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    How team training can make your EHR system a sound investment

    EHRs typically are underused and poorly understood, signaling the importance of team training, experts say


    Rosemarie Nelson
    Nearly 1 year ago, Medical Economics unveiled its 2-year EHR Best Practices Study, and the research has yielded interesting insights. For example, the study has revealed that inadequate time for—and access to—training is often cited as one of the top challenges facing doctors and others using electronic health record (EHR) systems.

    Without in-depth knowledge of the system's functionality, experts say, most physicians will never realize their EHRs' full potential to gather and interpret data that will be necessary to participate in quality reporting programs.

    TRAINING: EARLY AND OFTEN

    John Sawyer, MD, is an internist and medical director at Hudson Headwaters Health Network (HHHN) in Queensbury, New York. HHHN is a community health center with more than 100 providers practicing in a dozen separate locations.

    HHHN implemented a Web-based EHR/practice management solution that connects all of its practices over the Internet. Sawyer notes that EHRs are so complicated that people find ways to use them that aren't necessarily the most efficient methods available, and this approach can cripple a staff's ability to leverage the EHR.

    "Providers teach themselves ways to complete their work and never learn their EHR's built-in shortcuts, which take advantage of the technology in ways that can make their lives smoother and easier," he says.

    That's one reason "early and often" training is so critical to the success of an EHR implementation, Sawyer says. "Providers are resistant to do that, because they think they don't have the upfront time to invest. They don't realize that it'll save them lots of time in the long run."

    PROVIDER FRUSTRATION

    Rosemarie Nelson, a healthcare information technology (HIT) consultant, principal with the MGMA Healthcare Consulting Group, and Medical Economics editorial consultant, says, "Ask any physician or nurse about the training they received on their EHR, and most will express dissatisfaction, unhappiness, or harsh complaints. Ask EHR vendors about their approach to training, and most will express frustration at their clients' lack of attentiveness or of missed training sessions."

    Physicians complain that vendors react slowly to their practice's unique training needs. Vendors complain that physicians don't make time to be trained on the EHRs they purchase. The fault for ineffective training, Nelson says, actually lies with both parties.

    Training is critical before going live on an EHR, and "ongoing" training is essential for optimizing the EHR implementation after the go-live date.

    "First-time buyers don't know what they don't know and have been corrupted by the simplification of so many consumer technologies," Nelson says.

    An EHR is a much more complicated tool than the self-service kiosk used to buy movie tickets or the fitness app downloaded from iTunes. That complexity, Nelson says, requires training in earnest.

    "Just knowing what button to click on to write a prescription doesn't help providers coordinate incoming patient phone requests for prescription re-issues," she adds.

    The recipe for success, she says, is to examine, and sometimes re-engineer, your current processes, learn your EHR's full capabilities, and train your providers on the technical aspects of the system.

    HHHN ultimately trained its providers from a central location. "We pulled providers out of work for 4-hour blocks of time and placed them in classrooms with teachers provided primarily by the vendors. We completed all of the initial training before go-live," Sawyer says.

    "During the entire go-live procedure, we had vendor staff onsite," he continues. "We completed go-live in two 'big bangs'—four health centers at first and then the remaining eight later."

    Sawyer notes that the trainers for the first stage came mainly from the vendor. For the second, larger rollout, which took place a few months later, HHHN had both the vendor and its own staff trainers in place. "We had two sets of classroom teaching," he says. And yet, it was not enough.

    "We found out a few months later that folks really hadn't absorbed enough information," Sawyer says. "Even with the initial 4 hours, and with having the teachers helping them, they still hadn't had enough nuts-and-bolts training. So we set up additional 2-hour training sessions for the providers."

    SUPER-USERS

    Training EHR users can be efficiently accomplished in two steps: train a small group of motivated individuals to be "super-users" of the EHR system first, and then use your super-users to train the rest of the group. This method ensures that after the vendor's training staff leaves, you'll have someone on staff who can provide additional ongoing training.

    "We actually implemented the super-user concept well after we'd done our initial EHR implementation, when the frustration level of our providers told us that we weren't meeting the need," Sawyer says.

    He admits that Nelson advised HHHN to implement super-users earlier. "We thought it'd be too expensive," he says. "In retrospect, we should have done it far earlier."

    HHHN's super-users are midlevel providers as opposed to IT staff. Sawyer says they undertook this approach because they believed that midlevel providers better understood the flow of patient encounters. The organization also chose midlevel providers to train as super-users because their hourly rates were lower than those of the physicians.

    These individuals, however, were not only adept at the technology—and interested in it—they also had expressed interest in the teaching aspect of becoming super-users and passing their knowledge on to other providers, Sawyer says. This interest was critical.

    "We knew they would understand pressure points, problems with the technology, the nuts and bolts of lab testing and drug ordering on the fly, making diagnoses—all the things that stymie folks who aren't adept at an EHR system," Sawyer says. "It made sense that the people actually doing those things should be our super-users."

    FOLLOW-UP TRAINING

    According to Sawyer, for provider groups to keep up and make "best use" of an EHR, it's crucial that very good initial training be followed by rapid follow-up to ensure users grasp the initial training.

    "Ongoing training is critical, because EHRs change all the time," Sawyer says. "Even with good initial training, folks will figure out ways to use the EHRs that aren't the most efficient methods for doing things."

    HHHN initially tried "by-invitation" evening sessions for their on-going training. But the sessions were poorly attended, Sawyer says, and they often involved EHR users who needed the least amount of help.

    "We now meet with our three 'super-user' midlevel providers quarterly for 4 hours to discuss what they learned during the previous quarter, and [we] also review the new features of the EHR that we want them to teach to the other providers," Sawyer says.

