Keywords
electronic health records - computer simulation - COVID-19 - professional role - graduate medical education
Background and Significance
Background and Significance
Since the novel coronavirus disease 2019 (COVID-19) public health crisis outbreak in early 2020, health care systems nationwide have developed contingency plans to prepare for surges in demand for inpatient and critical care services.[1] Oregon Health and Science University (OHSU), the state's sole academic medical center, faced extreme capacity constraints in August 2021 when the COVID-19 delta variant drove up cases and hospitalizations to the highest level in the state since the start of the pandemic. In response, OHSU decided to execute on surge plans, expanding inpatient and critical care capacity.
Critical Care Capacity Expansion
OHSU deferred elective procedures and converted a post-anesthesia care unit (PACU) into an intensive care unit (ICU) to increase capacity for critically ill patients. Suspension of elective surgical cases requiring anesthesia allowed the deployment of certified registered nurse practitioners (CRNAs). CRNAs, with their unique training background and skillset,[2] were asked to provide care for critical care patients in the surge ICU under the supervision of an experienced critical care physician.
Workflow-Based Electronic Health Record Training
The electronic health record (EHR), a critical component of clinical workflows, generates large volumes of data daily, especially in the ICU.[3] To prepare the CRNAs for a new clinical setting with unfamiliar workflows within the short implementation timeline necessitated rapid onboarding, including workflow-specific EHR training.[1] There have been some concerns on the impact of COVID-19-induced changes in EHR use patterns on physician mental health.[4] Additionally, previous studies reported that high-fidelity simulation-based EHR training allows learners to gain critical EHR skills relevant to their clinical setting while simultaneously being a high-quality educational activity that could mitigate provider burnout.[5]
[6]
[7] We applied this paradigm during the operational crisis to rapidly facilitate our redeployment of the advanced practice providers.
Redeployment of Clinical Informatics Fellows
In addition to mobilizing clinical staff to change or expand practices in response to the COVID-19 surge, OHSU tasked Clinical Informatics (CI) fellows to respond to the crisis by deploying provider training. The precise nature of the training required the instructors to have contextual knowledge of clinical workflows and information systems. With their background as physicians who have completed training in a clinical specialty, CI fellows have domain knowledge of CI and are uniquely positioned to deploy the training. CI fellows have made meaningful contributions to health systems' responses throughout the pandemic, although only a few were explicitly involved in developing and deploying training initiatives.[8] To our knowledge, this is the first EHR training program for rapid operational change led by CI fellows.
Objective
This study aimed to deploy CI fellows as lead EHR instructional trainers for clinician redeployment as part of an organization's response to disaster management.
Methods
Setting and Participants
We conducted this study at OHSU's main campus which uses EpicCare (Epic Systems Corporation, Verona, Wisconsin, United States) as its EHR. CRNAs redeployed to the surge ICU were offered EHR training using our high-fidelity simulation-based patient cases and provided information about accessing our video library. The surge ICU was operational from September 1 to 27, 2021 ([Fig. 1]).
Fig. 1 Timeline of events for the development and deployment of the electronic health record training curriculum. ICU, intensive care unit.
Curriculum Development
CI fellows led a multidisciplinary team consisting of senior critical care physician informaticists, senior EHR trainers, and an educational technologist to work closely with inpatient and critical care physician subject-matter experts. This group helped define learning objectives and iteratively refine the curriculum, using Moore's expanded outcomes framework and based on prior curricula used for employee onboarding, for in-person training sessions.[5]
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[9]
[10] The curriculum emphasized efficient information retrieval, order entry, note creation, and other strategies to ensure patient safety. The content was prioritized based on the purposed workflow for the CRNAs in the surge ICU as determined by their clinical leader (K.B.) and knowledge of prior institutional patient safety vulnerabilities from EHR use through an author's institutional patient safety role (J.A.G.). We tailored the training to workflows and user interface customizations unique to the ICU environment. Additionally, we created a library of workflow-specific, purposefully built annotated videos to allow for asynchronous review of key concepts.
Deployment of In-Person Training
The single-session in-person training, conducted in a simulated EHR environment as previously described, was offered on six separate dates and times to accommodate learners' varying schedules immediately before and at the opening of the surge ICU. Each session was of 2.5 hours which allowed for demonstrations and practice in the simulation environment, followed by customization of the user interfaces in the production environment of the EHR. A senior physician informaticist delivered these sessions with at-the-elbow support from CI fellows. All CRNAs redeployed to the surge ICU attended the training.
Development and Deployment of Video Library
While CI fellows curated some training videos from the EHR vendor where applicable, due to the specific workflows of our institution, we needed to create most videos de novo, as other health care organizations have also noted.[7] These videos were, on average, under 5 minutes in length and hosted on our institution's intranet along with a user guide document with embedded hyperlinks to the videos. CRNAs were given instructions on accessing the videos but were not required to view them.
