HealthStream: Online Learning That Meets Today’s Medical Challenges

In Futuring: The Exploration of the Future (2005), Edward Cornish of the World Future Society predicted that rapidly developing technologies and a long-lived, increasing population were going to be two of the most influential trends of the twenty-first century. Nowhere is the impact of intersection of these trends felt so strongly than in today’s healthcare industry. As a society and as individuals, we demand that our healthcare be provided by educated, competent people who are skilled in using the most modern equipment and techniques available.

Change and ongoing transformation are ways of life in all aspects of the modern U.S. healthcare systems. Social and political upheavals in the world of care giving are in the news, and caregivers and patients alike await the impact of what these revolutionary changes will mean to them. Cost controls and reallocation of operational resources are under close governmental and media scrutiny. However, long before recent headlines predicted fundamental changes in how doctors and hospitals would manage and treat the next generation of patients, ongoing development and reinvention has been a daily routine in most clinical facilities. The increasingly expanding “knowledge explosion” (Spafford, Schryer, & Hrynchak, 2006) in healthcare has demanded that caregivers develop ways to assure that they are practicing the safest and most effective healing methodologies available. Consequently, today’s healthcare environment includes rapidly emerging new diagnostic, treatment, and documentation systems and hardware.

Those who are tasked to enforce healthcare quality expect that hospital outcomes not only reflect current best practices, but pave the way for future performance improvement. For example, national accreditation agencies such as the Joint Commission on Accreditation of Healthcare Organizations require hospitals to demonstrate not only a practice of care that reflects current clinical expertise, but to also ensure that protocols and mechanisms exist to provide continuous quality improvement and developmental activities (Ruthemeyer, 2000). It is no longer enough that caregivers are knowledgeable in their fields of expertise—today’s healthcare providers must demonstrate ongoing acquisition of professional and technical competencies (Ruiz, Teasdale, Hajjar, Shaughnessy, & Mintzer, 2007). Competency now implies more than knowledge alone—it also implies that the caregiver can provide documentation on demand that they possess the skills to enable them to maintain proficiency, now and in the future,

Touring a modern hospital can appear like watching scenes from a science fiction movie. The use of robotic surgery apparatus, 3-D imaging scanners, gene therapy equipment, telemedicine viewers, and similar futuristic technologies is now considered routine in many major medical centers. Of course, sophisticated equipment does not run itself, and healthcare workers must be specially recruited and trained in increasingly focused levels of specialization to gain expertise in its best practice application.

The practice of education itself within the healthcare community is in a state of flux. Many caregivers have traditionally learned new clinical skills by formal or informal apprenticeships, but clinicians are beginning to recognize that such educational practices may no longer be appropriate in today’s age of increased oversight and accountability, improved instructional education technologies, and increased expectations in efficiencies and outcomes. Nambiar (2009) provides evidence for the need for universal adoption of more structured training processes that include clear training standards, regular update and assessments, and formalized feedback mechanisms that rate the efficacy of the educational experience, even as the author cites a shortage of qualified educators available to manage such programs.

The challenge of delivering timely com-petency-based education in healthcare facilities is complicated by operational time and space logistical dilemmas inherent in the clinical workplace environment. Most hospitals operate 24 hours per day, 365 days per year, and often at multiple onsite/offsite locations. Danbury Health Systems of Danbury, CT, for example, is anchored by a 373 bed inpatient hospital, but as of this writing also consists of 52 offsite locations including primary care centers, diagnostic centers, specialty treatments centers, and support offices for billing and information technology services (Danbury Health Systems, 2010). Employees at most of these locations must demonstrate competencies to state and national accreditation agencies just as if they were onsite at the hospital building itself.

