Assessing the Usefulness and Applicability of Applying eRecord Training to New Hire Registered Nurses: An Evaluation

Abstract

With the implementation of electronic health record (EHR) systems in the majority of U.S. hospitals and healthcare settings, it is important for organizations to effectively educate Registered Nurses in the use of EHR and bar coded medication administration (BCMA).  One large, academic hospital system has developed and utilizes a hybrid model of EHR training for their new hire RNs.  Because RNs are the largest group of healthcare workers to use the EHR, it is important to educate them with the knowledge of how to perform the important tasks as well as to have a consistent process that can be used at all of its hospitals.  In an article from Kaye about nurses, “their perceptions of any new technology are important to understand, as it may ultimately mean the difference between acceptance and rejection of a product” (2015, p. 237).  This paper, written by a graduate nursing informatics student, provides an evaluation of an eRecord Training program.  The author applied the Technology Acceptance Model by Fred Davis (1989) to inform a study to determine the perceived usability and ease of use of the eRecord Training program by surveying new hire RNs who attended one class of the program. 

Introduction

Ongoing efforts by the Center for Medicare Services (CMS) and the federal government to improve healthcare in the U.S. include incentives to providers and hospitals to implement electronic health records (EHR), including bar-coded medication administration (BCMA) as soon as possible.  Charles, Gabriel & Searcyv (2015) shared, “In 2014, three out of four (76%) hospitals had adopted at least a Basic EHR system.  This represents an increase of 27% from 2013 and an eight-fold increase since 2008”.  “Nearly all reported hospitals (97%) possessed a certified EHR technology in 2014, increasing by 35% since 2011” (p.5).

EHR implementation began in the 1990’s and were emphasized in the Institute of Medicine’s (IOM) Future of Medicine article (Kohn, Corrigan, & Donaldson, 1999).  Ten years later, EHR implementation was reinforced by the Heathcare Information Technology for Economic and Clinical Health (HITECH) Act that was passed as part of the American Recovery and Reinvestment Act in 2009 (Office of the National Coordinator for Health Information Technology (ONC), 2009).  The HITECH Act budgeted $20 billion for incentive payments to hospitals and providers to implement healthcare technology using the Meaningful Use stages outlined in the Act.  Meaningful Use, which refers to the implementation and use of EMRs and associated technologies, was an important concept that nurses should know and consider when learning EHR charting, assessment documentation and BCMA processes. 

With the implementation of the EHR in the majority of healthcare settings, it is important 1) to effectively educate bedside RNs in the use of EHRs, 2) implement BCMA to minimize medication errors and 3) to provide high quality, safe care while controlling costs.  One large, academic hospital developed and utilized a classroom simulation hybrid method for educating its new hired RNs. This paper describes the usefulness and effectiveness of this eRecord training program for new hired RNs.

Background

Learning is a continuous process throughout a nurse’s career.  Nursing education is a critical and important element of high quality patient care and the application of evidence-based practice.  Healthcare technology is new to many nurses who have been working at the bedside for the past 15 or 20 years.  New nurse graduates, who received some training about health technologies in school and who also grew up using technology and computers, are much more comfortable with using technology in nursing practice.  In either case, any generation of RN can be part of a ‘new hire’ cohort and must be educated in the use and function of the EHR and BCMA systems at their facility.

Nurses are adult learners who require instruction in important areas of healthcare such as evidence-based practice, critical thinking, employer specific procedures and protocols, EHR charting and navigation, and BCMA use to name a few.  They are taught about processes and protocols of nursing practice for the patient [and family] depending upon their assigned unit’s level of care: critical, step-down, medical-surgical, and so on.  Nurses also require instruction in the use of a variety of technical equipment utilized at the bedside, i.e. vital signs monitors, infusion pumps, bar scanning equipment, drawing blood, and especially, the EHR.

Nurses are key to improving the quality of healthcare.  They are the largest provider population in every hospital and healthcare system.  “As such, their perceptions of any new technology are important to understand, as it may ultimately mean the difference between acceptance and rejection of a product” (Kaye, 2015 p. 237).  From the Institute of Medicine’s Report, Future of Nursing, “…nurses have a direct effect on patient care. They are at the front lines in ensuring that care is delivered safely, effectively, and compassionately” (2010 p.23).  Therefore, not only is it important to educate nurses on how to utilize an EHR, nurses need to perceive that technology will help them perform their job functions as well as improve the quality of care they provide to their patients and families.

