Training Strategies: C A L I FOR N I A EHR Deployment Techniques H EALTH C ARE F OU NDATION Introduction ◾◾ California Rural Indian Health Board This investigation and analysis of training (CRIHB) strategies for adopting electronic health records 3. Multi-site expansion. Support multi-site (EHRs) is the third in a series of tactically oriented clinics to expand adoption of their existing issue briefs arising from the California Networks EHR product and implementation services to for EHR Adoption (CNEA) initiative. The CNEA Issue Brief at least three additional clinic sites. Grantees: program was begun in 2006 to speed adoption and lower the overall cost of electronic health records ◾◾ Golden Valley Health Centers (GVHC) (EHR) in California community clinics and health ◾◾ Shasta Community Health Center (SCHC) centers (CCHCs).1 In August, 2008, eight grantees 4. Hospital-based regional extension. Work representing four models of EHR deployment with local hospitals to extend their existing were funded to advance the adoption of EHRs EHR product and implementation services to in the safety net and to share their experiences. CCHCs in a region or service area. Grantees: Through this health IT collaboration, an array of services is provided to support the adoption of ◾◾ San Mateo Medical Center (SMMC) EHR and other applications. The CNEA models/ ◾◾ The Children’s Clinic, Serving Children grantees include: and Their Families (TCC), Long Beach, California 1. National network. Build or leverage existing EHR networks, often national in scope, to For additional information about the CNEA provide for individual or groups of clinics in initiative and the collaborative models of adoption, California. Grantees: please see “Speeding Adoption of Electronic ◾◾ Open Door Community Health Center Health Records in Community Clinics” from (ODCHC) in partnership with Our the California HealthCare Foundation at Community Health Information Network www.chcf.org.� (OCHIN) Training Overview ◾◾ Next Generation Health Network The extensive training that is required to teach (NGHN) staff and providers to use an electronic health 2. Clinic consortia. Work with California clinic record (EHR) system is one of the larger costs of consortia to expand their existing EHR product implementation and an important opportunity and implementation services to at least three of for realizing the transformation in care delivery their members. Grantees: that EHRs can bring. This issue brief explores ◾◾ Redwood Community Health Coalition some approaches to training, their influence on (RCHC) the implementation strategy, and the ways they can streamline workflow and standardize policies and procedures. While training is often most J une 2010 intense in the weeks and days before the transition — or for software licenses, vendor services, and hardware and “go live”— all CNEA grantees found that without network upgrades. Training costs include: continuous, structured follow-up training, the benefits of ◾◾ Closing the clinic, reducing appointment availability, EHR are never fully realized. or re-assigning workloads during training; Investment vs. Expense ◾◾ Accommodating reduced productivity for some Finding time for training staff and clinicians involves months after go-live. trading off an early loss of productivity and revenue ◾◾ Hiring temporary staff to fill gaps; against a smoother and faster transition. Ideally, schedules are cleared in advance for intensive training just before the ◾◾ Finding, renting, and scheduling training facilities; EHR goes live, and for additional training and practicing ◾◾ Building out a training center internally; after the go-live date. This practice time is critical; several CNEA grantees found that expecting clinicians to practice ◾◾ Providing food, paying overtime, and incurring other their skills without actually giving them administrative expenses for weekend training or data-entry sessions; time to do so was wishful thinking. ◾◾ Providing time and resources to adjust work processes and templates in response to issues that arise from The cost of training for EHR implementation should be training; regarded as an investment rather than an expense because, without it, organizations risk spending money on EHRs ◾◾ Paying overtime so that providers and staff can catch without realizing the benefits. Investing in the training of up on their work in the evenings; a core group of internal staff members on all aspects of ◾◾ Developing or customizing training materials, the system pays large dividends for a network and health manuals, or instructional videos. center. Training staff and clinicians to use the EHR is never an Nonetheless, the initial costs are often unanticipated and entirely separate process from the implementation strategy seem to hit particularly hard in the midst of payments and plan. Therefore, instead of training staff on all the Super Users: Key to Success Identifying and training super users and clinical leaders will create a core of knowledgeable staff members familiar with the clinic’s processes and with the requirements (and advantages) of the electronic health record. Some super users should have clinical experience; all of them should be trained fully on EHR functions to understand the impact on the entire data flow. Training super users early is crucial to being able to champion the process of change throughout the organization, providing both clinical and technical perspectives. They can shepherd the analysis of existing workflows and the configuration of an EHR to achieve the best fit with the health center’s needs and client base. Early training also provides insight into the kinds of training that will be most effective for end-users, making it both more specific to their job function and more efficient. Super users can act as easily accessible mentors, providing front-line, ongoing support and training. There should be at least one super user at each clinical site and these new responsibilities need to be written into their job descriptions. Many EHR vendors offer a discount in maintenance fees if the clinic has “certified” super users and trainers within their organization. 