There’s good news and bad news when it comes to increasing end-user efficiency and happiness with the EHR.
The good news is, with the right mix of tools and resources, you can help your users feel more comfortable and efficient in the EHR. We’re seeing this firsthand from organizations that report having happy end users.
The bad news is, as you may have expected, there’s no quick-fix for this problem. It takes time to figure out the best formula or mix of tools and resources that will increase user adoption, and ultimately, satisfaction with the EHR.
Lauren Griessmeyer, our director of Training Solutions, recently sat down with Dr. Amy Maneker, a physician executive here at Nordic, to discuss this formula for end-user happiness. Both Lauren and Dr. Maneker have spent the past decade helping organizations improve user adoption by focusing on four key areas:
- Shared ownership
- EHR personalization
- System configuration and refinement
In this podcast, they discuss how these four components play an important role in helping organizations overcome EHR challenges and increase user happiness. They also share examples and advice for addressing these issues head-on.
If you’re interested in discussing the best formula for improving end-user happiness at your organization, please schedule a meeting.
[03:02] Struggles and symptoms of EHR dissatisfaction
[04:10] Using EHR data to identify opportunities for efficiency
[07:50] How KLAS’ Arch Collaborative helps organizations address user satisfaction
[09:28] What is "shared ownership" and how does it help increase user happiness?
[14:28] Making the case for ongoing education and training
[20:54] Tips for leveraging EHR personalization
[22:33] Components of a targeted system configuration
[25:00] Extending satisfaction efforts beyond the physician
[28:00] What we can learn from organizations that have happy end users
Lauren Griessmeyer: Hi. This is Lauren Griessmeyer, the director of training strategy here at Nordic. I've been in adult education for 15 years, doing Epic training for about 12. The reason that I am here to talk today is because education can be so key to having users happy with the EHR. I'm sitting here with Dr. Amy Maneker. Amy, would you like to introduce yourself?
Amy Maneker: Yeah. Thanks Lauren. I'm Amy Maneker. I'm a physician executive here at Nordic. I'm a practicing pediatrician. I’m also boarded in pediatric emergency medicine and clinical informatics and practiced medicine for 30 years. The past 15 years I've really focused on informatics, including implementing an EMR through a 10-hospital academic medical center, and most recently CMIO for a free-standing children's hospital. One of my large initiatives was addressing Epic's role in provider efficiency and satisfaction, where we really focused on education, what we now call shared ownership, and personalization, which has also been shown to be one of the key factors associated with user satisfaction.
Lauren: In today's podcast, we're going to be focusing on the struggles and symptoms of EHR challenges, especially as it relates to provider satisfaction, as well as four major components to increasing user satisfaction.
The four that we're going to focus on today are shared ownership, education, EHR personalization, and then we're going to focus a little bit on system configuration. So, Amy, when you were a CMIO, what were some of the main ways that you could tell whether or not your users were satisfied with EHR?
Amy: The level of engagement or rather lack thereof, when people became totally disengaged, or that whole idea of blaming the EHR on everything. I think those are the biggest ones. Or the idea, "All I do is type at this computer. It doesn't help me at all." That's that kind of low-level narrative you start to hear.
Lauren: Were there particular venues where you saw that dissatisfaction get voiced to you as a leader in the organization?
Amy: No. It was more the low-level narrative that people as they would chirp. I believe in being very visible and available. People would basically, "Oh, it's ruined medicine. It's ruined this." There's that extreme, that it's the worst thing that ever happened to healthcare. There are the people who also say, "Hey, it's a great thing. I can see results from last week when the kid was seen at another place near here, but I struggle so much, or I'm spending so much time during the off hours." So there were symptoms, but there's also data. I don't know if you want me to touch on that.
Lauren: Yeah. We always like to talk about data.
