Keywords
physician - efficiency - satisfaction - training - education
Background and Significance
Background and Significance
The electronic health record (EHR) is one of the most essential tools used in health
care today. However, despite the necessity of its use, it can be a documentation burden.
It has been shown that use of the EHR can lead to negative consequences to providers,
such as stress and burnout,[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9] while causing impact with organizational issues that hinder patient care and productivity.[10] Specific areas of the EHR identified as contributing to this burden include data
entry, discrete data elements, reporting, workflows, interoperability, design engineering,
and the in-basket.[2]
[11]
[12]
The initial transition to an EHR for providers can be challenging. One study showed
that when transitioning to an EHR system in an ambulatory setting, physician productivity
decreased as measured by relative value units (RVUs) and clinic volumes during the
year following implementation.[13] This was affirmed by Scott et al[14] who showed that, 2 months after EHR implementation, providers were spending twice
as much time documenting patient encounters and reduced time interacting with patients.
Evidence has shown that physician productivity improves with the number of years'
experience with an EHR.[15] However, even for those who have experience, constant system changes create an ongoing
challenge and prohibit mastery of all system features. It is a very real scenario
that once providers become knowledgeable with patient care workflows in the EHR, they
may need to constantly relearn the system due to ongoing system change.
Role of Provider Electronic Health Record Training
Role of Provider Electronic Health Record Training
The process of onboarding new providers in any organization should include EHR training.
Training expands beyond basic computer usage and may incorporate organizational workflows
and policies. Improvement in EHR confidence and efficiency have been shown to be possible
outcomes of training.[16]
[17] However, in a study by Rathert and colleagues,[18] participants felt that training was insufficient with EHRs that posed a subsequent
barrier to care coordination and communication. Upon hire, initial training must not
only be retained to memory but ongoing training for routine system updates and upgrades
is necessary, as the systems are further enhanced.
Because the EHR is not stagnant, organizations need to consider continued communication
and training following initial implementation or new hire training.[18]
[19] EHR optimization, or the assisting end users with optimal system usage, is essential
for clinician success. To this point, one organization conducted a pilot program using
one-on-one EHR support for its physicians. It showed that those who completed individualized
sessions spent approximately 25 fewer hours per month working in the EHR system, along
with a 12% increase in satisfaction and 24% increase in efficiency.[1] Using a similar approach, another study found increased EHR confidence with 98%
of providers reporting improved efficiency.[16]
[20] Furthermore, it has been suggested that the following several characteristics may
contribute to physician satisfaction with the EHR: 6 hours or more of initial training,
several hours or more of ongoing training, organizational culture, and system personalization.[21]
Challenges of System Change at an Academic Medical Center
Challenges of System Change at an Academic Medical Center
When our organization first went live with the EHR, instructor-led training (ILT)
in a computer laboratory served as the initial exposure to the system. This training
method evolved in 2015 into electronic-learning (e-learning) modules. The self-paced
format of e-learning was shown be a provider satisfier, allowing those who are familiar
with an epic-based system to move quickly and those unfamiliar to take more time.
The e-learnings are also a source of reference should the need arise to review content.
While this initial training is essential for onboarding physicians, it became apparent
that EHR optimization was just as important. Optimization involves on site EHR support
for end users that promotes optimal use of the system.
While providers may struggle to keep up with ongoing system change, they are not the
only ones. Information technology (IT) training teams can be challenged with training
and optimization of EHR changes to thousands of providers across multiple locations
within academic medical centers (AMC). They must ensure end user proficiency that
ultimately results in the delivery of quality patient care. Communication of changes
also becomes critical, but the most effective channel to deliver this information
remains an ongoing struggle. E-mail messages, presentations, newsletters, and super
user sessions are used but may not reach every provider. Finding the best method for
communication and education remains an evolving process.
