Advanced Proficiency EHR Training: Effect on Physicians’ EHR Efficiency, EHR Satisfaction and Job Satisfaction

Abstract

The best way to train clinicians to optimize their use of the Electronic Health Record (EHR) remains unclear. Approaches range from web-based training, class-room training, EHR functionality training, case-based training, role-based training, process-based training, mock-clinic training and “on the job” training. Similarly, the optimal timing of training remains unclear--whether to engage in extensive pre go-live training vs. minimal pre go-live training followed by more extensive post go-live training. In addition, the effectiveness of non-clinician trainers, clinician trainers, and peer-trainers, remains unclearly defined. This paper describes a program in which relatively experienced clinician users of an EHR underwent an intensive 3-day Peer-Led EHR advanced proficiency training, and the results of that training based on participant surveys. It highlights the effectiveness of Peer-Led Proficiency Training of existing experienced clinician EHR users in improving self-reported efficiency and satisfaction with an EHR and improvements in perceived work-life balance and job satisfaction.

Introduction

One of the major issues in the implementation and maximum utilization of the Electronic Health Record (EHR) is how best to prepare the care delivery team to use EHR in a safe and effective way. Clinicians’ resistance to EHR adoption and implementation is a well-studied phenomenon^1,2. One of the major factors affecting clinicians’ adoption of EHR system is low computer literacy and inadequate EHR training^1,2,3,4.

Historically, various approaches have been used to train clinicians to use EHR ranging from web-based training, remote phone training⁵, class-room training, EHR functionality training, case-based training, role-based training, process-based training, mock-clinic training and “on the job” training. It was also found that learning to use the system and taking care of the patients at the same time can be difficult and initial formal training was usually insufficient⁵.

So far most of the focus of training has been at the time of system implementation. There have been few studies on advanced proficiency training of clinicians⁶. Joan Ash et al. identified that successful implementation is more dependent on post go-live support than pre-go-live training. It has also been noted “physicians have insufficient technical knowledge and skills to deal with EMRs, and that this results in resistance”². Heather K. Hill et al. identified that pre implementation training alone “was not sufficient to make clinicians proficient. End-users found it challenging to translate what they learned in training into practice. Another hurdle was the ability to absorb the intricacies of the training all at one time.” It was also found that need for continuous training is there “because areas of improvement are always being identified, and end-user understanding and questions about the HITS became more sophisticated with use”. Periodic upgrades also require continuous end-user training and support⁷. It has been also identified that more research is needed to find ways to optimize end user training and support⁷.

There has also been some interest in the relationship of EHR and physician job satisfaction^8,9. However, there has been very limited research on the relationship of physician’s EHR proficiency and their job satisfaction and perception of work-life balance. Although phenomenon of work life balance is well studied in management sciences and to some extent in healthcare settings^10,11, we were not able to find significant research in this area in healthcare settings in context of EMR use.

Optimal approaches to EHR user training are not well studied. In particular, little is known about post-implementation EHR training of experienced users and its effect on them. In this study, we evaluated one health care organization’s program to improve experienced provider users’ EHR proficiency, job satisfaction and work/life balance well after EHR implementation.

Methods

Setting

Kaiser Permanente is the largest not-for-profit integrated health delivery system in the United States, serving 8.6 million members in 8 regions spanning 9 states and the District of Columbia. Kaiser Permanente provides and coordinates the entire scope of care for members including preventive care, well baby and prenatal care, immunizations, emergency care, hospital and outpatient medical services, and ancillary services including pharmacy, laboratory, and radiology.

Kaiser Permanente Northwest (KPNW) is located in Oregon and southwest Washington. KPNW is one of the early pioneers in the deployment and use of a comprehensive EHR. KPNW’s EHR, now called KP HealthConnect (KPHC), was fully deployed in the ambulatory setting by 1997, and is now fully deployed in both inpatient and outpatient settings through the KPNW region.

Despite our numerous years of experience in the use of an EHR, we believe that significant opportunity remains in optimizing our effective and efficient use of this powerful tool.

Pathway to Proficiency

In 2010 we implemented a program that we call “Pathway to Proficiency” (P2P). The goal of this three-day intensive off-site program is to improve the proficiency of clinicians (defined as physicians and advance practice professionals such as physician-assistants and nurse practitioners) who are already experienced users of an EHR. This training is organized and delivered by physician super-users and champions. It includes sessions on various functions of the EHR including computerized physician order entry, physician documentation, lab results retrieval, etc. Sessions are divided into teaching sessions where the clinician peer-instructor provides the presentation, and practice sessions where clinician-attendees are given the time to practice what they learned in the preceding session. During these practice sessions multiple additional clinician super-users and instructors are available to provide one-on-one help where needed. In addition, clinicians are given the opportunity to spend additional time, in the evening after the regularly scheduled sessions, to practice the skills they learned during the day.