Amy: So there's also data. One of them is you can get data out of the EMR, which is imperfect, the data you can get out of the Epic, just in all honesty, but it still gave you an idea of where people were spending their time, how they were spending their time. Then we also ... There's no national data on the Arch Collaborative that you can take a survey, and you compare your user satisfaction to some national benchmarks, which also is helpful.
Lauren: Yeah. Let's dig into a little bit to the data piece with Epic, because I know that's a piece that a lot of organizations struggle with. What were the primary places that you were looking for data to see whether or not people were using the system, whether they were efficient with the system? Were there reports outside of Signal? Were you guys primarily PEP dependent?
Amy: We used PEP a lot, although we felt that the PEP score wasn't helpful, because it was so based on time, but it helped us focus if someone says, "Hey, John over there is struggling." We could pull up John's data and get an idea of how to help him. Or what we also tended to do was look at a specialty level, and just take a snapshot of a few people and see what's going on there.
Lauren: Just for those of you that are listening, and playing along at home that don't know what PEP is, PEP stands for physician efficiency-
Lauren: Provider efficiency profile. Which is a specific Epic score, but it's something that organizations that are using Epic can use to look at different data for their providers. So, you guys use the PEP scores. Did you use data outside of the PEP scores? Did you look at throughput, or any overall revenue, anything like that?
Amy: By the way, we did not use the PEP scores-
Lauren: Oops. I'm sorry, the PEP data.
Amy: ... because we do not find them helpful. We used the PEP data. In this particular organization we had ... there was a large initiative surrounding access and what was going on in ambulatory soup to nuts. And so we started addressing Epic, because we knew to really push our providers, you couldn't do that without addressing the EHR. It was almost like what you often hear me call ... There was a freight train going through, and we attached this train, or the caboose to it.
We knew there was dissatisfaction. We knew that people were struggling. We used the PEP to some degree. We were one of the early adopters of PEP. But the real motivator wasn't so much symptoms or data. It was we attached ourselves to the caboose ... to the freight train as a caboose on this idea that we had to improve access and improve ambulatory in the healthcare system and how it was functioning in its efficiency.
Lauren: You had to have the business case that had to do with access in order to then get the funding and the motivation, or the operational, organizational not operational-
Amy: That was the freight train going through.
Lauren: ... organizational buy-in to actually implement some of the programs to improve life for your physicians.
Amy: I encourage people often to say, hop onto a freight train, and the freight trains we hear about often are access, that's a common one. Physician happiness, or burnout. So the organization is addressing that at an organizational level. It's time to get your caboose in order and hop on that freight train.
I also think some of the data is helpful. I've heard some organizations ... In fact, I was recently chatting with someone today who they did the Arch Collaborative survey and it showed that they were at quite a low percentile, and that becomes an impetus.
Lauren: Yeah, and the Arch Collaborative-
Amy: Not a freight train, but an impetus.
Lauren: So the Arch Collaborative. Talk a little bit more about how that can give organizations a view into this kind of nebulous dissatisfaction with the system, because that can be a really difficult thing to capture.
Amy: The Arch Collaborative started actually after we had done our intervention. Then we did the survey. We did very well. What the Arch Collaborative found aligned with what we had been addressing, so that's kind of how I came to believe in it.
To sum it up very quickly, the Arch Collaborative is a survey that asks organizations basically, does the EHR help you provide quality care? Then, from that data, and now for the first time ever, all of us out there have national data of what's associated with what is tied to user satisfaction. And of course, the more data they get, the findings will change, but right now, what it shows is training or education. I have to say that is the hardest sell when you try to tell people that education, or how to use the EMR, the push back is it's very hard for people inherently to understand how much that will help that. The push back is real. Personalization of the EMR, and then this phenomena of shared ownership has been shown to be associated with higher user satisfactions in this survey that's been done nationally.
Lauren: Thanks for that background on the Arch Collaborative. So let's dig in a little bit more into those four components because that really does give us the data behind why those should be the focus areas. I think that it's something that a lot of people that are listening might be kind of nodding along. Because from a gut level it feels right. These are things that addressing them should potentially help from an organizational standpoint. Let's talk a little bit about those pieces, kind of one by one.
