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May 24, 2010

Adult Educational Principles in Clinical Informatics
By Susan O’Leary
For The Record
Vol. 22 No. 10 P. 14

By providing staff with quality training tools, healthcare organizations increase their chances of a successful EMR launch.

Wow, what a catchy title. But what does it mean exactly? Well, it presupposes two things: There is such a thing as the science and theory of adult education, and it applies to the emerging field of clinical informatics.

Heady stuff, but why care? If you’re about to deploy an EMR system, or for that matter any type of health information software, it’ll pay big dividends to understand a few fundamentals about how people will need to go about learning it. These are basic educational principles but may not be obvious to the noneducator.

Included in this article are a few hints that can make the difference between success and failure when it’s time to get an entire office or department trained and moving in the same direction. By recognizing some basic facets of learning methodology and applying them to the EMR deployment process, the rate and amount of data that a learner can retain is improved.

The Goal
I have been a working professional in corporate training for more than 20 years, more than one half of which has been in the HIM field. I often joke that I’ve trained more doctors than Harvard (just a tiny overstatement). I’ve studied the work of authorities on the newest developments and thinking in the field of how we learn. Everything I’ve discovered has pointed me to the following two conclusions:

• The way people learn is hardwired in their brains and hasn’t changed much since we learned to make fire. It’s 95% experiential; in other words, it’s hands-on.

• The ways in which people assimilate data (ie, the tools they use and the speed with which that data can be applied) has changed—dramatically.

At this point you’re saying, of course the tools have changed. But here’s the rub: In this new era of high-speed training, the marriage between the experiential data (how your brain learns) and the methods to assimilate that data (the available tools) has not always been a happy one. Those tools don’t always utilize the principles that help us learn most efficiently.

Let’s examine two models of learning. For our purposes we’ll call them knowledge transfer and global experiential learning.

Knowledge Transfer
This is the old tried-and-true classroom model of training. In most cases, the EMR vendor will offer to send a trainer to your office and ask you to put aside some time for formal, uninterrupted instruction, either one on one or in a group setting. Or perhaps you will travel to their corporate training facility. Either way, classroom training is a great idea—when it works. And it can work very well, especially when used in concert with the second type of learning.

To make the most of the knowledge transfer method, there are three criteria to keep in mind to ensure that it happens smoothly and effectively: advanced planning, a strong curriculum, and quality instruction.

Advanced Planning
Quality education takes planning. A professional trainer will take the time to make a thorough assessment of the staff’s skills and readiness prior to any classroom time.

The curriculum should be focused on your protocols and workflows. This means that you or your key users have worked through the decision-making processes regarding how the new EMR will affect workflows prior to training. In this way, you can train staff in the new workflow and software simultaneously.

Hint: Assign a superuser or practice champion to work closely with the EMR trainer or project manager and set up weekly meetings to discuss proposed workflow and protocol changes. Get these items ironed out well in advance of any classroom time.

A Strong Curriculum
The EMR vendor’s curriculum should be organized into lessons with goals clearly stated for each phase. Also included should be an estimate of how long it will take to address each phase.

Hint: Ask to see a sample of the curriculum and then make sure the following four items are addressed:

Data chunking: For the brain to store data for easy retrieval, it “chunks” it into storable pieces. Visually, it helps to chunk data by making lists, graphs, charts, slides, bullet points, etc. If the data can be presented in a manner that involves even more of the students’ senses (eg, colors, sounds, video), even more knowledge will be retained.
Hint: Ask the trainer to help you make job aids for your users. These little cheat sheets that are small enough to tuck inside a pocket are invaluable tools that promote the chunking of data.

Training to roles: It also helps if information is directly applicable to a specific task. Learners pay more attention to facts they believe they will use. For most learners, this simply means, “Teach me what I need to know to do my job.” This is where advanced planning comes in handy.
Hint: Present information specific to a role or task. For example, train HIM personnel with HIM personnel, triage nurses with other triage nurses, etc.

Big hint: Putting more than two or three providers together at once for training is counterproductive. Providers each have a specific order in which they approach the documentation of a patient encounter. Going the one-on-one route to train providers takes more time, but providers clearly do better when they have the undivided attention of their trainer and can have their individual questions addressed immediately within the context of the learning experience.

Repetition: The average 35-year-old will need to see and do something roughly three to five times to thoroughly retain the knowledge—that is, to move it from their short-term memory to their long-term memory, where it will stay. Yes, there are always the computer-savvy whiz kids who only need to be shown something once and they’re ready to move on. Generally, however, that’s not the case.

