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1 Introduction

The healthcare industry has numerous different organizational structures that make up the overall industry. A large healthcare system can be made up of independent physicians, clinician offices, outpatient centers, and hospitals just to name a few. Each of these different business types requires a different level of information and/or functionality when considering an ERP option. Even within one of these practices, whether it is an entire hospital or even an independent physician practice numerous different types of users will need to utilize the system and pull different types of information to fulfill their duties [1]. Making a decision without factoring in this knowledge will put an entire IT project at risk from the onset, making it a critical point in the ERP implementation timeline.

Once an organization has identified the users that will be affected by an ERP implementation other factors more closely associated with user adoption will begin to become apparent. Most healthcare professionals see the benefit of the integrated healthcare solution that an ERP can provide. They appreciate the improved documentation tracking and the increased reliability of said documentation. Paper forms are easily lost and handwriting between individuals can vary greatly in quality, ERP systems standardize this process and greatly improve readability and access to these records [2]. However, in order to reap the benefits of an ERP system, data must be entered into the computer systems by these same employees wishing to reap its benefits; this is where user rejection begins to occur. Healthcare professional’s site usability problems as their primary concerns over medical ERPs, these concerns must be worked through in order to have a successful go-live. As health staff encounters usability issues to a process they perceived as being unintuitive, time spent with patient’s decreases and time spent within the ERP increases [2]. This can have a significant impact on patient care as discussed later in the Critical Success Factors section of the paper.

Mitigating the effects of poor end user adoption levels should be a primary goal of IT professionals when choosing and developing an ERP system for a healthcare organization. This paper identifies critical success and failure factors discovered from literature review that are linked to user training and propose a training design model for efficiently promoting user adoption levels of an EMR system.

2 Literature Review

Hundreds of previous studies mentioned system education and training is one of the key success factors in Information Systems implementations and operations. Alcivar and Abadclaim that issues with ERP systems are due to poor user training and underestimating the importance of training [3]. ERP systems have a long history of training issues that led to failure. Companies are usually surprised by the knowledge gap between the training provided by the ERP system’s vendor and the knowledge required by staff for them to work effectively with a new ERP system. This can be due to training being provided too early, insufficiently or even incorrectly [4]. Users must have a firm understanding on how to use a system or they will make critical errors when attempting to perform basic business functions which result in money and man hours spent fixing the issue when they should have been spent on training. Getting users trained and up to speed as the implementation is performed will help achieve the benefits of the ERP system [5].

In a study on rural health care industries, Trimmer emphasizes Efficiency of Operations in their list of CSFs that are important for a hospital’s success [6]. Healthcare costs are an ever rising burden on healthcare systems across the board. Due to these increasing costs, the government and healthcare organizations are always looking for new ways to improve efficient care and documentation methods. According to our research healthcare firms look towards ERP to improve efficiency in much the same way as industrial firms do [7]. By gathering patient data into integrated systems end users can more easily monitor a patient’s stay throughout a health system through to discharge? While the technical accumulation of data has clear benefits, concerns have been raised towards working through the social aspects of a hospital system. Understanding that patients are not simply data and that your end users ability to interact with the system and provide care with the collected data is a key concern when developing a healthcare ERP system [8]. More details on the social implications of an ERP system can be found in the following sections concerning CSFs.

In addition to the inherent problems in collecting patient data, hospital staff must become efficient in utilizing an ERP before truly reaping the efficiency benefits the system offers. One such problem affecting the efficiency of staff is their general attitude towards the ERP system. Physicians function at a certain level of autonomy that is allowed by their importance in the healthcare industry and extensive training. In healthcare systems that are only first implementing ERP systems, some physicians see the system as a threat to their professional autonomy and will resist the change [9]. Working with their staff to identify such physicians and utilizing other physicians to champion the software and pressure their peers to accept the system can assist IT leaders in improving adoption during implementation. Additionally, sufficient training can definitely help users change their attitudes towards the EMR [10].