Let's start with the shared ownership term. When you say, "shared ownership," Dr. Maneker, what do you mean?
Amy: So shared ownership is a term from Arch Collaborative. I used to call it ownership and engagement, but what it really is, is that the users who are using the EMR to provide clinical care need to own part of the EMR, more specifically the content. They're the ones who provide care. They have to own the content built into it, and they have to be engaged. Shared ownership is a term I think that is a nice way of describing that, and it's kind of different roles. I think most organizations, it's not going to be one size fits all. Epic the vendor is a big fan of physician builders, which I think are great, but that's not the only solution. Often organizations have multiple different roles. A trainer. An Epic medical lead. They may have different titles. A physician informaticist. All of those to some degree have ownership and engagement in the EMR. I personally think that, and we've seen that in the national data, that it correlates with user satisfaction.
Lauren: Do you have any thoughts as to why that would lead to better satisfaction?
Amy: Well, so, it's pretty simple. Simple things like the preference list. If you're an Epic user, you know what that is. Well, if IT owns it, that's not helpful if you're the one who knows, oh we really only use these forms of Augmentin, so let's decrease the cognitive load and get those three forms, so one, people pick the right med. Two, it's easier and faster. That's why shared ownership is going to help us with user satisfaction.
Also, I've this line where if you have shared owners, they become that they're inside the IT firewall, so they understand the IT processes. Or they understand some of the Epic build. They say, "Well, I want this." Then if they know enough to know, "Oh that custom SmartForm," that's a significant build so think of that as money. It's really expensive. How much is that really going to help you? And so sometimes they're like, "Oh, you know, not so much." They make an educated decision, and they don't feel like IT is making a decision for them. So, it really is having a little IT knowledge, but more importantly, knowing their medical priorities and their workflows, therefore, the right decisions can be made, and they also understand and are part of the decisions, so not being left out and having this black box of where their request went. I feel like that really enhances both the functionality of the EMR, but the satisfaction of people using it.
Lauren: So the ways that you've described so far are ways to get physicians or other providers in general involved in making the decisions with IT. What about that communicating out to their peer group piece? What have you seen work well there? Does that help increase buy-in? Is that part of this component? It sounded to me as though you were kind of keying into that piece about, they might be able to help IT say, "no" with a good "why," or a good communicating of the why. What have you seen with that communicating back out piece?
Amy: That's a really good question. So I think some of the roles ... Even just we had governance, where we expected every specialty to have a provider attend. And then we told them, we expect you to bring this back to your group. The other way to have accountability is I would send out attendance, and I would say to the chairs, do they report back to your group.
Part of those roles – remember I talked about that there are many different roles – that is to communicate and also sometimes just to gain consensus among their group, because IT ... You know there's a group of ENT surgeons and one says move it to the left, and one says move it to the right, and IT's doing both, and that's really a problem. And so that's another part of shared ownership is having someone who has to get consensus among the group, and oh by the way, they're going to leave it in the middle. Yes communication, getting consensus and communicating back to IT, and then being part of the decision, so once they get to know the software a little bit, they can make really good decisions about what new options to take. What needs to be fixed. What are the simple things about the build that will make life a lot better for them.
Lauren: So let’s move from shared ownership to talking a little bit about education.
Amy: Before there ever was national data, we somehow knew that training was the ticket. But, when you say that to people, almost always you get a response, "No, you just need to fix the clicks." Recently I was on a call. "No, you just need to fix the navigator." I think inherently people don't realize how much bang for the buck they're going to get in terms of education on how to use the EMR. I think from ... I've been doing this longer than I want to admit, we didn't realize it either, and so we would put it in. We would almost treat training as punitive, and walk away. Well in other industries where there's professional software, people get ongoing training. It's expected. I think that's how it came to be, and we're just all realizing. Now I'm going to turn it back to you, the guru on training.
