Workforce Training in Electronic Health Record (EHR) Use through Community Colleges in the Delta Region: Alabama, Louisiana, Mississippi

by Cheryl A. Plettenberg, EdD, RHIA, FAHIMA; LaShunda Smith, MSM, RHIA, CHDA, HITPro-IM, HITPro-TR; and Susan Hart-Hester, PhD, RHIA, HITPro-IM, HITPro-PW.

Introduction

Adoption of health information technology (HIT) was one of the major policy priorities of the federal stimulus package contained in the American Recovery and Reinvestment Act of 2009, with more than $19 billion in federal spending allocated for widespread implementation of HIT and health information exchange (HIE).1 The projected growth in the technology market and spending for HIT within state and local governments is focused on the implementation of electronic health records (EHR) and improvements to existing public and private healthcare facilities.2, 3 The successful implementation of EHRs, along with additional elements such as the achievement of governmental requirements surrounding meaningful use of EHRs4 and quality care, an increasing focus on patient-centered care,5–7 and consumer use of HIT8 increases the demand for a skilled workforce of HIT professionals.9–10

Most healthcare leaders agree that the United States lacks sufficient numbers of appropriately trained and skilled healthcare workers to meet current needs for HIT, let alone the future expansion necessary to create and sustain the Nationwide Health Information Network (eHealth Exchange).11 A 2008 analysis of the US workforce12 estimates that approximately 40,000 more HIT staff and professionals are needed for adoption of HIT, while data from the US Bureau of Labor Statistics indicate a future need for more than 50,000 HIT professionals.13 Furthermore, approximately 10,000 new health information management (HIM) workers are needed each year to fill new positions and replace those who retire or leave the field.14 With only an estimated 2,200 new graduates entering the HIM or health informatics field each year,15 alternative education and training pathways are needed to supplement the HIT professional workforce.16, 17

Recognizing the need for a sufficient professional workforce needed to develop, implement, and maintain HIT, the Manpower Training in Electronic Health Record Use through Community Colleges in the Delta Region project (Delta EHR Project) focused on developing three HIT courses on the following topics: (1) EHR implementation, (2) privacy and security, and (3) system design and workflow. This article describes the collaborative process used by the Institute for Improvement of Minority Health and Health Disparities in the Delta Region (Delta Regional Institute [DRI]), the American Health Information Management Association (AHIMA) Foundation, Alabama State University (ASU), Louisiana Technical College (LTC), and Tougaloo College for the development and beta testing of these courses.

Methods

The primary goal of this project was the development of a training program in the use of EHRs in the form of three 12-week online courses for individuals currently working in or studying for careers in the healthcare field. These courses were

  1. Implementation of the Electronic Health Record (EHR);
  2. Privacy, Security, and Health Information Exchange (HIE) Principles; and
  3. System Design, Analysis, and Workflow.

The mission of the DRI, which was funded by the Office of Minority Health (OMH) in 2009, was to serve as a hub of multistate activity, services, and information on health disparities and the impact on racial, ethnic, and rural communities within the Delta Region states of Alabama, Louisiana, and Mississippi. Five strategic cores guided programmatic activities of the DRI, with the Health Professional Shortage (HPS) Core supporting the collaborative efforts of the HIT workforce program. The objectives of the HPS Core were centered on health career “pipeline” education and training programs within the DRI’s rural and/or urban health professional shortage areas (HPSAs) and medically underserved areas (MUAs) that were designed to

  • expand the existing practitioner base,
  • implement recruitment and retention strategies to recruit minority students into the healthcare field, and
  • train unemployed and displaced members of the workforce.

Pipeline education refers to a conduit in which programs are offered to increase the number of professionals, such as physicians, nurses, and allied health professionals, in the HPSAs.

In recognition of the increasing gap in the number of skilled professionals within the HIT field, the HPS Core included programmatic activities that addressed workforce education and training programs. The DRI initiated a contractual agreement with the AHIMA Foundation to develop short courses designed to increase the skills of individuals working in or displaced from the healthcare field as well as students studying for careers in healthcare. Through an iterative process of communication and face-to-face meetings, the framework for the courses was developed. The objectives of the project were solidified during a face-to-face meeting held at the AHIMA Assembly on Education (AOE) in New Orleans in July 2010 and paralleled the mission of the DRI’s HPS Core. Initially, four courses were proposed for the Delta EHR Project involving implementation, workflow, HIE, and meaningful use. Follow-up discussions between the AHIMA Foundation, ASU, LTC, Tougaloo College, and DRI staff determined that meaningful use content would be covered within the EHR implementation course and that the proposed HIE exchange course should be revised to address the unique aspects of privacy and security in the EHR, such as HIPAA compliance, disclosure of protected health information (PHI), fraud and abuse, and legal issues. In the initial planning phases, it was decided that each course would consist of approximately 45 contact hours of lecture, 30 hours of lab, and an estimated 60 hours of homework. Course developers felt that this recommendation allowed for sufficient development and reinforcement of the subject matter for each noncredit, 12-CEU (continuing education unit) course.

