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Resident Superusers: Engaging Residents in Optimizing the EHR

About the Organization

UW Health is the integrated health system of the University of Wisconsin-Madison. It is comprised of seven hospitals with 1750 physicians (including residents and fellows), 87 outpatient clinics, and a partnership in a 350 000-member health plan. UW Health cares for 600 000 patients annually.

UI Health Care represents the integrated health care enterprise of the University of Iowa, the only comprehensive academic medical center in Iowa. It includes two hospitals which have an 811-bed capacity, admitting 37 000 patients annually, with 58 000 annual emergency department visits and more than 1 million annual clinic visits at main campus along with community and outreach clinics. In fiscal year 2018, UI Health Care employed 1750 physicians and dentists, resident physicians and resident dentists, and fellows.

What Was the Problem?

The Resident Superuser program was born out of the need to optimize incoming resident training and ensure that residents were prepared to use the EHR on the first day of their clinical service. Because each residency program uses different EHR programs, has a different workflow, and treats differing patient populations, the previous “one-size-fits-all” approach to EHR training and education was sub- optimal.

Developing the Intervention

Senior residents were best suited to provide real- world training for incoming residents. This led to the proposal to create a Resident Superuser program with the initial goal of improving training, which was immediately successful. Residents also serve as liaisons with their colleagues across multiple specialties. The program was broadened to emphasize these aspects.

Resident superusers work together with both the information technology (IT) and the clinical teams, speak both of their languages, and know both of their systems and processes. They provide feedback and training that benefits both groups.

Superusers serve to:

  • Answer clinicians' questions about the EHR.

  • Provide feedback from clinicians to IT staff.

  • Train incoming residents and fellows on how to use the EHR (ie, on-boarding).

  • Participate in testing and validation of new EHR features.

  • Bring new ideas for optimization to EHR staff, including leading an annual optimization project.

Why Residents?

At academic institutions, residents are uniquely qualified to serve as superusers. They have front-line knowledge of the EHR because they utilize it the most: they write most notes, place most orders, and perform most patient chart reviews. They also have a broad knowledge of how the EHR is used in various sites across the institution, as they rotate through different clinical areas in their respective departments. This gives them a different perspective compared to clinicians who are isolated to only one narrow area of clinical practice.

Additionally, residents have the motivation of frontline users to improve the EHR because changes will directly impact them. They speak clinical language fluently and are digital natives—making them more familiar with the language and processes of IT than older generations of clinicians. Importantly, participation in the maintenance and improvement of the EHR contributes to resident education, creating the kind of doctors we want in our communities—those who can identify problems, take initiative, and develop creative and collaborative solutions.

Implementing the Intervention

At UW Health, two residents from each residency training program are part of the Resident Superuser program. Having a resident pair (as opposed to a single resident) increases departmental representation as well as encourages those two residents to keep each other motivated and accountable. Ideally, the two residents are in different years of training to facilitate transitions to new superusers when one graduates from training. Residents must have completed intern year (ensuring they are familiar with UW Health EHR systems) and must be in good standing with their programs. They generally spend no more than 10 hours on EHR activities monthly. Hours are reported to their training programs to comply with duty hours.

Resident superusers attend monthly meetings, which are scheduled following evening sign-out to facilitate attendance. Meetings are led by UW Health IT teams, who present new projects, ideas, and areas for improvement to residents for their feedback. Monthly meetings allow for cross-disciplinary discussion, which are important because individual EHR changes may affect clinicians from individual specialties differently.

Resident superusers provide EHR training (“on-boarding”) to new residents and fellows. When compared with the prior system of IT-led EHR training, residents expressed much higher satisfaction with the peer-led arrangement. Superusers also complete an annual EHR optimization project to make the EHR more effective or efficient in their respective clinical areas. Examples of projects include: development and maintenance of EHR order sets, improvement of the readability and utility of clinical documentation, novel methods for clinical data visualization, and tools to facilitate safer hand-offs of inpatient care.

Residents are compensated for their contributions as a form of moonlighting. Compensation is provided twice yearly. During each half-year, superusers must attend two-thirds of monthly meetings and show progress on their annual project.

Barriers

There were a few barriers to implementing the Resident Superuser program in both organizations, including an annual cost to compensate residents and provide food at monthly meetings. However, these costs appear to be offset by reallocation of training resources as well as improvements in clinician engagement and EHR effectiveness and efficiency.

Residents tasked with superuser responsibilities have generally been fully engaged with the program. Compensation of residents for their time and efforts is crucial as it provides motivation and accountability. At UI Health Care, several years prior to initiation of the Resident Superuser program, a voluntary group was formed and attempted to hold regular meetings to discuss EHR improvements. However, it was poorly attended and eventually stopped functioning.

Results

Besides several specific improvements to the EHR and a general improvement in EHR ownership, resident superusers have conveyed that they benefit from the educational opportunity. The program specifically addresses Accreditation Council for Graduate Medical Education (ACGME) competencies in Systems-Based Practice and Practice-Based Learning and Improvement. Moreover, the Resident Superuser program has helped some residents prepare for specific jobs after graduation and provided them experience to assist their future practices with the EHR.

Specific examples of superuser improvements include:

  • Standardized EHR orders to reduce inappropriate dosing of post-operative medications.

  • Standardized admission orders to make it easier for nursing staff to care for patients and increase efficiency for residents.

  • Improved efficiency and accuracy of clinician hand-offs.

  • Improved access to health maintenance tasks during primary care visits.

Testimonials

A recent survey of residents at UI Health Care included the following responses:

  • “I thought having residents teach the [EHR] course was great. I have been to generic courses in the past that haven't been as helpful.”

  • “Our residents provided lots of pertinent examples that made the training process more focused and tailored to our specific needs.”

  • “It was helpful to work with residents in our own department because of their level of skill with the information that is relevant to us as incoming residents. This was much preferred to the style of generic learning that I have had in the past for [the EHR].”

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