Design and study population

This program was offered to all KPNW clinicians on self-select basis. Usage data from our EHR was also used to attempt to identify clinicians who were struggling in their use of the EHR. Clinicians that had extensive after-hours use of the EHR and those who had large numbers of delinquent In Basket items were encouraged to attend this program. Clinician leaders were also encouraged to attend. The stated focus of this program was to help clinicians in improving their effective and efficient use of the EHR.

A pre-test, post-test study was provided to all participants of our P2P program using an online questionnaire. A total of 155 clinicians who worked in both ambulatory and hospital settings were trained at five different sessions throughout 2010. Three of the five sessions were geared to outpatient use and two of the sessions targeted inpatient use. Clinicians were asked to fill an online questionnaire before, and 30 days after, they participated in the Pathways to Proficiency training program.

Survey instrument

A questionnaire consisting of five-point Likert scale questions was used to evaluate clinician self-perception of their efficiency, satisfaction with the system and job satisfaction. The pre-survey contained a checklist to find out who they turn to as their primary source of system support, along with questions about demographics, attitude/work life balance, experience with our EHR, self-rating of specific skill areas and the quality of the system support that they had received. Similar question were asked in the post-survey, but an additional section was added to ask clinicians about their specific experience with our Pathway to Proficiency (P2P) program.

Both surveys also included areas for respondents to enter free-text comments.

Data Analysis

Out of 155 clinicians who participated in the P2P sessions we received 139 pre-surveys and 76 post-surveys. Only surveys with matching pre and post responses were included in the paired-analysis. Clinicians who completed the pre-survey but did not attend the program were excluded from the paired-sample analysis. In similar fashion, clinicians who completed the post-survey but did not complete pre-survey were excluded. When a survey was partially completed, we excluded the responses from any individual item that did not have both a pre and post response for that item.

Data was downloaded from the online survey site into Microsoft excel and was transferred to SPSS for statistical analysis. Descriptive analysis was used to assess frequencies, percentages, means, medians and standard deviations. Related samples Wilcoxon signed rank test was used to compare differences between before and after responses for each individual Likert scale question.

Results

Preferred source of support (Pre- survey)

On the pre-training survey, respondents were asked to select from a checklist of options about their preferred source of EHR support. Each respondent was able to pick more than one answer from the checklist. A total of 260 responses were received from the 126 respondents who answered this question.

Clinician peers/champions were a source of support named by over 78% of the respondents, followed by local support desk (38%), onsite non-clinical support staff (35%), national help desk (31%), Nurses/MAs (17%), and web-based help (2%). As Figure 1 shows, clinicians, by a wide-margin, turn to other clinicians as their source of help compared to other resources.

Figure 1.

Who do you usually turn to for help when you have an information system/ KP HealthConnect problem?

Demographics in the paired-analysis

Of the 57 participants who were included in the final paired-analysis, 47 reported their role as Physician (MD/DO), 3 as Nurse Practitioner (NP), 4 as Physician Assistant (PA), 1 as Dentist (DDS), 1 as Podiatrist (DPM) and 1 as Mental Health Practitioner. When asked about specialty area, 18 reported themselves as surgical specialty, 16 as medical specialty, 19 as primary care, 3 as mental health and 1 did not respond. Twenty-five clinicians identified themselves as full-time, while twenty-nine of them were part-time. Two clinicians did not answer this question.

EHR efficiency and satisfaction

Table 1 shows that on a five-point Likert scale, significant improvement was seen in clinicians’ perception of the adequacy of training and in their ability to find orders and diagnoses (both p < 0.001). Clinicians also felt, following training, that they were spending less time on the EHR outside of their scheduled work hours, compared to their colleagues (p = 0.012).

Table 1.

Questions/Results for EHR efficiency and satisfaction

Questions about EHR effeciency/satisfaction.	n	Before		After		p value
		Mean	SD	Mean	SD
I receive adequate training to use KP HealthConnect effectively and efficiently.*	54	2.69	0.968	1.87	0.825	<0.001
It is easy to find the orders and diagnoses that I am looking for in KP HealthConnect.*	53	2.47	0.799	2.00	0.734	<0.001
Compared with your colleagues, how much time do you spend on KP HealthConnect outside of scheduled work hours?**	50	3.46	0.908	3.20	0.969	0.012

^*Scale (Strongly agree=1, Agree=2, Neutral=3, Disagree=4, Strongly disagree=5)

^**Scale (Much more=5, More=4, About the same=3, Less=2, Much less=1)

EHR/Computer skills

Table 2 shows significant improvements in self-rating of general computer (p = 0.003) and specific EHR skills (p < 0.0001).

Table 2.

