Shrager, Florence E. BSN, RN-BC, OCN
Section Editor(s): Thede, Linda Q. PhD, RN-BC
* Training should mimic work flow
* Help learners see the whole
* Follow-up and retraining as needed
Effective end-user training is essential to the success of any electronic medical record (EMR). Learning how to maneuver and document in a new clinical system can be a daunting task by itself. But imagine starting a new position in a nursing area that is unfamiliar and having to master a new EMR system all at the same time. Often, training is skills focused, and the clinician has difficulty understanding how individual screens and tasks relate to the patient's medical record. This article reviews the successful transformation of one hospice's EMR training program for new users.
This midsize, not-for-profit hospice, with an average daily census of 400 patients, provides residential care to patients and their families. A residence which could be their home, a nursing home, an assisted-living facility, or one of the organization's three residential hospice houses. Currently, this organization has approximately 90 field staff who document in the EMR, including nurses, social workers, and chaplains. Clinicians, patients, and families work as an interdisciplinary team to provide end-of-life care. Because staff provide care in the field, access to a single paper patient record not feasible.
Prior to the EMR, staff carried a paper face sheet containing basic patient information such as patient demographics, assigned clinical staff, diagnosis, and current medications. Most interdisciplinary communication occurred via telephone, and clinical notes from other disciplines were not accessible in the field. As an organization, it was determined that an EMR solution would enable them to improve the delivery of patient care.
The organization decided to implement Misys Homecare, now called Allscripts Homecare (Allscripts-Misys Healthcare Solutions, Chicago, IL). This stand-alone system has billing, scheduling, reporting, and point-of-care documentation functionalities. A system administrator was selected from existing staff to support the system and provide end-user training. The vendor supplied train-the-trainer classes to the system administrator and a handful of super users and the journey began.
Training classes were provided monthly for five 8-hour days. Clinical end users included nurses, chaplains, and social workers. Each student was supplied a tablet the first day of class. Training materials included a folder of individual instruction sheets that walked the user through different tasks in the system. Some of the sheets provided screen shots for reference.
After a brief introduction, the first morning of class, students were instructed to complete the computer vendor's tablet tutorial on using the tablet and stylus. In the afternoon, they learned how to synchronize their computers to the server. The remaining 4 days of class was a combination of didactic instruction with demonstration and hands-on practice. The instructor would demonstrate how to enter information into a particular screen, then students were given time to repeat the skill on their tablets. Instruction covered patient entry through discharge. All clinicians attended the five days of training regardless of their disciplines or which functionality they would use in their positions. Class surveys were provided on the last day of class. After completing the class, clinicians were paired with a mentor for several weeks to learn the remainder of their jobs. Clinical mentors may or may not have been successful in incorporating electronic documentation into their daily work flow. Once in the field, students' work was not checked for potential retraining needs.
A year after implementation, the staff was frustrated with the system and had continual end-user issues. Many of these issues were related to a lack of understanding of the system and how to resolve simple problems. The organization moved an LPN from the field into a position as nurse mentor to assist the system administrator. The nurse mentor was responsible for supporting basic end users' issues Monday through Friday from 8 am to 5 pm. There was no after-hours support, although users worked in the system 24/7.
After evaluating the organizational flow and the clinical system training, I realized that users were being taught skills they would not be required to use and were not getting enough concentrated practice in the tasks they would be using daily. The training was screen based, and although the users were provided training in each screen of the system, they were never taught to tie the screens together and view the system as an EMR. There was no follow-up after completion of the class to ensure understanding. Because most of hospice care is provided at the patient's residence, the clinicians are not always able to turn to a coworker to ask for help in the system. They were spending a large amount of time in the office trying to resolve computer issues with the nurse mentor. They needed better reference materials to take into the field, 24/7 telephone support, and a review of their documentation after being in the field for several weeks to ensure understanding.
