TOPAZ, MAXIM MA, RN; RAO, ADITI MSN, RN; MASTERSON CREBER, RUTH MSc, RN; BOWLES, KATHRYN H. PhD, RN, FAAN
The US healthcare system is at a pivotal point of change. The widespread use of electronic health records (EHRs), implemented as part of the health information technology (HIT) revolution, is here to stay. Enacted as a part of the American Recovery and Reinvestment Act, HIT has been instigated by the 2009 Health Technology for Economical and Clinical Health Act.1 According to these acts, most healthcare providers across the US are required to become meaningful users of HIT by 2015.1 Meaningful users are healthcare providers who use “certified Electronic Health Record technology in ways that can be significantly measured in quality and in quantity.”2 The implementation of HIT is obligatory for providers receiving Medicaid and Medicare reimbursement. Healthcare practices that meaningfully use HIT will receive monetary incentives, whereas practices that fail to meet meaningful use criteria by 2015 will be penalized.2
Although some controversy exists regarding the effect of HIT and EHRs on the quality of care,3,4 there are a general understanding and a growing body of evidence indicating that the meaningful application of healthcare technologies leads to better care processes, patient safety, and better outcomes.5,6 These benefits are achieved through better care coordination, instant access to the best available evidence, healthcare information exchange between providers, and improved client engagement in health and self-care processes. The widespread adoption and the capabilities of HIT and EHRs are growing as providers and vendors actively join forces to further develop and implement HIT throughout clinical practices.
One of the biggest challenges for healthcare providers is the effective implementation of HIT into the real-world clinical environment.7–9 Effective implementation requires regular system updates and appropriate user education. Because inappropriate use of HIT and EHRs can result in patients’ privacy breaches, unsafe care, medication mistakes, and other medical accidents,10–13 it is critical that changes and updates to EHRs are properly communicated to the users through education and training.13
With the widespread use of the Internet and recent developments in theoretical and practical applications of distance education, providing HIT education and training online seems to be one of the most efficient and cost-effective approaches to educate healthcare providers on the use of HIT and EHRs. The first aim of this manuscript was to briefly review the theoretical background and published literature on the possible options for distance education or e-learning for HIT focusing on EHRs. The second aim was to describe and evaluate one example of an EHR educational intervention that was implemented to educate nurses on new elements incorporated into the existing EHR system.
WEB 2.0 AND THE THEORETICAL BASE FOR DISTANT EDUCATION
Recent advancements in the field of information technologies have enabled widespread individual access to vast amounts of information through the Worldwide Web (WWW), commonly called the Internet. During the last several decades, the conceptualization of WWW has evolved rapidly. In the early 1990s, the Internet was envisioned as a tool to deliver and disseminate information in a top-down fashion.14 Consumers of WWW were seen as passive “receivers” of information delivered by the expert content provider. This conceptualization is often referred to as Web 1.0. In education, Web 1.0 was used to teach students by giving them access to learning materials with the assumption that motivation would come from the availability of information provided by an expert via distant access.
With the evolution of the social media, delivered by a ubiquitous and personalized technology, Web 2.0 emerged. Instead of an original expert-user information dissemination approach, Web 2.0 emphasizes active participation, connectivity, collaboration, and sharing of knowledge and ideas among users. Web 2.0 tools help users create a knowledge-oriented environment often called the “participatory Web” or the “read-write Web.”15 In education, Web 2.0 helps to create an interactive learning environment in which participants are more engaged in learning processes through participatory technologies.16 Therefore, the assumption is that active participation enabled by Web 2.0 tools should create motivation and help to engage the learner.
Several theoretical frameworks explain how Web 2.0 is supposed to be applied to facilitate education. For example, the Engagement theory posits that technology should enhance the learning process by meaningfully engaging students through involvement in a worthwhile task and interaction with others. Technology should enable three core elements of the learning process, namely, relate-create-donate.17
* Relate: Learning should occur in a group context. Technology should enable learners to understand that they are a part of a larger learning group or organization.
* Create: Learning should occur as a purposeful and creative activity. Technology should be used to facilitate interactive learning processes and enable users to actively interact with the system or others.
* Donate: Learners should be able to see that they are making a useful contribution while learning.
According to the Engagement theory, these three core concepts should be merged to create meaningful real-world learning activities.
In addition, EHR education and training should be grounded in traditional theories of education,18 including the Social Cognitive Theory19,20 and the adult learning theory of Situated Cognition.21,22 The former posits that learners are more likely to change their behaviors when they understand the importance of the outcomes of their behaviors. The latter suggests that learner’s experiences are situated within larger contexts and are affected by organizational and cultural factors. To develop a successful Web-based educational intervention, integrating aspects of each of these theories is important.