Questions/Results for EHR skills

Questions about EHR skills	n	Before		After		p value
		Mean	SD	Mean	SD
How would you rate your skills in the following areas? - General computer skills	53	3.55	0.911	3.81	0.709	0.003
How would you rate your skills in the following areas? - KP HealthConnect (Kaiser Permanente EHR)	53	3.42	0.719	4.00	0.555	<0.001

Scale (Very good=5, Good=4, Average=3, Poor=2, Very poor=1

Job satisfaction and Work/Life balance

Table 3 shows significant improvement in self-ratings of job satisfaction and work-life balance. In addition, there was significant improvement in the perception that the organization was supporting them in providing good care to patients (p = 0.016).

Table 3.

Questions about job satisfaction and work/life balance

Questions about job satisfaction and work/life balance	n	Before		After		p value
		Mean	SD	Mean	SD
KP HealthConnect improves my job satisfaction.	53	2.68	0.976	2.28	0.818	<0.001
When I wake up in the morning I usually look forward to my workday ahead.	54	2.83	1.145	2.46	0.905	0.002
My work life and personal life are well balanced.	53	3.08	1.158	2.72	0.968	0.004
The organization supports me in providing good care to my patients.	54	2.31	0.865	2.07	0.843	0.016

Likert scale (Strongly agree=1, Agree=2, Neutral=3, Disagree=4, Strongly disagree=5)

Participant’s perception of the program (Pathway to Proficiency)

In response to direct questions about the Pathway to Proficiency course, participants were overwhelmingly positive. Because of minor changes in the wording of the Likert scale that was used in the outpatient vs. inpatient sessions, we have presented the data from the outpatient sessions in Figure 2 and the inpatient sessions in Figure 3.

Figure 2.

Participant responses from ambulatory pathway to proficiency post survey

Figure 3.

Participant responses from inpatient pathway to proficiency post survey

Over 90% of respondents in both groups “Strongly Agreed” that they were glad that they attended the P2P program and over 90% of respondents in both groups “Strongly Agreed or Agreed” that “the skills learned in the P2P program enable me to use the EHR more efficiently”. Over 50% of respondents in both groups “Strongly Agreed or Agreed” that “I am experiencing a better work-life balance as a result of the training I received in the P2P program”. The specific responses to each of these items for each groups is shown in Figures 2 and 3.

Some of the themes identified in analysis of the free text comments included:

Recommending the program for other clinicians, and the need for continued training:

“Provide this same training to more physicians”

“Offer Pathways to Proficiency to more clinicians!”

“Pathways to Proficiency should be mandatory training for all NWP MD’s 6 months to 1 year after they start. That will make us all better. There was SOOO much that we learned so quick that in a year, if we could have another refresher course, that would be great as well.”

Improved efficiency

“Support training in keyboard short cuts, smart sets, auto change, building smart phrases. I am using these more in my daily practice and think it is adding to my efficiency”

“I really enjoyed the Pathways to Proficiency and I have been using the things I learned to work faster”

Preference for off-site training:

“Keep P2P at an away site so that people focus on helping themselves (developing their .phrases, auto-dictionary, etc)

Some clinicians still felt that it was too much information to process in a too short period of time.

“I just don’t have time to process it all.”

Discussion

This program was aimed at improving the EHR proficiency of clinicians who were already experienced users of an EHR. Our pre-survey showed that clinicians already overwhelmingly turned to other clinicians for help in using the EHR. Based on earlier attempts to build a meaningful program to help clinicians using an EHR, we developed a program that was led, organized, and taught by physician expert-peers. Our surveys were aimed at understanding and measuring the effect of such a program on clinician efficiency and effectiveness in using an EHR, and to measure the effect (if any) on job satisfaction and perceptions about the effect of the EHR on patient care. There is general consensus that on-going support and additional systems training is needed to optimize the effective and efficient use of EHRs, but studies in this area are limited. We found that this intensive off-site physician-peer-led program not only improved clinician self-perceived comfort and efficiency in using an EHR, but also had significant measurable impacts on their job satisfaction and perception of work-life balance.

We believe that this may be one of the first studies to report on the relationship between EHR proficiency and job satisfaction, and how improvement in one may be associated with improvement in the other. Given the well-studied phenomenon of physicians’ difficulty with adaptation to the EHR, a program such as Pathways to Proficiency may be a useful way to reduce that resistance, improve proficiency with the EHR, and measurably improve a physician’s perception of work-life balance.

Given the amount of time that clinicians spend with an EHR12, it is not surprising that interventions that improve their comfort and skill in using an EHR have a measurable impact on their overall job satisfaction and their perception of the organizational support for providing good care to their patients.

Conclusion

We found that an intensive 3-day off-site physician peer-led proficiency training program for experienced users of an EHR can significantly improve clinician self perceived efficiency with the EHR, perception of organizational support for providing good patient care, and clinician job satisfaction. In this setting, clinicians already overwhelmingly turn to other clinicians as a source of help in using the EHR.