Electronic medical record training beyond go-live

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Training is obviously required when rolling out a new electronic medical record (EMR). There are two main approaches to a roll out. Either a big bang approach with all the training up front and every module ready to go day one – or a phased approach where you launch modules or functionality one at a time and train users on each as they roll out. What may not be as obvious are the long-term training requirements. Whether homegrown or a commercial EMR, once established EMRs are rarely stagnant. There are updates and upgrades that happen. Clinic or hospital workflows change usually in an effort to improve care. All of this requires a method to communicate or train these changes. The average user does not want to go back to class on a regular basis. Nor can hospitals or practices support the loss of productivity with sending users back to class repeatedly. Each user may have distinct gaps in their ability to use the system.

Medical schools expect students to be competent in EMR use and cover this competency under systems-based training in their evaluation. This is also required by the ACGME when evaluating residency training programs. Computer competencies are also being examined in nursing programs. A study by Ornes evaluated nursing programs for the extent of informatics skills taught. (1) Key computer skills sought were skills in administration, communication, data access, documentation, patient education, patient monitoring, basic desktop software, and systems. Ornes found many of these elements lacking in the nursing curricula evaluated and concluded that nursing faculty were the greatest block to incorporating this training in classes. (1) This means that when starting employment many employees will not have basic EMR skills. Although with each passing decade, computer literacy in hospital employees seems to increase.

Kaiser has developed a performance improvement system that creates a culture of organizational learning. (2) In Schilling’s article they discuss several components defined by NIST (National Institute of Standards and Technology) and others that are building blocks for learning organizations: real-time performance data sharing, training in problem solving, work-force engagement and informal knowledge sharing, leadership behaviors, benchmarking, and technical knowledge sharing. While this learning organization is by no means all about EMR training it is a potentially perfect avenue to fold in the ongoing training needs of EMR updates. The article references a Kaiser commissioned study that determined “personal connections were pivotal to sharing knowledge”. (2) While Kaiser uses their intranet for cross-site knowledge sharing, Schilling acknowledges that technological tools require an investment of time and energy to make them work for learning. Sharing both the “(technical information about what to do) and know-how (process content about how to do it)” (2) are key. She concludes “knowledge management systems…[are] relative[ly] ineffective…compared to … communities of practice and social networks.” (2) These components should be strongly considered in developing a long-term EMR training program.

Computer-based tutorials can prove to be a cost effective tool for training needs. In a study published by Hlusko, nurses were trained with 4 on-line modules that covered everything from basic Windows functions to email and spreadsheets. (3) They used a pre-test, which allowed 44% of nurses to test out of training. Other nurses completed the on-line training in half the time planned for classroom training. Those that did train were able to do this during down time and thus avoid the costs of replacement staff. This lead to a significant estimated savings in training costs with on-line training costing only 25% the cost of classroom training in this study. Certainly the ability to test out of something you are comfortable with satisfies the employee and should meet the organization need of knowing the user is skilled. Computer-based tutorials allow flexibility as to when training is done and can be a foundational element of long-term EMR training.

Porcheret evaluated improved data quality in a study using assessments, feedback and training. (4) In this study he was able to demonstrate an improvement in documentation with the use of cycles of assessment – feedback of the results and comparison to other groups – followed by individualized training on specific gaps. Using each group as its own control they were able to show this method improved documentation even if not all groups achieved the level of performance desired after 4 cycles. Individualized assessments of all employees within large organizations would be challenging and time consuming so this methodology is best employed in specific high yield settings.

A somewhat different methodology was used by Dykes to provide ongoing provider training in an evolving EMR. (5) In this study workflow analysis was performed observing providers interacting with the Partners Healthcare EMR. A new module was determined to be beneficial in the workflow and physician champions were then trained on this module through a 1-hour training session with a consultant. Additional training was optionally available. An additional 8 physicians requested and received training. The routine use of this module increased significantly with this training plan. Partners Healthcare planned to use this data to design an advanced training plan for primary care practices.

