While I was finishing a night shift in the ED a few years ago, the oncoming ED doc, who happened to be the Medical Director, looked unusually frustrated so early in the morning. As I was signing out, I asked what was bothering him. He replied that our upcoming conversion from paper records to Epic was weighing heavily on him. More pointedly, he was concerned about how doctors would respond to the training that is generally provided prior to go-live.
As he was considering options for how to best train physicians, he had difficulty believing they would sit through hours of lectures. He was envisioning an email inbox full of complaints, phone calls with potential threats to quit, and rising tensions in the ED. In my post-call, delirious state, I tried to put myself in his shoes and asked if we could meet later to discuss.
When we met, he was calmer, but still nervous. We knew the conversion from paper to an EHR was inevitable; the only question that remained was, how can we navigate this change to the best of our ability? We broke out the white board and jotted down some ideas. Some good, some naïve. One idea in particular caught my eye. He suggested that I become certified as a Credentialed Trainer and train our docs directly. He was willing to fund this endeavor and have my shifts covered. Although I was intrigued, I had my reservations. As an ED doc, I’m all too familiar with the phenomenon of the messenger being the target of highly charged emotions. Nonetheless, the challenge seemed both worthy and surmountable, and so I bit.
The next six months consisted of a return to academic rigor, project management, emotional intelligence sharpening and, above all, hand-to-hand combat with both the end-users and the IT staff. I learned to be an intermediary who could see the world through both lenses — and this proved invaluable. Some days my role was simply to be the Rosetta Stone to both sides. Other days, it was more nuanced and required a deeper conversation to uncover the root of the issue. Some days it was about knowing what was possible. Most days it was about clarifying reality and knowing what’s not possible.
Over the course of this experience, I learned a thing or two about what training success looks like at the intersection of doctors and computers. I’d like to share a few lessons learned during my combat tour that I hope may be helpful for others who are either implementing a new EHR system or, equally important, initiating an ongoing training program to ensure that the providers stay up-to-date on and remain efficient in their EHR capabilities.
- Clinical and Operational Workflow: Understanding the actual boots-on-the-ground workflow of your audience is the single most critical factor in the training process. Take the time to understand this in detail, and make every effort to mirror your lesson plans with EHR build and capability. Moreover, make sure the required operational workflow can actually be accomplished in your TEST environment. On more than one occasion I found myself having to back track when the TEST environment didn’t include a sample CT result or access to a PDF that’s required to see the patient’s code status. Nothing disheartens providers more than when their teacher guides them confidently to a software glitch.
- Learning Styles: Every EHR vendor will provide guidance on ‘learning styles’ — usually in the form of a video series to prepare the credentialed trainers for the varied learning approaches that exist. They highlight the four basic styles: visual, auditory, reading/writing, and kinesthetic. They ask you to survey your audience to identify which learning styles are represented and then adjust your approach appropriately. I take exception to this. With respect to the EHR, we all learn by doing, period. It’s similar to learning to ride a bike. We can watch the bike, we can read about the bike, and we can hear the bike riding along. But at the end of the day, we won’t know how to ride a bike until or unless we actually get on the bike and start pedaling. We’ll probably fall down a few times, but eventually we’ll get the hang of it. It’s the same with the EHR. Get your people on the bike and guide them to pedal and balance. When they fall off, help them back on. Focus your energies on being present for them when they’re attempting to ride — they’ll thank you.
- Pedagogy: In 1968, a Brazilian author named Paulo Freire wrote a seminal book titled Pedagogy of the Oppressed. One aspect of the book is particularly impactful to our EHR work: the teacher-student dynamic. He proposed a new paradigm where education is framed to maximize thinking in students. Instead of the traditional model of lecturer/lecturee, he supported a model where the teacher and student enter into a partnership and dialogue to solve problems jointly. In short, the teacher and student learn from each other. As a credentialed trainer, stay humble and remember that your end-users will teach you more than you teach them, if you are open to it.
- Personal Connection: For the average end user, the ITS system is a big, black box with little transparency, fraught with bureaucratic intricacies that they often believe are too difficult to penetrate. You may not be able to change that perception (or reality) all by yourself. You can, however, be there for your end users. Every one of my students had my personal cell number, and I made myself available to them as they encountered IT related issues. I primarily served as Air Traffic Control for everything from logging quality issues, to hardware incompatibilities, to software break/fix issues. I was able to solve some issues outright, but took pride in helping to guide their effort to get it figured out. Be available and present for your students, and it will pay dividends long past go-live.
- Celebrate Wins: Kotter’s principles of change management include 8 steps, one of which is particularly relevant: generate short term wins. Nothing gets docs out of the pit of despair more than actually accomplishing what they set out to accomplish. Remember that they have spent their entire career setting goals and accomplishing them. That’s how they arrived to their current state as a respected member of the medical community. As they make progress, point it out clearly and often. It builds confidence and gives them something to fall back on when further challenges present themselves.
There are certainly more lessons that are worth discussing in the future. For now, I suggest taking a long, hard look at the go-live training and the educational programs you’re offering. Remember, once software is built properly and tested, the only thing standing in the way of usability is the quality and impact of training we’ve provided for those who devote themselves to patient care.
Lee Milligan, MD, serves as VP and CMIO at Asante, a multi-hospital system serving patients in nine counties throughout Southern Oregon and Northern California. An emergency medicine physician, Milligan remains tied to his clinical roots. He is also director of the Governing Board for both Asante and the Oregon ACO.