2  |  California HealthCare Foundation EHR functions at once, it can be effective to separate Vendor personnel are expensive to bring onsite and training and implementation into the different functions. their time needs to be used wisely. Changes in provider For example, a clinic organization might initially train schedules or last-minute emergencies can wreak havoc providers and staff in the use of e-prescribing, e-referrals, on a carefully designed training schedule. For this and electronic lab orders. Once that part of the EHR is reason, many vendors are now offering distance-based or working smoothly, training could move on to include computer-based training via the Internet. This type of more complete chart documentation. The best strategy training is well suited for communicating the basics of the depends on how the organization has approached change system’s features and functions and for allowing flexibility in the past, on the clinic staff ’s level of comfort with to individual providers and staff to access training. computers, and on how much the organization can afford There is no substitute for hands-on training with a live to pull staff from their jobs for training at any one time. instructor, however, and the sooner organizations can “train the trainers” in their own organization, the more Who Does the Training? flexible and cost effective the training will be. While training provided by the software vendor is important, it is unlikely to be sufficient. In general, the An important consideration in designating internal super CNEA grantees found it necessary to supplement vendor users and trainers is that training is not a single event; it is training and, in some cases, take full responsibility for an ongoing process. Dr. Robert Moore, medical director end-user training. The vendor will know the product, at RCHC and Clinic Ole, describes this process: “There’s but may not understand the needs of a particular clinic, training, implementation, a little more training, a little or of specific providers and the patients they see. Clinics, more implementation, and continued training over time. in particular, have unique reporting and billing needs This process is critical, especially as new modules are that vendors struggle to support with products designed rolled out and as clinical leadership identifies issues that for private practices. Most EHR applications are highly need to be fixed or tweaked.” configurable so that they can meet the needs of many different types of providers, specialties, and care settings. While the responsibility for training often lies with With that configurability comes complexity, which is information systems (IS) or information technology often best understood by vendor personnel. (IT) staff, CNEA grantees have found that clinician-to- clinician training is more successful with certain parts of An effective training approach often takes advantage of the EHR. Dean Germano, CEO of Shasta Community the vendor’s training for a designated core group of “super Health Center noted, “Implementation of EHR pushed users.” These are staff members trained to configure the our organization into putting more resources into system (i.e., populate, order, or filter drop-down lists, training. We established a full-time clinical nurse trainer, define clinical decision rules, and determine when alerts an RN, who’s responsible for the clinical piece, and we appear) and then to provide front-line support to other have an LVN and a medical director who work with our users in the clinic. Super users organize much of the rest informatics department to make sure the training meets of the training internally, where network staff or clinic the needs of the organization. We do less classroom-based super users take over. In this way, the trainees can learn training now and a lot more one-on-one or very small and practice with the customized forms and templates group training, because that’s what people need. And the best suited for a specific client population. This approach clinicians in particular do not want to be in a classroom marries the knowledge of how the EHR works with how for two hours. They all learn at a different rate and so you the EHR will be used at the health center. just have to start accommodating those nuances.” Training Strategies: EHR Deployment Techniques  |  3 Training as a Means for Data Conversion Three Training Strategies Data from existing patient charts will need to be extracted and propagated to the EHR, along with appointments, Role-Based Training billing codes, etc.2 It is often effective to make this task Training is most efficient when it is organized according part of the training by devoting several days to having to function, and trainees are most