Methods

To gain insights about the eRecord Training program for nurses, it was important to review the history of the program, examine all of the program documents, engage as a learner in all three classes of the program and survey some of the other learners.   The first task of this project was to interview the Senior Director of Clinical and Operational Informatics at UPMC Presbyterian Shadyside.  As one of the original members of the focus group created back in 2005 when UPMC first purchased the Electronic Medical Record system, she provided the background and described the eRecord training process.  Next, a review of three different scripts available as Microsoft Word documents, and two Power Point presentations that outlined the program were obtained for reading and review.  Gaining permission from my preceptor, a bedside RN profile was set-up by Information Systems.  They provided instructions on how to toggle into that role.  When this writer gained access from the bedside RNs perspective, I clicked on the “A to Z” button, accessed every help topic link, read each one then performed the steps as instructed.  Every link was working and every help topic was easy to understand and perform.  Finally, in order to evaluate the program process I attended each of the three classes of the program as a learner. 

Setting

At the UPMC, EHR integration began in 2006.  At that time, EHR implementation was new and innovative for both the Information Technology and Nursing departments / staff, and a specific Informatics group or team had not yet been created.  In response, a small group of IT and nursing managers who were interested in computers and technology formed a focus group.  This focus group soon turned into a ‘Super User’ group that went to each unit in the hospital to educate the RNs on the use of the eRecord system.  With the rapid growth of UPMC into a health system, it was apparent to administration that a Nursing Informatics Team would be essential to plan the education and complete implementation of the EHR.

EHR Training

The eRecord classroom training consisted of three separate classes spaced out over ten days. Each class is approximately four hours in length.  The first class covers the electronic documentation functionality that nurses use for patient care plans, critical care and patient safety.  The second class covers the system’s interdisciplinary summary dashboard functionality. In the last class, the RNs learn scanning and the BCMA function of the EHR system.  In addition to the classes, there are two, self-directed quizzes for RNs to complete; one after the first class and the other after the final class.

The RN learners use a training environment that looks and behaves exactly like the hospital EHR system.  Each learner has their own work station complete with a PC that is loaded with the EHR training platform, a pseudo in-patient database and all of the functionality and nursing applications a bedside RN will use.  Attached to every PC is a working bar code scanner which is used for Medication Administration training and a working laboratory label maker that is used to print actual laboratory and bloodwork labels for their assigned pseudo patients.

The class instructor is an Informatics Nurse at UPMC.  They too have a PC that has been loaded with the same EHR platform, applications, functionality and equipment.  The only difference is the instructor’s desktop is projected onto a large screen in the front of the classroom.  The instructor follows a written script, step-by-step, demonstrating the tasks and documentation while every RN follows along, performing the same tasks and charting as the instructor.  A nice feature of this platform that is easy to find and use is the “A to Z” button located in the top toolbar of every patient’s chart.  When this button is left-clicked, the result is an alphabetized list of eRecord Help Topics with detailed instructions to show the RN how to perform a specific task.  This “A to Z” list is extremely well maintained by the Informatics team to ensure that every link works properly and is updated often as new functionality is added to the eRecord system.  The eRecord Training program overall is evaluated on an annual basis by the Informatics team and is updated when new functionality is implemented that may affect the nursing staff.

Curricula Development

Nurses are certainly adult learners and welcome learning when it will benefit and help them perform tasks.  There is not enough time nor the opportunity to tailor every eRecord class to each RN’s personal experience or preference, nor would that be cost effective, so user experience did not factor into the program’s development.  However, informatics nurses, as the significant creators of this training program, have the same education background as every RN being trained as well as bedside experience.  Therefore, the Informatics Team applied knowledge from their own nursing experiences when creating this training program.  The nursing informatics team determined which functionality was most important to nursing and combined that with JCAHO and CMS documentation regulations as the base for the training program.  The team was hopeful that the RNs would learn the main nursing functionalities of the system and then apply this at the bedside and in their own nursing practice.  However, they had no way of truly measuring the effectiveness of the curricula.

Without assistance by the vendor, Cerner®, the Informatics team created a training program based on the functionality of the EHR.  In planning this training program, several pertinent aspects had to be taken into consideration, specifically: 1) Nursing documentation requirements of JCAHO and the federal government, 2) the hospital’s current nursing processes and protocols and 3) the Stakeholders’ requirements for the system’s future direction. These were all incorporated into the educational program called eRecord Training - a hybrid model of classroom training – including hands-on simulations, and self-paced e-Learning quizzes.

