The Invest in engaging and understanding learners in the clinical context theme includes both understanding learners’ needs and understanding what incentives may best enable learner participation in HIS education.

Several papers have identified the importance of assessing the current capability level of learners in terms of clinical and technical skills to tailor learning accordingly, including providing adequate staff and time for education. Many health care providers received their education as health care providers before information technology became ubiquitous and, therefore, may lack the essential technical skills required to use an HIS effectively [1]. Benwell et al [23] reported that learners often felt that the HIS training sessions failed to address their learning needs, as the program was either too simplistic or advanced. This point was further reinforced in a study that examined traditional forms of education approaches, assuming that each health care provider shared the same knowledge and skill level. However, the authors discovered that the skillset of care providers differed based on their experience and educational levels [26,27]. In another peer-reviewed paper, the educational team at a hospital designed a course for health care providers with average computer skills.

Previous experiences with computers and the perceptions that learners bring with them regarding the value of technology influence their receptiveness during training sessions [21]. Edwards et al [4] stated that pretraining enabled those health care providers who needed it to gain baseline familiarity and improved their performance. Furthermore, Bredfeldt et al [1] reported:

Adequate technology literacy and general competencies of health care staff have been identified as critical factors for implementing HIS systems [16,26]. Without these, further education sessions may be required to support health care providers before they engage in learning specific to HIS.

Four papers discussed the significance of providing incentives to help health care staff expand their information technology competencies to encompass new skills [1,6,17,18]. A study by O’Brien [18] asserted that to cover the expense of adequate training and replacement nurses, the organization provided incentives to staff to complete their training on days they were not scheduled to work. In addition, the organization has developed an incentive program to encourage staff to fill in for colleagues who were participating in training or to attend a training class in the evening or weekend at full pay. In another study, providers were recognized for their time by being eligible for continuing medical education credits [1,6].

The theme of Maximize the transfer of learning to care encompasses providing hands-on practice, integrating real-life case scenarios, engaging key stakeholders and staff champions, and scheduling education sessions close to the actual use of the system, all of which contribute to a learner-centric approach and a more successful HIS implementation (Table 2).

Many papers stressed the importance of providing learners with significant amounts of time to engage in hands-on activities [4]. Interaction with the HIS was a key priority among all participants across several studies [4,6,17,25]. Participants were provided with an overview of the key features of the system, using a combination of lectures and practical exercises, thus enabling the learners to gain hands-on experience using the new system [25]. In addition, hands-on activities enabled health care providers to gain more practice and become familiar with the system and have an opportunity to ask questions [6].

This finding corresponds with concerns from health care managers that learners should be competent in using HIS in their work setting [4]. By providing an opportunity to deliberately practice with the system, active learning is encouraged, thereby increasing learners’ confidence [4]. Nicklaus et al [17] described that hands-on experience allows for the practical application of the concept and enables distraction-free instruction. This approach encourages learners to set the pace of their learning without becoming overwhelmed with a lot of content in a short period of time while increasing their confidence and competency levels [17]. By promoting a self-regulated learning principle, effective learning can be achieved by empowering learners to take part in their own learning process, set their own goals, and challenge their critical thinking skills [17]. Self-regulated learning is defined as a cyclical process that enables the learner to guide their goal-directed activities, evaluate their performance, and then reflect on the outcomes [28]. McAlearney et al [7] asserted the following:

This point was reinforced in a study by Bredfeldt et al [1], stating that classroom-based training and hands-on activities were associated with the improved utility of using the new system. The authors noted that a live EHR environment allowed staff and clinicians to build tools they could use when they returned to the clinic and the use of ancillary resources [1]. Through continuous interaction with the system, learners reduced their cognitive effort associated with performing the task [16].

In addition, several studies have found that educational programs that incorporate real case scenarios, with an emphasis on clinical workflow enhance outcomes [25,26]. Interactive scenarios presented with a mini case study highlighted the importance of new HIS elements, enabling the care providers to better understand the new updates involved with the HIS and the manner in which they needed to document [22]:

Studies have highlighted the importance of developing expertise-specific scenarios that are relevant to health care providers [25]. The use of various approaches may appeal to individual learning needs, with learners appreciative of relevant clinical scenarios in particular [25]. The scenarios were designed to reflect the daily workflow process and enabled learners to visualize how the HIS can potentially be used in their work environment [22]. Furthermore, the scenarios provided each learner with further exposure to the workflow and an opportunity to critically reflect through the different processes [22].

