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· A mixed methods study of how clinician ‘super users’ influence others during the implementation of electronic health records.
A mixed methods study of how clinician ‘super users’ influence others during the implementation of electronic health records. EHR implementation context in which super users operated. Super users operated within the context of a hospital- wide EHR implementation that had negative and positive aspects. In terms of negative aspects, participants on both units consistently mentioned challenges related to the technology itself, including problems related to the functionality of the EHR (e. EHR platform. A nurse manager from Unit 2 (ID1.
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Many participants also voiced their dissatisfaction with the EHR training, which covered general principles of using the system but not the specifics required for their daily workflow. A nurse on Unit 1 (ID1.
The training itself was worthless. I learned pretty much everything that I learned by doing it.” Several participants attributed this lack of tailored training to the non- clinical backgrounds of most of the trainers and support staff that were contracted by the EHR company. For example, a super user on Unit 1 (ID1. They really weren’t that helpful because they were mostly IT people so it’s not like they were clinical…They know how to navigate through [the EHR] and everything but as a nurse on the floor…they didn’t have any answers to their questions.”Furthermore, several participants reflected on adverse changes in the interactions and communication patterns that arose from the EHR implementation. For example, a nurse on Unit 2 (ID5) expressed how the EHR created new relational dynamics between clinicians that placed a greater emphasis on work roles than interpersonal relationships: “I always knew my physicians, they always knew me…now you’re looking for that familiar face or person; you’re going up to them and there’s no relationship.
I think that’s sad about all the technology. I mean it’s faster and that’s great and I can get what I need…but then you never learn. Like “I can count on her, oh she’s on tonight, great.” Before you would build a relationship where you would trust each other. Now you’re like, “Whose who, what’s what? Who am I talking too? Who am I calling?” I guess that’s just the wave of the future.
It doesn’t really matter; everybody’s equal is what they say. A nurse is a nurse. A doctor is a doctor. Just get what you need.
It’s a little colder.”Along with these challenges, participants identified several factors that positively affected implementation, including structured opportunities to share best practices on how to effectively use the EHR (e. EHR “go- live.” Having super users was perceived to be a particularly helpful strategy because it provided clinicians with someone to turn to for support, who knew their work, and with whom they were familiar, as evidenced by these illustrative quotations.“I think that was just comforting for [staff] to know that if they had any problem someone was always there to help” (ID2. The super- user was a great idea…because they’re familiar with your own specialty. They’re able to key in and drill down the specific documentation that’s needed for our specialty… where the [the contracted support staff] were very generic” (ID2).“Having the super users I think helped de- stress a lot of the people on our floor… because it’s one of us that they can come to and not just a stranger” (ID1. Super user behaviors that support implementation – shared across units. Participants highlighted key behaviors that super users on both units used to support implementation (Table 2).
These supportive behaviors included: (1) reporting problems with the EHR to someone in a position to fix it [e. So whenever somebody had a question and I couldn’t really answer it… I would present that problem to the [cross- departmental EHR] meeting to see if they could give me a faster answer than the ticket” (ID9)]; (2) employing teaching strategies that promoted “learning by doing” (e.
ID5)]. Notably, these shared behaviors were emphasized in the hospital- wide training program for super users. Super user behaviors shared across units. Super user behaviors that undermined implementation – shared across units.
Super users on both units also engaged in behaviors that undermined implementation (Table 2). Particularly in the early stage of implementation, serving as a super user was physically and emotionally draining. Epitomizing this, a super user from Unit 2 (ID4) lamented, “If I hear my name called one more time, I’m going to have a breakdown.” At times, the weight of these demands manifested in the following unsupportive behaviors: (1) losing patience with coworkers [e.
I don’t think that she even realized that she started to get aggravated… you felt bad. You’d be like, ‘Oh, now I don’t want to ask her ‘cause she’s gonna get aggravated so you would stay away’” (ID5)]; (2) losing track of what material was taught to whom [e. She was exhausted… she thought so many times she said this but still people didn’t know. She thought everybody knew it because she’d said it probably 1.
But then there’s 5. ID1. 2)]; (3) spreading negative opinions about the system [e. Super user’s name] does vent a fair amount and if there were frustrations that she had with [the EHR] you would get just as much direction as you would sort of her opinion and frustration about it as well” (ID2. EHR [e. g., “The only problem is a lot of the super users are young and so they’re very computer savvy, so they figured out workarounds.
And then we weren’t doing [it] the right way” (ID5)]. Super user behaviors that differed between units. Our analysis revealed differences in behaviors between units: super users on Unit 1, who volunteered for the position, used more effort- intensive behaviors to foster implementation success than super users on Unit 2, who were appointed by nursing management. Specifically, four key behaviors differed between units: (1) proactivity, (2) depth of explanation, (3) framing, and (4) information- sharing (Table 3). Super user behaviors that differed between units. Proactivity. Staff on Unit 1 described how super users proactively supported the learning process by devising ways to expand on the EHR classroom training (e. EHR tasks), offering assistance proactively [e.
Every 2 seconds she’d ask me do you need help with this or do you need help with that?…Every single shift I worked…she would go around asking” (ID2. I was sitting with the staff members and saying, show me how to do this, are you comfortable with this, do you have questions?” (ID9)]. Conversely, the super users on Unit 2 assumed a more reactive approach to supporting their peers. For example, when a super on Unit 2 was asked whether she proactively shared information about the EHR with others, she responded “Well people will come and find you.” In addition, respondents noted that some of the super users on Unit 2 were not cognizant of their needs [e. Those two super users were just hanging around…they weren’t very attentive.
I don’t know what they were doing.” (ID1. Depth of explanation. Even though there was evidence of learning by doing on both units, the super users on Units 1 and 2 differed in the extent to which they explained the rationale for various actions in the EHR.
On Unit 1, the super users placed greater emphasis on making sure that their peers understood not just what was expected but why they had to do something in the EHR. For example, a secretary on Unit 1 (ID1. Super user’s name] just didn’t show me how to do it. She explained why it happened.” In contrast, on Unit 2, the super users showed their colleagues how to accomplish tasks in the EHR but did not explain the logic behind these actions. For example, a nurse on Unit 1 (ID5) shared, “my super user … he’d say you don’t need to know that.”Framing. As noted previously, during the implementation process, staff on both units would regularly voice their dissatisfaction with the EHR. In an effort to diffuse tension, super users provided frames, i.
The frames differed between units.