Knowledge: Key to EHR Adoption

By Dr. Greg Forzley and Mr. Tony Onorad

As health care organizations of all sizes struggle to meet the challenge of electronic health record adoption and meaningful use, one recurring theme is common: How to effectively educate learners on both the new and / or adapted processes resulting from the implementation of the new system and the necessary skills to use the new technologies in order to efficiently execute those processes. Physicians in particular may feel challenged to learn how to use a particular EHR or EMR with the skill and finesse needed to balance patient care activities with the capture of information in the electronic record.

As Dr. David Blumenthal, National Coordinator for Health Information Technology (ONC), succinctly surmised in an April 2009 interview:

Simply having an EMR system isn’t enough. We need to ensure that physicians can actually use it.

It is important to understand the distinction between an EMR and an EHR. A clearer definition can be found in the April 28, 2008, report to the Office of the National Coordinator for HIT, “Defining Key Health Information Technology Terms:”

With the recent Federal legislation, it is clear that the focus will be on EHRs and their ability to share information securely across health organizations. In order to meet meaningful use standards and, more importantly, in order to provide more efficient and safer patient care, EHR users must be equipped with the knowledge that they need to successfully use any system they be required to use for patient care.

A key component to an EHR’s success is a clearly defined, measurable, and effective strategic knowledge improvement plan. This is not just an important component of the initial implementation, but critical to the long-term success and vibrant use of EMR technology.

Five major pieces to successful strategic knowledge improvement plans include:

  1. Successfully Managing Change
    1. Answer “Why are we doing this?”
    2. Answer “What’s in it for me?”
    3. Articulate the benefits and features.
    4. Purposefully review and communicate the process, including timelines.
    5. Set realistic expectations (we’re not flying to the Moon on day one).
  1. Implementing Readiness and Skills Assessments
    1. Assess current, basic PC and Windows skill levels (not everyone knows what a radio button or a “right” click are). Don’t take the learner’s report of skill level without an assessment verification tool.
    2. Ensure that all learners’ basic skill sets (i.e., Windows and PC) meet a minimum proficiency level prior to go-live training.
  1. Designing Knowledge Improvement Approach
    1. Key concept: Implement role-based training – you’re not training your users to be EMR experts; you’re training your learners to provide safer, more efficient patient care using a new system.
    2. Think long term: What is a sustainable model that will yield the most for a diverse set of learners?
    3. Evaluate your options carefully, understanding the cost, implications, and necessary support.
    4. Be prepared to stay in the game: Learning doesn’t stop at go-live. Now what?
    5. How are you going to determine the level of support and communication needed for new processes, system “fixes,” upgrade training, etc.?
  1. Assembling Your Knowledge Improvement Team
    1. Who will train your end users?
    2. What adult learning facilitation skills do they have?
    3. Who will design your knowledge improvement tools (classroom curriculum, eLearning, Knowledge Banks, mLearning, etc.)?
    4. Think long-term: Do you need a full EHR training team, comprised of full-time employees? Is relying solely upon consulting talent wise? A blended approach?
  1. Evaluate, Measure, and Realign Your Strategy and Tools
    1. Evaluate training strategy, curriculum, etc., against real-life results.
    2. Address the “pain points” quickly.
    3. Always seek to learn from every encounter and adopt an attitude of continuous improvement.

We’ll explore each component of a strategic knowledge improvement plan in detail in subsequent articles.

About the Authors

Dr. Greg Forzley ( is the Director of Informatics for St. Mary’s Health Care in Grand Rapids, Michigan, and serves as Chairman of the Michigan State Medical Society. Dr. Forzley has been instrumental in improving physician adoption of EMR systems and is a champion of improving patient care through meaningful use concepts.

Mr. Tony Onorad ( is the founder of OnoradSolutions, an EHR knowledge improvement consulting firm and has been an innovator in the adult learning field for over fifteen years.

ICD-10 “Training?” Think Again.

ImageThere has been much talk about providing ICD-10 “training” to your practices and teams.  What does that actually mean, though?  What do they really need to know to move to this “10” coding structure?  What about the practice managers; what do they need to know and do?  And when?

Having designed several healthcare IT training programs, I would argue that the transition to ICD-10 isn’t really a traditional “training” initiative.  Your teams aren’t new to coding; they already know how to do their jobs.  The transition to ICD-10 is about the “delta” – tell me what’s changed and what I need to do now!

