IT Super-Users To the Rescue
Changing organizational culture is challenging to say the least. Implementing disruptive technology to a physician's workflow is no different. But, the implementation is just the tip of the iceberg. Several CMIOs speak out about their successful training initiatives, such as employing super-users to champion technology and providing at-the-elbow support for healthcare professionals in a changing IT environment.
Before becoming CMIO for Rockingham Memorial Hospital (RMH) in Harrisonburg, Va., Robert M. Underwood, MD, director of clinical transformation, was an emergency department (ED) physician for the nonprofit community hospital. In addition to Underwood's promotion, a lot has happened to the organization in the last couple of years. In 2010, RMH moved its entire facility across the Friendly City to open a new 238-bed hospital with approximately 70,000 ED visits annually.
In 2007, when Underwood was still an ED physician, RMH switched EMR vendors. According to Joe Beahm, manager of financial applications at RMH, the big-bang transition included significant changes to physician workflow, including electronic document signing and use of a one-sided EMR module to view clinical results.
To facilitate a smooth transition, training video materials were created, mailed to physicians' homes and run on a continuous loop in the physicians' break room. However, Underwood, speaking from the perspective of an ED physician at the time, believes the implementation did not go well. "I don't think the impact was well understood by physicians as to what changes were going to take place," Underwood notes.
After being promoted to the role of CMIO, Underwood stepped up to the front lines of the ED trenches when the department switched to a new EMR system in 2009—after just adopting its first EMR in 2007. Underwood was on the ED floor as a physician champion helping physicians with over-the-shoulder support as needed. "That paid a lot of dividends," says Underwood. "We set up support until every ED physician worked at least one shift on the new system. The ability to be there with the physicians and have no disruption to workflow was great."
The immediate availability of support allowed the physicians to solve problems rather than give up on the system, Underwood says. "With the immediate support, the next time the physician ran into the same problem, he or she would know how to work through the issue."
Armed with these numbers, Zaroukian and his team set out to create a training program that would pay for itself through the higher rate of qualification. MSU has given 22 physician super-users and 17 staff super-users 26 hours of classroom training, enabling them to provide at-the-elbow support for physicians and staff undergoing advanced EMR training for meaningful use. Duties for a super-user include becoming "EMR Ambassadors" to facilitate buy-in and user acceptance, resolve problems, assist with EMR optimization and provide feedback on EMR user proficiencies. With physician super-users getting paid $80 an hour for classroom training, and up to 10 percent paid time for subsequent help with provider training in the classroom and clinics, the total compensation of the physician super-user training represents less than 20 percent of the expected the CMS meaningful use incentive payments and will facilitate new efficiencies and greater qualification for pay-for-quality initiatives. Zaroukian says this model is a sound investment.
When San Mateo Medical Center in San Mateo, Calif., went live with an EMR in 2009, Michael Aratow, MD, CMIO, trained approximately 80 super-users to assist when the system was rolled out to both primary and specialty care clinics. In addition to training EMR users, super-users received 10 additional hours of training beyond the standard training for their user group and champion super-users received 20 additional hours beyond their super-user training.
The champion super-users acted in a supervisory role for users, going a step beyond assisting training that the super-users did. "We didn't identify champion super-users until one year into the program," Aratow says. "We had to have the super-users first to see who was more motivated."
With the EMR system successfully in place, Aratow shared some lessons learned from their experience:
The result was a summer program where 30 Pennsylvania State University pre-med students were hired to assist providers with learning the electronic discharge system. Because the scope was narrow in focus, the students trained on the discharge process in one day before being released into the clinical wild.
Drawn from 145 applicants, Tingley wanted to ensure the pre-med students were engaging to the physicians. For part of their interviews, Tingley asked the applicants to explain how to do something without the help of props or laptops. With lessons varying from how to make a buffalo chicken dip to how to properly cut the toenails of a parakeet, Tingley assessed the applicants' ability to explain tasks as well as their personalities.
Thus, on the go-live date, the students were prepped to help providers learn the 65 different discharge templates. The program cost $51,000 and today, 90 percent of discharges are done electronically. Tingley says the investment was well worth it. "Having inexpensive students out on the floors meant that our application specialists could act as their backup and could spend their valuable time working on enhancements to discharge instructions templates and other processes which helped the whole thing move forward," says Tingley.
As seen at Mount Nittany, enthusiasm and the ability to break down complex tasks into clear and understandable workflows are crucial traits for a super-user. Zaroukian, when deciding upon MSU's super-users for its EMR rollout, used the following criteria to determine which candidates should fill the super-user role:
Despite using online and classroom training, she admits there are challenges such as competition for physicians' time. With more than 2,100 professional staff members, training duties at NorthShore include teaching physicians how to utilize note writing tools, find information about a patient and review nursing documentation. However, Schramek admits that as EMRs become prevalent, future generations of physicians generally will be more tech savvy.
