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EMR development...Always be prepared

Kulhanek, Brenda PhD, RN-BC, CPHIMS

doi: 10.1097/01.NUMA.0000407575.88737.e8
Feature: Ce Connection

Put down the pen and paper...Scheduling software saves time and money.

Brenda Kulhanek is a training and performance improvement specialist in Litchfield Park, Ariz.

Nurse leaders play a pivotal role in end-user education.

The author and planners have disclosed that they have no financial relationships related to this article.



Implementing an electronic medical record (EMR) system offers countless benefits: major healthcare savings, reduced medical errors, improved quality of healthcare, and improved health.1,2 To profit from an EMR, staff must understand how it works. This can only happen when new programs are supported through detailed, precise training. An unprepared healthcare unit can result in increased staffing needs, contribute to patient-care errors, cause organizational turbulence, and impact a facility for months or years.3 Effective end-user training can prepare employees to practice in a redesigned work environment so that instead of spending excess time learning new processes, the nursing staff can focus on reliable, safe patient care.

Nurses are most often assigned the task of generating and conveying EMR training. They must develop guidelines that address the complexity of EMR processes, however, to do so requires knowledge and skills that typically aren't taught in nursing schools across the United States.4,5

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A look at the stats

A 2010 research study surveyed board-certified informatics nurses and nurse executives about the impact of the organizational environment on the design and delivery of EMR training.6 The results of the survey were analyzed to further understand organizational training experiences and the barriers or enablers encountered during the training process. (See Research criteria.)

Board-certified informatics nurses were asked to rank a list of 15 tasks that would typically be performed when training for an EMR implementation. (See Training production tasks.) In addition, the informatics nurses were asked to list their significant successes and greatest barriers encountered while providing EMR training. Approximately 88% of study participants represented hospital environments, 2% were employed in home care or hospice environments, and almost 10% were employed in other healthcare delivery settings. Facility sizes included less than 100 beds (5.9%), 100 to 199 beds (3.9%), 200 to 300 beds (27.5%), more than 300 beds (25.5%), and multiple hospital systems (35.3%). (See Nurse executive questions.)

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Informatics nurses ranked obtaining training space and enforcing training attendance as their most complicated tasks. Jobs ranked slightly less challenging included creating a training schedule and evaluating instructional outcomes. Tasks posing no difficulty for the informatics nurses included understanding educational practices and using computer technology for training.

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To explore the current state of training evaluation, informatics nurses were asked what type of instruction was used for EMR education. Competency testing was used by 64.7% of the organizations, whereas user satisfaction surveys and clinical documentation audits were used by 41.2%. A pass/fail evaluation method was used by 23.5% of the organizations represented in the survey, and 15% used either no evaluation method or required training attendance as the only measure of success.

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In qualitative responses, 47% of informatics nurses identified the most significant project enablers as the training methods used; 20% said training materials; 12%, evaluation and outcomes; 10%, leadership support; 6%, structure and processes; and 4%, power users. Nurse executives identified leadership, resources, and effective change management as enablers essential to the success of the training projects.

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In contrast, the greatest barriers blocking training, as identified by the informatics nurses, included lack of leadership support (23%), the timing of training (18%), disparate computer skills (15%), training space (13%), training materials/resources (8%), creating educational materials (8%), staff impact and resistance (3%), and technology or system issues (2%). Nurse executives identified barriers as a lack of resources (creating a drain on the nursing department), attendance, change management, and poor training outcomes.

The impact of ineffective training on the EMR system included practice issues and increased incident reports. The impact on units included loss of staff, increased stress, and a downward adjustment of nurse-to-patient ratios. In one organization, physicians felt that nurses were always on the computer and needed to spend more time with their patients.

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Brave new world

In the new world of health information technology, change is steady, meaning that existing and incoming employees will need constant training. Training must not be approached as a one-time or infrequent event, but increasingly as a part of the typical education routine for each healthcare organization. Appropriate space or alternative methods of instruction must be developed and integrated into ongoing instructional preparations.

