1. Figlietti, Crystal DNP, RN, CNL, PHN

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Key Points:


* Develop an onboarding process for staff who utilize the electronic health record (EHR)


* Training for the EHR based on roles


* End-user feedback to reinforce standardized use of the EHR




An urban, long-term-care facility, with 780 licensed beds, implemented an electronic health record (EHR). Once the EHR was successfully launched, it became apparent an onboarding process for new staff members was necessary.


Approximately 10 new staff members are hired monthly who utilize the EHR as part of their jobs. A smooth transition into their new positions requires access to the EHR and proper training based on role. Training, prior to utilizing the EHR on the job, decreases frustration and potential documentation errors.1,2



Onboarding is a process that occurs once a new staff member is hired and extends for a period while being socialized into the respective department.1-6 Organizational socialization is another name for onboarding, and both refer to the process of introducing new staff members to the culture, rules, and expectations of the organization.1-6


During the first few days on the job, the department of education conducts a hospital-wide orientation to communicate the organization's mission and vision, as well as rules and expectations. Orientation is conducted in multidisciplinary groups and allows for organizational socialization. Developing relationships early can facilitate commitment to an organization and increase job satisfaction.1-5 Job satisfaction can be linked to improved retention rates and can positively affect customer satisfaction.1,2


Three key factors considered by the informatics team when developing the onboarding process were (1) technical considerations regarding access to the EHR, (2) training based on clinical roles, and (3) technical support and end-user follow-up to reinforce standardized charting expectations. Providing clear expectations regarding EHR use was a fundamental goal of onboarding.1,2,6



The nursing informatics team consists of four members: one registered nurse assigned to training and support of the EHR, one registered nurse assigned to electronic devices such as call lights and communication equipment, and two certified nurse assistants who provide support for the electronic and communication equipment. Supplemental support is provided by one clinical nurse specialist (CNS) trained as backup technical support and trainer for the EHR.


The nursing informatics team works closely with the chief nursing officer and the chief medical informatics officer. The informatics team supports all interdisciplinary staff who utilize electronic and communication devices and is not exclusively responsible for nursing staff.



Initially, access to the EHR must be granted to new staff members who will utilize the charting system. The process of granting access to new users necessitates a partnership between nursing informatics and departmental leadership. Communication is primarily through e-mail and a computer ticketing system that assigns a number to a request. The ticketing system allows for trackable task assignment and follow-up.


The nursing informatics team, primarily the EHR informatics nurse, is responsible for obtaining EHR access for new staff. New account requests are submitted to the EHR informatics nurse by e-mail from the nursing orientation coordinator or respective departmental supervisor. Subsequently, the EHR informatics nurse relays the request, using the ticketing system, to the EHR vendor's representative for account creation. Typically, account log-in information is relayed to the new user during EHR training.


At the same time account requests are submitted, training is scheduled. Training is based on roles and the number of hours necessary for training varies. The in-person training can vary, from one 2-hour session to 7 hours divided over two sessions. The staff members who only view medical records and do not document in the EHR (read-only accounts) receive the least amount of training, whereas nurses and physicians receive the most training.


Account requests and scheduled trainings are tracked on a spreadsheet saved on a shared computer drive that is accessible by the informatics team and the supplemental CNS. This centralized document eliminates redundancy and optimizes communication. In addition, a whiteboard in the informatics office contains an area devoted to the EHR, and important information is posted regarding scheduled trainings, scheduled and unscheduled system downtime, and software enhancements.



Training for the EHR is scheduled during departmental orientation. Specific departmental orientation occurs after hospital-wide orientation, and this is when new staff members typically shadow senior staff members. The EHR is introduced during this time and formal training is scheduled to provide the knowledge and skills necessary to use the EHR independently. Utilizing organizational workflows, training is focused on mock tasks that mimic actual scenarios.7 Role-specific, organizational workflows were developed prior to implementation of the EHR and form the basis of role-based training.


Nurses typically receive an orientation of 2 to 4 weeks, and EHR training is scheduled during the early part of orientation. Scheduling training during orientation does not place a burden on staffing, because nurses are not responsible for their own patient assignment during this time. Ideally, nurses are on the floor shadowing a senior nurse for a couple of days prior to attending EHR training. This allows exposure to the EHR in the actual work environment prior to practicing with mock patients in the training environment. Training, in the designated computer laboratory, is 7 hours divided over two consecutive afternoons.