DRI’s funding for the Delta EHR Project supported additional collaborative efforts in the form of AHIMA Foundation subcontracts with ASU, LTC, and Tougaloo College and funding for supportive services by Nortec and Career Step (see Table 1). In line with the DRI’s region, the training program focused initially on three states (Alabama, Louisiana, and Mississippi). During beta testing of the first course, Implementation of the Electronic Health Record (EHR), ASU, LTC, and Tougaloo College initially agreed to limit enrollment to 25–30 beta students per site (start date August 2010); however, once the course was advertised by the AHIMA Foundation and the three academic sites, more than 157 beta testers enrolled in the first beta course (107 students at ASU, 28 students at LTC, and 24 at Tougaloo College). No enrollment fees were incurred by participating students during the beta testing phase.

Recognizing the need for the courses to be easily accessible to potential students, the course developers used an e-learning delivery system. The first course was developed internally by the AHIMA Foundation and utilized the Moodle access format for content delivery, with utilization of AHIMA online education modules to support additional “hands-on” training in actual EHRs. ASU, LTC, and Tougaloo College provided instructors for the first course and participated in beta testing. In 2011, following completion of beta testing of the first course and review of student and instructor feedback, the AHIMA Foundation subcontracted with ASU to revise and update the content of the first course and develop the additional courses related to privacy and security and EHR workflow redesign. Feedback from beta students and faculty regarding the Moodle delivery mechanism prompted a change of access mechanism to the Learning Management System (LMS) supported by ASU.

Construction of the second course, Privacy, Security, and Health Information Exchange (HIE) Principles, was completed by ASU through a contractual agreement with the AHIMA Foundation (with funding and project oversight from the DRI). Beta testing of the second course utilized instructors at two participating colleges (ASU and Tougaloo College). Only students who had completed the first course as beta test students could participate in the second course. While this requirement decreased the number of students who agreed to participate (from 157 to 35), ASU course development faculty, AHIMA Foundation staff, and DRI faculty felt that the need for continuity across the courses was important and would facilitate feedback specifically related to the delivery mechanisms and assessments since students would have knowledge of prior delivery and instructional methods. The third course, System Design, Analysis, and Workflow, was developed by ASU during 2012 with beta testing occurring at ASU and Tougaloo College. LTC faculty served as auditors and assessed course content and examinations. Twenty-six beta test students from the two prior courses participated.

Surveys were administered at the conclusion of each course (see Table 2) to obtain feedback on the courses from beta students, and performance measures required by the DRI (the number of students completing the course by age group, gender, and ethnicity) were collected. No additional demographic information was collected for beta students. To assess further impact of the courses on job performance, knowledge and skills, and satisfaction with the course content and delivery mechanisms, comprehensive evaluation surveys were developed and delivered via SurveyMonkey for students, faculty, and employers at the completion of beta testing of all three courses (see Table 3).

Results

Students who successfully completed course requirements and passed the comprehensive exam for each course received certificates of completion with 12 CEUs and had the opportunity to sit for two of the Office of the National Coordinator for Health Information Technology (ONC) Health Information Technology Professional (HIT Pro) credentialing exams: (1) Implementation Manager and (2) Workflow Redesign Specialist.18 Professional credentialing for these workforce areas is now overseen by AHIMA (http://www.pearsonvue.com/chts/). (Table 4 shows the number of beta students participating in each course by age group and ethnicity. The majority of participants in beta testing of the first and second courses were Caucasian (64% and 54% respectively), with the third course having a majority of African American (54%) participants. The data do not clearly differentiate participant ages because the DRI-required data element for age was a designated grouping of 18–64 years.