Implementing a computerized clinical documentation system can present challenges and significant changes to the culture of an organization. The use of training development models provides a platform for consistent and successful outcomes, while helping the staff and facility focus less on learning new information technology programs and more on delivering safe patient care.

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Research criteria


The purpose of this study was to provide an initial exploration of the perceptions of informatics nurses and nurse executives of organizational environment impact on the development and delivery of computerized clinical documentation training for patient-care staff, as well as to explore the enablers and barriers that are encountered by nursing informaticists during the development and training processes.


A mixed methods study was conducted to determine:

  1. What's the relationship between organizational environmental factors and training methods utilized by nursing informaticists to train patient-care staff to use computerized clinical documentation in healthcare organizations in the United States?
  2. What are the enablers and barriers that are encountered by nursing informaticists as they design and deliver computerized clinical documentation training to patient-care staff in healthcare organizations in the United States?

Time frame

Data were collected for a period of 4 weeks in 2010.


The study population included all board-certified informatics nurses that were members of the professional organizations American Nursing Informatics Association—Capital Area Round Table on Informatics in Nursing or the Minnesota Nursing Informatics Group. Criteria for inclusion in the study included board certification in nursing informatics and leadership or involvement in the design, development, and delivery of clinical documentation training implemented within the last 12 months within a healthcare organization.

Collection tool

Data were collected using a questionnaire e-mailed to all board-certified informatics nurses in the identified study population; in addition, a telephone interview was conducted with a second group of study participants.

Sample size

Questionnaires were sent by e-mail to approximately 680 board-certified informatics nurses. Study response rate was 17%, n = 52. Telephone surveys were conducted with five nurse executives, n = 5.

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Training production tasks

  1. Make a training project plan.
  2. Construct training materials.
  3. Create training schedule.
  4. Obtain training space.
  5. Communicate to students.
  6. Acquire leadership support.
  7. Enforce training attendance.
  8. Obtain access to nurse executives.
  9. Understand the best training practices.
  10. Use computer technology for training.
  11. Utilize the best training practices.
  12. Adapt to student skill level variations.
  13. Choose method of training delivery.
  14. Evaluate training outcomes.
  15. Implement training delivery method.
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Nurse executive questions

  1. In what type of organization do you practice?
  2. What's the size of the organization in which you practice?
  3. On a scale of 1 to 10, with 10 indicating superb success, how would you rate the success of your computerized clinical documentation system implementation?
  4. What were the strongest contributors to the success of your computerized clinical documentation system implementation?
  5. In what ways did the clinical documentation training contribute to the success of the clinical documentation system implementation?
  6. What were the biggest roadblocks and obstacles encountered during the implementation of the clinical documentation system?
  7. To what extent did the clinical documentation training contribute to the roadblocks and obstacles encountered during the clinical documentation system implementation?
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1. Hillestad R, Bigelow J, Bower A, Girosi F, Meili R, Scoville R, Taylor R. Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health Aff (Millwood). 2005;24(5):1103–1117.
2. Crane JN, Crane FG. The adoption of electronic medical record technology in order to prevent medical errors: a matter for American public policy. Policy Studies. 2008;29(2):137–143.
3. DePhillips HA, III. Initiatives and barriers to adopting health information technology. Dis Manage Health Outcomes. 2007;15(1):1–6.
4. The HIMSS Nursing Informatics Awareness Task Force. An emerging giant nursing informatics. Nurs Manage. 2007;38(3):38–42.
5. Health Information and Management Systems Society. HIMSS 2009 Informatics Nurse Impact Survey.
6. Kulhanek B. Enablers, Barriers, and the Influence of Organizational Environmental Factors on Computerized Clinical Documentation Training Developed and Delivered by Nursing Informaticists. Minneapolis, MN: Capella University; 2010.
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