    Throughout the year, HHHN's super-users spend time with physicians who have developed useful EHR techniques, which they then teach to the other providers.

    During each quarter, they spend a few hours with each of the more than 100 providers in the organization to review important changes to the EHR and new techniques learned.

    "Without this ongoing training, EHR users become extremely frustrated, because it's such a complicated tool to use," Sawyer says.

    SMALL PRACTICES

    HHHN is a large-scale operation encompassing dozens of medical sites and more than 100 providers. Some training techniques used there might not easily translate to smaller practices, where cost is more of a factor.

    Sawyer suggests that for complex healthcare organizations similar to HHHN, it makes sense to create super-users at the outset. Therefore, identifying and training multiple people to be super-users at the very beginning is critical.

    For smaller practices, however, it could be enough to have just one person who's dedicated to thoroughly learning all of the EHR's operations and to sharing that knowledge in regular meetings.

    "They can review (and/or install, as in the case of client/server EHR systems) all upgrades to the EHR," he says. "They can study any utilization reports and then relay that information to the rest of the practice to increase staff efficiency and knowledge on how to best utilize the EHR."

    Sawyer says this is a "best practice" for providers who want to use their EHRs to the best of their abilities but who lack the time needed to do so.

    ASSOCIATED COSTS

    Effective use of HIT can control and reduce operating costs in a medical practice.

    Technology also can drive revenue, monitor reimbursement, and position and support a practice's participation in payers' new reimbursement models, but only if a practice is well-trained in how to use that technology.

    "Providers must accept that training is part of the overall cost of the system," Sawyer says.

    Just as transferring patients' data from paper charts to digital files is one of the costs associated with implementing EHRs, so is training.

    "People should not underestimate how expensive that will be," Sawyer says, "in terms of the cost of the software, of the vendor's training time, and also of the provider's training time. Four to 6 hours of provider time is very expensive, but it prevents a lot of frustration."

    Similarly, ongoing training also is quite expensive. Without it, however, productivity suffers, and users experience frustration and that affects their performance and morale, Sawyer says.

    "Physicians need to understand that a large chunk of an EHR's implementation costs goes into training and factor that into their financial planning," Sawyer says.

    It's possible, he adds, to implement a great EHR but have lousy training and end up with a bad outcome. But with good training, you could implement a "so-so" EHR and do just fine.

    In the end, it might not matter all that much which EHR you're using. What matters most is how you implement it, and good and ongoing training is the key, he adds.

    "Don't under-estimate or under-budget how much time and money it will take to implement an EHR," Sawyer says. "And certainly don't go skimpy on training. Don't be penny wise and pound foolish."








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    Training: a lifeline for EHR utilization

    For the most part, medical groups are not trained effectively for integrating an electronic health record (EHR) system into their workflows. Here are tips for doing just that.

    DON'T SKIMP ON EDUCATION

    All too often, doctors negotiate out many hours of training as a way of lowering the purchase price of the EHR. Vendors often will agree to the reduction in EHR training during the negotiation because they want to close the sale. In addition, the training dollars, for them, are just a resource cost that they pass along to the client. Vendors don't really profit from those training revenues.

    What to do?

    Doctors

    Don't under-buy training.

    Vendors

    Hold your line on requiring training during contract negotiations.

    REDUCE COSTS

    The EHR vendor is an expert at training on the features and functionality of its technology. The vendor is not an expert at how best to incorporate those features and functions into the various workflows of your practice.

    You and the nurses, reception staff, medical secretaries, and ancillary support staff in your medical practice know your needs and workflows. The vendor knows how its EHR works. The integration of those two fields of expertise is where the appropriate training plan can be delivered.

    What to do?

    Doctors

    Assign the best and brightest to lead the project, and empower them to collaborate and coordinate training jointly with the vendor.

    Vendors

    Listen to your customers, and commit your resources to truly customizing the system how-to lessons with its practical day-to-day operational needs.

    MESH SCHEDULE, NEEDS

    A bipartisan solution requires compromise and cooperation. The vendor must be willing to modify its scripted, generic training curriculum, and the practice must be willing to devote time to self-evaluation of workflows and time to be trained.

    Too often, a vendor has a timeline and pushes aggressively to stick to that timeline because it has committed its training and implementation staff to other engagements. Equally often, a practice continues to juggle patient appointments during training sessions and shortchanges itself of the learning opportunities that will optimize EHR implementation in the practice.

    What to do?

    Doctors

    Stop juggling. Close the practice to patients, or pay staff for after-hours training sessions.

    Vendors

    Recognize that sometimes schedules need to be adjusted. If you want your customers' full attention, you might need to work outside of typical business hours, too.

    Physicians and practice managers who have missed meeting e-prescribing requirements will face future penalties in Medicare reimbursement. Many practices are struggling with qualifying for meaningful use incentives. In each of these practices, their technology implementation is the reason they are fighting reduced reimbursement.

    Better-performing practices have figured out how to increase profitability with the effective use of technology. Those groups that spend more on HIT (including training) per full-time equivalent (FTE) physician tend to generate more medical revenue after operating cost per FTE physician.

    Declining and/or changing reimbursement and increasing operating costs are three of the top four challenges sited in the Medical Group Management Association's 2012 "Medical Practice Today: What members have to say" research. In fact, every year in the past 4 years of the survey, those same challenges have been in the top four. But those are only the results of ineffective technology utilization. Technology is the number one issue for providers and staff.

    —Rosemarie Nelson
    MGMA Healthcare Consultant and
    Medical Economics editorial consultant

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