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Wednesday, May 27, 2009

Training the EMR: A Case Based Perspective - Best Practices and Training the Trainer

Part Three of a Four-Part Series

It is estimated that only 5% of hospitals in the US have a completely electronic medical record system (EMR). Given this statistic and wide-spread public support for President Obama's healthcare reform initiative, the EMR is standing on the eve of an era of accelerating growth. In the first two articles in this series, Training the EMR: A Case-Based Perspective and Training the EMR: A Case Based Perspective - Drilling Down, I have compared this position to pioneering on a new frontier and have discussed some of the challenges and decisions clinicians and trainers face in "charting" new territory. In this third and final article I want to briefly comment on training the trainer and best practices in training the EMR.

Due to the tightly-knit relationship between medical knowledge and charting medical results, I believe that medical schools will offer degree programs for teaching and supporting the EMR. I believe this will happen sooner rather than later. For now, however, instructors, trainers, and designers from many different backgrounds have an exciting window of opportunity to enter the medical field as EMR trainers. A case in point is the new hospital where I worked as an EMR trainer this winter. During startup, the hospital employed traveling consultants to train large groups of staff. Many of these folks, who have had experience bringing Cerner and other EMRs online at hospitals throughout the nation, have remained, and the hospital is currently in the process of hiring FTE's as well.

Trainers at our new hospital come from varied backgrounds. Some entered through the doors of traditional education and/or HR Training. Some are clinicians. Others, like myself, came from IT support backgrounds. Yet others were promoted from internal ranks - unit support techs who had undergone a rigorous training program with both the physicians and the nurses during the hospital's startup phase. Assuming this population of trainers is representative of hospitals across the country, one might presume that programs for "training the trainer" may vary depending on individual blends of content skills, presentation skills, technical skills, and teaching strategies. Even so, a training department must define a clear set of over-arching goals and objectives as well as a way of effectively communicating them, and objectively and reliably measuring achievement toward them.

Based on an opportunity to train and be trained in the EMR at a new hospital in our area this past winter, I want to jot down a few observations and suggestions on what I learned about best practices during this period - recognizing that in the new frontier, these are still in process of being defined and discovered. I'd like to start by discussing a few of the learning theories and strategies that can inform best practices in training the EMR. These are Adult Learning Theory, Constructivism, Critical Theory, and a blend of Experiential / Situated / Hands-on /Discovery teamed with Small Group Learning - using simple coaching techniques such as guiding the eye and sophisticated software simulation tools such as a virtual hospital. Positive reinforcement and a systematic analysis and design process that yields clear and measureable goals and objectives that are effectively communicated are also critically important to a successful training program.

Many precepts from Adult Learning Theory are of course applicable to training the EMR. I'd like to discuss the following ones specifically.
  • Adult learners require autonomy and control over their own training and learning. They should be able to make suggestions about the when, the where, the how, and even the sequence of learning. One example of accommodating this need could be providing access from home. There are many others.
  • Adult learners require processing time to link new knowledge gained to previous experience. This simply means that training schedules should recognize, acknowledge, and, inasmuch as possible, incorporate measures that accommodate this driving need to make meaning of new content. Allotting time for debriefing, reflection, and group discussion are some examples of how this can be done.
  • A key way to respect adult learners is to acknowledge them as collaborators and equals in the training process. It's okay to have a certain amount of give and take, or role switching, if you will, between student and trainer - or as one new nurse I taught noted with some satisfaction, "We train one another."
The simplest precept of Constructivism is that knowledge is not so much transmitted as it is constructed. Applied to learning the EMR, Constructivism simply recognizes that trainers and clinicians need to wrap their heads around EMR individually, whatever their background and whatever resources are provided to facilitate their learning. At the same time they need to negotiate their knowledge socially. This would include agreeing upon common language and terminology for teaching and communicating EMR screen objects, for example. Constructivist approaches oriented toward Experiential / Situated / Hands on / Collaborative and Discovery Learning are perhaps most uniquely suited for pioneering on the EMR frontier.

Critical theory and critical thinking skills become increasingly necessary in a society that is becoming more techno-reliant. Back in the "good old days," we faced a similar problem with print media. How often have we heard the admonition from our teachers and mentors, "Just because it's in print, doesn't mean it's true." Equally, just because the computer says so, doesn't make it true. An important aspect in training the EMR is reinforcing and affirming the clinician's clinical judgment. After all, software systems have been historically notorious for their low reliability scores in the engineering field. The best programs still have bugs. Additionally we all know that software users make mistakes. Hence the term GIGO - garbage in, garbage out - coined in the systems field. On the other hand and despite our best efforts, methods, and intentions, sometimes we human beings are just plain wrong. Sometimes clinicians are wrong. The best any of us can do is to maintain an attitude of alertness and respectful skepticism whether we use an EMR or a paper-based system, recognizing the EMR may come with its own set of perils.