Additional literature searches of major biomedical databases (PUBMED, CINAHL, and MEDLINE) do not provide much evidence regarding effective strategies for training healthcare professionals on the use of EHRs. Although several publications highlight the critical importance of educating healthcare professionals on the use of EHRs to increase the quality and safety of care,13,23,24 none of the articles focus on the best strategies for nurse-oriented distant EHR education and training. Therefore, publishing the description of our training project is a relevant and timely endeavor that may initiate dialogue about evidence-based strategies for delivering effective EHR education.
PRACTICAL EXAMPLE: OUR PROJECT
The goal of our project was to develop a conceptually sound, evidence-based, user-friendly, and interactive e-learning approach to bring relevant EHR updates to nurses. The presented project was part of a larger National Institute of Nursing Research–funded study (R01NR007674) that identifies factors affecting clinicians’ discharge planning decisions. As part of the data collection process for this study, several data elements were added to an existing EHR. This study received institutional review board approval, and hospital authorities provided active support and collaboration. To educate nurses about these study-related updates to the EHR, an interactive tutorial was constructed to demonstrate the changes that the nurses would see and the manner in which the nurses needed to document.
Before the e-learning tutorial could be developed, however, assessing the organizational culture was an important initial step. The hospital participating in this research project is a large, academic medical center that has achieved Magnet recognition. Therefore, the institution values research as well as the active involvement of nurses in organizational initiatives. Gaining support for this project, in turn, needed to come from both senior organizational leadership and unit-based clinical leadership, or shared governance councils led by clinical nurses.
Although approaching the unit-based leadership in the early phases of the research project was time-consuming, these initial meetings were important to the success of the training module. By meeting with unit-based leadership, we were able to engage with the clinical nurses to explain the study’s purpose and the changes that would be made to the EHR for data collection. These meetings gave them an opportunity to understand the significance of this research and the manner in which their documentation could provide information critical to identifying factors affecting discharge planning. Actively involving the nurses in discussions related to research efforts, resulted in a group of early adopters who served as educational champions as the project progressed and the training module was implemented on units throughout the hospital.
To develop the tutorial itself, we teamed with the hospital’s nurse educators to identify the best strategy for communicating the EHR changes. Consulting with the education department helped confirm the feasibility of an e-learning approach but revealed that there were also several important issues to consider. First, an understanding of the hospital’s current process for communicating EHR updates was needed. To ensure that the nurses recognized that training provided information regarding upcoming EHR changes, the tutorial had to conform to a familiar format and be disseminated through established channels.
Second, nurses faced an overwhelming amount of change and information. The hospital’s documentation system had recently been updated and the nurses were still adapting to new forms and changes to their workflow. As the hospital fine-tuned this new system, there were frequent updates to which the nurses needed to adjust. In addition, the nurses in the target hospital were frequently asked to participate in research and were encouraged to engage in a number of ongoing educational programs. In this information-rich environment, it was important to ensure that the tutorial would not become diluted or overlooked. Therefore, nursing management made the tutorial a requirement for clinical nurses. To improve the likelihood that nurses would engage with and internalize the material, the tutorial was designed in a concise, interactive format. Teaming with nursing education, senior, and unit-based leadership helped clarify how to meet the nurses’ educational needs, while accounting for organizational constraints and cultural factors that affected the nurses’ information uptake.
Once it was clear that an e-learning presentation would be an effective strategy for reaching the nurses, there were several software solutions available for constructing the presentation. Most of these software options shared somewhat similar functionalities. We chose Adobe Captivate v. 5.5 (Adobe, San Jose, CA), an authoring software used to create and maintain interactive e-learning content, because it was a flexible, user-friendly program available at the academic institution. The software is relatively easy for intermediate computer users and detailed online tutorials enable basic and continuous learning. For more information on the online tutorials, see Web sites offering online software training, for example, http://www.lynda.com.
The interactive e-learning tutorial included several modules:
* Introduction including the description of the importance of our research project and its expected impact on patient outcomes (using a voiceover slide technique in which an enthusiastic narrator presented the slides’ content).
* Brief software tutorial that showed the new elements incorporated into the existing EHR system. In this module, the learners were able to see an example of the actual changes to the system and the narrator presented the rationale for incorporating these elements.
* Interactive scenario where learners were presented with a brief case study emphasizing the importance of the new EHR elements. Through the case study, nurses learned about the impact of their data on discharge decisions.
* Conclusion with a general summary emphasizing the impact of thorough nursing documentation on patient outcomes and well-being. At the end, the development team expressed their gratitude to the nurses for participating in the e-learning tutorial.
