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    EHR implementation: Training pays dividends

    Thoroughly understanding your system before going live will save money and minimize practice disruption later

    Training is a crucial part of successfully implementing an electronic health record (EHR) system. Although you may be tempted to skimp on it to save money, doing so could wind up costing your practice far more in the long run.

    “I have not been made aware of any EHR implementation program that failed because of too much training, but I know of a number that have occurred because of too little,” says Jason Mitchell, MD, director for the Center for Health Information Technology (IT) at the American Academy of Family Physicians. “We’re talking about significant decreases in productivity for months to years, which could have been avoided if training had been appropriate and expectations about what you will be able to do with the EHR were made clear from the beginning.”

    Starting a training program

    Although no prescription guarantees success, experts agree on steps a primary care practice should follow when developing a training regimen aimed at smoothly transitioning from paper to electronic records.

    Bruce Kleaveland, president of Kleaveland Consulting, Inc. in Seattle, Washington, says no “radical new training methodology” is revolutionizing EHR training, but vendors are replacing bootcamp-style training with a more measured approach.

    “Most innovation has to do with how you teach a fairly complex application without blowing everybody’s mind,” he says. “Training in a more incremental fashion,” Kleaveland says.  “Dealing with a few components and making sure people master them, and using that as an opportunity to develop a comfort level. Also, physicians need to be cognizant that the way a physician uses an application is different than a front-desk person.”

    Although training continues to evolve as technology becomes more advanced, Lisa Bradshaw, director of training for NextGen Healthcare’s ambulatory division, says that successful EHR training “requires a practice’s commitment to and dedication of resources for the project. It is essential [that] there is physician and clinical involvement in configuring software to ensure that expectations, requirements, and standards are met.”

    Margret Amatayakui, president of Margret/A Consulting, LLC says that EHR training should infuse physicians with an understanding of a system’s value in clinical decision support rather than simply teach the nuts-and-bolts of screen navigation.

    “This is not as simple as taking away the pen and using the keyboard instead,” she says. “This is changing how you practice medicine.”

    Don’t underestimate the impact of solid training,” adds Michael S. Barr, MD, senior vice president of medical practice for the American College of Physicians, who coauthored the 2011 American EHR Partners’ report showing incremental increases in training resulted in measurable increases in clinician satisfaction. “If you think you need ‘X’ amount of training, you should go ‘X’ plus.”

    What will it cost?

    Like all other aspects of EHR implementation, the cost of training physicians and staff members to use the system comes with a price tag. The exact amount your practice will pay will vary depending on the type of system you use (SAAS- or server-based), the vendor or consultant providing the training, the extent of the training, and how many people receive training.

    A 2010 study of 26 Texas-based, five-physician primary care practices found that the teams responsible for implementing the practices’ EHR systems required an average of 52.5 hours of training at a cost of $2,777. The system’s physician end-users received an average of 23.9 hours of training at a cost of $1,538 per physician.

    Results of the study, which was funded by the Agency for Healthcare Research and Quality, were published in the March 2011 issue of the journal Health Affairs.

    Here are 14 steps to building an effective EHR training program for your practice:

    1.  Get input from staff

    Staff members who have a role in selecting the EHR have a better perception of the system after implementation. “Becoming an early stakeholder may make you a little more comfortable, because you know what the EHR should do,” Barr says.

    2. Lead by example

    Physician leadership is crucial when implementing an EHR. “I’ve been associated with really successful projects and projects that were train wrecks,” Kleaveland says. “The big difference is physician leadership, particularly in a small practice. That very much applies to thinking through how you do training and the training process itself.”

    3. Establish an end goal

    To create a successful training program, Mitchell says, physicians need to know what they want their EHRs to do for their practices. “Have a vision of your practice using an EHR system,” he says. “That helps guide the training process. You have to have some idea of where you are trying to get and what the EHR is going to do differently than a paper-based system.”

    4. Uncover technophobes

    Staff members who do not have basic computer skills will need extra training to get up to speed before go-live. “If you can’t type, that’s going to be an issue,” Mitchell says. “If using the mouse doesn’t make sense to you, if you don’t understand key combinations to be able get shortcuts, if using the voice-recognition software takes you 15 minutes, those things are going to destroy you over time.”

    5. Investigate training options

    Although your EHR vendor is likely to have unmatched knowledge of its product, value-added resellers, consultants, and local regional extension centers (RECs) for health information technology (IT) are worth considering. “Even though vendor representatives should be quite knowledgeable, generally they are the most difficult to schedule and most expensive,” Kleaveland says. “If you can find local resources that are knowledgeable, you’d be crazy not to avail yourself of those.” (See box, “Regional Extension Centers.”)

    6. Customize your training

    Because training can cost a small practice nearly as much as the EHR itself, Lou Ann Wiedemann, senior director of health information management practice excellence for the American Health Information Management Association, says that physicians should define in advance their training objectives and ensure training is tailored to their practice.

    “There is not a cookie-cutter approach,” she says. “Each physician practice is unique in some of the things they are looking for so they need to take that into consideration.”

    The timing of your training sessions also is key.  “You don’t want to do training too far in advance or your staff may forget it,” Wiedemann says. “You do it too close and you may rush it.”