Meanwhile, the average 55-year-old may need twice the repetition of someone 20 years their junior to get a new skill embedded in their long-term memory. It has nothing to do with intelligence but rather with establishing a new brain pattern, or “neural net,” if you will.

Hint: All students need opportunities to perform exercises that replicate their real-world workflows and embed the new data before they can use it. Also, after providers and their respective nurses and medical assistants have received training, be sure to schedule some dry runs using volunteers as patient stand-ins so everyone can get more practice and rid themselves of the jitters before going live.

Timing of training: The speed at which a learner absorbs and applies a new piece of data correlates directly to when they anticipate using the information.
Hint: This means you should schedule training as close as possible to go-live, with a few days beforehand being optimal.

The Quality of Instruction
Finding and keeping a good trainer throughout all phases of the deployment can be critical to success. Typical instructors most likely have some clinical background and learned the software by using it and helping with deployments. They may understand the software’s functionality, but be sure they also have undergone in-depth instruction regarding the learning methodology and how to organize and present information in a logical and understandable way.

The situation that providers want to avoid at all costs is to have a trainer who starts talking and doesn’t stop until you’re numbed into senselessness. This is not teaching but rather something coined a brain dump, and it’s the prime flaw in most unseasoned trainers.

Hint: Insist on working with the vendor’s best trainer. Ask for references and check them. And when you get an instructor you like, insist that he or she be assigned to your deployment at every phase. Continuity is essential for learners. Once they’ve established a relationship with an instructor, it’s easier to build on that relationship than to start over with someone new.  

Global Experiential Learning
This learning method represents the biggest paradigm shift in our learning experiences and, when coupled successfully with the knowledge transfer model, good results are achieved.

Typically, our brains assimilate information from many directions at once. Most people are statistically what we call global learners. We don’t learn how to do something from one source alone or in a succession of rote steps. Instead, we absorb information all around us, sometimes in steps and sometimes in pieces, or even all at once. Active learning patterns are defined as linear and nonlinear, simultaneously, like a controlled chaos theory.

Think about how you learned to drive a car. Most likely, you had some standard knowledge transfer experiences when you took driver’s education classes: You studied, took lessons, and practiced. Global experiential learning, such as using an interactive video to practice steering and navigating in different traffic situations, may also have been part of the experience.

Likewise, the “student” who learns to make the most of an EMR program will typically utilize various sources in addition to a classroom training session. Multiple learning opportunities include the following:

Distance learning courses: The technology to provide first-rate instruction via the Web has improved immensely over the past decade, so much so that it comes close to duplicating the classroom setting at a much cheaper price. When evaluating this option, consider your learners’ level of computer confidence level. Tech-savvy students do well here, but those less agile, especially providers, may find this to be a poor fit.

Interactive training videos: These can be awfully good or just plain awful. If an EMR vendor offers training videos, don’t count on them to be your only learning tool. Video learning has improved greatly in the past few years but until it can interactively answer questions, it can’t replace an instructor. On the other hand, the technology can serve as an excellent introduction to the project and a terrific tool for review.

Online demonstrations: Provide your staff with opportunities to watch as often as they can, especially prior to their classroom instruction.

Training manuals: Even if they rarely refer to them after the initial training, it’s amazing how many learners prefer to be given something when they arrive for training. Learning anxiety is dramatically reduced when students have something in their hands that they can refer to if they miss something. Even if the program comes with an online user’s manual, a training guide can be an excellent tool if it contains review exercises, job aids, and space for note taking.

Social learning: Remember that, by definition, global experiential learning is a social exercise. User groups, blogs, peer-to-peer mentoring, and chatting around the water cooler can have an enormous effect on organizational knowledge transfer models. In addition to a full palette of training delivery options, a savvy training organization will address this social side of learning by providing clients with the tools and opportunities to share and interact with other users. 

Hint: Ask the EMR vendor how many of these different options it offers and let your staff take advantage of as many as possible prior to and immediately after (for review purposes) formal classroom instruction.

The Bottom Line
If a multipronged approach is combined with the conventional knowledge transfer model, it will allow learners to practice, utilize, think about, and test their knowledge in the global experiential learning process that makes up more than 95% of how humans learn (see figure).

Incorporating a variety of timely learning opportunities and tools, showing the direct benefit of those tools, and allowing for adequate assimilation and repetition can and will pay off big dividends in ramp-up time, support costs, and overall utilization of program features.

— Susan O’Leary is an independent EMR consultant and trainer who is currently writing a book about EMR training methodology.

Adult and Continuing Education: Theory and Practice by Peter Jarvis

Adult Learning Methods: A Guide for Effective Instruction by Michael W. Galbraith

Experiential Learning Theory by Alice and David Kolb