Quotes from the chief nursing officer of the hospital about the importance and impact of nursing data were included in the 7-minute presentation. This interactive presentation was posted on the educational section of the hospital’s intranet site and was announced via an e-mail alert to all of the hospital’s nurses and nursing leaders (eg, senior leadership, clinical nurse specialists, and nurse managers). Another e-mail including screenshots of the new elements and a brief description of the project was sent to nurses and nurse managers so they could be printed and displayed at nursing stations. The e-mails were sent twice to maximize uptake of the educational material and added to the “what’s hot” section of the nursing intranet site.
EVALUATION AND LESSONS LEARNED
We believe that our blended strategies for targeting and educating the nurses were successful. Approximately 74% (1546) of the 2080 nurses in the hospital system completed the interactive tutorial, and the actual completion percentage is likely higher as some of the nurses included in the total number of eligible persons either work per diem (once in several weeks up to several months) or hold administrative positions in which they would not need to work with the added EHR elements. Personnel from the education department at the hospital deemed the project successful in terms of the completion rate. Unfortunately, it is difficult to compare the tutorial completion rate with that of other projects because the current literature lacks reports of rates of completion. In addition, preliminary evaluation suggests that good quality data are being captured from the elements added to the EHR; the completeness of data captured by the new elements is more than 80%. Therefore, we believe that our structured approach to both addressing organizational factors that affect learning and creating a theoretically grounded, interactive tutorial contributed significantly to the success of the project.
The biggest challenge in educating the target population was in dissemination. Clinical reality is complex: nurses’ time is limited, new information is abundant, and EHRs are updated constantly. After extensive outreach within the organization (targeting the leaders, making the tutorial required, providing additional information for the managers, etc), about a quarter of the nurses did not participate in the tutorial. A recent Institute of Medicine report titled Best Care at Lower Cost: The Path to Continuously Learning Health Care in America25 suggests that learning healthcare systems of the new millennia cannot exist without constantly learning practitioners. As we learned, for practitioners to continuously learn, clinicians require comprehensive and varied learning opportunities. Moreover, educating clinicians on frequent EHR updates is critical. In this case, it would have been helpful if the healthcare organization afforded nurses time to meaningfully engage in training opportunities. It might also have been helpful if incentives encouraging clinician participation in such activities were available.
CONCLUSIONS AND SUGGESTIONS
In the context of theoretical frameworks, scientific evidence, and experience with the presented project, we suggest several core principles that should guide the implementation of the distant EHR education and instruction:
* Engage, engage, engage: several software options are available to achieve better user interaction with presented material. This is necessary to increase learners’ engagement in the learning process and improve chances for actual implementation of the learned materials. Case studies, interactive scenarios, and quizzes are all valid options to achieve this goal.
* Provide relevant examples: with the help of user-friendly software, creating interactive tutorials is very feasible for the intermediate computer user. These tools should be used to provide learners with relevant examples of expected step-by-step actions.
* Consider the organizational culture: understanding the organizational factors (structure, chain-of-command, key stakeholders) of a hospital or medical system is critical for success with implementing innovation. Educators should engage the organizational stakeholders and staff champions to facilitate the adoption of the desired behaviors.
* Simplicity over complexity: creating brief but informative e-learning presentations is yet another component to success. The overall message needs to be clear and precise and the amount of information presented to learners should not be extensive. It is sometimes better to divide the e-learning presentation into several parts rather than overwhelm the learner with vast amounts of information.
Finally, more evidence is needed to understand how to best structure and implement effective EHR education and tutorials. The lack of evidence could adversely affect the successful adoption of EHRs and quality of care in several ways. First and foremost, inadequate or inaccurate documentation limits the ability of healthcare practitioners to provide safe and efficient care. Therefore, as suggested by the most recent Institute of Medicine report titled Health IT and Patient Safety: Building Safer Systems for Better Care,13 greater attention to the creation of comprehensive training modules is critically needed. Second, the lack of evidence increases the disparities between small and big healthcare practices. Research shows that smaller practices face more issues while implementing EHRs,26 meaning that while bigger and more affluent practices might invest more resources in the EHR-related education, small practices will increasingly lag behind.13 Finally, as these technologies become more sophisticated, instigated by the meaningful use incentives, the need for well-educated, technologically savvy healthcare providers will grow. If evidence-based strategies for training providers HIT are lacking, appropriate and effective use of these technologies will be limited and many costly and potentially powerful HIT projects may fail to improve the quality of healthcare. In conclusion, healthcare stakeholders, researchers, and policy makers should pay more attention to generating evidence-based knowledge about effective HIT and EHR educational approaches. On the basis of our experience, we suggest that healthcare systems create theoretically grounded, interactive tutorials and afford nurses time to meaningfully engage in training opportunities; this investment will pay off in the long-term.
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