Evaluations
At the end of the in-person training session, all participants were provided a two-dimensional barcode (QR code) that connected them to the immediate posttraining survey using Qualtrics (Seattle, Washington, United States). This survey assessed the in-person training based on the participant's satisfaction, perceived usefulness and improvement in EHR skills, and the pace and clarity of instruction. We also evaluated the training experience holistically with a single-question Net Promoter Score (NPS; [Supplementary Appendix A], available in the online version).
After the closure of the surge ICU, we sent follow-up surveys to all participants by e-mail to evaluate the impact of training on perceived performance in the surge ICU, the specific concepts taught, and the videos watched. We also asked the CRNAs about the perceived usefulness of this activity for their anesthesia role ([Supplementary Appendix B], available in the online version).
We collected pageview data from the online video library. We also encouraged written feedback on all surveys and received unsolicited feedback, through e-mail, from others who viewed the video library.
Statistical Methods
We analyzed all data with descriptive statistics using RStudio (RStudio Inc., Boston, Massachusetts, United States). Study procedures were reviewed by the OHSU Institutional Review Board and deemed exempt from individual informed consent.
Results
In-Person Training Sessions
Eighteen CRNAs participated in the hands-on training, and 15 participants (83%) completed the survey immediately after the training session ([Supplementary Table S1], available in the online version). All respondents felt the training would improve their EHR skills, with 11 anticipating a great improvement (73%), and the remaining four “a lot of improvement (27%).” Regarding perceived usefulness, 13 felt the training was “extremely useful (87%),” and the remaining two felt it was “very useful (13%).” The majority of respondents felt the activity was enjoyable, with 10 finding it “extremely (67%),” four “very (27%),” and one “moderately enjoyable (7%)” As shown in [Fig. 2A]. Respondents also felt the content was relevant and expressed appreciation for the training ([Supplementary Table S2], available in the online version): “Really liked the instructors teaching style…. Great job considering the audience and prioritizing time and materials.”
Fig. 2 Participant survey data. (A) Postactivity satisfaction survey immediately after the in-person training activity. Certified registered nurse anesthetists (CRNAs; n = 15) were surveyed on a 5-point Likert's scale for whether they felt the simulation-based learning activity was enjoyable, was useful, and improved their skills. (B) Postactivity satisfaction survey immediately after the in-person training activity. CRNAs (n = 15) were surveyed on a 5-point Likert's scale for their impression of the learning activity's pacing and ease of following the instructor. (C) Postdeployment survey after the surge intensive care unit (ICU) closed. CRNAs (n = 12) were surveyed on a 4-point Likert's scale for their impression of the usefulness of the activity for their surge ICU deployment, as well as the degree to which the activity increased their comfort level.
In terms of the perceived structure of the session, all but one respondent felt the pace of the session was “just right (93%).” Eight respondents felt the instructor explained concepts “just right (53%),” and the remaining seven found it “extremely easy (47%)” as shown in [Fig. 2B]. Comments also reflected learners' satisfaction with the structure of the simulation activity: “Moved at a good pace while covering a bunch of info in a clear, concise way.” Overall, the NPS was +87, and 14 (93%) intended to view the video library at a later date.
Postdeployment Evaluation
After the surge ICU closed, 12 CRNAs completed the post-deployment survey (67%; [Supplementary Table S3], available in the online version) Of those who completed the survey, eight worked 3–5 shifts (67%), two worked 6–10 shifts (17%), one respondent worked more than 10 shifts (8%), and one respondent did not work any shifts (8%). Of the 11 respondents who worked in the surge ICU, five respondents each worked predominantly day shifts or night shifts (45%), and one worked both equally (9%). Ten participants felt the training prepared them to work in the new role with minimal guidance (91%), and one needed significant guidance (9%). All respondents felt the training increased their comfort level with the redeployment, with six respondents indicating “a great deal (55%)” and the remaining five indicating “a moderate amount (45%)” as shown in [Fig. 2C].
Respondents also expressed appreciation for the training: “while the class was a whirlwind, it was amazingly informative and I learned a lot more about Epic. I think that I will be able to look up ICU/ward patients more easily and thoroughly.” This sentiment may have been especially magnified as our activity was the only structured orientation or training specifically for their redeployment: “as we had never done this role before our first shift, it was very helpful to go through workflow incorporated into the EHR. This was a very odd situation where we were expected to show up to work with only EHR orientation and zero clinical orientation. I think given this circumstance, the training was extremely helpful.”
The perceived value of the concepts taught varied by the respondent and the clinical role. ([Supplementary Table S4], available in the online version). One hundred percent of respondents felt the learning activity would be useful upon return to their anesthesia role. Some concepts that were found to be not useful for the surge ICU setting were nonetheless perceived to be useful as the CRNAs returned to their anesthesia role, such as the Bookmarks feature within Chart Review functionality. Conversely, concepts highly useful for the surge ICU, such as ICU-specific order sets and transfer workflows, were perceived as not useful for their anesthesia role ([Fig. 3]).