Lauren: In my experience ... my ultimate background is in psychology and so I think that education is kind of a tool to help change people's behavior. What we're really trying to do when we're educating somebody on software, when we're talking about using software as a tool to help with patient care, or to help ease documentation burden, which is really what it should be. It shouldn't be a barrier. It should be a tool.
What you're really talking about are behavior changes. You're really talking about trying to change habits. So education can be that tool to do that, if it's done well. That's the big caveat is that a lot of organizations, because up to this point they've treated it kind of like a box to check, their programs really haven't been particularly well designed. Part of that is because they don't necessarily ... "they" being a lot of organizations, don't necessarily see it as an integral component to behavior change. Like behavior change isn't the ultimate goal. It's more like let me tell you what this thing could do for you, rather than really having it focused on, here is the correct way to go through a workflow. Some really solid samples of what I'm talking about ... Education programs where you show a user four different ways to do a thing, and they're a new user, not helpful. When you have a new user, or a new set of users, agreeing on the best way for that set of users to do the thing, and showing them that one way, and then reinforcing that one way, that's an effective education program.
That ties back to that piece of shared ownership that you're talking about, because who determines the best way to do the thing. That's not a trainer. That's not my job, as the trainer. My job is to figure out how to capture that information into a class and then figure out how to have the tools to do reinforcement. The best way to do things, or the right content, that has to come from the subject matter experts who are the people who are actually using the software on a day to day basis.
That's actually the second component. So, one, make it simple. Two, make it relevant. You have to make sure that you are teaching the best way to do a thing, and for that you need really good communication with SMEs. For example, Epic has this specialists training specialists program, which I think is wonderful for getting providers at a specialty level involved in designing the training. Maybe having them be a presenter is not the best use of their time, but it does increase the amount of time that the specialists are using looking at the curriculum and telling them this is going to be a useful tool. This is how we should be using it. This is how we should be training people. That's a good use of their time. So, it needs to be simple. It needs to be specific.
Amy: And that ties right back into shared ownership. The roles of shared owners coming up with the teaching curriculum in conjunction with an expert like yourself.
Lauren: Yup. Yeah. So it needs to be simple. It needs to be specific, and it needs to also be something that you return to. It has to be ... In order to actually have habits change, you actually have to have people take what they've learned and apply it.
There's a principle in psychology called the GI Joe Fallacy. It's one of my favorite psychological terms. GI Joe Fallacy is, GI Joe would always say, "Now you know, and knowing is half the battle." That implies that knowing a thing means that you're going to make use of it. Humans don't actually work that way. I can tell you that the best way to search for an order is to use the first three letters and stop typing, but that doesn't necessarily mean you're going to do it. We have to focus not just on knowing that that's how the system works, but actually getting users to then do the thing, to actually form the habit.
That means that a lot of education has to move from the classroom to outside the classroom. It needs to be reinforced, which means that education starts bleeding into support, which is another piece of shared ownership, and it also bleeds into being talked about with your super users, which kind of fall under support. But it's something that has to be consistently talked about. You can't just simply say that user went through training once, they're in the classroom, "We're good." It doesn't work that way.
And that actually bleeds into personalization because education and personalization do tend to be tied pretty closely together.
Personalization I would put into that practical, “How do we form habits?” piece. Again, I might know that it's possible to create a custom smart text, or to adapt a smart text, but it's not until I actually start using the system, and I see how that smart text can be adapted to my workflow, that I'm actually probably going to put that into use, and actually make it a habit.
As you mentioned at the beginning of our podcast, personalization is a big component for satisfaction. It can give people mastery over the system. It's a way to really apply habits. How have you seen personalization work well within organizations that you have worked with?
Amy: I agree with the finding that personalization is wildly underutilized. I think the idea that every single person is going to spend the time to personalize or understands how to best leverage personalization isn't realistic. The great thing about Epic is that much of the personalization can be shared, so not everyone has to do it. I have found that many people can't visualize how they can leverage personalization to make their life much better.