The literature findings described the importance of and positive changes in engaging key stakeholders and staff champions in achieving targeted organizational change. Super users (expert users who have received supplementary education and are capable of educating other staff) were found to play a critical role in providing unit-level assistance and reducing the need for expensive external education and training [18,25]. They act as facilitators in each area or department, supporting and educating new staff [18,26]. McAlearney et al [7] reported:

The authors emphasized the importance of positive behavior modeling (role modeling from peers in the work environment), which demonstrates effective approaches to help overcome these challenges. They acknowledged that engaging champions and super users may foster transformative learning and contribute to a learner-centric approach. In a study on training programs that leverage the skills of super users, it was reported that they contribute to better learning outcomes and meaningful use of the HIS [7]. Pantaleoni et al [6] described that the success of the training program was also attributed to the lead physician, as they provided guidance on the clinical context and knowledge of institutional workflows, such as the number of distinct provider workflows and how to group providers in a training session [6]. In addition, physicians were involved in the design and delivery of the training communication for hospital and staff leadership [6]. Pantaleoni et al [6] asserted that it is vital that the super user has an interest in education, institutional knowledge, and good communication skills.

In addition to the engagement of organizational stakeholders and staff champions, formalized education scheduled close to the actual use of the system was identified as beneficial to end users [23,26]. The study findings suggested that health care providers benefit from formal education only when it occurs in close proximity to their use of the HIS. Pantaleoni et al [6] emphasized the following:

It has been noted that education delivered too early or too late could potentially waste resources and raise frustrations among staff [23,26]. Moreover, the authors stated that following 30 days of unit-based experience, most staff ultimately exhibit a similar skill level. Education that is scheduled in close proximity to the time of end-user use may facilitate the greatest impact on performance and knowledge acquisition [23,26]. Furthermore, formalized (instructor-led) education may not be needed for all learners, as some participants reported formal education to be inefficient and of little value; however, daily exposure to the HIS improved their performance [23].

A review of the studies suggested that continuous evaluation supports an agile approach to meet the emerging demands of the clinical environment (Table 2).

Pantaleoni et al [6] described the need to conduct an evaluation of an HIS educational program:

Furthermore, McCain [21] stressed the value of evaluating educational programs continuously to identify course strengths and weaknesses in stimulating curriculum revisions. The authors emphasized that all HIS-related training and education programs should be continually updated to stay abreast of the evidence base and innovations.

Hence, the evaluation allowed educators to understand the need for change in work processes and practices and an opportunity to establish mechanisms to share learning across the organization.

Importantly, although continuous evaluation can lead to learner-centric education delivery, HIS data can also be leveraged to prioritize interventions for system optimization and workflow redesign and to identify struggling learners who may require additional training or support [5]. In a study by Kadish et al [5], clinicians requested individualized training after several rounds of group training to improve their own efficiency in the EMR. Ensuring that the educational content was relevant and applicable to all learners was challenging, as individual skill sets in using the system varied among care providers. This study accentuated the importance of capturing data over time to inform continuous and personalized assistance to optimize the use of the HIS after initial training. Individualized education ensured that educators were able to adapt the content to accommodate the diversity of clinical practice at the individual and group levels to improve the competency and confidence of learners in the use of HIS to find clinical information [5].

The assessment of the current capability of learners (individuals and teams) before the delivery of training appears to be a critical facet of effective HIS implementation. As learners progress in their environment and acquire new skills and methods of engaging in their ecosystem, education should be adapted to address their learning needs. Hence, it is worth acknowledging that there may be different levels of HIS knowledge and adoption among providers. Terry et al [30] and Harton et al [31] noted that although there is variability regarding the influence of previous technical knowledge on perceptions of EMR adoption, learners with lower digital literacy may require extra sessions to learn the functionality of the computer and the processes necessary for clinical practice. This finding is particularly important as health care systems evolve to leverage HISs to support clinicians’ adaptation to the new workflows and integration of this technology into their clinical practice. Despite the value placed on interprofessional learning, the literature has primarily focused on individual learning and a dearth of evidence has been provided on team-based learning. Future research exploring interprofessional education could provide greater insights into designing an effective educational program.

Culture pervades learning, and to meet the needs of diverse learners, issues revolving around the social and cultural dimensions of task design, structuring of content, and communication channels must be considered when designing a curriculum [32]. Culturally responsive pedagogy (CRP) recognizes learners’ differences and stresses that the cultural congruence of an instructional environment increases learners’ success [33]. A study from the University of British Columbia revealed that learners who are culturally diverse have a tenuous relationship with institutions that focus their curriculum on traditional, Eurocentric, and normative approaches [33]. These approaches tend to neglect learners from marginalized cultural backgrounds by disregarding their cultural habitus, leading to a cultural discontinuity for learners and the organization [33]. Rijal [34] reported that learning organizations moving toward a culture that encourages openness, creativity, experimentation, and tolerance for mistakes will enhance learning outcomes. An important part of a learning organization is being able to create new knowledge and use it to capitalize on new opportunities [35]. CRP has been hypothesized to connect all facets of learning with each other on emotional, social, mental, and physical levels [33]. In this framework, CRP is an important element in understanding individuals’ and organizations’ needs.

