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BOBBY ZARR: Hello and thank you for tuning into the Becker’s Healthcare podcast series. I’m Bobby Zarr, Vice President of healthcare strategy for uPerform.

Today I’m joined by Dr. CT Lin, who is here to discuss the importance of ongoing training and support in the HR, including UCHealth’s innovative approach to training with their uPerform Learning Assistant. Dr. Lin is the Chief Medical Information Officer at UCHealth. UCHealth is one of CHIME’s Most Wired level 10 systems, made up of 12 hospitals and 900 clinics across the Rocky Mountain region.

Dr. Lin is a professor of medicine at the University of Colorado and is a board certified internal medicine and clinical medicist. While seeing internal medicine patients, Dr. Lin also facilitates workshops on excellence and communication to reduce burnout and improve outcomes. His national awards include healthcare IT innovator and electronic physician of the year. In addition to these qualifications, I can tell you that Dr. Lin is an all around great human being, devoted husband and father, blogger, ukulele enthusiast and talented songwriter.

Dr. Lin, welcome and thank you for taking the time to speak with me today.

DR. LIN: I appreciate the time to be here.

BOBBY ZARR: Well let’s jump right in. Got a lot to cover here.

You’ve been a champion for helping providers become more efficient EHR users for many years. Can you tell us a little bit about your involvement in the sprint optimization project at UCHealth and what you found improves the EHR satisfaction and usability?

DR. LIN: So, we’ve been running sprint programs, which is our Electronic Health Record optimization program since 2017, so we’re into our fifth year now. And what we’ve understood from this work is that really 20 percent of improving the EHR for a particular clinic or for a particular clinician is technical improvement. 80 percent is training of the end user.

Despite the fact that most people go “hey can you come in here and fix this thing?” it turns out that most of the work is fixing how you use your tools more effectively. One of the temptations for clinicians is ‘oh good, sprint is coming to town, so I can leave for two weeks and when I come back it’s all done. And the answer is “No actually, we want to work with you. It’s you that we need to make the intervention on. It’s your teamwork; the tool is sort of a sidelight, and it’s how your team functions best together.”

So, it’s really about training. And at the end of sprint, people are like “You’re leaving already? And when can you be back? Because we could use this again next month.,” and we have to tell them based on our current funding, since we have 600-900 clinics depending on how you count them, we’ll be back in about three to five years. So, we’ve done one cycle through everyone so far, but there is a clamor for lots more training going forward.

BOBBY ZARR: Awesome, yeah, that matches with what we’ve seen with studies out there that the report that 50 percent of the satisfaction in the EHR is based on training. If the training goes well, if their training is well organized and if they have ongoing training and support their satisfaction with the EHR is much higher than if they don’t.

With that, we know that the providers tend to be struggling because of the lack of training as you said there. So how do you identify those providers who may be struggling with the EHR and how do you intervene with those?

DR. LIN: You know, I think there’s three ways we really get at it. I want to talk about onboarding. I want to talk about our InBasket redesign in terms of messaging. I want to talk about our chief wellness officer and our partnership with other parts of the organization that are interested in doing the same thing.

From an onboarding perspective, we’ve blown apart our training – and I know we’re going to talk about this a little bit more later – but the idea is that you don’t get a login until your initial training is complete, and that allows us to do sort of just-in-time, self-paced learning and then after that we have follow-up training, and then we have intervals of training that your login is at risk if you don’t complete all the components of it; it’s just that we’re not going to do it all on the first day anymore. And we can talk about that in a few more minutes.

Secondly, we’re redesigning the InBasket. One of the statistics we very disappointedly, very surprisingly noted is that there has been over a 350 percent increase in incoming messages from patients over the course of the pandemic. If we compare 2019 monthly volume, we used to receive about 50,000 messages per month. We now exceed 183,000 incoming messages per month. And the question is how are we going to address that? Right now, the clinicians deal with it during pajama time, sometime between 5:00PM and midnight. And how can we not burn clinicians out by having to handle this increased volume? We have a lot of work we’re doing to try to redesign that work.

And then finally, we have a chief wellness officer now, who is addressing burnout, who is addressing cognitive load. And how can we design our work, so that we get the EHR burden as far out of the picture as possible, so we can focus back on caring for the patient?