There are other ways to assess ERP success by looking at critical failure factors summarized from previous studies and research. There are total 35 failure factors categorized in seven components proposed in the study. These factors come up regularly in failure cases and there is a lot of research that points back to these factors as having a negative impact on successful IT Adoption in healthcare. While it is impossible to note all existing factors, these are most common. Also, there is not one factor that is more important than others. It truly depends on each unique situation and set of challenges that are faced. Lack of employees’ morale and motivation, inadequate employee involvement, high employee’s resistance to change, lack of people skilled in the organization’s processes, inadequate education and training, and poor key users are the failure factors related to user education and training aspects.

Lack of employee morale and motivation is one of the most common and well documented themes relating to failure of IT Adoption in Healthcare. It takes leadership at every level to boast motivation and improve morale. A true leader will command their role and not demand it. That is why it is so important to have all employees involved and hands on. The challenge with this critical failure factor is that it is qualitative and harder to get a grasp on or measure. End user’s really needed to be involved at inception and given the opportunity to take on leadership roles throughout the planning and implementation stages. Healthcare providers that follow this path have shown to be far more successful with faster implementations.

“The reason change initiatives are unsuccessful are the failure to change mindsets, attitudes and culture” [11] Changing mindsets, attitude and culture truly resembles the biggest challenge in a successful ERP implementation. Employees need to understand the value and benefits of new systems. The sooner they can be involved and feel a “part of” the process the better. Overcoming cultural resistance to change can prove to a kiss of death if not addressed early on.

Many healthcare organizations lack people who are skilled in the organization’s processes. This is often because employees perform specialized jobs and are very segmented between departments. The lack of process knowledge becomes a critical failure factor as these employees are not engaged during implementation. “Lack of user involvement: IT projects require all users of the system to be involved. Lack of user involvement and stakeholder participation may hamper the success of IT systems. Hierarchical structures and top-down management practices may often come in the way of user involvement” [12].

In the healthcare industry, many employees will have varying skill sets and education that is in no way related to Information Technology. This isn’t an issue of low skills or less education but miss-applied skills and specialties. When you are in the testing stages it would be conducive to get employees and end users with different skill sets involved early. Their feedback will be tremendous when working out bugs and redundancies that may come about later.

Employees with less education and a lower skill level will present challenges during IT adoption. It is nearly certain that training and getting these employees on board will require more training with greater interaction at an early stage. As stated earlier in this paper, less education and low skill is not necessarily a concern within the healthcare industry. Unfortunately, often times the education and skills are so specialized that there may be some barriers involved. For this reason Davis has created an Information technology Acceptance Model. (Figure 1) “ITAM is however interesting as it introduced the notion of fit, explaining that it is not individual attributes which are important, but the quality of fit between e.g. IT complexity and IT knowledge” [13].

Fig. 1.
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TAM model

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In the ITAM you can see the employees will need to perceive the usefulness and ease of use in an IT adoption before they will develop a positive attitude towards and then begin to actually use the system. This process may take longer for employees who have less education, a lower skill level or specialized skills and education. It may be difficult to get physicians to buy in as they may feel superior to learning something new as they already have a high level of specialized education. This can lead to critical failure quickly if the value usefulness is not communicated early and often. The best way to address this is through leadership at all levels and finding the right agents of change.

When implementing IT, one question should be, do we have the right people and key users? We know that people are the most important asset in business so people should be our first priority. “Modern IT is designed to foster input from individual end users. This increasingly human centered design should promote honest and active feedback” [14] the human centered design is paramount and is ultimately the theme of this paper. If you focus your efforts on empowering your employees and offering them leadership opportunities your results will be tremendous. You will get a better buy in and feedback that will help speed the process of adoption and eliminate potential problems and bugs down the road. Much of this starts with identifying the right people early on. Potential key users should be tested to see if they possess the leadership qualities needed to become the agents of change that are necessary for a key role.

Providers will need to bring in or train employees so that they have skill level necessary to complete and implement ERP. This will include key users who are aware of organization processes across all function units. There will need to be a clear process in place so that the vision maybe carried out and management will need to employ long term planning to ensure that the implementation is a success before, during and after. This will include evaluation of processes and potentially the further implementation of modules and updates.

