Adapting To EHR Changes In The Workplace

July 2017

The shift of healthcare organizations transitioning to electronic medical records (EMR) and electronic health records (EHR) from paper documentation systems has become the norm over the past fifteen years or so.  The initiative for computerized health records began in 2004 when President George Bush established the Office of the National Coordinator for Health Information Technology (ONCHIT or ONC).  The foundation surrounding this initiative was to improve a patient’s care while reducing medical errors and cost, all while promoting the meaningful use of electronic systems.1  President Barack Obama’s administration further promoted this initiative by establishing the American Recovery and Reinvestment Act (ARRA) in 2009.2   

Since the inception of these initiatives, healthcare organizations countrywide have been consistently moving forward with the transition to computerized records.  This transitional period has not only brought about countless changes to individual organization’s documentation systems, but it also is responsible for a significant amount of change in the workplace for hospital staff.  Change in the workplace is not isolated to the healthcare industry or the profession of nursing, as we will talk about later in this post, as it is present across all walks of life.  No matter the workplace, the one constant when it comes to change is that it can be difficult.  Understanding how change impacts both the workplace and an employee’s workload, and then learning how to positively adapt, is paramount to succeeding in any industry, especially in healthcare where the stakes are so high. 

In 2015, Colligan, Potts, Finn, and Sinkin conducted a quantitative research study, published in the International Journal of Medical Informatics, to explore changes in cognitive workload of pediatric nurses during the transition from a hybrid paper and electronic information system to an EHR.3   Specifically, the study focused on cognitive workload surrounding tasks of data input and retrieval during this implementation of a commercial EHR that was implemented in a “top-down” manner (pg. 470).  “Top-down” is a synonym of the Big Bang implementation approach in which an organization disables the legacy system(s) and transitions employees over to the new system all at one time (pg. 470).  The mental workload assessment tool used during this study was the NASA TLX: Task Load Index, which is a reliable tool that measures subjective workload of employees across a wide range of applications based on the mental demand, physical demand, temporal demand, performance, effort, and frustration of an employee (pg. 471).  NASA TLX scores have been shown to correlate with error rates in a variety of domains, including healthcare (pg. 471).  In the industries of aviation and aeronautics, a NASA-TLX increase over 15% is considered significant by engineers when testing new technologies and prompt reevaluation and/or redesign (pg. 471).  Pre-EHR implementation, researchers gathered baseline demographic information (including age, years in profession, years in that particular hospital, hours worked per week, previous EHR experience) and computer attitude and skills scores of the nurse participants involved in this study using the NASA TLX tool.  Computer attitude scores measure an individual’s positive and/or negative attitudes towards computers and are used to study anxiety surrounding computer use.  The NASA TLX was then administered four times after the EHR go-live date after the first shift, fifth shift, tenth shift, and then after four months of being live.  The results of this study showed that there was a significant increase in the cognitive workload of nurses between the first and fifth shift after the EHR go-live (pg. 474).  Scores demonstrated an increase of greater than 15% between baselines and shift one and shift five, which indicates substantial cognitive workload increase (pg. 474).  Results indicated that increases in cognitive workload subsided after approximately ten shifts, but also showed a considerable amount of interpersonal variation surrounding adaptation between nurses during the transitional period (pg. 474).  “The key predictor of fast adaptation was a positive computer attitudes score.  We also found an effect of computer skills and age, but they appear to be mediated by the computer attitudes score” (pg. 474).   It was not unexpected to see a correlation of the multi-factorial variables present to an employee’s rate of adaptation which in this case showed an impact in the degree of cognitive workload increase or decrease.  Take the following example, in keeping with the new EHR scenario, of a nurse with very little experience with technology and a low computer attitude score, they not only will need to adapt and learn all the necessary information to be able to become proficient in that specific new EHR, they also must adapt to and learn new overarching technology concepts all while battling their negative predispositions about computers.  This experience when compared to a nurse who has a staggeringly high computer attitude score and years of experience using a particular EHR, is rightfully so much, much different.  Due to the effect that these variables have on staff, it is not surprising that another conclusion of the study was that a “one-size-fits-all” training strategy may not be suitable for all employees across the board during a top-down commercial EHR implementation (pg. 474).  In addition, it was also noted that “sudden discontinuation of support services (hotline discontinued and super-users back to full-time patient care) may disadvantage workers experiencing slow adaptation, or with shift schedules that precluded their learning with initial available support” (pg. 474).

Providing role-based end user training strictly based on type of staff, such as nurse or physician, and not taking into consideration the computer attitude and aptitude of a staff member, is both a disservice to the end user and the organization.  If the majority of a department, such as nursing, has a negative attitude towards computers that is left unaddressed, it can have a ripple effect and negatively impact the entire EHR implementation process.  There are several points of consideration when it comes to nursing and other healthcare staff members that are crucial to take into account during the planning of both the end user training phase and the post go-live support phase.  The learning curve, and therefore additional adequately budgeted for time considerations, surrounding learning new workflows in a new EHR cannot be overlooked.  Additionally, time differences between shifts and availability of support services need to be given considerable analysis, as an underestimation in these areas can inevitably lead to slower EHR adaptation by staff.  

While there are of course challenges surrounding adapting to change in the workplace, the benefits of change can more often than not outweigh the challenges employees face during the process.  If employees have a full understanding as to why the change is taking place and therefore can resonate with the fact that the change will be beneficial, they then will be more likely to embrace the transition and become motivated to be a change agent assisting in facilitating the process smoothly.  An example of this can be seen in the EHR implementation area as discussed above.  Electronic systems are ever changing and organizations are being faced with not only new software implementations, but also with multiple annual updates and upgrades.  The trend for systems to become fully integrated is gaining more and more industry traction, but with this oftentimes comes additional hurdles, especially for organizations who are utilizing multiple different systems.  One of the end goals for implementing a fully integrated solution is that it can of course eliminate the use of multiple systems, which in turn can reduce work load on clinicians and staff, which will eliminate the numerous disparate or work around processes currently in place. Healthcare providers such as nurses, physicians, and ancillary staff must be informed enough throughout the progress to fully comprehend the reason for large scale change like this in order to realize the benefits less painlessly.  Remembering that the patient comes first and the reason for these changes are ultimately for patient care and safety, is crucial for a staff member to keep in the forefront of their mind continuously throughout the implementation process. Regardless of the scope or scale of a project, communication should begin as early in the process as possible in an attempt to reach all employees in order to prepare them for what is to come.

It is clear that further research is needed surrounding adaptation to change in both the workplace generally speaking, and more specifically regarding mitigating increased cognitive workloads for hospital (or healthcare) staff who are undergoing an EHR implementation.  Continuing to keep the Colligan et al. 2015 study a topic of conversation is paramount in ensuring that the momentum in uncovering valuable information that will have a tangible impact on countless of healthcare organizations keeps moving forward.

About The Author:  Jennifer Adams is a Senior Consultant for HealthNET Systems Consulting, Inc. Jennifer has 20 years of experience in healthcare.  She is a Registered Nurse who has worked in both inpatient and outpatient facilities. She is an experienced healthcare IT professional with experience that crosses several Electronic Health Record solutions, bringing a combination of IT with clinical operations experience to her client projects.