So, I’m not recommending endless hours of classroom training or watching canned videos on the history of coding.  What am I recommending is a simple path with key components to transition your teams to ICD-10:


  • Awareness:   There continues to be much confusion around ICD-10.  Start by addressing some common questions and misconceptions:  What does it mean for me?  Will the October 1 deadline really hold?  What are the top five things that we, as a practice, can start now?  What do we do after October 1?  What are our key milestones?  What’s next?  Then take some “baby steps” to start your transition: Convert your top twenty codes, meet with your payors and vendors; begin to plan your ICD-10 transition project; budget (time, money, and resources) accordingly through January 31, 2015.
  • Role-Specific Education:  Now that we are all aware of what this ICD-10 transition really looks like, it’s time to take a deeper dive by role:  Providers, practice / project managers, billing, coding, and claims professionals.  Start your providers off by performing chart reviews and converting their most commonly used codes.  Practice managers and ICD-10 project managers should be knee-deep in project planning, including budgeting, timelines, vendor management, and testing.  Billing and coding folks should begin a review of the new features with ICD-10, guideline comparisons, and the major differences between ICD-9 and 10.
  • Tools:  You’ve made your teams aware of the ICD-10 transition and clarified any misconceptions.  Oh, and you’ve reminded them that the October 1, 2014, date is set in solid cement.  You’ve told them what they have to do to prepare (e.g., planning, converting codes, etc.).  But, how?  Using what?  Providing the right, trusted tools – such as ICD-10-specific project planning software for your practice and project managers; robust code translators for your providers, etc. – is the “rubber- meeting-the-road” piece of the successful equation.  Overlooking this is equivalent to having blue prints to build a new home, without any of the tools to do so.  And don’t take the easy way out; there are no simple, free, direct, and thorough code translators.  But there are robust tools that can help.
  • EHR Training:  Finally!  Training!  After your electronic health record (EHR) has gone through testing and, most likely, an upgrade – and tested again – it’s time to provide some level of “delta” training:  What’s changed as a result of the upgrade / transition to ICD-10?  Have my workflows changed as well?  Are there new, changed reports?  I doubt this EHR training would be a significant initiative and most likely can be achieved through interactive eLearning – as long as the eLearning modules match your specific build and workflows.
  • Where do I go for help?!  This is the most important piece of the equation.  After the awareness, education, and training are done and we’re live in October 2014, now what?  What if I’ve forgotten or get stuck?  Have a cost-effective, user-driven, easily updatable resource (no, not calling the help desk) to answer the multitude of questions that will come up and to address changes.   See where you can repackage your education and training tools into bite-sized snippets for topic-specific help.  Don’t recreate; reuse and repackage for just-in-time performance support.

Written by Tony F. Onorad

Mr. Onorad is CEO of OnoradSolutions and has been in the healthcare IT industry for over a decade.  His background includes designing knowledge improvement strategies for a diverse variety of organizations.

5 Phases for a Successful ICD-10 Transition

22013 ICD-10 Small Coach Final LogoICD-10 is the LAW, and it’s not going away.  In August 2012, HHS announced a final rule moving the ICD-10 compliance date to October 1, 2014. This means that health plans, health care providers, and health care clearinghouses that transact standard health care transactions must use ICD- 10-CM diagnosis codes for services occurring on or after October 1, 2014.

The suggested timeline for a successful ICD-10 transition from start to finish is 18 months, meaning the time to begin preparing is NOW.  What’s required is a sane, measured, and phased approach involving the following five phases: education & awareness, impact assessment, transition plan development, plan implementation, and implementation review.

Phase 1: Engaging and educating Physicians and Staff

Education begins with informing the physicians and staff of the regulatory requirements and deadlines for ICD-10, including the differences between ICD-9 & ICD-10.  Physicians and staff should know how to use the GEMS mapping system, and what documentation changes need to occur to comply with increased code specificity.  Additionally, the benefits and opportunities of ICD-10 CM should be understood.

Phase 2: Assessing Current Readiness and Impact

ICD-10 will touch all aspects of a practice, so understanding current readiness is paramount to a successful implementation.  Health care providers should begin to ask themselves how this new coding system will affect documentation and reporting, as well as the influence it will have on office processes. Physician practices will need to examine the significance of this transition on referrals, payers, and business partners. Budget and productivity will be affected, but to what degree? A detailed impact analysis assessment will determine how claims and electronic transactions will be affected by ICD-10 as well as the impact it will have on PM and EMR software.

Phase 3: Creating a Timeline and Transition Plan

The creation of a timeline and transition plan will support in guiding a practice through the various moving parts of a successful ICD-10 implementation. Create an ICD-10 transition project team with role specific tasks, deadlines, and accountability. Determine area-specific resource needs (human, technological and monetary), including a proposed budget.