Quality assessment of the content and structure of each course was conducted via surveys and face-to-face meetings with instructors and beta students (see Table 2). A final comprehensive survey was conducted following completion of the beta testing of all three courses. Thirty-eight beta students (those whose emails could be verified) were queried regarding the perceived impact of the course(s) on such variables as knowledge and skills, job performance, and satisfaction (Table 3). Fifteen beta students (39.5%) responded. One student indicated a change in employer as a result of the courses, stating that “the program helped get me into a successful career in health IT and EHR implementation.” Other narrative comments from respondents indicated that the course(s) were “beneficial,” “increased knowledge base,” provided “significant knowledge transfer,” and were “well executed.” Identified areas of weakness were mainly focused on issues with computer access to the course material, lack of credit for the courses, and delayed timeline for receipt of the CEU completion certificates. Four students stated that course developers could contact their employers as part of the evaluation process; however, only two employers responded to the survey. Both employer respondents indicated that they felt the courses added to the training or skills needed by an employee; however, they were split on whether the completion of the courses would be a factor in hiring two potential employees with similar qualifications. One course faculty member responded to the final survey, noting that the “courses were good and the only suggestions I had as a faculty member were addressed and resolved during our monthly meetings” (all faculty provided feedback during scheduled monthly meetings). Ongoing quality assessment of course content occurs via input from the AHIMA Foundation and ASU faculty to ensure timely updates regarding federal and state regulations and requirements, as well as upgrades to course activities and delivery mechanisms. All three courses are complete and have received OMH approval for dissemination and use by participating colleges.

Discussion

To realize the benefits of HIT adoption in terms of both the economic and patient care (clinical care and access to care) benefits, time and resources must be invested in workforce training and the development of educational programming. The Delta EHR Project recognized the importance of partnering with HIM professionals to develop, implement, and maintain educational programming directed at increasing the available workforce for EHR implementation. The participating HIM academic departments provided expertise in content areas for the courses and provided experienced instructors for the delivery of course material. Three 12-week online courses were designed to address a need for expanded training in areas surrounding implementation of EHR technology for current and future professionals. Initial face-to-face meetings and conference call follow-up discussions provided assessment of the knowledge and skills needed within three areas of EHR implementation and maintenance. Understanding specific needs for “hands-on” training in EHR use was important to the curriculum development process and was addressed within the first EHR implementation course.

Participating faculty reviewed and revised the curriculum, including the syllabus, examinations, and learning activities, during monthly meetings throughout the course of the project. Course faculty had the opportunity to test concepts, ideas, and suggestions until all members of the group were satisfied with beta course content delivery. Final refinement of content of the courses was driven by beta students’ and instructors’ comments and further assessment of industry standards by course design faculty (at ASU) and faculty evaluators (at LTC and Tougaloo College).

A limitation of the course beta testing process was the small number of beta testing students for the second and third courses. The courses were developed to be sequential; that is, beta test students were required to have completed the first course (the EHR implementation course) prior to enrolling in the second and third courses. The initial pool of beta test students for the first course was 157 students, while only 26 students participated in the entire sequence of courses. Anecdotal information from non-completers was obtained by course instructors and indicated factors such as family issues, job responsibilities, and an inability to keep pace with the course content while working full time that influenced decisions to drop out of the course and/or not participate in subsequent courses. Limited demographic data affected the ability to contact beta students, particularly students who did not complete all three courses. The collection of formal data regarding why beta students did not complete the courses was not required by the DRI; however, such knowledge would have added to the overall assessment of the course content, flow, and delivery methods.

A strength of the development process of the Delta EHR Project is that it built on the HIM discipline and leveraged existing HIM programs and faculty that were already providing new graduates in the Delta region. The use of “hands-on” training within the first course provided opportunities to navigate and experience an EHR. Streamlining the course content and completion time enabled course completers (students as well as current workforce members) to enter the healthcare workforce quickly with essential EHR knowledge and skills.

Conclusion and Future Plans

The Delta EHR Project focused on developing three courses in the HIT areas of (1) EHR implementation, (2) privacy and security, and (3) workflow redesign. These 12-week online courses were designed to address a gap in the professional workforce needed to develop, implement, and maintain HIT. Current plans are for these courses to be offered to all healthcare workers employed or unemployed throughout the United States. The development process described in this article demonstrates the positive impact of collaboration between academic institutions and the AHIMA Foundation. This process also demonstrates the need to identify and collect demographic data on future participants to enable assessment of the courses’ effects on participants’ job placement, job responsibilities, and salary, as well as assessment of students who drop out of or do not successfully complete a course.

 

Cheryl A. Plettenberg, EdD, RHIA, FAHIMA, is the department chair and professor in the Department of Health Information Management at Alabama State University in Montgomery, AL.

LaShunda Smith, MSM, RHIA, CHDA, HITPro-IM, HITPro-TR, is an associate professor, division director, and Health Informatics Management and Systems program director at Tougaloo College in Jackson, MS.

Susan Hart-Hester, PhD, RHIA, HITPro-IM, HITPro-PW, is associate professor in the Department of Health Information Management at Alabama State University in Montgomery, AL.

Acknowledgments

The courses were developed through an award from the Department of Health and Human Services’ Office of Minority Health (Prime Award no. 1 CPIMP091054-03) to the University of Mississippi Medical Center, and the AHIMA Foundation was issued a sub-award (no. 68141-AHIMA-03) to partner with universities and community colleges to offer this educational opportunity under the project titled “Manpower Training in Electronic Health Record (EHR) Use through Community Colleges in the Delta Region.” The findings, opinions, and recommendations expressed therein are those of the authors and not necessarily those of the Office of Minority Health or the Delta Regional Institute.