The first day of training, for nurses, is an overview of EHR functions, terminology, and how to navigate through the charting system. Individual computers are assigned, and functions are demonstrated and projected on an overhead screen. Time is allowed to practice role-specific tasks in the training environment. Exploration in the training environment is expected and encouraged. Reference guides, such as screenshots of common charting tasks; checklists for specific charting functions; and guides for common medication orders are provided for reference and reinforcement.


The second day of training covers the functions represented in the organizational workflows. For example, there are 12 basic nursing workflows that represent common scenarios, such as admission, discharge, immunization documentation, and medication verbal orders. Reference guides are provided, and tasks are demonstrated to mimic tasks from the workflows. During the second day of training, EHR log-in information is provided. This sequence is intentional, so new nurses will not document in the EHR prior to training.



Conducting audits serves to reinforce and encourage standardized documentation as presented in organizational workflows and to meet "meaningful use" objectives. The new EHR enabled the facility to comply with the HITECH Act. The HITECH Act allows the federal government to provide financial incentives payments through Medicare and Medicaid for the adoption and meaningful use of an EHR.8-10 The Centers for Medicare & Medicaid Services and the Department of Health and Human Services have developed a list of meaningful use objectives that must be met in order to qualify for the incentive payments.8 The new EHR fostered compliance with the objectives, such as recording vital signs, recording smoking status, maintaining an active medication list, and other measures intended to demonstrate and track that the EHR is being utilized by physicians to improve patient care.8,11-13


In addition to organizational meaningful use audits, the EHR informatics nurse developed tracking tools to specifically audit for (1) physician cosign compliance for nursing verbal orders, (2) progress note medication order transcription, (3) verbal order medication documentation and transcription, and (4) unsigned physician progress notes. The audits are saved on a shared computer drive, as well as distributed by secure e-mail to physician and nursing leadership. Information obtained through audits assists with creating remediation classes or in-services to address documentation or workflow topics. For time-sensitive issues, the EHR informatics nurse contacts the appropriate individual to follow up on items that may require immediate attention.


To provide technical support for staff, the EHR informatics nurse is available by pager, phone, e-mail, or in person during regular business hours. Timely support is important to assist with charting functions such as medication orders or proper documentation of workflow tasks. Support topics are tracked on a log and provide opportunities to discover trends or frequently asked questions and plan future in-services or updates accordingly. Occasionally, the EHR informatics nurse schedules time on the weekend or during the night shift to assist with questions regarding EHR functions. In addition, a Web site on the facility's intranet contains EHR-specific reference guides, workflows, screenshots, and instruction sheets that can be viewed or printed easily.



During development of the onboarding program, tracking, training, and communication tools were created. Members of the informatics team can access electronic versions of the tools on a shared computer drive. The tools are also available in three-ring binders located in a central location in the informatics office; details are shown in Table 1.

Table 1 - Click to enlarge in new windowTable 1 Support Tools for Onboarding Process


Investment and adoption of EHRs will continue to grow across all healthcare settings as organizations and providers begin to benefit from improved quality, legibility, interoperability, and incentive payments. When facilities implement EHRs and move beyond implementation into the reporting stages for meaningful use, and perhaps regulatory requirements, the opportunity for publishing success stories, case studies, and lessons learned regarding onboarding and sustainable training programs will benefit the field of health informatics.


The EHR offers a unique system to design data gathering tools to create report queries for a multitude of clinical, educational, and operational topics. The next generation of clinicians will be accustomed to electronic charting. Technology is becoming more integrated into society, and advances such as EHRs will be expected in healthcare facilities as a standard of documentation. Paper charting will no longer be utilized because of the difficulty with data extraction and the inability to easily share information with other providers, settings, or facilities.


The future of EHRs offers many possibilities to improve care and outcomes. Development of an optimal onboarding process for new hires will continue to remain a key element for introducing new staff members to organizational goals and expectations. In summary, the most effective onboarding training program will include a team approach, nursing leadership, clear roles and responsibilities, standardized charting expectations, practical workflows, and end-user feedback. The EHR onboarding process for new employees will be most successful within a work environment that fosters continuous learning, open communication, and technical support.




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