3 Research Method and Data Collection

To properly answer both our question regarding users’ education and training, we adopted case study method to find hidden facts or themes behind daily operations of EMR systems. We have used a combination of information from the reviewed literature and interview data a large healthcare provider in southwest Florida. Semi-structured, in-depth interviews were adopted for data collection in the case study. The interview process aimed to explore the subjective accounts of people working at the organization with regard to three main phases: the selection and adoption of the EMR system, the implementation process and the post-implementation phase.

As part of the research process, a pair of interviews with technology perspectives were held with the CIO and two of the IT system directors, the System Director for Revenue Cycle Information Technology, and the System Director for Clinical IT. Additionally, four doctors and 6 nurses were interviewed about issues of daily operations and EMR training and education. The healthcare organization has enjoyed a multitude of successful go-lives of various IT implementations including Epic medical records system, their ERP of choice.

The interview with the system director was an exploratory interview of LMHS. Information was gathered concerning some of the systems LMHS uses to track and gather information and why they were chosen. In this discussion, the topic of implementation was discussed and the importance of user involvement was highlighted. The system vendor made it a point to contact operational staff in making their decisions on which systems to implement. This decision falls in line with our research as a good practice, and has been utilized with success in other healthcare organizations [15]. The IT teams in the healthcare organization developed a list of criteria from previous input that the operational staff could utilize to grade vendor presentations. Using this tool, the organization was able to make an informed decision on their new IT projects with end user input. Once a better understanding of their organizational structure was gathered, a more focused interview on user acceptance was scheduled with the system director of IT.

The director has an extensive history in the clinical field, particularly with this healthcare organization. Her 30 years of experience with the organization has been a useful tool in her role as clinical director. She highlighted the importance of focusing on the concept of transformation of care rather than simply implementing new software. Healthcare institutions are well known to resist change [16], and ERP systems in particular completely change how healthcare can be administered. Nursing leaders were brought into monthly transformation meetings which became more frequent as go-live drew nearer. These transformation meetings focused on the difficulties associated with the upcoming go-live. Leaders were given assignments to provide lists of complicated areas of work and to provide information down to their staff in order to better prepare end users for the upcoming change. This placed a higher level of expectation on the end user leadership by making them accountable for pieces of the implementation. The increase in ownership and accountability is believed to have made a large impact on the go-live and post go-live efforts. These practices fall in line with the research, by increasing end user participation and involvement LMHS improved their overall acceptance [17].

The third interview was conducted with the CIO of the organization. This time, user education and training was the main topic. Key factors and issues were identified and discussed from a technology perspective.

A focus group of four doctors and six nurses were interviewed lastly to collect more data from users’ perspectives about user training and education of EMR in the organization.

There are two critical systems adopted in the healthcare organization: Epic and 3M including 3M automated coding. Epic is specialized in data aggregation and while it does expand its offerings, it leaves resources intensive tasks to outside vendors. 3M performs some of these resource intensive tasks in their natural language processing software and coding suites. It is believed that in the future, a new feature of 3M software that will provide instantaneous feedback on documentation processes to physicians.

4 Discussion and Research Model

Information System training is known as one of the key success factors influencing the system adoption and usage. [18] Once the Information System has been implemented, the entire system and all of its functions can raise concerns. Being exposed to the full scale and scope of an EMR system can be very daunting to an inexperienced user. These systems can be complicated as there is much for users to learn, this is especially true if their training was lacking. It is difficult for many users to grasp the system once it is fully available to them. After the system is installed, there are still many supports the company may need, and that is where post implementation support comes in. It is a fact that lack of hands-on training will cause issues [19].

Although training programs enable users to gain operation skill and to understand how EMR systems change business processes, the complexity of EMR systems limits the amount of knowledge that users can absorb before they actually use the system [20]. Users have to engage in post-implementation learning to obtain the knowledge and skills required for effective EMR usage [4]. With a system that has a wide array of capabilities it would be difficult for users to learn how to use each of the modules efficiently within the first few weeks or months with the systems.