I often tell a story. This is how I do it. And then this is a great thing for the shared ownership. You have the cardiologist who's the guru for cardiology. We'll call him the Epic medical lead. You explain to him, this is how I use personalization. If he's someone who can wrap his head around it, he or she, will then say, "Oh, that's great. That's how we could use it in cardiology." So, it's beyond the basics. It tends to be very specialty specific. Then if that gentleman, or woman, whoever, but we'll go with gentleman, goes and builds a lot of the tools, he can share them, and not everyone needs to take the time to build them. Or many people can't, they just don't think that way, of how to leverage personalization. I think it's a way to leverage the shared ownership, and also beyond the basics, it's specialty-specific, and then share it.
Lauren: So, we haven't talked much about the system, but that is a component. I think to make sure that we round this out, if you did have an organization that was to come to you and say, "Hey, we want to fix the clicks." Yes, of course, you would try to help them understand the bigger picture, but what clicks are worth fixing, in your opinion, to make providers happier?
Amy: I think we assume ... It used to be, oh, we'll fix the build. Now we've learned the hard way, all of us, that you need user engagement to make their life better. That's harder. Wouldn't life be easy if we could just fix the build?
Lauren: In that statement, I just want to clarify, you're saying the "we" like a consulting company can't just come in and fix the build. We actually need to have client engagement to really figure out what we're building.
Amy: What I've learned is you really need people to know the system, to really make the best configuration changes in the long term. You need people to know the system, so that's training, which Lauren spoke about, and you need the owner, who understands ... I'm the cardiologist. I understand cardiology, and I understand the Epic system, so I can really make good decisions. So that's the long term.
In the short term though, there's definitely clean up. We tend to see the preference list is just a treasure trove of some ... just clean up there can make people's life better. If I have to randomly guess always go after the preference list of all forms, and some of the speed buttons built in. Then what I've learned is there's always build involved. Even when we did advanced training, there was configuration and build involved. Every once in a while, when you shadow or spend time in a clinic, you do find these, "oh my gosh, how did that get there?" That does need to be fixed. Those are the unknowns. Those big standout things that really are a nuisance. But, if my first guess is often speed buttons, and the preference list.
Lauren: Sure. So so far we've really focused on providers. Part of that's because that's really where the national conversation around burnout has focused. Do you feel like this kind of shared ownership model, focus on education, etc., do you feel personally as though that can extend to other types of providers? Have you seen that work at other organizations? And if so, how?
Amy: I think we've both learned, just to back up a little, is that training also we learn, especially in ambulatory, we focus on the training and education for the provider, because if they can't keep up, the whole clinic stops. But the more you talk to them, you realize that some of the upstream components of the patient's visit is impacting their workflow. The education and training gets moved outside just the provider's purview.
I think that's also true in terms of shared ownership and governance. I think in the perfect world, it would spread throughout. Everyone that uses the system. I think in some ways, it's spread earlier, so in nursing I think they've done a much better job, because physicians, people were very reticent to take their time to invest in the EMR. I think in some areas, nursing is far ahead of providers.
Lauren: They do tend to be more enthusiastic about training, just in general. A little observation I have made. Pharmacists and nurses tend to be like pretty happy to go through training.
Amy: And having pharmacists and nurses, they long have had shared ownership. I think, quite frankly, it's the cost of physicians. And, not just the money. It's also, I can't take that cardiologist away from cardiology. We need him to see patients. What we don't realize is if we take them away from seeing patients to make the EMR more efficient, it will help the whole, all the cardiologists and potentially the whole health system. I feel like shared ownership, the providers are behind most of the other ones. I feel like training, and education, we're focusing on the providers but that should spread.
