Designing Professional Development/Healthcare

Summary
The Electronic Medical Record (EMR) or Electronic Health Record has been treated as a panacea for many of the problems that plague healthcare today. With it, costs will be reduced as practitioners have access to results of tests performed elsewhere. Physicians will have timely access to patient medical history, reducing time required to diagnose the patient. Computers will reduce errors transcribing orders and notes, avoiding dangerous misinterpretations. Lastly, medical practice is based on what we think works, rather than what we know works. The EMR will facilitate the use of evidence-based practice.

Despite its great promise, the full implementation of the EMR is relatively rare. The reasons for this are many, but inadequate planning and execution of professional development have played a crucial role. Additionally, not involving the users as system owners has also doomed some high profile projects.

EMR Overview
The EMR ultimately will contain all the details of a patient's medical history. In addition to test results, it will contain clinicians' notes, diagnoses, and treatment details. Currently, most of these details are on paper and that paper is dispersed among hospitals, doctors' offices, treatment facilities, and labs. Physicians are dependent upon patients' memories which are both unreliable and highly selective. The EMR would resolve this issue. Some implementations focus on collected data from automated medical equipment. Others have attempted a more holistic approach including all data. The issue is that this data ranges from images to unstructured text, from numbers to time sequence data.

Best Practices
Based on the experiences of those who successfully implemented an EMR, professional development needs to start earlier and include more than training. In medicine, professional development in clinical subjects is owned by the professionals involved. They have great deal of input into its form. Some would claim that stakeholder resistance is the most important predictor of failure. They point to an overly optimistic implementation process that discount the objections of the recalcitrant, believing that they will be converted with time. More commonly in EMR implementations, the resistors doom the process and everything reverts back to paper. These institutions tend to view professional development only as training and fail to extend it both to laggards and new hires. The notion of professional development needs to extended to fostering stakeholder ownership and direction and creating a system that is usable by the intended audience. It cannot be limited to just training. All to often, healthcare information technology projects use non-clinicians for subject-matter experts (SME's) for both system installation and instructional design. Clinician time is rightly viewed as very valuable, but by limiting their involvement, the systems themselves and professional development are less likely to meet the needs of the primary stakeholders.

Ownership
Clinicians need to own the process. Mission Hospital in Asheville, North Carolina realized that EMR involved changes in the way clinicians worked. They knew that success depended upon physician ownership of the change process. Mission found that accessing medical records was a pain point. They put all records online. This encouraged clinicians to use computers. They then moved all diagnostic results online. By solving problems, the EMR team built credibility. They then went to the heads of each division and got them to agree to be major stakeholders. The division heads emphasized that the goal needed to be to improve patient care, not collect better data. Clinicians are always interested in improving patient care, but see little benefit in better data.

Usability
Concentrating on usability was found to be a key factor for success. Usability drives out mistakes. Physicians have a low tolerance for mistakes. Medical errors kill and maim. Any system that appears to allow or foster errors will be rejected. Mission made sure that common clinician ordering practices were accommodated, first by comparing it to existing written orders and then by having physicians assist in usability testing. Ultimately, they felt there was no more than a 2% error rate. Again, having physician validation lent credibility to the system.

Training
Mission Hospital intended to do a rolling pilot system roll-out followed with a big bang that required everyone to use the system, no laggards allowed. Because they reviewed this as a professional development endeavor, they got permission to grant Continuing Medical Education (CME) credits for participation in the training. This is the standard for medical professional development and they felt it was important that physicians view this training as equal to the rest of their professional development. All staff was required to complete an eLearning on the system. They could repeat the module multiple times without penalty. Those who felt comfortable after completing the module were allowed to take a test that exempted them from classroom face-to-face training. These strategies were so successful, that physicians asked to be moved into pilot groups. A review of the Mission website shows the system is in full operation and is included in physician recruitment materials.

The nature of Mission's eLearning module was not discussed, however, research has revealed some general recommendations: modules should involve realistic simulations. They should short and specific. It is preferable to create a number of small units that reflect a medical specialty peculiarities than general ones that are too generic. Clinicians need to be assured that they will be able to do their jobs. Many do not have the computer skills to transfer the information to their own practice.