The authors would especially like to thank the following individuals without whose expertise, knowledge, and leadership this project would not have been possible: from the AHIMA Foundation: William Rudman, Desla Mancilla, Bonnie Aguda, and Kate Jackson; from Alabama State University, Kenley Obas, Huang Kong, Karen Chambers, Annette Stewart, and Sabine Simmons; and from Louisiana Technical College, Angela Kennedy.

Notes

1.   Howell, C. “Stimulus Package Contains $19 Billion for Health Care Technology Spending and Adoption of Electronic Health Records.” WTN News, February 19, 2009. Available at http://wtnnews.com/articles/5523/ (accessed March 12, 2013)

2.   Lipowicz, A. “State and Local Health IT Spending to Hit $9.6 Billion by 2014.” FCW, August 27, 2009. Available at http://fcw.com/articles/2009/08/27/state-and-local-agencies-spending-more-on-health-it-input-says.aspx (accessed March 12, 2013).

3.   Jones, L., C. Dixon, and A. Petty. “Health IT Transformation: FY 2009-FY2014 State and Local Market Forecast.” GovWin, August 2009. Available at http://iq.govwin.com/corp/library/detail.cfm?itemid=9153 (accessed March 12, 2013).

4.   Centers for Medicare and Medicaid Services. “EHR Incentive Program.” 2013. http://www.cms.gov/Regulations-and-Guidance/ /Legislation/EHRIncentivePrograms/index.html?redirect=/EHRIncentivePrograms/ (accessed March 9, 2013).

5.   American College of Physicians. Joint Principles of a Patient-centered Medical Home. March 2007. Available at http://www.acponline.org/pressroom/pcmh.htm (accessed March 10, 2013).

6.   Institute of Medicine Committee on Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001.

7.   Reed, P., D. Conrad, S. Hernandez, C. Watts, and M. Marcus-Smith. “Innovation in Patient Centered Care: Lessons from a Qualitative Study of Innovative Health Care Organizations in Washington State.” BMC Family Practice 13 (2012): 120.

8.   HealthIT.gov. “Consumer eHealth Program.” 2013. Available at http://www.healthit.gov/policy-researchers-implementers/consumer-ehealth-program (accessed March 12, 2013).

9.   HealthIT.gov. “Health IT Adoption Programs: Workforce Development Programs.” 2013. http://www.healthit.gov/policy-researchers-implementers/workforce-development-program (accessed March 12, 2013).

10. US Department of Health and Human Services, Health Resources and Services Administration. “Health IT Safety Net Employers.” 2013. Available at http://www.hrsa.gov/healthit/workforce/safetyemployers.html (accessed March 11, 2013).

11. Silberner, J. “Stimulus Bill Calls for Computerizing Health Care.” NPR, January 27, 2009. Available at http://www.npr.org/templates/story/story.php?storyId=99916019 (accessed March 12, 2013.

12. Hersh, W., and A. Wright. “What Workforce Is Needed to Implement the Health Information Technology Agenda? An Analysis from the HIMSS Analytics Database.” AMIA Annual Symposium Proceedings (2008): 303–7.

13. US Department of Health and Human Services, Health Resources and Services Administration. “Health Information Technology Workforce.” 2013. Available at http://www.hrsa.gov/healthit/workforce/index.html (accessed March 8, 2013).

14. Hersh, W., and A. Wright. “What Workforce Is Needed to Implement the Health Information Technology Agenda? An Analysis from the HIMSS Analytics Database.”

15. Ibid.

16. HealthIT.gov. “Health IT Adoption Programs: Workforce Development Programs.”

17. US Department of Health and Human Services. “HHS Announces New Health IT Workforce Grants.” Press release, December 23, 2009. Available at http://www.hhs.gov/news/press/2009pres/12/20091223a.html (accessed March 10, 2013).

18. Office of the National Coordinator for Health Information Technology. “The HIT Pro Exams.” http://www.hitproexams.org (accessed June 30, 2013).

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Cheryl A. Plettenberg, EdD, RHIA, FAHIMA; LaShunda Smith, MSM, RHIA, CHDA, HITPro-IM, HITPro-TR; and Susan Hart-Hester, PhD, RHIA, HITPro-IM, HITPro-PW. “Manpower Training in Electronic Health Record (EHR) Use through Community Colleges in the Delta Region: Alabama, Louisiana, Mississippi.” .Educational Perspectives in Health Informatics and Information Management (Winter 2013): 1-11.

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