Kamath describes a more comprehensive approach used by the Mayo Clinic in Rochester to maintain EMR competency. (6) Recognizing that competent use of the EMR (in this case MICS Mayo Integrated Clinical System) is critical to safe patient care and user efficiency, Mayo has developed a tiered learning approach. As a large facility with many busy users and an evolving application, training was a challenge. Their foundational training level is termed “infrastructure” and targets new staff, new tools or significant functional changes. They deliver this through classroom training, “classroom-in-a-box” and e-Learning tools. Their middle tier is considered “ongoing” and targets add-on functionality, refreshers, and tips & tricks. They deliver this through MICS café, local resources, and e-Learning tools. Their top tier includes “JIT” or just-in-time training and works like a quick reference. This training is provided with an online reference, “Google” search, and eDemo. (6) Mayo appears to have incorporated many of the previously mentioned tools into a cohesive training plan.

There is currently not a lot of research on the best methodologies to provide on-going training in EMRs. What is clear is that providing just initial training alone is insufficient. There are new standards like “Info buttons” being set for clinical decision support and knowledge management where based on context within the EMR specific information is surfaced to help the user. Example: In the patient context of a 55-year-old male with diabetes and hyperlipidemia presenting with chest pain and an electrocardiogram with ST elevation - the info button could surface the AHA/ACC STEMI guidelines or order sets for acute myocardial infarction.

It could be beneficial to potentially develop similar standards for surfacing ongoing training in EMRs. Example: A user receives an error message repeatedly when using a specific EMR feature – the “training button” surfaces a brief how-to about that feature. Example: A new module is available in your EMR - the EMR puts a flag at the top of the screen that takes you to a training video when you have a few spare minutes. Example: A user regularly omits the foot exam on diabetes care – the EMR can surface training on the EMR care plan tool for diabetes or diabetic guidelines.

While nurses and providers have to meet a certain number of hours of continuing education in their specialty, there are no requirements for ongoing EMR training. Kaiser’s model of a learning organization is a great example of bringing healthcare system training to a new level. (2) Lowes stated, “A $30,000 electronic medical record system is like a $30,000 grand piano. Whether you play the equivalent of Beethoven’s ‘Moonlight’ sonata or ‘Chopsticks’ depends on your level of training.” (7) When quality healthcare is at stake, we should all strive to be virtuosos. The judicious balance of classroom training, social networking of best practices, evaluation/testing and focused training, e-Learning tools and online references will likely help hospitals and practices achieve this goal.


1. Ornes LL, Gassert C. Computer competencies in a BSN program. J Nurs Educ. 2007; 46(2): 75-8.

2. Schilling L, Dearing JW, Staley P, Harvey P, Fahey L, Kuruppu F. Kaiser Permanente's performance improvement system, part 4: creating a learning organization. Jt Comm J Qual Patient Saf. 2011 Dec; 37(12): 532-43.

3. Hlusko DL, Pahoulis E, Branson L. Cut training costs with computer-based tutorials. Nurse Manage. 1998; 29(11): 31-3.

4. Porcheret M, Hughes R, Evans D, Jordan K, Whitehurst T, Ogden H, et al. Data quality of general practice electronic health records: the impact of a program of assessments, feedback, and training. J Am Med Inform Assoc. 2004 Jan/Feb; 11(1): 78-86.

5. Dykes PC, McGibbon M, Judge D, Li Q, Poon EG. Workflow analysis in primary care: implications for EHR adoption. AMIA Annu Symp Proc. 2005; 944.

6. Kamath J, Ferguson J. EMR competency: supporting quality, safe and efficient care. AMIA Annu Symp Proc. 2006; 974.

7. Lowes R. EMR success: training is key. Med Econ. 2004 Jun; 81(9): 11-4.

Submitted by Lisa Gleason