Drawing from experience, Underwood is preparing to provide over-the-shoulder support for physicians as he preps the workflow rollout of electronic physician documentation and order entry in RMH's EMR system. The new component systems will go live in the ED in June before going live facility-wide in March 2013. He plans on making training required, using interactive incentives such as awarding continuing education credits for computer-based training and deploying at-the-elbow support at go-live for 24/7 assistance. The proper use of technology is a patient safety issue, he says. "If you don't know how to get into the record and order appropriately, that can be a safety issue with your patient."
Underwood advises CMIOs not to sugarcoat the workflow disruption, but be proactive and help physicians learn and adapt to curtail technology aversion. "There will be workflow issues, but it's better for the patient [and an organization can] work through the problems to have a better system down the road."
As CMIOs look to their implementation strategy, they should look to their frontline support to assess their resources and which tech-savvy individuals can help guide the organization to the next level.
Before becoming CMIO for Rockingham Memorial Hospital (RMH) in Harrisonburg, Va., Robert M. Underwood, MD, director of clinical transformation, was an emergency department (ED) physician for the nonprofit community hospital. In addition to Underwood's promotion, a lot has happened to the organization in the last couple of years. In 2010, RMH moved its entire facility across the Friendly City to open a new 238-bed hospital with approximately 70,000 ED visits annually.
In 2007, when Underwood was still an ED physician, RMH switched EMR vendors. According to Joe Beahm, manager of financial applications at RMH, the big-bang transition included significant changes to physician workflow, including electronic document signing and use of a one-sided EMR module to view clinical results.
To facilitate a smooth transition, training video materials were created, mailed to physicians' homes and run on a continuous loop in the physicians' break room. However, Underwood, speaking from the perspective of an ED physician at the time, believes the implementation did not go well. "I don't think the impact was well understood by physicians as to what changes were going to take place," Underwood notes.
After being promoted to the role of CMIO, Underwood stepped up to the front lines of the ED trenches when the department switched to a new EMR system in 2009—after just adopting its first EMR in 2007. Underwood was on the ED floor as a physician champion helping physicians with over-the-shoulder support as needed. "That paid a lot of dividends," says Underwood. "We set up support until every ED physician worked at least one shift on the new system. The ability to be there with the physicians and have no disruption to workflow was great."
The immediate availability of support allowed the physicians to solve problems rather than give up on the system, Underwood says. "With the immediate support, the next time the physician ran into the same problem, he or she would know how to work through the issue."
Call of the super-user
An EMR switch-up or implementation can cause significant upheaval but disruptive technologies should be viewed as office efficiency tools. Michigan State University (MSU) in East Lansing is currently five months into their super-user program. Michael H. Zaroukian, MD, PhD, professor of medicine and until recently, MSU's CMIO (now serving as CMIO and vice president at the MSU-affiliated Sparrow Health System), used the standpoint of a business case to advance shared goals for quality, safety and efficiency. He crunched the numbers of the 219 attending physicians and 130 residents and found that, without any additional training, only 30 percent of the eligible providers would likely qualify for Stage 1 meaningful use incentive payments in 2011 or 2012, compared with potential qualification rates of 90 percent with training, feedback and support.Armed with these numbers, Zaroukian and his team set out to create a training program that would pay for itself through the higher rate of qualification. MSU has given 22 physician super-users and 17 staff super-users 26 hours of classroom training, enabling them to provide at-the-elbow support for physicians and staff undergoing advanced EMR training for meaningful use. Duties for a super-user include becoming "EMR Ambassadors" to facilitate buy-in and user acceptance, resolve problems, assist with EMR optimization and provide feedback on EMR user proficiencies. With physician super-users getting paid $80 an hour for classroom training, and up to 10 percent paid time for subsequent help with provider training in the classroom and clinics, the total compensation of the physician super-user training represents less than 20 percent of the expected the CMS meaningful use incentive payments and will facilitate new efficiencies and greater qualification for pay-for-quality initiatives. Zaroukian says this model is a sound investment.
When San Mateo Medical Center in San Mateo, Calif., went live with an EMR in 2009, Michael Aratow, MD, CMIO, trained approximately 80 super-users to assist when the system was rolled out to both primary and specialty care clinics. In addition to training EMR users, super-users received 10 additional hours of training beyond the standard training for their user group and champion super-users received 20 additional hours beyond their super-user training.
The champion super-users acted in a supervisory role for users, going a step beyond assisting training that the super-users did. "We didn't identify champion super-users until one year into the program," Aratow says. "We had to have the super-users first to see who was more motivated."