Theoretical Framework

Efficacy

The Technology Acceptance Model (TAM) was created in 1989 by Fred Davis, an Information Systems professor at the University of Michigan.  He believed it was necessary to construct a theoretical framework to analyze the acceptance of workplace technologies because at that time, there were many industry reports indicating workers were not using, or were underusing, available technology in the workplace.  The constructs of the TAM are based upon Perceived Usefulness (PU) and Perceived Ease of Use (PEU).  PU is defined as "the degree to which a person believes that using a particular system would enhance his or her job performance” and PEU is defined as "the degree to which a person believes that using a particular system would be free of effort” (Davis, 1989, p. 320). 

“Self-efficacy research does provide one of several theoretical perspectives suggesting that perceived ease of use and perceived usefulness function are basic determinants of user behavior” (Davis, 1989, p.321).  Therefore, if an adult believes that the technology he or she is learning, can be applied to their work or life, then they are open to understanding and using the technology.  This concept is important in the context of this assessment because the nurses’ acceptance of health information technology and eRecord training affects whether or not they will use the EHR system as intended.

Using the concepts of PU and PEU, from the TAM, a brief survey of eleven questions was created based on the EHR training that the new RNs received.  There were six items to measure PU and five items to measure PEU.  Each question was answered using a 5-point Likert scale with 1 equal to Strongly Disagree and 5 equal to Strongly Agree.    Permission to survey the students on paper was granted by my Preceptor.  Please see Figure 1 for a copy of the survey that was distributed and the likert scale used.

Results

Twelve learners, all new hired RNs attended the eRecord training program classes that I attended.  The survey was distributed to these twelve learners and 100% of the students responded to all of the questions.  In the category of PU, items a, b, e & f were answered positively by 12 out of 12 students indicating they ‘agree’ or ‘strongly agree’ that they are able to use eRecord to perform those tasks.  For questions c and d, one student out of 12 replied ‘neutral’ to those PU questions.  The total sum score of the PU questions was 27.50, where 30 would be the highest score.  The mean sum of the PU questions was 4.583 with SD=0.550.  In the category of PEU, for question g, 11 of 12 (92%) responded positively and one was neutral, question h. 11 of 12 (92%), question i. 8 of 12 (67%) responded positively, 3 of 12 (25%) were neutral and one student disagreed, for j. 10 of 12 (83%) responded positively, 2 of 12 were neutral, and finally, question k. 9 of 12 (75%) responded positively, 3 of 12 remained neutral.  The total sum score of the PEU questions was 21 with 25 being the highest score possible.  The mean sum of the PU questions was 4.20 with SD=0.776.  (Please see Table 1 for response rate and Table 2 for Mean & SD calculations).

Conclusion

According to the survey responses for PU, the majority of the new hire RNs who were in eRecord Training were confident that they could use the eRecord system to perform their nursing tasks and charting, based on the training they received.  These results would lead one to believe that the usability after training is high and that the eRecord Training program for new hire RNs is successful.  Because of the small size of respondents, I have not compared these results to any previous studies, however, another larger scale study would provide useful information for researchers interested in designing EHR training programs.  With regards to PEU, though the majority of the 12 students felt eRecord was easy to use, there is enough evidence indicating that some students have not yet made up their mind or they are not convinced that eRecord is easy to use.  This fact could also mean some RNs are not confident in their computer skills.  There was only one person out of twelve who disagreed that eRecord was easy to use, but this finding should still be taken into account when designing training programs.

A limitation of this assessment was that there were only twelve students in the class so the sample size is small and the survey responses may not be representative of the population.  This was an evaluation of the program and results were not compared to other studies.  Further evaluation is warranted and more new hire RNs should be surveyed in order to obtain a more reliable representation of the usability and ease of use of the eRecord Training program.

Citation: Dengler, C. (July, 2018). Assessing the Usefulness and Applicability of Applying eRecord Training to New Hire Registered Nurses: An Evaluation. Online Journal of Nursing Informatics (OJNI), 22(2), Available at http://www.himss.org/ojni

The views and opinions expressed in this blog or by commenters are those of the author and do not necessarily reflect the official policy or position of HIMSS or its affiliates.

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