    7. Hold a dress rehearsal

    Before your go-live date, set up EHR test cases using dummy patient charts to simulate common scenarios, such as a follow-up visit for hypertension.

    “If physicians are going to be seeing patients with this software in the room, then simulate that so you are not completely freaking out when the patient shows up and you’re trying to examine them and document,” Kleaveland says. “The patient wonders, ‘Are they examining the computer or examining me?’ ”

    8. Don’t try to learn everything at once

    Heather Haugen, Ph.D, senior vice president of research, development, and IT at The Breakaway Group in Greenwood Village, Colorado, says EHR trainers set practices up for failure when they attempt to teach users a vast array of features and functions at once. “If I put you in a classroom for 3 days and I teach you 300 things the EHR does for a physician, you likely won’t remember how to log-in when we’re done,” she says.

    Haugen advocates for “scenario-based” learning, which enables users to learn by doing and is modeled after flight simulators in the aviation industry. “Bite-size” training sessions typically are 5 to 7 minutes long and can be done during off hours. This task-based training focuses on physicians and staff first becoming proficient in their primary job tasks.

    “Ensuring people can use the application to treat a patient the day of go-live typically means they have to know the key functionality, but they don’t know all the bells and whistles and the advanced functionality,” Haugen says. “Then overtime they learn that. When the opposite happens, we get in trouble.”

    9. Implement in stages

    When Jennifer Brull, MD, a solo family physician in Plainville, Kansas began converting her practice to EHRs, she knew flipping a switch all at once would wreck havoc. Instead, the practice implemented the system in stages over 3 months; first by converting to the new electronic billing system, then transitioning to the EHR’s scheduling software, before finally rolling out the clinical portion of the system.

    “When we went live with clinical, our front office was comfortable with what they were doing,” she explains. “They had a couple of months under their belt doing things the new way so when the back office got really stressed, there wasn’t stress in both places.”

    10. Understand the impact on workflow

    Practice workflows slow by as much as 50% during implementation, a phenomenon documented by Medical Economics’ EHR Best Practices Study. Practice management consultant Mary Pat Whaley of Manage My Practice in North Carolina, argues that failing to consider an EHR’s impact on workflow can be a major oversight.

    “Being trained on the software is totally different from inserting the EHR into the workflow or changing the workflow,” she says. “People think, ‘We know how to use it. Let’s throw it out there and see how it works.’ That can be devastating to the practice, to morale, and, of course, devastating financially.”

    11. Develop in-house experts

    No matter whether your EHR point-person is called a “champion” or “super user,” every practice needs one or more staff members who receive extra training and become resident experts who can help others learn the system, assist at go-live, maintain a relationship with the vendor, and stay abreast of system updates.

    “The super user is somebody who is going to be able to troubleshoot after the onsite support and training is no longer available,” Barr says. “The more super users you have, the easier it is for somebody to turn and find somebody who can help them.”

    Brull, however, says she made the mistake of failing to remove some of her champions’ regular duties during implementation so that they would have time to devote solely to helping others.

    “They got through it, but looking back, I would have said 25% of your hours are marked for going around saying, ‘Do you need help?’ as opposed to letting problems come to them and making them deal with it on top of their regular volume.”

    12. Foster teamwork

    Knowing that EHR implementation will cause bumps in the road for staff, the implementation team needs to find ways to boost morale. When implementation-related issues stressed a member of Brull’s staff, the person was likely to find a row of Hershey Kisses lining his or her desk. “That was a signal to take a deep breath, calm down and eat some chocolate,” she says.

    13. Think long term

    Your practice needs a long-term commitment to EHR training. For 2 years following implementation, Brull made an EHR question-and-answer session a regular agenda item during bi-monthly staff meetings. Staff could discuss challenges, ask questions, or offer tips to coworkers.

    “In the early days we probably took 30 to 60 minutes of our staff meeting just doing things around the EHR implementation,” she says. “We never had anybody who had tremendous amounts of frustration build up because they knew every two weeks there was that opportunity to ask questions and get feedback from everyone.”

    14. Join user groups

    Online user groups and forums are excellent ways to discover shortcuts, discuss solutions or share concerns about your EHR. Some user groups are associated directly with vendors. Others, such as eCWusers.com are independent groups comprised solely of users of a particular EHR—in this case, eClinicalWorks.

    Although Brull stops short of describing her EHR implementation as perfect, she says, “We achieved our objective of moving everyone from a paper world to an electronic world in a way we didn’t lose staff and we didn’t pull our hair out too much.”

    Brull established a goal of converting at least one patient’s records to the EHR each half day. At that pace she was able to convert her 2,000 patients to electronic records in about 5 months, compared with another physician with an older patient population for whom the process took 18 months. She is confident her step-by-step implementation created fewer headaches than if she had tried implementing the system all at once.

    Five years after her go-live date, Brull says her patients are benefitting from improved care, with quality metrics rapidly increasing for preventive measures such as colon and breast cancer screenings. She credits her EHR with enabling her to practice better medicine.

    “When you really look at patient population numbers instead of a just the chart of the patient in front of you—which is all you can do in a paper world—it’s a real wake up call,” Brull says. “That’s been really good for us.”

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