BOBBY ZARR: Wow, yeah with the providers experiencing heightened levels of burnout, especially during the pandemic, but even before the pandemic, I believe that the burnout was starting to rear its head. How do you recommend training teams engage providers in their EHR improvement and training efforts?

DR. LIN: Well first of all, I do want to acknowledge that the spectrum of burnout is quite broad. We believe that between 10 and 20 percent of folks will resist training for one of a number of reasons. There’s about a tenth of our clinicians who are so burned out that when we come to town and we say “we’re here to help improve your practice efficiency,” they go “you know what? Nothing is going to help” and they close their door in our face. And those folks probably have other interventions that we need to go after to retain them and to improve them.

But we think about burnout and the EHR burden sort of in three buckets. One is governance. Does your leadership support that we need to create a healthier workplace for you? Second is practice efficiency. That’s where we come in, and we talk about reducing the burden, teaching you to be more efficient with this new procedure – this new tool – you have. And part of it is personal resilience. If you’ve just emptied your tank, and you’ve given everything, there’s nothing left. Well, no amount of efficiency training is going to get you out of that. So, we think about that in a holistic, tripartite way and we think we need to address all of those components at the same time.

We want to try to give providers their sense of purpose back. People went into healthcare to help patients and, fundamentally, it’s an amazing mission that we have. We’ve just sort of exhausted people’s buckets, and how do we pull ourselves back out of it?

The concern that we have is that people look at the EHR and think about the record part of it. They think that the EHR is that thing that I have to go and pick up the chart and scribble something in it as an afterthought after I’ve done care, and we have to flip people’s opinion about that to say no it’s not just something you scribble and go get something billed for.

It’s more something where you’re actually using this to take care of patients. The better we use the Electronic Health Record, the more that the tool can help you. It’s more of a colleague rather than an afterthought. It reminds you, it nudges you, it tries to reduce your chance of prescribing error.

Right now, we’re trying to develop predictive analytics, so we can detect sepsis, or we can detect deterioration before the clinician can, because the clinician is doing other important things. So, by being a better partner to the EHR, the EHR can be a better partner back to you.

BOBBY ZARR: Yeah, you’re singing my song now. I’ve always been a proponent of taking the “R” out of the EHR, because I just think it connotates the scribe, the paperwork, that people feel that their burdened down with the Electronic Health Record system out there. I know that the training can help with the efficiency side, not much we can help with on the personal resilience or governance.

Speaking specifically to training, why is there such a resistance to training from providers when it’s been proven to help them reduce burnout and improve satisfaction?

DR. LIN: I think clinicians think “well, I’ve already got it. I’ve been using this thing forever. I know how it works.” And unfortunately, what people usually do when they start using a record is they get to a certain level of proficiency and then they stop. What’s the minimum amount of attention I can pay to the Electronic Health Record and get by? And they feel like “well I already learned it one way; I’m just going to stick with that.” Even if it’s 17 clicks to do the thing that we have shortcuts for everything. “but that’s good enough, because I really want to focus on the patient. I’m too busy to learn to be more efficient.” And that’s the challenge we have to overcome.

BOBBY ZARR: Yeah, I understand the busy part of it. I heard that all the time as well. “I’m too busy.” Well, if you’re too busy to spend 30 minutes to save 30 hours a week, then you know we’ve got to figure out something here to be able to find the time, because it is valuable.

UCHealth recently implemented uPerform – a just-in-time learning and support platform – as part of its training strategy. How has it enhanced your training program?

DR. LIN: Well, this has been a big deal for us. We recently sat down and rethought the way we do training and onboarding in a big way. Not sort of tinkering at the edges. We’re sort of blowing everything up. And we think that classroom training is a dinosaur concept. I think we’re done with classroom training. No one was ever happy with classroom training.

First of all, sitting in a classroom for 8 hours, no one is happy. But on top of that, we have a mixture of learners. We have sort of post-millennials who… ”I can touch everything. I’m a digital native. I know what all the menus do. I figured it out already in the first half hour of training.” And then we have aging boomers like myself “Wait wait wait. that’s too fast. Can you go back?” And so, no one is happy. It’s either too fast or too slow. It’s not at the pace that anyone wants to go at.