One-on-One Support
As an option for additional provider support, our AMC used an EHR coaching session
that was historically offered by the IT training and optimization (T&O) team. Evidence
has shown that one-on-one support is effective for EHR adoption.[20] A specific e-mail address was created, so that requests could come to the coach
mail, and a calendar was established by the training team to manage staff-provider
time. During these sessions, a provider who is struggling or wants to be more efficient
will spend time with a member of the IT T&O team. The IT trainer would work with the
provider either on specific EHR functionality or workflow efficiencies pertaining
to features such as orders, messages, and documentation. This approach was very effective
but limited by the trainer–provider ratio. One provider coach and two ambulatory trainers
were responsible for over 1,000 physicians.
While additional staff members were added to the IT T&O team, it was still not enough
to reach the plethora of providers who could use more support. Many of our providers
who were here prior to our EHR implementation last had training over 8 years ago with
no formal training since. It is cost-prohibitive to remove providers from patient
care for EHR training, yet the value of EHR knowledge is recognized. There was a strong
desire by the principal provider trainer to reach larger numbers of providers and
still provide the same quality of support as a one-on one session.
As this was being developed, one clinical department at our AMC offered its physicians
a wide range of wellness opportunities. The service that they wanted most was EHR
assistance. This has been found in the literature, whereby annual wellness surveys
to providers have revealed the EHR burden placed on them.[22] The medical director approached the IT T&O team about providing additional resources
to see if a coaching format be done at a faculty meeting. To fill this need, a physician
efficiency workshop (EW) was developed as a means of faculty development. The intent
was to pilot a program with this group, then branch out to additional departments
if proven successful.
Objectives
As a solution to this issue, we set out to build a provider EHR efficiency program
that would improve the experience of these end users.
The objectives of this project were as follows:
-
Identify EHR optimization needs for providers in various clinical departments.
-
Improve provider satisfaction with the EHR.
-
Develop an EHR optimization program focused on provider efficiency tools and personalization.
-
Determine a how to monitor program success metrics.
Methods
Pilot Program
A multitude of tasks were done in preparation of this pilot session. Reports from
our Epic-based systems were used to show how physicians in this department were using
system functionality. This review of EHR data showed areas of opportunity for both
efficiency and personalization. Time was spent on learning more about the department's
operations, provider workloads, and common patient conditions. Rooms were booked for
several sessions so that the providers were equipped with a computer in the conference
room used for the faculty meeting.
The final measure of preparation before initiating the pilot was a meeting with the
medical director of this department. This served the purpose of understanding the
physician's EHR perceptions to further ascertain what the climate and attitudes were
like toward the system. Subsequently, the medical director sent an e-mail to clinical
faculty, connecting this to the wellness initiative, and stated the expectation that
attendance was required.
The first pilot session had 12 attendees and was scheduled for 1 hour in a conference
room. Physicians were asked to bring their own laptops to the session. Challenges
occurred with internet connectivity not being optimal. In addition, some providers
did not bring their laptop, so the work laptops of IT staff were surrendered to accommodate
these users. The session lasted for 1 hour and verbal feedback was positive. The department
chair was so enthusiastic, a second session was scheduled with five attendees.
Efficiency Workshops
After the positive feedback from the pilot session, a decision was made to expand
the program. The program was named EW on wheels. As the success of the program was
verbally shared among physicians and leaders, more and more clinics and departments
were requesting sessions. The EW team did their own marketing at leadership, chair,
and faculty meetings to gather interest, as well as new provider orientation and resident
coordinators meetings. When interest evolved into scheduling an EW session, managers,
administrators, and lead physicians would assist with establishing a date, time, and
location.
A program package was developed that is adjusted and repeated for different specialties
and groups. Small groups of less than 15 providers were the focus during times of
their convenience, be it early mornings, evenings, or lunch time. Hands-on work in
the system is critical for success, yet we were challenged to have physicians remember
to bring their laptops. The EW team purchased 15 laptops and rolling cases equipped
with charging stations to effectively implement a classroom on wheels, which ensured
system access for all. As an added incentive, participants of EW earned 2.0 hours
toward continuing medical education (CME).
The EW team consists of four to six trainers per session, including one lead trainer
and additional T&O staff to answer questions and allow for individualized support.