The first task was to develop a clinical training manual covering all required system functionality. This manual is a step-by-step guide with screen shots and explanations. The manual is laid out to follow the usual workflow of the clinician but also includes instruction on less frequently used functionality. A troubleshooting guide provides solutions to the most commonly encountered end-user issues.
Each student is assigned two patients to work with in the training environment during class. These training patients have been set up to provide realistic patient profiles. A structured class schedule was developed that includes small 45 to 60-minute sessions that provide time for instruction, demonstration, and hands-on practice. Additionally, the most common errors and their solutions are presented for each section. A prewritten hands-on practice, including problem solving, is conducted after each learning segment. Each of the sessions builds on the previously learned skills in the order they will be performed during a routine visit. The first 2 days of class are designed to address the common functionality used by all disciplines, such as setting up their schedule, documenting an assessment, writing clinical notes, verifying visits, sending and responding to tasks, searching for information, and synchronizing their work to and from the server.
To get the students used to referencing the manual, as skills are taught, the students are asked to follow along in their manual. Less frequently used skills are briefly introduced during class without hands-on practice. Students are advised that they are not expected to learn these particular functionalities in the basic class but only to know that they exist and can be referenced in the manual for step-by-step directions. They are also reminded that 24/7 assistance is available and are encouraged to call when performing a new skill for the first time if they need support in addition to the manual.
As the students work their way through the sessions, they can see how their work in individual screens come together as an EMR. For example, the first thing students learn after logging into the system is their personal "My Day" screen that contains a list of their patients, scheduled visits, and assigned tasks. With the exception of their two assigned patients, the screen has no information at the beginning of the first day. By the end of the first day's lessons, their "My Day" screen is populated from the work they entered into the system and they review where each element came from. At the last learning session of each day, students are given hands-on practice scenarios to complete, tying together all learned functionality. The first session of days 2, 3, and 4 is also a scenario-based hands-on skills tests of everything learned since the first day. Students are encouraged to use their manuals to help guide them through the skills before asking for assistance from the instructor.
Chaplains and social workers require less functionality than nurses do, so they attend only the first 2 days of training. Nurses learn additional functionality such as order entry, medications, and specific assessments required for various patient situations during the third day of training. On the fourth and final day, the nurses are given two complete patient scenarios that test their ability to maneuver and document correctly in the system. The student documentation is checked by the trainer, and then both scenarios are discussed in an open forum as a learning experience.
After several weeks in the field, the quality assurance chart auditor reviews random patient records completed by each student to ensure that they are documenting correctly. A training survey is also sent out requesting feedback on the trainer, the manual, and the class structure and content to ensure that the basic class was comprehensive and to identify areas for improvement.
The feedback from the clinical staff regarding training has been very positive. They feel that the scenarios help them put the system together in their minds. The nurses carry their manuals with them into the field as a guide, and more seasoned nurses who were trained prior to the restructuring have requested copies of the manual. Students appreciate the chart audits to identify areas for improvement early in their learning.
Clinical system help desk calls have decreased by 70% since the rollout of the new training. Users are willing to attempt more problem solving on their own following the troubleshooting guide. Even nurses who enter class having never worked in an EMR before say they feel confident in their ability to perform the routine electronic documentation that is required. I have witnessed tremendous growth in many of the nurses who were with the organization when the system was first implemented. Several have proudly told me about being able to assist a coworker with a documentation task.
When new functionality is implemented, additional training on the specific functionality is provided in small groups of 10 to 12 users prior to the rollout. Compliance is then monitored and supervisors receive a report on staff who requires reinforcement or possible retraining. The clinical staff still pushes back, but the time to full compliance has seen a dramatic decrease.
The importance of carefully thought-out training cannot be overstressed. Teaching skills in the order they will most likely be used and allowing staff hands-on scenario-based skills practice help to tie the EMR together as a patient medical record rather than a group of unrelated documentation screens. Performing chart reviews and providing feedback are helpful in ensuring understanding and early correction of identified errors. Training to use a system, like the system itself, should mimic the work flow of end users.
© 2010 Lippincott Williams & Wilkins, Inc.