And we do have tools for self-paced learning, and uPerform’s a large part of that strategy. And if you’ve used Epic before – the EHR before – you can run through the training quickly and go “Yup, I got it. Yup, I know that one. Wait a minute – that’s different for me. UCHealth has configured this differently; I can spend some time thinking about it.” And we have about two and a half to almost three hours of material that you can do in half the time or less if you’re experienced with the EHR.

But we no longer do a test out. We think that so many people who use the EHR at best use maybe 25 to 30 percent of the tools available, and going through that refresher, even for the experienced folks, can be very powerful. And uPerform lets us do that in a good way.”

BOBBY ZARR: That’s awesome. Sounds like you guys are already driving the future. Some hospitals, some organizations may think that’s too far out there already. I personally don’t think so. I think that you’re just now on the cutting edge of where you should be going with your training program. Given that, based upon where you are today, knowing that you’re probably light years ahead of many organizations out there, what does the future look like for your organization?

DR. LIN: Well, we want to augment this training even further. So, we’re on this journey, we think we’ve redesigned 80 percent of it, and there’s lots more to do. What we’re trying to do is get people to a point where A. we help you with the technical tool.

So, let’s say we’re onboarding a new provider. Our stance right now is you have sort of ‘learning 101’ – the 101 is one hour with a group of new onboarding clinicians, and it’s how do you use two factor authentication and set up that app on your smartphone? It’s how do you set up your dictation software on the smartphone so that this becomes a microphone for what goes into the EHR? It’s how to download the – For Epic it’s the Haiku app where there are smart tools that, on the go (mobile), you can do these things. And that configuration does sometimes need a trainer to go “wait how do I configure this to make it work?” and that’s the one hour spent in person.

Then we have the uPerform self-paced learning [for Epic], which can be up to three hours. At the end of which, here’s your login. Go start taking care of patients. So, in as quick as about two hours, you’ve gone from ‘I need to get trained’ to ‘I can start taking care of patients.’ And then at seven days we have another tool called Amplifier, and we’re putting the two tools as complementary tools, and we call that sort of pothole training, and it’s required that you set your appointment to come back and do your seven days pothole training for 30 minutes. There’s 27, 25 topics that if you don’t get this right, this is going to affect the way you deliver care.

For example, there are things in Epic that are hard to do. I’m discharging a patient, and I want to give them IV antibiotics to go home with. Do you know how to do that? We’re going to ask you questions on how to do that. And if you don’t know we teach you during that session, and OK, great, I got it. That’s our seven day. Then we have a touch base at 30 days and at 60 days and at 90 days. And you have an in-person 101 coach who sits with you and makes sure that we’re looking at your performance, and we’re trying to optimize your performance.

We’ve now taken that eight hours you would have spent in classroom all at once where you’re not paying attention after the first two hours and brought adult learning theory into it with intermittent reinforcement, which I think works quite well.

BOBBY ZARR: Wow, yeah, I can see that impacting not only burnout, but helping you guys be more efficient, because turnover is going to happen no matter what we do. And it’s going to be really important to bring those guys onto the floor caring for patients faster than they ever have. And I think the pandemic has shown us that we need to be able to get providers and hospital systems who are agile, who are able to adapt quickly, learn quickly. Things change and so we’ve become an all-of-the-above type of organization, whereas previously in healthcare we were really a closed mindset. Here’s how we do it. Here’s our applications. Here’s our systems. And somebody would bring something radical like a YouTube video and say we don’t allow you to access YouTube. Don’t give me that. We’d put those blinders on. It sounds like you guys are taking that all-of-the-above approach. If a technology works, if it can have a positive impact, let’s take a look at it.

DR. LIN: We have to be willing to disrupt ourselves before the industry disrupts us and we thought you know, Class A, we’re tired of classroom B. What things can we do to apply this to the onboarding? We actually were able to take what I’ve described and apply that to about 350 new residents in June, and that scales very well and the feedback has been ‘You know what? I was expecting to sit in a classroom for a full day and I was done in about two and a half hours and I’m out seeing patients,’ and that’s been very, very well received.

