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Curbside Consult with Dr. Jayne 5/20/19

May 20, 2019 News 2 Comments


In a recent issue of Applied Clinical Informatics, researchers from the Arch Collaborative detailed their examination of the relationship of EHR user satisfaction to the investment in training made by the users’ organizations.

This comes as no surprise to those of us who have spent time in the EHR implementation trenches. Those who have more effective training tend to be better users of a given system. Being a better user often leads to less frustration compared to those who are struggling with the system. In general, people who experience less frustration might tend to be happier with their workday, or at least with the tasks that have to be completed in the EHR.

The data was compiled from a survey of 72,000 clinicians across 156 provider organizations to identify which elements determine whether a user reports higher levels of user satisfaction. The authors noted, “If healthcare organizations offered higher-quality educational opportunities for their care providers – and if providers were expected to develop greater mastery of EHR functionality – many of the current EHR challenges would be ameliorated.”

I’ve seen health systems that would allow physicians to go live on a system with only a couple of hours of classroom training with no hands-on experience and no ability to personalize or configure the system even though the system had those capabilities. In my experience, users trained in this manner have a greater tendency to turn into raging EHR haters than those who receive training that includes laboratory scenarios and the ability to create favorites and defaults.

I’ve also seen plenty of go-lives at organizations that didn’t hold physicians accountable for mastering the EHR. “Difficult” individuals might be allowed to opt out of training altogether after putting up barriers to participation in scheduled sessions.

I watched one hospital bend over backwards to schedule training at the time and place demanded by each subspecialty department, only to have a large number of physicians no-show their scheduled sessions. Conversely, I’ve worked with hospitals that demanded their providers attend training sessions and complete practice scenarios before being allowed access to the production system. Of course the latter group of providers seemed happier with the changes in workflow brought by the EHR than those who fought the process. In the study, physicians who reported poor training were “over 3.5 times more likely to report that their EHR does not enable them to deliver quality care.”

The researchers looked at multiple organizations across a subset of EHR systems and noted that a smaller portion (20%) of variation in user experience can be attributed to the actual software, but a larger portion (50%) of variation resulted from differences in how users acted on the system. They were able to identify both successful and unsuccessful provider organizations using the same systems. They also noted nearly 500 examples where two physicians of the same subspecialty at the same organization used the EHR and cited markedly different user experiences. In almost 90% of those situations, the more satisfied physicians said they had better training or more effort spent on personalizing the EHR.

Ultimately, the authors recommend that organizations require at least four hours of EHR training if they want to avoid frustrating their users. I would suggest that four hours doesn’t scratch the surface of what it takes to be an EHR power user. Physicians often argue that systems aren’t intuitive and it shouldn’t take them that long to learn how to do it since paper is “a no brainer,” but I point them back at the countless hours that they spent as medical students, interns, and residents learning to write a good note. Only through time and practice are the 10-page history and physical documents generated by third-year medical students whittled down into a two-page admission note done by a resident and a one-pager dictated by an attending physician.

The authors use the example of the scalpel, which “is a tool that has a very simple interface and use, but using it with confidence and safety requires knowledge of anatomy and surgical techniques coupled with practice to use it skillfully. In other industries, it is well recognized that education and training are of paramount importance to the successful use of professional-grade software. We need to recognize that this also holds true for EHRs and the practice of medicine.”

The authors recommend standardizing EHR training paradigms, although they were not able to identify a single methodology that performed better than the rest. They did note that more training needs to be focused on user-level configuration or personalization. However, they also noted that improved user training “needs to be balanced with a parallel focus on better designed and smarter software that can better meet nuanced needs of healthcare.” They also note that “these findings do not negate the need for EHR developers to continue to improve their user interfaces to be more intuitive, nor do they negate the critical need to reexamine the current regulatory and billing requirements that drive so much of the clinical documentation burden faced by providers today …”

They look to the future in considering the growing role of decision support within EHRs and how it might impact patient care. “For this vision to become a reality, physicians will need to know the limits of their technology’s advice in the same way that pilots know the limits of a plane’s autopilot. Without clearly understanding the EHR’s limits or how to use the technology, care providers will not trust the technology they work with.”

I like the airplane analogy. One of the EHRs I’ve worked with is an extremely robust system and some users complain it’s too complicated. I used to say that it is like a fighter plane – you want a system that is completely capable in case you wind up in a dogfight, even though most of the time you are just going to be on patrol. Users need to understand how to efficiently and effectively use the features that make up 80% of their day, but they also need to know how to access the next level of features for when the one-off situations arrive in the office.

The authors made some forceful comments that made my attention, one being that “caregivers who do not understand EHR technology are a threat to quality care and will likely not realize an efficiency gains in using the EHR nor be able to use the technology fully to advance care quality.” They go on to “advocate for caregivers to adopt EHR technology expertise as a core competency of their profession.”

I’m sure some physicians reading the study might be up in arms over its conclusions. I’ve been known to say that if some physicians would spend the same amount of time actually learning the EHR that they do complaining about it, they’d find themselves in a different place. This piece seems to reinforce that sentiment.

What do you think about the impact of training on EHR user satisfaction? Leave a comment or email me.


Email Dr. Jayne.

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Currently there are "2 comments" on this Article:

  1. Your pain scale image reminded me of this:


    (Slightly NSFW since some of the pain descriptions use profanity)

    Not at all surprised about the results of the training and satisfaction study. After all you can’t start using *any* complex software program without training and time using it before you can become remotely competent. Think Adobe Photoshop or any video editing software. These are designed for professionals to use and still require 1k page manuals and many hours of training and practice. Lots more to say on teaching methods, vendor services and costs, and provider org choices, but everyone has a stake in this.

  2. Any complex software that you spend a lot of time in, you’d better learn it well. Most people do that but if you invest your time in resentment instead, you get nowhere.

    For highly skilled software users, they memorize key application pathways. It becomes second nature to them, to the point they don’t even think about it. Then for every work task, the only application questions that arise are:

    1). Do I already know how to do this?
    2). If I don’t, do I think my application can do it and I just need a nudge to get there?

    Remember Lotus 1-2-3? I had one user who fought the transition to a different spreadsheet tooth and nail. He had memorized the Lotus commands and never thought about them. When they changed he lost productivity and his stream of thought was interrupted. I had some sympathy until he went to upper management, got their support and became the lone holdout in the entire company. Years later he was still chattering on about Lotus even though Lotus was irrelevant in the spreadsheet market.

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