This study surfaced the relevance of problem-based learning in HIS education and training. A majority of the papers focused on a task-based learning approach to training, where learning is built based on predefined tasks addressed in clinical practice. Unfortunately, a task-based approach can lead to learners being dependent on instructors and support tools to provide them with guidance to perform the task, rather than encouraging them to critically think about how to approach the task [36]. Focusing on a narrow learning parameter without examining the larger context of the HIS system may not be sufficient to successfully transform learners from the existing approach to the new electronic documentation [17]. Problem-based learning provides a promising avenue for delivering an optimal learning experience while fostering an active independent learning attitude in learners. This learning approach enables learners to internalize knowledge through a process of solving clinical problems and stimulate deeper thinking with an emphasis on how and why questions [36]. Education that is at the appropriate skill level of learners and focused on a problem-based learning approach may encourage learners to critically reflect and attempt to understand not only the tasks themselves but also the concepts and mechanisms underlying the tasks.

This study underscores the importance of incorporating hands-on practice as part of education to increase learners’ confidence and competency in successfully using the HIS system. In a review by Younge et al [37], the authors asserted that hands-on practice addressed the learner’s level of computer literacy, which also relates to their ability regarding the ease or difficulty of using HIS. Similarly, Youssef [10] contended that hands-on experience enables learners to develop realistic expectations of what the HIS is able to offer. Thus, learners are able to strengthen the connection between personal experiences, learning content, knowledge, and a concrete task, resulting in better comprehension of abstract concepts [38].

Iterative assessment of learners’ performance with new scenarios enables learners to demonstrate their knowledge and their competency in using their knowledge to deal with the new and more difficult cases being presented. Practice-based learning strengthens learners’ knowledge integration and application in a real-life setting [38]. Younge et al [37] noted that educating with materials, which provide opportunities for active learning and using assessments that evaluate what learners know (efficiency) and how they use existing knowledge to solve new problems helps to foster adaptive expertise. Learners highlighted real-life scenarios as a way to augment critical thinking by engaging in discussions. Hence, digital learning resources must be designed in a manner that offers better immersion while not increasing cognitive load [38].

Use of hands-on learning is consistent with the main phases of the experiential learning theory by Kolb [39]. The incorporation of hands-on practice and real case scenarios provides learners with an opportunity to deal with the workflows in clinical practice, which occurs when clinicians engage in an uncertain and unfamiliar context and allows learners to take an active role in the learning process. Using hands-on practice and case studies built on the 4 stages of the experiential learning theory would elicit evidence for changes in the cognitive process, learning, and behavior. This is critical in underpinning the design of an HIS curriculum and the role of educators and learners.

The clinical environment is an ideal setting to identify knowledge and skill gaps and then pursue learning with colleagues and instructors in a venture to fill these gaps. The authors advocate for the development of an interprofessional community of practice (CoP) as it facilitates the sharing of best practices and allows for the creation of new knowledge to advance the domain of HIS in clinical practice [40]. A CoP is built based on the assumptions of co-participation, where all learners from varied geographical locations engage in the activities of the community intending to facilitate meaningful learning [41]. As long as learners and instructors are present and engaged, an online community will evolve dynamically to meet their specific needs [41]. The digital space allows participants to share their experiences and knowledge in creative ways to cultivate new approaches to problems. When designing the HIS education strategy, this element of sustainability should be considered to enable individuals to optimally adopt and effectively use an HIS.

Another critical element as part of an educational strategy is identifying and engaging super users early in the project to help foster learning and understand the value of the HIS in clinical settings. Engaging super users in the development of an educational program enables the content to be tailored to specific provider needs, which, in turn, will contribute to the overall HIS adoption and successful implementation. The identification and engagement of champions and super users are rooted in the diffusion of innovation theory developed by Rogers [42]. Super users and champions are early adopters and innovators who adopt the HIS very early and take part in the dissemination of the new idea within the organization. They use the communication channels established to influence people’s attitudes and accelerate the rate of adoption [42].

Evaluation plans should not only evaluate the efficacy of the initial training but also use this information to inform plans to address the ongoing learning needs during and post-HIS education and implementation. In addition, ongoing evaluation can provide insights into emerging learning needs not only about the HIS system but also about emerging practice gaps and variations, which can help refine the goals and objectives and guide the implementation of the most effective education strategies. Through evaluation associated with HIS education and implementation, areas of significant strength can also be identified; for example, one part of the organization may demonstrate exceptional use of the HIS in practice. Positive deviance allows the organization to identify the top performers and foster analysis and discussion of such performance to elevate performance among other groups within the organization [43]. This approach characterizes not only the processes and practices that exist in top-performing groups but also the context in which they are implemented, such as the organizational culture and norms of behaviors [43]. Evaluation can be used to maintain and garner support for an education program in addition to assessing learner achievement.