In addition to meaningful use, we need to define meaningful training.
How do we train hundreds of thousands of doctors to become meaningful users in a year or two in time for full stimulus incentives?
With technology, that's how.
Meaningful use of a certified EHR was recently defined by the Health Technology for Economic and Clinical Health (HITECH) Act enacted as part of the American Recovery and Reinvestment Act (ARRA) of 2009. Signed into law by President Obama, HITECH provides a benchmark for the attainment of federal incentive bonuses initiated to help drive the adoption of health information technology (HIT) across the nation. Over the next five years, hundreds of thousands of doctors will be trading their pens or dictaphones for template-driven computer applications promising to not only store charts, but transmit prescriptions electronically, provide up-to-date decision support on the delivery of patient care and cut down on administrative waste by electronically submitting visit charges to payers.
Advanced technology, such as the Allscripts Enterprise EHR, already delivers on much of this functionality, aiding in achieving certification and helping doctors transform healthcare. However, for hospitals and physician practices to fully adopt these highly sophisticated EHRs and qualify for HITECH Act incentives by demonstrating meaningful use, they must incorporate computer-based training technology.
Physician participation and motivation is critical
Most HIT leaders would agree that training is one of the most important aspects of implementing new technology — especially certified EHRs with advanced functionality. However, the challenge many encounter with any type of training strategy is getting the doctors to participate and maintain a high level of attention to ensure meaningful learning.
Many HIMSS Nicholas E. Davies Award of Excellence recipients have achieved excellence through significant investments in training. This award recognizes excellence in implementation and attaining value from HIT with a special emphasis on EHRs. One award recipient, Multicare Health System, amended its medical staff bylaws to require EHR training and competency in order for staff to maintain privileges. As one can imagine, this is a very powerful motivating factor, especially when combined with awarding CME credit for participating in training. Unfortunately, many obstacles exist that can hamper training efforts.
EHR implementations are plagued with failure rates as high as 50 percent, depending on how success is defined. One commonly cited failure involves a large hospital system in southern California that failed implementation of computerized physician order entry (CPOE). Despite significant resources, strong leadership and experience in informatics, the CPOE system had to be uninstalled because of configuration challenges and lack of physician support.
Several studies have looked at physician age and adoption of HIT, such as an EHR. Soumerai and colleagues (1998) found that older physicians are less likely to change their practice of medicine even when presented with evidence that alternative approaches yield improved outcomes. Burt and Sisk (2005) found that physicians older than 60 were less likely to adopt than younger physicians, but they thought this might be related to these doctors being less comfortable with computers. Examining how this might tie into practice characteristics, it turns out that older physicians are less likely to work in large practice settings. Physicians age 55 and older represent 22 percent of physicians in practices of two to four physicians and 12 percent of those working in groups of five to nine physicians (Kane, 2004). Going full circle, the selection and adoption of an EHR is greatly influenced by the size of the practice. Enterprise EHRs, commonly selected by larger organizations, are expected to meet the needs of many specialties across an organization. They are known to be less “natural” than those systems designed for a single specialty, and thus they are more difficult to adopt.
Understanding the differences in physician and practice characteristics, their impact on adoption, as well as motivating factors that can enhance learning under these same conditions is critical to developing effective training.
E-learning increases productivity
Technology has proven highly effective in many industries as a means to facilitate training to drive productivity within an organization. As early as the 1980s, Motorola studied the impact of its Motorola University, finding a return on investment of $30 for every dollar invested in training (Brandenberg, 1987). Today, most Fortune 500 companies have sophisticated human-resource applications interfacing with a learning management system (LMS), where managers can enroll and monitor employees' participation in continuing education. Many have taken courses like this, typically in regards to HIPAA compliance or code of ethics within the healthcare field.
The power of technology to influence productivity really comes from several core factors: convenience to access, ease of tracking participation and scalability of distribution. Also, taking into account the targeted group of adult learners, power also comes from immediately providing relevance on how the training will benefit the learner. Threshold time for providing this relevance is even more critical for e-learning. Thus, the full benefit of technology can only be realized if the online training, or e-learning initiatives, are developed appropriately and take into account the full breadth of variables that can affect learning.
Effective e-learning is customized
EHR training should be relevant to physicians' specialties. Can you imagine having a neurosurgeon take time from her busy schedule to sit down in front of a computer to complete a training module that references the clinical scenario of a 21-year-old athlete who planted and twisted his right knee, felt a pop and now presents with right-knee pain and swelling? Such a situation loses out on the opportunity to grab the learner's attention by providing immediate relevance. It will also most likely turn the learner off from any additional learning.
Now imagine the orthopedic surgeon who operates on 10 knees a day encountering the same scenario. He not only becomes immediately engaged, he begins to activate prior knowledge regarding the care for such a patient. This makes the absorption of new knowledge about the EHR far more efficient, according to well-established learning theory (such as schema theory). The concept of customization to provide immediate clinical relevance makes perfect sense. However, it wasn't commonplace among most enterprise-level, multi-specialty organizations incorporating e-learning into their implementation plans because customizing computer-based training for each specialty was complex and cost prohibitive — until recently.
ImplementHIT specializes in e-learning for Allscripts, incorporating the use of patent-pending technology to swap out different clinical scenarios, depending on the specialty of the physicians being trained. Through the use of this advanced online simulation technology, ImplementHIT customizes learning to replicate the EHR exactly as configured by the user organization. With highly sophisticated systems, such as the Allscripts Enterprise EHR and its V11 Note module (a problem-based, template-driven documentation tool that renders text via the clicks on a form to capture discrete data), online learning can also provide a means for physicians to learn about clinical content, such as what is available on a form for chest pain, even before going live with the system. This level of customization and simulation makes the transition from training to live environment less stressful for doctors and results in higher levels of adoption.
When appropriately implemented, online learning becomes a scalable tool that allows few to train many. With robust tracking, it can enable an organization to continuously improve, and via convenient, anytime/anyplace access, it makes it possible for learners to advance their knowledge of the EHR at their own pace.
The ROI of online EHR training
Using e-learning reduce the amount of training time prior to EHR implementation. This approach keeps physicians in the clinic longer and lessens the impact on their productivity and revenue-generating activities. E-learning for the Allscripts Enterprise EHR produces ROIs of $6 to $10 for every dollar invested in training. More importantly, this drives EHR adoption that will result in meaningful use targeted by the HITECH Act, leading to improved patient care and
Andres Jimenez is chief executive officer, ImplementHIT (www.ImplementHIT.com).
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