Employee efficacy is affected by the amount of support a company provides after implementation. The employees, after having the system installed and working, have to use it to complete work just as they did before, however now the new system is their main method of delivering the work they provided before [21]. If the employees have trouble with the system and completing their work, they are going to be stressed, leading to an overall decrease in productivity. The EMR system must have post implementation support to avoid these kind of negative build ups. An EMR system is so complicated that the amount of post implementation support required is vital to the life of the ERP software in an organization.

Most companies use training they provide to users as their form of post implementation support. The idea being that this training is more like preparation for use, so by the time training is complete, the user should be quite familiar with the system [4]. The problem with having training as the only kind of post implementation support is that if the training is not effective, end users will have even more trouble and no way to reach out for help. The healthcare organization had training programs, but they were treated like as part of their post implementation support, as opposed to part of the implementation itself, which is a reason why users are still having trouble with the system six months after implementation.

EMR employee training is without a doubt a necessity. In cases where a company must utilize consultants for the EMR system—whether for training employees or actually operating the EMR system—the company should expect to pay $150–225 per hour for a consultant [22]. Therefore, training employees to perform tasks in order to reduce the need for a consultant is a must [23]. The cost of an EMR consultant per hour shows why many companies take training into their own hands. It is important for the company to take their time with the vendor’s representatives seriously and take their advice on what the most efficient methods of training are. Vendor’s want their systems to succeed as much as the companies that purchased them because a good success rate with the software makes it easier to sell to future customers.

Training as a whole is expensive to businesses as there is no limit to how much it can cost as employees being trained are not doing their day-to-day job and others are being paid to train. These costs will unfortunately cause organizations to rush the training process to save costs. The reason this training is so expensive is that training may involve 10–20% of the personnel and take about 20% of the budget [5]. In a vain attempt to save money, a company may choose to provide lackluster training or no training at all. EMR system implementation is already so costly; this training cost seems to sneak up on a lot of companies. There any many things affecting these costs, such as personal skill, training packages and the personnel required to train each user.

One thing in particular that drives these costs higher is the competencies of the personnel. If users that plan on using the system are unfamiliar with EMR systems of a similar nature, they are going to have a lot more trouble understanding and navigating the system. Users who do not have a complete understanding of an EMR system can make critical and costly mistakes. These can cost the organization a tremendous amount of time and money to fix. Training cannot be delivered with a “one size fits all” approach; training is more beneficial if it can be tailored to each user’s individual skill level in order to better help them understand the new system. Unfortunately, most organizations have training budgets and doing this is not realistic. When a new EMR system is implemented in an organization, training is not something to be taken lightly; poor training can result in errors that would potentially be more costly.

EMR training packages need to be evaluated in order to make sure the training offered is going to be effective. Training packages can come in the form of automated training, such as programs that provide general instruction and user based training, such as bringing in an expert on the system to teach individually. The difference being that automated training tends to be over the internet via prerecorded videos and help systems [24]. Training the users without making sure the program is going to teach them key skills is a waste of time and money. Training should be able to offer an effective knowledge transfer and be cost effective [24]. To make a training package cost effective, it has to give the user the right tools to use the system. The problem with automated training is that you cannot modify the training package to better suit individuals and it can be harder for the trainee to have their specific questions answered. However, automated training is less expensive as you do not have to pay a trainer for multiple hours with different groups or individuals. Another tactic some companies use is to hold a web conference with screen sharing and allow users to comment and ask questions. The host of these conferences can walk users through various processes and answer their questions live. Companies can then save the video conference and have it available for their employees to access at later dates.