Trainer specialties exist in a wide variety of workflows such as inpatient, ambulatory,
procedural areas, and specialties (cardiology, radiology, women and infant, emergency
department, oncology, ophthalmology, orthopaedics, and transplant).
Establishing an agenda is important for each program. Every EW session is tailored
to the department's specialty, but the topics are generally the same as mentioned
below:
-
Tools to quickly find information in the chart.
-
Specialty specific documentation tools.
-
Messaging and communication tools within the EHR.
-
Customized ordering tools.
-
Reporting.
End user data are obtained on an ongoing basis from the EHR vendor that shows how
much time providers are spending in the EHR and using distinct features. There is
an expectation by both the vendor and organizational leadership that this data be
used to identify areas of need, focus optimization efforts, and improve provider system
use. Prior to EW sessions, this information is reviewed to determine how the department
and individual users may be struggling with the system. This allows the EW team to
save providers time by targeting the agenda to make them more efficient. This, in
turn, increased provider satisfaction. Providers are able to leave these sessions
with templates, ordering tools, filters, macros, and other personalization tools in
the live system so that they can begin using them immediately.
At the conclusion of each workshop, attendees are sent an e-mail that contains the
links to supporting training materials and additional resources. They are also informed
of the availability of individual coaching, should the need arise. All workshop trainers
are accessible at the physician coach e-mail address. They are also asked to complete
a CME evaluation and satisfaction survey to receive CME credit. The survey included
a five-point Likert scale whereby 1, strongly disagree; 2, disagree; 3, neutral; 4,
agree; and 5, strongly agree and nominal data.
Results
Quantitative Data
There is a continuous commitment to understand how to measure program effectiveness.
To do this, descriptive data from the CME evaluations served as a means for program
feedback and continuous quality assurance. Evaluations were reviewed from January
2018 to September 2019 and obtained from our organizational CME department. A total
of 129 respondents completed CME evaluations for the program. While these sessions
were focused on providers, other health care roles attended these sessions. Of the
108 who responded to the question, 65% identified themselves as physicians ([Table 1]).
Table 1
Attendees of the efficiency workshop program
|
Attendee
|
Total
|
|
Physician
|
70
|
|
Nurse
|
6
|
|
Health care professional
|
12
|
|
No response
|
20
|
|
Total respondents
|
108
|
Overall, participants reported a positive impact on their practice ([Table 2]). The majority of participants found no evidence of commercial bias or influence
on the program, as well as feeling as though they received enough information to bring
about practice change in how they cared for patients ([Table 3]). Lastly, a 10-point Likert scale was used asking participants, “overall, how satisfied
were you with this educational activity?” Of the 117 respondents, 56% reported that
they were extremely satisfied, while another 43% reporting some level of satisfaction
with the program.
Table 2
Satisfaction questions
|
Statement
|
Mean
|
SD
|
|
I have developed new strategies to address the issues that were discussed
|
4.62
|
0.78
|
|
My ability and skills have been improved
|
4.55
|
0.80
|
|
I have identified changes that I will implement in my practice
|
4.59
|
0.80
|
|
I expect positive changes in my patient outcomes
|
4.43
|
0.78
|
|
The learning objectives of this activity were achieved
|
4.59
|
0.78
|
Abbreviation: SD, standard deviation.
Table 3
Nominal data
|
Question
|
Yes (%)
|
No (%)
|
|
Was there any evidence of commercial bias or influence in the content of the program?
|
2
|
98
|
|
Do you feel you need more information before you can change the way you care for your
patients?
|
26
|
74
|
Qualitative Data
In addition to quantifiable information, patients were asked open-ended questions
to elicit subjective information about the program. These were classified into the
following three groups: impact comments, overall comments relating to satisfaction
with the educational activity, and practice problems to be addressed for future sessions.
Responses to these questions were categorized into themes for further interpretation.