Moving past the theoretical to the more concrete and practical, I'd like to offer the following "potpourri" of suggestions and ideas (credited to varied sources) which I found helpful in training and learning the EMR.
  • Training the trainer should model how the organization wants the trainer to train the clinicians. All the same rules should apply.
  • Training all out in front of your colleagues whilst working through your class content in give and take, stop and start fashion, as well as in a final dress rehearsal is recommended. At first glance, inviting your colleagues to critique you as you learn may sound intimidating, however, it can actually lead to a collaborative mentoring process on a grand scale. When done well, it can open to the individual trainer the wisdom and skill set of his or her peers, yield a rich learning experience for everyone as together they craft the instructional experience, and in the end, result in a great instructional product. In short, it can be time well-spent for everyone. Inviting new trainers to first observe the process may help them be more comfortable with trying it.
  • Along these lines, strategic management and arrangement of staff work space(s) and schedules to maximize time together and provide private time as needed can greatly enhance both the work and the learning experience for employees, put social negotiation and knowledge construction on a fast track, and encourage mentoring. I can honestly say that I was warmly received into the training group from the very first day, and in my entire time at the hospital, I never ate lunch by myself. And while I can function contentedly in either solitary or social mode, my social experience with the training group was fabulous and greatly enhanced my learning experience.
  • Developing short, fifteen minute to half an hour training segments and then teaching them right away as part of someone else's class may accelerate the learning process for the trainer. Additionally, continuing to shadow clinicians and other trainers throughout the training period is very helpful to observe a variety of work flows and training styles.
  • If you are using a virtual hospital or simulation, giving a new trainer a variety of log-ins representing different clinical roles and teaching them how to set up for a class early on could be very empowering.
  • In our hospital most trainers also provided day to day support on the units, and to this end, kept a shared descriptive log of problems and resolutions. Jump-starting a new trainer from the log, so that they quickly learn how to answer some of the most commonly recurring questions could be very empowering.
  • Situated learning is the preferred approach for training clinicians to use the EMR.
  • Computer simulation is the preferred tool for training clinicians to use the EMR.
  • Leading your students to the "Aha moment," and structuring your training to allow students to experience many small successes along the way is a powerful approach to teaching technology.
  • In a similar vein to the last comment, I was introduced to a training technique called "guiding the eye." At its simplest, it can be a refined way of pointing out objects on the screen. At its subtlest, it is a way of leading the user on a treasure hunt to locate certain screen objects and areas through the use of metaphor and descriptive language. Somewhat of a guided discovery learning approach, if you will. The rationale behind this approach is that if the student does the work of finding and identifying screen components, he or she will be more likely to remember them.

In the end, bringing the individual trainers or clinicians up to speed with the EMR is akin to project management on a smaller scale. It should have clearly defined educational goals and objectives, communicated to all the players. It has hard and soft deadlines or milestones with deliverables, with hopefully some flexibility built in-between. For trainers, learning the content and learning the training technique can run in parallel with both activities occurring early on in the training. In this way, no one need be surprised at the end of the training period.

In closing this series of articles on training the EMR, I recognize the topic deserves a really thorough evidence-based literature review - while this blog series affords only a lightweight treatment. But right now I have other fish to fry and other gardens to tend. Perhaps one day I shall return to this topic in a more rigorous manner. Undoubtedly, somewhere, sometime, somebody already has done this or is now in the process. In the meantime, there are many good articles out there about the EMR and its risks and benefits for the practice of medicine. I encourage you, my readers, to continuing exploring the EMR frontier.


Here are the beginnings of a list of other articles on job opportunities and training the EMR.
3 Emerging Skill Sets
More on Opportunities in Healthcare IT
Health Information Technology: the next frontier

The writer of this series has twenty years of experience in the information technology and education fields with an emphasis on systems analysis and design, including two years working for a university health center. She has earned a bachelor's degree in Speech Education from Bob Jones University, and an associate's degree in Computer Programming Technology and a master's degree in Educational Technology, both from Purdue University. Recently she spent 10 weeks as an EMR trainer at a new hospital.

On to Part Four in the series Training the EMR: A Case-Based Perspective - The Patient's Perspective

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