Lauren: Yeah. I feel like the way, at least in organizations that I've worked with historically, the training of physicians specifically tends to be a hot button issue, more than other roles. It's like they're willing to take ... You know you have union rules, or something that you might have to deal with for nurses for example, but there's a little bit more of a willingness to have those folks go through training. Whereas with providers, that tends to be like where the conversation can sometimes stop, and you all of a sudden start having a conversation more around how do we minimize the training which gets back to that conversation of, well this isn't a punishment. This is actually something that we should be framing as a benefit, because it's going to, in the long term, help the provider if they're able to use the system more efficiently, and they're able to use the build more efficiently.
Amy: I think it's that overall reticence to take providers away from patient care, and people see it as a cost. I don't just mean in dollars. In reality, by not taking them away, and not providing providers with education, training, or involving them in shared ownership, the long term cost is greater. I think it's taken us a long time to learn that.
Lauren: Yeah. So, to sum up, the organizations that are really doing this, this being the living with an EMR, EHR, and really using it to its maximum benefit, those are the organizations that have some sort of shared ownership structure that put value on initial training, as well as ongoing education, on how to use the EHR. They emphasize personalization, and do spend time with the system but maybe that's not the bulk of the focus of their time and effort when they start talking about optimization. Do you feel like that's a pretty good summary of those that are doing this thing "right." You can't see my air quotes, but I'm definitely putting it in air quotes because this is an evolving, ever evolving area.
Amy: Yeah. I think that the organizations who are the, I call leading practices, the rock stars, seem to be excelling in ... They may not be doing all of it, shared ownership, and/or education, and/or personalization, and the configuration is a given that everyone works on their Epic configuration, but what seems to be the ones that the stand outs are doing endeavors and spending time and energy in the three areas we keep mentioning.
Lauren: Yeah. What do you think those organizations look like in comparison to organizations that are struggling? Are there hallmarks of success that you could maybe point to and say, as an outside observer, or as a provider that could potentially want to practice some place. Those are the organizations that I'm looking for, or looking to as successful.
Amy: I actually spent some time with one of the highest scorers in the Arch Collaborative. And it's very funny, and the Arch Collaborative says this too, they don't say, "oh, we're great." Those organizations often are surprised, and vice versa. The ones who don't score well are often surprised. I think it's this idea of they have a spirit or culture of continuous improvement, and continuously working on the EMR, and people's engagement in the EMR and training for the EMR. It's not that they're sitting there thinking they're great, but it's that spirit that we're working on it, and we're all involved. They even are surprised. They don't say ... You don't go to visit an organization and they say, "Oh, it's the best ever." But they'll talk about ... You'll hear about engagement, and the ongoing efforts. I think that is the-
Lauren: Hallmark of a successful organization.
Amy: I think that would be the indicators that things are really better there than in many places.
Lauren: Yeah. So that maintenance of ongoing user satisfaction is not resting on our laurels, not doing a program and then stopping. It's that constantly asking, OK, what could we be doing? How could we serve our organization's providers and patients better?
Amy: And feeling that there's a relationship, maybe not with theirs, but someone in their group, "Oh Joe over there, yeah he works with the Epic team," so that they have a relationship. That's that shared ownership-
Lauren: With IT as well.
Amy: ... and that people are working towards it. It's interesting, the organization that I'm thinking of didn't say, "oh, we're great." They were like, "Really, we scored so well?" But, when you really push them, they say all those things. Then the Arch Collaborative says that's a common response. The people who score well, the organizations that score well aren't necessarily so aware of it. They're more aware of how much effort, and ongoing energy they put into continuously improving. Maybe that's the hallmark.
Lauren: Well Amy, I appreciate you being willing to have this conversation with us today. For those listeners out there that are wondering, "Geeze, a lot of this sounds great, but we're not really sure where to start, or how to bring shared ownership, training, personalization, and that component of targeted system configuration to your organization, definitely reach out to Nordic about potentially doing an assessment, or working with us on an EHR enhancement project. We'd be happy to help.
Thanks for joining us again today, Amy. We really appreciate your time and your input.
Amy: Thanks so much. It's been a pleasure.