BOBBY ZARR: Well, I’m a big follower on your blog, so I know that you’ve embraced technology like social media. Even platforms like TikTok. How have those new platforms changed the way you think about education and, more importantly, effective communication?

DR. LIN: Well, my kids constantly tell me that I’m the dinosaur, and so it is humbling to see what kids can point out to you. And I’ve recently looked at TikTok and the comparison between – well, I’ll admit that years past, back in 2011, in order – I’m an internal medicine physician and I want to explain things in excruciating detail, and I actually am not proud of the fact that I had a 14 minute video, a comprehensive video of how you use the electronic health record to see an outpatient with every possible sort of variation included in my video, and what’s the uptake? Well, it turns out I – maybe a single digit number of viewers for my 14-minute video.

On the other hand, you know Chef Ming Tsai, one of the Iron Chefs, now has a TikTok channel, and in 60 seconds he’ll teach you how to cook a complex dish. And if they can do that in 60 seconds, what are we doing at 14 minutes? I mean some of these videos are 15 seconds long. How can we take what the new thing is to repackage how we train? And I think there’s an opportunity there. How can we deliver something in one minute that might save you half an hour every day going forward? Why aren’t we taking advantage of these sorts of innovations? So that’s where we’re going next, I think.

BOBBY ZARR: That is awesome. So, you mentioned coming from your residence training out there and some response from them. Have you had feedback from other providers since UCHealth made this transition to virtual training and implemented in-application help in Epic?

DR. LIN: Oh yeah, so we’ve heard feedback from our learners, and I’ve never heard this in the context of training before, like: “that was fun. Can I take it again?” You know? That’s amazing that we have feedback from clinicians like that. And then the fact that – “I was surprised I didn’t have to sit through 8 hours. I could be out there practicing in as short as a couple of hours.” Those things have been helpful as well.

We did have some stumbles right in the beginning. We didn’t necessarily schedule their seven day out follow-up, their 30 day out follow-up, their 60 day out follow-up, and as we started to email clinicians who were already seeing patients, we couldn’t get their attention again. “I’m off to the races, I’ve got my login, and ha ha – we’re all set.” And what we’ve done is we remind onboarding clinicians, you know “you’re not done with training until you take the 102, the 103, the 104 class all of these things out to 90 days.” And by scheduling them at the beginning people know it’s already on their calendar. They can’t miss it, and their login is at risk of being redacted if they don’t complete training. And so now everything is working well. We’ve got about 99% sort of adherence to all of the meetings, and we’re getting really good feedback from that sequence of a deconstructed training, so that’s gone well.

BOBBY ZARR: That’s great. One of the best posts I read on your blog that I’ve actually saved, and I cut up and started working on myself is your failure resume. That’s just a tremendous concept for me, and it’s humbling, but it also enables me to, you know, measure my attempts as well. It’s not about the failure. It’s about the attempts, and so in the failure you realize, hey, we made an attempt that didn’t work. Let me try something different. And keep pushing forward.

I know that’s one of your tenets out there, but other than – I know you’ve learned some things from your failures and successes out there – what advice would you give to other organizations who are struggling with, specifically, clinician satisfaction and burnout with the EHR?

DR. LIN: Yeah, I think fundamentally, you have to think about, are you willing to disrupt yourself? Are you willing to disrupt the way that things have operated before in the past? The good news is from a classroom training perspective, the tools are available now to be able to blow apart the old dinosaur concept of everyone has to sit in a class.

I mean even with the pandemic, there’s no classroom anymore. There’s no place where you can sit 30 people in a room with two large screen monitors where you can learn on one screen and practice on the other. People are learning it on their laptops at home. People are learning it on the go. How do we meet people where they are? And I think there’s lots of tools, including uPerform, that are worth having a strong look at to see what opportunities we have to redesign ourselves.

Same thing for the Sprint optimization. Are you thinking about refreshing the skills of your clinicians? Can you paradigm shift your clinicians from “the EHR is a record, that’s an anchor responsibility that I have to do at the end of care,” instead of thinking about “this is a scalpel that I need to be more skilled at. This thing can do a tremendous number of things. I’m only using 10, 20, 25 percent of the tool that this thing can do. How can I be a much more effective user so that it can help me be a better clinician?”

