EPtalk by Dr. Jayne 6/10/21

I recently completed a short-term consulting engagement where I was asked to evaluate a health system’s physician training strategy and to make recommendations to make it more effective. Like many organizations, they’re struggling with physician burnout and many fingers are being pointed at the EHR. The IT department is convinced that the technology can’t possibly be at fault, so it must be how the physicians are using it, and therefore the training team’s fault. Since the IT team has a stronger political voice in the organization, training went under the microscope and a friendly CMIO was dispatched to the scene (virtually, of course).

I’m no stranger to these scenarios and was happy to take the engagement. I’ve seen enough failed EHR implementations to know that the success and happiness of physicians is directly proportional to not only the level of configuration of the EHR to meet local needs, but also to the amount of training required by the organization. For a complex system that will be ever-present within patient care, expecting physicians to know how to use it well after a couple of hours is not realistic. There’s often a belief that physicians won’t tolerate a greater amount of training, but I’ve found that they will be glad to attend if the training is high value and helps them use the EHR effectively. What they won’t tolerate is poorly delivered training with inappropriate clinical scenarios and lack of recognition of how they do their work.

Often training teams lack sufficient budget to be able to deliver the type of training needed, so I always arrive armed with journal articles and case studies. One of my favorites is from Applied Clinical Informatics. The title says it all: “Local Investment in Training Drives Electronic Health Record User Satisfaction.” It’s from the pre-pandemic era, published late in 2019, and I suspect that it might not have been widely read because by the time it was getting into circulation, most of us were laser-focused on COVID-19. The authors surveyed over 72,000 clinicians across more than 150 organizations to identify opportunities to have better return on EHR investments. One overarching theme is that there are “critical gaps in users’ understanding of how to optimize their EHR” and a proposed solution is to invest “in EHR learning and personalization support for caregivers.” I can’t tell you how many practices I’ve visited where the physicians don’t have any medication favorites built, don’t have defaults set properly, and have their drug/drug and drug/allergy checking settings at annoyingly high levels. Just fixing those few things typically reduces provider frustration immensely.

In evaluating my client, it turns out that the training team, IT, and operations all share the fault around poor usability and poor adoption. The users haven’t been able to take advantage of individual configuration and personalization settings because IT told operations it would make the system difficult to support. Training can’t deliver content around what’s not available, and unless physicians had used the same EHR in another venue, they wouldn’t be aware of what they were missing.

For the training content that the organization was attempting to deliver, they were lacking in resources, not only in headcount to deliver the training, but in having someone with expertise in adult learning who could design appropriate resources. They had decided that all training would be classroom style and group oriented, often with mixed subspecialties which added to attendee confusion as people asked questions that were not relevant to other attendees.

When the pandemic hit, they just migrated everything to Zoom and hoped for the best. Indeed, what wasn’t working before still wasn’t working, and for those not accustomed to online meetings, the training strategy truly failed to deliver. I had to do some significant education around learning styles, the risks of multitasking, and the need to assess mastery rather than simply presenting content. Fortunately, my client was receptive to the suggestions and is hoping to use some adult learning experts from an affiliated university to help fill the gaps. They’re also going to send members of the core application team back to training so they can fully understand the EHR’s personalization and customization features, since the people who made the decisions not to use them are long gone.

They’re also surveying the physician user base to find out how they want to learn and what works best for their needs. Some are going to still want/need classroom training, but in the post-pandemic era, they might value the convenience of a remote approach. I’ll check back with them once they have their survey results and the application team finishes training, and hope to be able to help them finalize a plan for rolling out additional personalization features to their user base. I see some additional satisfied users in their future.

I had some things to celebrate this week, and after reading a recent article about the Promoting Interoperability program, I decided that not having to worry about whether I was going to attest or take a penalty should be added to the list. A recent study showed I’m not alone at saying no. The study looked at Florida Medicare providers who participated in the Meaningful Use (and successor) programs between 2011 and 2018. Only 43% of those receiving a first-year incentive payment went on to achieve payments in subsequent years. This translates to a cessation in funding that was intended to help support EHR adoption and practice transformation. I certainly don’t fault physicians for failing to continue participation – the reporting requirements were painful and for smaller practices the additional work was daunting.

However, since Medicaid providers tend to serve the state’s most vulnerable patients, it may mean that those practices that didn’t continue participating haven’t fully embraced the tools in their EHRs that could help them close care gaps for those populations. On the other hand, it could just mean that they were sick of the reporting requirements and decided to use their scarce resources to work on initiatives that provided direct patient benefits. I’m interested in hearing from practices that stopped participating, and whether they were able to continue to advance EHR adoption and use of additional technologies such as patient portals and outreach tools without receiving additional funding.

Are you part of the Meaningful User Drop Out club? Leave a comment or email me.

Email Dr. Jayne.