Fig. 3 Concepts that were perceived as useful (yellow) or not useful (orange) for the surge intensive care unit (ICU), and perceived as useful (blue) for return to the anesthesia role. CMICU, medical intensive care unit admission order set; IO, intake and output review; MAR, medication administration record review.
Asynchronous Video Library
Seven postdeployment survey respondents indicated that they viewed the videos (58%). An aggregate of 258 views was recorded from the upload time until the surge ICU closed. Each video had at least five and up to 27 views, with a median of 10 views ([Fig. 4]). In addition to the CRNAs who attended training, other providers also viewed these videos and expressed appreciation for the content through unsolicited feedback, “(the materials are) high yield, efficient, and I'm learning skills/tools I wish I would've known as a resident.”
Fig. 4 Page views of individual video modules for electronic health record training that were hosted on the intranet.
Discussion
During the COVID-19 pandemic, clinicians have had to adapt to rapid changes, including using technologies to deliver care.[1] This workflow-specific training was developed and delivered rapidly in response to an operational need to redeploy clinical providers. Despite the rapid timeline, this customized training addressed the unique needs of the clinicians and received overwhelmingly positive responses, demonstrating a high-quality program that was both relevant and enjoyable. Additionally, the online video library was available to reinforce the in-person training and served the needs of clinicians who did not attend the sessions, as evidenced by unsolicited clinician feedback. Attention to workflow and training during the pandemic can continue to reap benefits for clinicians' well-being.[11]
CI is a new clinical subspecialty of fellowship-trained physicians who have completed residency training in a clinical specialty.[12] Since the onset of the COVID-19 pandemic, our CI fellowship program has discussed the opportunity to utilize CI fellows as subject matter experts, maximizing their value at a time of crucial need. With their informatics and clinical specialty expertise, we demonstrated that CI fellows are ideally placed to provide this vital training during an operational crisis, given their familiarity with EHR utilization, clinical workflows, and best practices for EHR use. By deploying the fellows to provide the training, we conserved faculty informaticists for other operational challenges and EHR trainers for other clinical training needs.
Importantly, for the fellows' education, this project allowed them to demonstrate several key subspecialty competencies, particularly to “engage, educate, supervise, and mentor clinicians and other health care team members in their use of clinical informatics tools, systems, and processes.”[13] This project also allowed the fellows to partner closely with informatics and operational staff across the healthcare enterprise system to elicit goals and requirements, develop a curriculum, and execute the training.
Limitations
Our project had several limitations. The training was developed and deployed for use at a single hospital, and our survey captured only CRNAs deployed to the ICU setting. Due to the urgency of the operational need, there was no designated control group. This activity was the only training the CRNAs received prior to their deployment to the ICU. There were fewer respondents in the postdeployment survey compared with the immediate posttraining survey, as expected due to the difference in survey distribution method and timing. The nature of this surge period during the pandemic may also limit the reproducibility of this activity at other times. The survey was also not designed to evaluate the specific contributions of individual CI fellows.
Conclusion
This work highlights the unique role of CI fellows in developing and deploying a just-in-time educational experience within time, personnel, and resource constraints across the organization. Their value in providing high-quality and creative solutions for operational challenges allows modern health care systems to incorporate them innovatively alongside new technology to rapidly respond to crises. This work should now provide the impetus for establishing a series of guiding principles to effectively integrate CI fellows into organizational responses to crisis management.
Clinical Relevance Statement
Clinical Relevance Statement
Leveraging CI fellows to lead the training efforts through user-centered design principles can be an optimum way to achieve operational and education goals. These goals include high-quality training for end-users, showcase fellows' leadership and informatics skills, and conserve other informatics professionals to address other issues. Our approach offers an innovative framework which can be adapted to use for other groups and clinical settings.
Multiple Choice Questions
Multiple Choice Questions
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Why were clinical informatics fellows best suited to lead a multidisciplinary team to develop and deploy electronic health record training during an operational crisis?
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It avails other informatics professions to address other aspects of the operational crisis
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The clinical informatics fellows have deep clinical expertise
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The clinical informatics fellows have deep informatics expertise
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All of the above
Correct Answer: The correct answer is option d, All of the above. Clinical informatics fellows are well positioned to leverage their dual-domain expertise in their clinical specialty and in informatics, to deliver electronic health record training while freeing other clinical informatics professionals to address the operational crisis in other ways.
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Simulation-based, provider-led, electronic health record (EHR) training focused on specific workflows is perceived as:
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Enjoyable
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Improves EHR skills
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Useful
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All of the above
Correct Answer: The correct answer is option d, All of the above. Training CRNAs for redeployment during the COVID-19 surge demonstrated that our training activities were perceived as highly enjoyable, useful, and improved the EHR skills of the clinicians.