attentive when the the appropriate staff enter the information into the EHR. training is directly related to the work they do. Because For example, several of the CNEA grantees found that it is tailored to the specific EHR functions that end-users having clinicians abstract the data was invaluable in terms will be performing on a daily basis, the super users of the integrity and relevance of the information that familiar with these duties are most effective as trainers. ended up in the EHR. It also gave clinicians a thorough For example, a clinical trainer has great credibility understanding of how the EHR worked, fostered buy-in, with clinical trainees and can answer specific questions and allowed clinicians to give informed feedback on the about clinical documentation, templates, computerized design of templates and forms. Similarly, once front office physician order entry, and similar functions. Customized staff have entered all the appointments into the EHR, training materials developed after the system has been they will have a good mastery of that part of the system. configured — with the health center’s preferences and Often, closing the clinic for a day, or working intensively forms — are much more effective than the generic over a weekend, proved to be the best way to accomplish workbooks offered by vendors. this data-entry task. End-users in training need to be comfortable with the Scheduling long days or weekends for front office staff use of computers. CNEA grantees often administered to input appointments, clinicians to input patient data, a general computer skills assessment prior to role-based and back office staff to input billing codes is a great way training so that computer literacy could be addressed, to get different functional groups up to speed on using making the training less stress-inducing. Competency the EHR. It often works well to prioritize inputting exams administered after role-based training and at several data on patients that are chronically ill and those with points following go-live can serve to pinpoint individual co-morbidities. Data on other patients can be added to training needs, create accountability for data accuracy, the system as they schedule appointments. The health enforce organizational standards, and identify trends in center will need access to data on the chronically ill first, training effectiveness. and inputting that data will show what is not important to abstract from the paper chart, as well as what is Process-Based Training important. There is no substitute for working with real Although role-based training is fundamental to learning data for evaluating how the forms and templates in the the new system, the need for process-based training will EHR work for the practice. Similarly, such intense work inevitably surface, because learning how to use a new with the new system will help users to know what they system will raise issues of workflow. For example, training are going to want out of the system, and changes can be on e-prescribing is as important as training on the new, made accordingly, before the full implementation of the technology-enabled medication refill process. The former EHR. may involve only providers, but the latter will also involve medical assistants and call center staff and/or nurses. All staff involved in the process will need to understand their responsibility and the hand-offs that occur. 4  |  California HealthCare Foundation Process training provides the opportunity to update during the initial go-live period) allowed staff to discuss and standardize policies and procedures, to make sure which processes worked well and which needed further that new responsibilities are captured in updated job refinement. descriptions, and to incorporate best practices into the care team’s training. Processes will change and evolve as Some multi-site health centers were able to rotate staff end-users learn to integrate the EHR more deeply into into their pilot clinic for a shift or for several days to train daily operations. Surfacing these issues during training in a live environment. Clinical champions or mentors sessions rather than in the course of a busy clinic day at the pilot site proved to be very effective in providing will ease the burden and anxiety many staff members feel peer-to-peer training and easing the transition for a during the initial transition to EHR. site-by-site EHR rollout strategy. Mock-Clinic Training Insights from CNEA Grantees To provide end-to-end, integrated process training, The experiences of CNEA grantees and their clinics many CNEA grantees elected to close the clinic entirely provide some insights into training strategies and the for a mock clinic, or dry run, of a typical clinic day. lessons learned. This exercise lasted anywhere from four hours to two ◾◾ At San Mateo Medical Center, 75 to 80 individuals full days immediately preceding go-live. Administrators were trained as super users to help with all often played the role of the patient, going from check-in implementation tasks and to support end-users to exam to check-out. Modeling different types of at 14 clinics. In addition, 15 “champion” super patients — routine preventive care and well-child visits users were given extra training to support the to patients with several chronic conditions—helped implementation team. “They’re like the EHR SWAT providers and staff understand how the integrated care team,” noted Chief Medical Informatics