According to the literature review and our case study, we believe most of the organizations, during both their EMR implementations and post-implementations, understand the importance of training. However, there are still many studies, including our case, showing that training budget and programs is one of the first parts to be cut off while facing to limited project budget. Most of the current training programs are providing similar trainings to everyone and hope employees could understand the whole system, especially on current module they are using in their daily business operations. However, the results are far from what organizations expected. Some users can easily handle their module while others still have difficulties after the same training, and some of the users actually were trained beyond what they need. The training cost on each user is similar, but the outcome is significantly different. Some training may be wasted on those users who can easily understand the contents while others may be not enough. Therefore, we suggest customizing the training based on several factors we found out from the literature and case study. Additionally, we use a new concept, training intensiveness, in our proposed model to help organizations provide trainings more efficiently with limited budget (Fig. 2).

Fig. 2.
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Proposed training model

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User characteristics represent the pre-training individual differences among all the users. Age and Prior Computer Experiences are the two components associated with this variable. We propose that older users with lack of computer experiences will need more intensive training while younger users with more computer usage background will need less training.

System Interface Complexity represents how complicated the EMR system is. The more complicated the system is, the more training may be required and the higher intensive training needed.

User support system includes knowledge support system embedded in the ERM system, help desk, help from consultants, and vendor support. A good knowledge support system will help users easily find correct answers of their questions. Most of the questions may be answered and handled by the system instead of sending requests to help desks, consultants or the system vendor. The most expensive supports are from the consultants and vendor.

Training Intensiveness includes training materials, frequency of training events/classes, percentage of key members in each user group, length of training events/classes, and knowledge of training instructors.

Once we can customize the training based on our proposed model, organizations can identify users in different groups and provide different training programs. Organizations will not only save their training cost, but also provide users with adequate and efficient trainings.

5 Conclusions

The role of end user adoption in a healthcare IT implementation holds great importance towards the success of a project. When it comes down to it, all the money spent on an expensive EMR system integration is practically thrown away if the training provided to the users is not effective. If users can not complete their jobs basic functions or take extremely long to do things that took them moments on the legacy system. This is why it is important for companies to not slack at all when they provide training. [Alcivar and Abad 2016, 3]. All the benefits the new EMR system may provide the organization are lost when the training provided is not effective or not efficient.

In order for training provided by the healthcare organization to be effective, managers need to consider critical success factors needed for EMR when designing the implementation process to ensure success. These critical success factors contribute greatly to a successful implementation of an EMR system. These critical success factors have a better chance of being met if they examined early on in the EMR implementation. It is imperative that employees become acquainted with critical success factors so everyone is working towards the same goals.

To prevent EMR users from becoming frustrated with the documentation and turning to more expensive forms of support such as the helpdesk or other users, the documentation should facilitate learning by explaining the rationale for transformed processes as well as emphasize support for new tasks [Scott 2008, 25]. Just creating step-by-step guides and sending them to schools is not enough to support staff members while implementing a new EMR. Managers must ensure that they are distributing the guides in an efficient manner. Out-of-date information should be avoided by printing only the more static content in manuals and posting the dynamic content online where it is more easily updated. A learning management system would help organize training related content [Scott 2005, 26]. This way if the system is updated which is natural for a new system with any organization, the resources can be adjusted in one place as opposed to recalling all the outdated guides. Documentation can be a very practical and inexpensive way to train but these are point that are important to consider before committing to a distribution structure.

Under the findings of the research presented, we proposed a training model that will help the healthcare industry identify different end users and customize their training programs. The results of our proposed model will benefit other research as it provides a simple template to the decision of adequate training. When making these decisions considering the following components of; User Characteristics, System Interface Complexity and User Support Systems will assist the decision maker. Much of the research was centered on end user participation, training and critical factors. A more customized training derived from the components listed above should provide value usefulness and greater end user participation.

The results of our proposed model will benefit practitioners such as healthcare organizations and hospitals through its simplicity and ease of use. Healthcare organizations often seek to save money to stay within budget. Frequently, training is reduced as a result of budget limitations. Research shows this to be counter-productive as adequate training is the key theme in successful ERP implementations. Knowing this, our model can be utilized to identify the adequate level of training needed for all users. Our Training Intensiveness Model can be used to stay within a limit budget while providing the adequate training necessary employed to set expectations for users, decision makers and implementation teams.