For impact comments, the most common themes were that the sessions were great, helpful,
and provided tools to be more efficient. One attendee commented, “love all the new
buttons I was able to create.” Another said, “providers and myself have benefitted from this.” The structure of
the format was praised by some, with one saying, “concise and efficient with explanations.”
One suggestion for improvement was given that the workshop team, “should have people
hold questions until the end.”
Overall comments were asked for additional feedback on any aspect of the program.
This section repeated the themes for impact comments, that the workshop was organized,
helpful, and well done. One participant described the session as, “efficient, focused
presentation; thorough, well-explained.” Another user stated, “excellent and appreciated.”
One user was unsure that it would be helpful given a complex patient population. Several
people were interested in additional sessions. A participant stated, “(I) want this
every quarter, if possible.”
Many suggestions were given for possible future workshop sessions. Examples included
referral letters, charting office visits, phone encounters, additional customization,
communication in patient portals, and learning additional tools to increase efficiency.
This feedback is then used by the team for consideration in future program development.
Discussion
As we began the pilot, it was important to understand the optimization needs of providers
before, during, and after workshops. In preparation for events, gathering information
about clinical operations and patient populations, through data review and communication
with providers, refined the session content. The results showed that providers who
attended these sessions were satisfied with this method of EHR optimization and that
they felt it had a positive impact on their EHR use. Qualitative feedback supported
quantitative data and also directed the program to topics where help was needed.
After the pilot was conducted and several workshops had been completed, we learned
more about the most effective structure of these sessions. This included knowing what
tools were needed for planning and implementation. One change that evolved was that
we began bringing laptops, removing that expectation from the provider. That way we
ensured that everyone would have a computer that was connected to the internet and
running optimally. Our department invested in this program by purchasing additional
laptops specifically for this program that were taken to each session in a rolling
cart. Overall, the results show that attendees were pleased with these sessions and
in many cases not only were they satisfied, they wanted additional workshops to learn
tools for efficiency.
Having the knowledge of effectiveness of these sessions was important to be able to
provide leadership with metrics on how successful this program is. Provider feedback
via e-mail, word of mouth, referrals and postsession surveys has proven to be not
only great feedback, but also helpful with workshop marketing. The CME evaluations
also helped us to verify that these sessions were useful and giving providers the
training on system features that may have been forgotten when onboarding. System customization
is a key feature of efficiency. EW feedback confirmed this, leading us to believe
that the content was exactly what was needed to benefit providers.
Limitations
We do acknowledge the limitations of the CME data, in which neither all participants
answered each question nor does it give us the amount of time saved by the provider
from attending the workshop. We also acknowledge that 26% of those responding stated
that they need additional information before changing practice. Also, the qualitative
information relating to expressed need for additional sessions informed us that one
session is likely not enough for each group.
Conclusion
Evidence has suggested that the key factors of training program success for providers
using the EHR include design of the curriculum, accessible training location, staffing
of the training team, and a physician champion.[23] Our EW findings support this. In the future, we plan to use the EHR reporting features
to evaluate efficiency before and after the EW program. As departments invest time
in supporting physicians by blocking time away from clinic to attend such events,
we would also like to measure a return on investment. We hope that continued efficiency
workshops provide providers with tools that lead not only their satisfaction but that
of patients in our organization. As an IT training team, we have learned that this
is an important program that should be developed further and sustained in an effort
to continue to reach as many providers as possible.
Clinical Relevance Statement
Clinical Relevance Statement
The EW program established has been found to be a successful supplement to initial
EHR training for providers, especially in the presence of ongoing system change. They
provide the opportunity for provider customization and improved efficiency with clinical
practice and can bridge the gap that occurs with ongoing system change. These programs
should be considered by IT training teams.
Multiple Choice Questions
Multiple Choice Questions
-
Specific functionality of the electronic medical records that contribute to user burden
are:
Correct Answer: The answer is option e. Evidence shows that all of these areas have created a burden
for end users.
-
Outcomes of electronic medical record training for end users includes
Correct Answer: The correct answer is option a. Evidence shows that improved confidence and efficiency
occurs from EHR training.