Officer, process would be changing. Having a debrief session Mike Aratow. Some of the champion super users at the end of these mock clinics (and for several days traveled to sites where the EHR was going live, with the goal of having at least ten support staff at each site. Training Part-Time Providers, Volunteer Providers, and Locums ◾◾ RCHC took quality improvement (QI) approach to Many health centers rely heavily on part-time providers, training and implementation. CEO Nancy Oswald volunteers, visiting specialists, and locum tenens to cover the demand for services. Training these providers said, “Before they can be trained on the product, on complex EHR features and functions can be health centers need to be trained on the opportunities challenging in that they may only use the system on an for redesign. EHR implementation disrupts how occasional basis. everything is done, and thus provides a unique Most CNEA organizations found ways to allow these opportunity to see how the EHR tool can be used providers the opportunity for training if they wished, most effectively. Assisted by a training team consisting or to use traditional paper documentation that is either of an IT staff member trained in the product, a QI scanned into the EHR or entered by medical assistants or nurses subsequent to the visit. Templates can be staff member to address process flow, and the health built for specialists that ease the documentation burden center site manager, everyone starts by doing ‘as is’ for them. Pending orders can be entered by nurses or workflows; this gives them the knowledge that what medical assistants and approved by either the part-time they do is part of a larger workflow that will have to provider or supervising physician. be accounted for in the EHR.” Framing this as a QI Training Strategies: EHR Deployment Techniques  |  5 project “leads us naturally to process improvement,” Conclusion added Oswald. Electronic health records are tools to help a clinic or hospital succeed more fully at its mission of providing ◾◾ Golden Valley’s CIO, Ray Parris, described how the best care for its client population. Like other types of their training strategy is tightly interwoven with health information technology, implementing an EHR their two-phase implementation strategy. “In will prompt discussions about best medical practices, Phase I, we train the providers and staff how to and about expectations for the shared use of the data use the e-prescribing system,” he said. “We then collected. As a result, the training process will have an allow the providers to advance toward 100 percent impact on many aspects of the organization, far beyond e-prescribing over no more than nine weeks —  the technology itself. EHRs change the quality of patient although this usually happens faster.” While the care as well as the way care is delivered and recorded. A providers are getting up to speed, training in strategic approach to training can turn those changes into additional duties continues for the support staff. opportunities for improvement, and can help staff and “Our goal is get the support staff ready to support providers negotiate the anxiety that always accompanies the provider staff when Phase II begins. During change. this phase, providers begin full charting, advancing toward 100 percent charting over 12 weeks.” ◾◾ Stacy Watkins, deputy director of operations for Open Door, described the health center’s EHR “dress Author SA Kushinka, M.B.A., Full Circle Projects, Inc. rehearsal” conducted the day before go-live. “It’s a half-day session, where we close down and have About the F o u n d at i o n fictitious patients in the form of our administrators. The California HealthCare Foundation is an independent We go though the entire patient visit process, from philanthropy committed to improving the way health care registration to exam room to check-out.” After is delivered and financed in California. By promoting ODCHC’s first go-live experience and mock clinic, innovations in care and broader access to information, our where the “patients” had very complex conditions, the goal is to ensure that all Californians can get the care they organization decided that a ramp-up of increasingly need, when they need it, at a price they can afford. For more complex patients may be more effective training. information, visit www.chcf.org. Accordingly, the first visit would be a patient with a cold and a medication prescription. The second Endnotes visit would be a patient who required an exam, a 1.The Blue Shield of California Foundation (BSCF), the diagnosis, and a lab order or medication. The next California HealthCare Foundation (CHCF), and the patient would be a well-child check-up or an annual Community Clinics Initiative (CCI), a joint project of exam on a patient with a chronic condition. Most the Tides Foundation and The California Endowment, are providers were able to see two to three patients per funding this project. four-hour mock clinic, and at the end of the day 2.For a comprehensive exploration of the chart abstraction there was a debrief. “What worked? What didn’t process, please see CNEA issue brief “Chart Abstraction: work? Did things print where they should? Did EHR Deployment Techniques,” California HealthCare everyone have the permissions they needed to do Foundation, March 2010 at www.chcf.org. their job the next day? That took a lot of anxiety out of the go-live.” 6  |  California HealthCare Foundation