in bringing their patients back to where they were the day before.
Simulation is an invaluable tool for teaching new clinicians, and the healthcare network has a good start with their train domain. Some relatively minor changes could make it even more effective. The test patients should have real names, and orders, tasks, and medicine administration records realistic to their diagnosis. Within the test population should exist a variety of ages and cases. (Conceivably setting up realistic scenarios in a virtual hospital could be a full time job in the EMR frontier!) Additionally the train domain should not only contain training units but also practice units - ideally one for each new clinician. These should be available from any computer whether at work or at home. The workbook exercises should sync with both the training software and the manual. To effectively set up for their classes, all trainers should be provided multiple log-ins that accommodate a variety of clinician roles.
A more profound change would be to have a train domain that was instantaneously and completely up to date with the features in the production environment. The education department has started a collaborative project with the parent organization to this end, so the new hospital's train domain will become even more streamlined and effective over time.
Another disconnect experienced by new clinicians was access from home - both to the employee website in general (which had loads of clinical resources) and to the EMR simulation software specifically. While it is impractical for organizations to support any home-based desktop, laptop, or palmtop that comes along, they could at the least offer some hardware and software configuration standards to employees who want to connect from their home computers - preferably in the form of a handout during orientation. IT departments could also offer some minimal assistance - fielding general setup questions, while referring employees to outside vendors for more difficult problems. I believe the gains from providing wider home access for learners would offset expenses incurred in doing so. In my opinion, an optional training session for connecting from home should be included as part of an employee orientation.
In conclusion, access is tantamount to employee success. Removing access barriers to manuals and simulation tools in the end provides healers access to their own creativity, ingenuity, and problem-solving abilities, and even more importantly to their clinical judgment and critical thinking skills. In preparing clinicians to practice on the EMR frontier, the old saying still holds true: Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime.
Our new hospital is one small case of what is occuring with the EMR across the nation and across the world. Pioneering has always been a process of discovery that requires breaking new ground, navigating uncharted territory, and creating your road map as you go - as well as the uncanny ability to bring order to the relentless and ever-present chaos. Take my EMR trainer for example. At one point during my training, we had a scheduled session, however there was no room or computer available anywhere - so we made our way to the nurses' lounge, sat down on a sofa, and she taught me straight from the book while the nurses ate their lunches (Sort of reminded of me of the impromptu nature of the five day clubs and street ministries I participated in years ago as a Christian youth worker in Philadelphia - AND of the old adage "The Show Must Go On."). It's always a marvel to see someone pull this off. In my teacher's case, I think she could have taught me while hanging upside down from a flag pole if she'd had to, and she wouldn't even have batted an eye.
This series of articles is my own personal road map through the wilderness of the EMR frontier.