So now, back to my post about common EMR training methods.
When you plug in an EMR into your hospital environment, one of the biggest mistakes (challenges?) is the underestimation of training needs. Hospitals sometimes budget for money around the go-live. In reality, the training budget usually increases as time goes on. (This is one of those "Hidden costs of EMR implementation" that many hospitals don't prepare for.)
So I thought I'd talk about what some common educational tools are, that front-line informatics departments use to accomplish this feat. They include :
1. Department meetings
2. Emails / Paper mailings
3. Posters / Screen savers / Billboards
4. CBT (Computer-based testing)
5. Clinical Superusers
7. Classroom instruction
8. One-on-one instruction
9. Electronic Decision Support (Alerts / Order Sets)
10. Clinical Managers / Directors
Each of these tools has distinct advantages and disadvantages. I thought I'd go through each one and offer some insight.
- Department Meetings - Department meetings are a good way of getting people to your training - They're not good for much more than that. Trying to communicate how to operate a particular software feature, at a meeting when most physicians/nurses are coming in late, or looking for coffee, is generally a poor way to get across proper EMR technique.
- Emails / Paper Mails - Like Department Meetings, emails suffer from a few challenges. First, many doctors have such a high noise-to-signal ratio that emails and paper mails almost never get through. (Notice the stuffed paper mailboxes? Physician email boxes are usually pretty similar.) Next, mail suffers from a lack of feedback - Did the physician actually learn the educational objective? How do you know they spent the time to actually properly understand the objective you were trying to get across? As a result of these problems, both paper and emails are notoriously bad for trying to use as an educational tool. My advice : At best, use them to get your staff to the training you set up. Don't mistake them for a training device.
- Posters / Screensavers / Electronic Billboards - It's tempting to consider screensavers and electronic billboards for training - One powerpoint slide, seen intermittently around the hospital, might communicate the educational objective! The problem : You can't really guarantee it's seen by everyone. If the electronic billboard is in your cafeteria, then you'll miss employees who don't get lunch in your cafeteria. If the billboard is by the front entrance, then you'll miss employees who go in the back entrance. And like email, there's no way to know if your clinical staff learned the educational objective. Posters take more time to create, but work by the same principle as screensavers and electronic billboards, and so they suffer from the same geographic limitations, and also don't have a way to determine if the educational message has been received by your clinical staff. My advice : At best, use them to augment your training. Don't mistake them for a training device.
- CBT (Computer-based testing) - Computer-based testing (e.g. having little computer-designed tests on your web server) is amazingly tempting. Clinical staff can do the tests at work, or at home. The software packages usually let you track which employee has completed which module, so you'll have great data on who completed their training. The downside is that the development of CBT (Computer-based tests) is much harder than it looks. There is a lot of programming and media development that goes into making a single CBT. So while most people dream of being able to save on teachers, usually they end up paying for people to develop the CBT. My advice : This can be very effective, if you plan resources to set up and maintain the CBT site. Don't underestimate the challenge.
- Clinical Superusers - This is one of the most misunderstood terms in EMR education. Some people perceive "superusers" as non-clinical staff who wander around your hospital, usually during the month before and after your EMR go-live, to help "answer questions" and provide on-the-spot remediation. Other people perceive "superusers" as clinical staff who are just "really good with computers" and maybe got "extra training", so they could help the clinical staff who aren't as quick to learn. My advice : If you plan on using superusers, plan their time budget carefully. If your superusers are clinical people, and they have a full clinical load, they will not have much time to help your other staff. If they are non-clinical people, it will cost you money. Prepare a superuser strategy carefully, and prepare to spend money on them.
- Train-the-trainer - This is also often mistakenly confused with "superusers". Train-the-trainer, done properly, can be a very effective way at educating a large number of clinical staff quickly. It involves a single person developing an educational tool (e.g. a quiz, usually with 4-5 questions, which tests whether or not a clinical member understood the training. Then the primary trainer needs to go out and find, usually, 5-10 secondary trainers. The primary trainer then teaches the secondary trainers how to teach the educational objectives, and give the clinical staffmembers the quiz designed by the primary trainer. The secondary trainers then go out, and usually complete this short education module with another 5-10 clinical staffmembers each. In the end, it distributes the teaching load, and as each secondary trainer comes back with successful quizzes, they bring it back to the primary trainer who can then keep track of "What percent of our staff completed the educational objectives?". My advice : This is a little like guerilla training. It can be very effective if done properly, but try to save it for the emergency, "Every-doc-has-to-know-this-feature-by-next-month-or-they-won't-be-able-to-sign-into-our-system"-type problems.