With the EMR system successfully in place, Aratow shared some lessons learned from their experience:
- Communicate: Dissemination of information is critically important. "Get the email and distribution lists correct," says Aratow. He believes that email is becoming antiquated for EMR wide-scale implementation projects, so he is currently setting up a collaborative platform for status reports and alerts.
- Train: While a lot of work went into training the users and super-users, physicians should train physicians and front office staff should train front office staff, Aratow says. "You can hire a vendor to train users, but those are not usually clinical people and they don't know a physician's workflow."
- Maintain Momentum: "Keep everyone interested and manage expectations," says Aratow. "If you have problems with the system and don't give staff progress reports, they could suffer from alert fatigue or from the system not working. Maintaining communication keeps momentum up."
Super-user sources
Super-users don't have to just come from the top brass or CMIOs. Stephen Tingley, MD, CMIO at Mount Nittany Medical Center, found super-users in the backyard of the 260-bed State College, Pa.-based acute-care facility. When attempting to have the entire 250 provider population start using electronic discharge templates, Tingley sought to provide at-the-elbow support without using expensive applications specialists.The result was a summer program where 30 Pennsylvania State University pre-med students were hired to assist providers with learning the electronic discharge system. Because the scope was narrow in focus, the students trained on the discharge process in one day before being released into the clinical wild.
Drawn from 145 applicants, Tingley wanted to ensure the pre-med students were engaging to the physicians. For part of their interviews, Tingley asked the applicants to explain how to do something without the help of props or laptops. With lessons varying from how to make a buffalo chicken dip to how to properly cut the toenails of a parakeet, Tingley assessed the applicants' ability to explain tasks as well as their personalities.
Thus, on the go-live date, the students were prepped to help providers learn the 65 different discharge templates. The program cost $51,000 and today, 90 percent of discharges are done electronically. Tingley says the investment was well worth it. "Having inexpensive students out on the floors meant that our application specialists could act as their backup and could spend their valuable time working on enhancements to discharge instructions templates and other processes which helped the whole thing move forward," says Tingley.
As seen at Mount Nittany, enthusiasm and the ability to break down complex tasks into clear and understandable workflows are crucial traits for a super-user. Zaroukian, when deciding upon MSU's super-users for its EMR rollout, used the following criteria to determine which candidates should fill the super-user role:
- Personal attributes: Are they curious and do they inherently want to know how to use technology better? Super-users should be adaptable, approachable to their peers and personable, he says. "They should be able to cope well with the sometimes difficult behaviors of some that they are trying to help."
- Professional skills: A super-user should have relevant clinical experience or expertise along with the ability to break down complex activities into discrete, manageable tasks, Zaroukian says. In addition to being computer proficient themselves, potential super-users should have a good understanding of the workflows in a clinical environment.
- Intrapersonal attributes: Super-users should be seen as good listeners and problem-solvers. "Colleagues should view the super-user as the 'go-to person' who leads and mentors peers," says Zaroukian.
- Organizational attributes: Notably, Zaroukian says that potential super-users should be excited and positive about the place in which they work. "They should like where they work, their employer, the EMR project, have a strong track record in their current position and be willing to be held accountable for results," he adds.
'Training never stops'
The secret about disruptive technology implementation is that it's an ongoing process. "The training never stops," says Bobbi Schramek, MS, RN, director of Epic training-inpatient at NorthShore University HealthSystem, based in Evanston, Ill. With standard employee turnover and regular software upgrades, maintaining a roster of expert system users requires constant training, according to Schramek.Despite using online and classroom training, she admits there are challenges such as competition for physicians' time. With more than 2,100 professional staff members, training duties at NorthShore include teaching physicians how to utilize note writing tools, find information about a patient and review nursing documentation. However, Schramek admits that as EMRs become prevalent, future generations of physicians generally will be more tech savvy.
Drawing from experience, Underwood is preparing to provide over-the-shoulder support for physicians as he preps the workflow rollout of electronic physician documentation and order entry in RMH's EMR system. The new component systems will go live in the ED in June before going live facility-wide in March 2013. He plans on making training required, using interactive incentives such as awarding continuing education credits for computer-based training and deploying at-the-elbow support at go-live for 24/7 assistance. The proper use of technology is a patient safety issue, he says. "If you don't know how to get into the record and order appropriately, that can be a safety issue with your patient."
Underwood advises CMIOs not to sugarcoat the workflow disruption, but be proactive and help physicians learn and adapt to curtail technology aversion. "There will be workflow issues, but it's better for the patient [and an organization can] work through the problems to have a better system down the road."
As CMIOs look to their implementation strategy, they should look to their frontline support to assess their resources and which tech-savvy individuals can help guide the organization to the next level.