Phase 4: Implementing your Transition Plan

Project Managers should plan for productivity loss before, during and after training. Learning and implementing new processes takes time and resources away from day to day duties.  Set a date to begin the transition plan urgently. Coding professionals recommend beginning training on the actual codes 6 – 12 months prior to Oct. 1, 2014. Remember Phase 1-3 need to be accomplished prior to this phase so the time to begin is NOW.

Phase 5: Post Transition Analysis and Reporting

At this point, one can only speculate the requirements of the post transition phase, but monitoring key metrics will be invaluable in determining the results versus desired outcomes of the transition plan. Key metrics include revenue by payer, claims denials, and provider productivity. Monitoring and reporting key metrics will determine if course correction is needed.

With October 1, 2014 rapidly approaching, it is important that every physician practice and healthcare provider in America begin to take urgent action in completing the 5 phases for a successful ICD-10 transition.


ICD-10 Coach provides education, training, and software to hospital systems, physician practices, and health care providers. ICD-10 Coach is strategically partnered with over fifteen state and national medical associations and societies, and its software developer is an AdminiServe partner with MGMA-ACMPE. For more information on ICD-10 Coach, please call (650) 242-5442 or visit

Building Strong Super Users

Experience has shown that forming a solid team of “super users” – those team members who will be your front-line support teams – is critically important for a successful transition to a new or replacement electronic health record (EHR).  All too often, little care or direction are given to selecting and developing these critical contributors to both your initial implementation and to ongoing adoption and optimization.

Recent experience with a large health system in San Francisco demonstrates this. The lead of their EHR training team requested senior leadership commitment to a robust super user program.  The result –  these key members of the team were instrumental to a very smooth, successful go-live.

What are the ingredients to making super users truly super?

  • Clear job descriptions – Would you hire someone without first identifying the key responsibilities?  Of course not.  Before you identify who your super users will be (either internal or external), create a clear job description that includes estimated hours required for: their own training, super users support of training, go-live support hours, and ongoing support of your EHR.
  • Skills and Abilities – After drafting an accurate job description, be sure to use that to select the right super users, based on their skills – not on who might be your favorite on the team.  Conversely, don’t select a poor performer, just to get them out of the way.  It is also important to make certain that they can comfortably approach all types of users, especially health professionals, and that they are skilled listeners that don’t react to user frustrations or concerns.
  • “Art” Classes – No, we’re not going to teach our super users how to paint; the first class a new super user should participate in should be The Art of Being a Super User.  This class addresses the “soft skills” needed to be successful in this support and training role: What is a super user?  How do adults learn?  What if I’m providing support and I don’t know the answer?  How do I handle a frustrated provider?  It’s critical that new super users understand adult learning methodologies before you start to train them on your EHR.
  • A Committed Journey– To completely understand both your new EHR system and their role in training and support, your super users should be “out-of-the-count” (not splitting duties) and have a clear, committed path:
    • Art of Being a Super User
    • Super User EHR training
    • Supporting at least two full rounds of classroom training for their co-workers.
    • Pre-go-live 1:1 support and training to further prepare their teams for implementation.
    • Implementation support.
    • Ongoing training, system testing, new-hire support, etc.

And, don’t forget to keep the super user team intact – they will be also be important to assist the staff with refining best practices, learning new features and functions, and invaluable when you are implementing a future upgrade.  Recognizing this key role and empowering your super users to be effective will pay off significantly not just for go-live, but far beyond your initial implementation.

About the Authors

Dr. Greg Forzley

Dr. Greg Forzley ( is the Chief Medical Information Officer – Health Networks, Trinity Health, and serves as Chairman of the Michigan State Medical Society. Dr. Forzley has been instrumental in improving physician adoption of EMR systems and is a champion of improving patient care through meaningful use concepts.

Tony Onorad

Mr. Tony Onorad ( is the founder of OnoradSolutions, a knowledge improvement consulting firm, and has been an innovator in the adult learning field for over fifteen years. He has led several complex training projects for a variety of clients.

Lessons Learned from a Seasoned EHR Training Manager

All too often “training” is overlooked and at the bottom of many EHR project lists.  The impact to not investing in improving the knowledge levels of your teams contribute to a disastrous go-live and a constant up-hill challenge to achieving adoption, let alone optimization.  A well-developed strategic training plan is a critical component to a successful go-live.