- Classroom Instruction - Classroom instruction seems like a good way to train clinical staff. The problem is that often it's hard to get the clinical staff to the classroom, and if they don't have non-clinical time budgeted, their attention span and patience will be minimal. If you plan on using classroom time, make sure you have a well-developed curriculum, and you budget time and resources so that your clinical staff can learn in a relaxed atmosphere. Another challenge with classroom instruction, in the modern hospital, is that you generally end up running classes at all shifts - Don't forget your night staff if you're doing classroom instruction. My advice : This is a mainstay of teaching in hospitals, but it has its flaws and problems. Make sure you budget time and resources effectively, and develop a good educational curriculum, and keep it short and concise. My advice : Use this as a workhorse-type solution, but don't think it's going to solve all of your training needs.
- One-on-One Instruction - This is often perceived as a nightmare (How can we have the time and budget to have a trainer do one-on-one instruction with all of our clinical staff?), but in the hands of a real teacher, this can be enormously effective. It involves one teacher sitting down with one clinical staffmember, and going through a set of educational objectives. Think of it as "your tutor" in high-school. One-on-one is certainly not good for large-scale training (e.g. all your clinical staff in the next month), but can be useful for small amounts of very intense, personal training. In my experience, one-on-one can be very helpful because as a teacher you can really perceive the learning problems and adjust accordingly. You'd be amazed what clinical staff will confess when they are learning one-on-one. My advice : This is good for "problem cases", and good for "brush-ups", but definitely won't work for major software updates or major workflow changes.
- Electronic Decision Support (alerts / order sets) - Some people point to alerts in the software as an educational tool, e.g. "We'll just make a pop-up window that tells the doctors what not to click on". This is a major mistake. A pop-up window is not training. At best, it can help educate a doctor about a possible problem. At worst, your clinical staff may be suffering from alert fatigue, and ignore the alert entirely. Some people look for other electronic decision support (e.g. order sets) as a possible educational tool. While some order sets can be useful in educating your staff (e.g. is there a new antibiotic that you should be using for UTIs? Change the UTI order set to the new antibiotic!) - The problem is generally that EDS is not well-understood by most hospitals, and at best it helps guide clinical staff towards successful navigation of a small workflow issue. My advice : It helps a little, but definitely don't count on alerts or order sets to educate your clinical staff.
- Clinical Directors / Managers - While some people don't focus training on clinical directors or managers, mistakenly thinking "only the front-line staff will need to know how to use the EMR!", I can tell you this is a big mistake. Clinical Directors and Managers are exactly the support people that the front-line staff go to for help. If your clinical directors and managers aren't familiar with your EMR software and workflows, then they won't be an effective resource for your front-line staff. My advice : Make sure you have a teaching strategy set up for your clinical directors and managers, and make sure they learn your EMR software. They can be a tremendous asset to the educational process, and in general, departments where the manager feels "I don't need to learn to use the software!" have very poor EMR implementations. The directors need to learn the software so they can be an educational resource for front-line staff.
So what have we learned? "Dirk - None of these sounds that great...." You're right! None of them are perfect. This is why EMR training requires a combination of all of these tools. And to know how much money to devote to which tool, you'll need an EMR educational strategy, which generally includes EMR policy development in your institution.
And how will you develop that EMR educational strategy and EMR policy? By having a good clinical informaticist (or CMIO) to help you with the entire EMR implementation. Remember : Good informatics starts at the budgeting process. Make sure you get expert help early, and don't underestimate the challenge of training and education in the EMR environment. Remember, as I said - The challenges generally get harder after your EMR go-live. Outsourcing training generally doesn't work well, because only in-house trainers will really know your culture and know which tool to apply to which problem.
Hope this was a good overview for folks! Write me with any questions!