These are the types of things you need to sort of blow apart your previous expectations and put it back together. And then we need to embed them in the tools going forward. One of the precepts that we’re thinking about sort of next step is not only should our training be much briefer, video based and sort of self-paced, but can we put the road signs on the road and not in the garage, right?

So many things we go ‘here’s your training. So now go store it in the training library, and I hope you can find it if you type the right keywords.’

We want to put those road signs that are stored in the garage right on the roadside, so you get to the point where you go, “yeah, I’m at discharge. There was that thing about how to prescribe IV antibiotics. Oh, look that little information ‘i’ button is right there. Click. Oh, this is how you prescribe IV antibiotics.”

It’s a little bit tricky, so it should be right there at the time that I’m struggling. We’re looking to try to embed all of these things in the EHR that way.

BOBBY ZARR: Yeah, I would say that the embedded – what we call our in-application help – has been one of the biggest impacts of uPerform. You can have all the content in the world. You can do all the wonderful things with it – animation, gamification, dancing bears – all that stuff for even 60 second TikTok videos. If you don’t deliver it where the user needs it, when they need it, it’s really useless, because people aren’t going to go back to something to just sit in their spare time reading through a learning management system, reading through a SharePoint site, reading through their document library. They want to know what they need to know when they need to know it. And so your concept of signs on the roadways are great. And then in addition to that, the pothole type learning is, you know, you’re going to be on that road, but you’re going to hit some speed bumps along the way. We want to stop you at that speed bump, say okay, let’s do a check real quick. Here’s what you need to know. Those are tremendous concepts, so I do appreciate the feedback and the input from you. Anything else you’d like to share before we jump in? I think that we may even have time for a song.

DR. LIN: [laughs] If you’re willing, I have a ukulele song for you.

BOBBY ZARR: That would be great. We’ll take a minute here to have a song from Doctor CT Lin, and all these are on his blog as well, I’m sure.

DR. LIN: Yes. So this one’s called Epic Man.

[Ukulele chords and lyrics to the tune of “Rocket Man”]

She checked my templates last night preflight

Zero hour 8AM

And I’ll be deep in my InBasket by then

I miss paper charts so much, I miss my life

It’s lonely in hyperspace

On such a timeless flight

And I think it’s gonna be a long, long time

Before I make another error again.

I’m not the man they think I am at all

No, no, no. I’m an Epic Man

Epic Man writing APSO up here alone

Paper ain’t the kind of place to write your notes

In fact, it’s illegible

And there’s no one here that can read them if you did

And all these screens I don’t understand

It’s just my job five days a week

Epic man, Epic man

And I think it’s gonna be a long, long time before I make another error again

I’m not the man they think I am at all

No, no, no. I’m an Epic Man

Epic man writing APSO notes up here alone

And I think it’s going to be a long, long time

And I think it’s going to be a long, long time

BOBBY ZARR: That was awesome. Thank you so much for sharing. I’m sure that everybody that is on mute – you can’t hear them – are clapping right now. It’s a great – and that’s probably going to be much better than that TV commercial you see where the guy says, and this is going to get hundreds of hundreds of views. I’m sure that this is going to get many more than that. And the wisdom in that song too. I just – they say there’s wisdom in song, and that definitely is showing it.

So well, this wraps up our conversation for today. Thank you for sharing both your wisdom, your words, and your song for us. Your many talents are amazing, and we look forward to continuing this journey with you as a partner and as a friend. So, thank you so much Doctor Lin.

DR. LIN: Thank you.

BOBBY ZARR: This podcast is sponsored by uPerform. uPerform is a just-in-time learning & support platform that bolts on to your EHR, ERP, HCM, and other enterprise apps to centralize software training and support. With tools that accelerate content creation and delivery, uPerform empowers users with access to the right information, at the right time, specific to their role, creating more productive users and increasing clinician satisfaction.

You can tune into more podcasts from Becker’s Healthcare by visiting the Becker’s podcasts page at BeckersHospitalReview.com.