Having managed an ongoing EHR training project for the past several years, I’ve experienced many “lessons learned:”

  • New EHR Users: Any user who is new to your organization or even current employees that are new to the EHR or taking on a new role within EHR should go through training and pass a proficiency before they are given access to the system. This ensures that you have users that understand your system workflows before they begin any type of documenting within your EHR system.
  • Support Your Training Team: The organization must back up the training team so that if the Training Manager needs to deny access to a user they can. The trainers should also work with the department Managers and allow the Manager to determine if the user should continue with training or if the user just isn’t a good fit.
  • Schedules, Schedules, Schedules: Set a training schedule and stick to it. I have heard to many times how the Training Team of an organization is run ragged because they are constantly trying to satisfy the demands of new hire training sessions. Set schedules and stick to them. For Ambulatory you can alternate you weeks training Red/Sched one week and Clinical the next. You may have to tell a Manager that a new users training will be delayed a week because of the schedule but as long as the schedule is published for all to see, they will soon catch on and plan their hiring of new employees to coincide with the training schedule.
  • All the Goodies – at Once? When going live with EHR, build and implement what is needed at the time. You can always add additional functionality later. EHR has a lot of cool features, but without the staff to maintain the functionality of these features after you have implemented them, you may find dissatisfaction among users because of the length of time it will take for updates and changes to occur.
  • You Changed What?! Make sure you have a strong Change Control process in place. Your IT Management Team and Analyst should meet on a weekly basis to discuss any system issues and changes. When implementing any changes, all applications within EHR as well as any integrated systems should be involved in the planning and testing. A change may work for the EHR application needing it, but as EHR is an integrated system the change may not work for downstream applications or other integrated software systems. Including all applications in testing should catch any issues.



Shelley Fletcher CPC, PCS, CHCO

Epic Certified in ADT, Prelude, Resolute PB

Soft Skills for Hard Results: Training EHR Trainers to…Train!

A casual observation of many EHR trainers reveals an unsettling truth: they’re not great classroom trainers. While most possess adequate subject-matter expertise in their given Epic application, their ability to engage learners and facilitate knowledge transfer in the classroom often falls short of what is needed to adequately prepare end users to make a seamless transition to the new system at Go Live.

Most Epic training departments within healthcare organizations spend too little if any time preparing trainers with the soft-skills needed to ensure success in the classroom, concentrating their energies instead on dealing with build issues, rewriting lesson plans and making sure their trainers know the curriculum. All important tasks to be sure, but the unintended consequence is a group of trainers often ill equipped to manage classroom dynamics, facilitate adult learning, or skillfully handle overwhelmed, confused and resistant end users.

The good news is that most of what trainers need to learn can be integrated into a train-the-trainer process that seamlessly complements their Epic training. We start by giving trainers well-written Epic lesson plans and making sure they understand their organization’s unique build and workflows, but we ultimately set them up for success by equipping them with 14 key soft-skill training competencies that differentiate average trainers from great trainers. Specifically, trainers need to know how to:

  1. build rapport, trust and credibility with end users.
  2. hook, engage and motivate learners during classroom sessions.
  3. deliver with impact and make effective use of nonverbal communication—tone, volume, body language, eye contact, gestures, volume, pacing—to keep learners tuned-in and engaged.
  4. optimize learner readiness by helping end users not only understand course objectives, but appreciate how they’ll personally benefit from the new system.
  5. read their audience and teach to all learning styles—auditory, visual, kinesthetic, interpersonal, intrapersonal—to help end users comprehend, retrain and apply what is taught.
  6. use directional statements effectively to ensure all learners are rowing in the same direction and keeping pace with the instructor.
  7. develop strong in-classroom partnerships with Super Users, who play a vital role in helping latecomers get caught up and helping slower learners get back on track.
  8. use music, icebreakers and energizers appropriately to lighten the mood and create a positive classroom training environment.
  9. ask effective questions to check for understanding and involve learners.
  10. make sure the end user “got it.”
  11. handle questions from learners and use the “parking lot” effectively
  12. help participants navigate through, align with and support the change to Epic.
  13. give end users strategies for simultaneously managing patient care and the PC.
  14. handle difficult, frustrated and confused end users and manage resistance in the classroom to neutralize disruptions and enhance everyone’s learning experience.

The time spent preparing trainers how to train, and not just memorizing lesson plans and studying workflows, pays handsome dividends. Not only are end users better prepared, leading to smoother Go Live events with fewer speed bumps, but ultimately the patient experience is positively impacted, as clinicians and other Epic end users spend less time fumbling through the system and more time paying attention to patient care and safety.

Written by Danny Lewis, Senior Learning and Development Professional