The role of cognitive and learning theories in supporting successful EHR system implementation training: A qualitative study

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In their 2012 article titled "The Role of Cognitive and Learning Theories in Supporting Successful EHR System Implementation Training: A Qualitative Study", McAlearney et al. examine the evidence relating the application of social cognitive and adult learning theories to EHR training as an implementation best practice. [1] They cite several studies establishing the potential value of EHR adoption in ambulatory care settings, despite which this adoption has low relative to in-patient settings. The authors examined the training practices of six organizations which have been recognized for outstanding electronic health record(EHR) implementations. Interviews and focus groups served as the source of data for the analyses. The authors concluded that incorporation of social and cultural factors are highly predictive of effective training, [1] which is, in turn, widely recognized as necessary for a successful implementation process. Considering the importance of the quality, scope, and timing of training to successful adoption of information technology, the authors examine the clinicians' training experience for six different implementations recognized as being successful. They suggest that qualitative factors including sociological and cultural considerations may have been determinants for the relative success of these implementations. The authors consider this study's focus on cognitive and adult learning theories as an important contribution of specificity to the on-going work of developing implementation best-practices.

Conceptual Framework

The authors constructed a framework built on cognition theory to study the training practices of the six subject EHR implementations. Key components of this construct are:

  • Social cognitive theory [2] – individuals will be more likely to change behavior if they value the associated outcomes.
  • Social cognitive theory [2] – self-efficacy whereby individuals with a belief that they are capable of controlling events effecting their life will extend this belief to their belief in their ability to master the new system
  • Social cognitive theory [2] - social persuasion whereby learners observing others success gaining competency using the new EHR will develop confidence in their own ability to do the same.
  • Situated cognition and organizational learning [3] - proposes that an organization's past experience with IT initiatives affects those that follow. Also identified as relating to situated cognition is the concept of a community of practice, in which the organizations social system can heavily influence (promote or impede) implementation.


The six best practice sites were chosen based on (1) receipt of the HIMSS Davies award for Ambulatory EHR, (2) recognition as a "most wired" hospital by the Hospital & Health Network (HHN). The field was further narrowed based on input from an advisory committee of professional and academic experts. 42 individual interviews were conducted between Feb. 2009 and Dec. 2010. These included organization leaders, IT personnel and clinicians. In addition, Focus groups were conducted (one for each of the six organizations) consisting of physicians (both generalists and specialists) as well as residents. Analyses were conducted by codifying the transcripts according to a coding dictionary developed by the research team. A deductive analysis was applied to the authors' theoretical framework to determine the presence of traits consistent with the concepts identified within the framework. An inductive process was then applied to identify commonality across the six subject sites.


Based on the authors' findings, they propose the following seven best practices for EHR system training: 1) Obtain organizational commitment to invest in training 2) Assess users' skills and training needs 3) Select appropriate training staff 4) Match training to meet users' needs 5) Use multiple training approaches 6) Provide training support throughout implementation 7) Retain and optimize training, and provide for iterative learning


The study and cultivation of best practices for EHR implementation remains an active area of discussion. One can expect training to remain central to that discussion. While most best-practice studies are understandably referenced to large (high stakes) in-patient implementations, and a lesser number are based on smaller out-patient adoptions, there is a noticeable void in studies comparing the two. It seems a worthy area of study to examine the distinctions and similarities between best practices for EHR implementation in hospital settings vs ambulatory care practices. This study presents a point of convergence where change management, technical innovation and learning theories intersect. There is certainly ample room for further study in this area.


  1. 1.0 1.1 McAlearney, A. S., Robbins, J., Kowalczyk, N., Chisolm, D. J., & Song, P. H. (2012). The Role of Cognitive and Learning Theories in Supporting Successful EHR System Implementation Training: A Qualitative Study
  2. 2.0 2.1 2.2 Bandura, A. (1986). Social foundations of thought and action. Englewood Cliffs, NJ: Prentice-Hall
  3. Robey, D., Boudreau, M., & Rose, G. M. (2000). Information technology and organizational learning: A review and assessment of research. Accounting, Management, and Information Technologies, 10, 125-155.