For many years, healthcare organizations have regularly conducted ongoing mandatory traditional classroom training activities in order to attempt to meet regulatory requirements. These training sessions often required that participants travel from offsite facilities to classroom locations, resulting in shortages of staffing at their work locations or in the expenditure of expensive overtime pay if training was offered during nonworking hours. However, staffers may be forced to skip scheduled training sessions if high patient volumes prohibit employees from leaving their workplaces to attend, which is not uncommon. Unlike in many other industries where operational productivity times can be strategically managed to provide scheduled developmental opportunities, healthcare daily patient volume and acuity workloads are difficult to predict. In emergency room trauma services, for example, several studies have attempted to correlate weather patterns with trauma admissions in order to schedule staffing more appropriately (Friede et al., 2009). Regardless of how valid these correlations may be, longrange weather prediction is in itself an unreliable science, and newer, technology-based educational strategies needed to be developed in order to deliver the right education to healthcare staffers at appropriate times when they could take advantage of it.

The HealthStream Corporation was founded in 1990 in Nashville, TN, with the purpose of creating technology-based solutions to address the healthcare industry’s educational challenges (M. Condra, HealthStream Senior Director of Communications, personal communication, April 5, 2010). Initially, the company focused on installing software for healthcare clients on their local servers, and today all content is provided through its Internet-based application. Since its inception, HealthStream has grown by acquiring several competing healthcare education content and delivery providers, and in 2007 launched a healthcare research and data service after acquiring two prominent providers of such products (About HealthStream Research, 2010). Today, HealthStream is considered the leading provider of such services in the United States, with 1,974,000 healthcare employees at over 1,600 healthcare organizations online with active accounts on their Internet-based learning network. Despite recent economic downturns, the company has experienced steady growth, including an online learner increase of over 14% from 2008 to 2009 (HealthStream, 2010).

HealthStream requires that clients provide initial and then twice-monthly updated data transfers of each employee name, employee number, department, hire date, job code, and similar information in order to automatically create and maintain accounts for them in their database. Customers are charged monthly usage fees based upon the number of active employees in the database, and inactive employee records are archived for reporting purposes. Client organizations must nominate systems administrators to create authored programs, assignments, and reports, who are then sent to HealthStream’s headquarters in Nashville for 3 days of systems training. Once activated, client organizations are provided a gate Internet address for all employees and administrators to access the system’s remote database. Typically, this address is posted on hospitals’ internal Intranet pages, but it may also be accessed from any Internet-connected computer.

Once active, hospital systems administrators may immediately create course assignments from HealthStream’s core regulatory library. Library access includes unlimited use of 60 courses on general safety, compliance, and customer service related topics. Employee learners may be assigned courses individually, or system administrators can create employee assignment groups based upon their departments, job titles, dates of hire, or any combination of search criteria. Learners receive notifications of assigned courses with required due dates on their corporate e-mail accounts. Employees log onto their password-protected accounts, click on links to assigned coursework, and take any assessments incorporated into the course. Administrators can determine passing percentages of assessments, as well as any permitted number of retakes allowed. Once completed, records of course completions are entered into the individual employee’s electronic transcript, which also maintains a calculated record of any earned continuing education credits.

Administrators may also choose to have custom coursework created using HealthStream’s authoring tools. Authors can be selected by administrators from any employee in their database, who are then issued licensed copies of Macromedia Contribute for the purpose. Typically, course material is created via fill-in-the-blank html templates, or simply transferred from digitized PowerPoint slides. Authors using the standard authoring tool can choose to include text, digital pictures, clip art, or brief animated Flash files digitized from video or created from programs such as Adobe Captivate. An optional enhanced authoring tool includes the use of a gallery of medical clip art and animated medical illustrations, video editing tools, and SCORM 1.2 level compatibility for the inclusion of courses created outside of the HealthStream system.

Online courses may be published as stand-alone entities, or may be assigned as blended courses that include in-person workshops. The system allows authors to create templates of regularly assigned live courses (such as annual nursing training marathons) and then create copies of these templates with individual day, time, and location variability. Learners can then choose the workshops that are logistically possible for them to attend, and the system will automatically close registration or create wait lists for classes that are booked to capacity. Courses can be programmed to require learners to successfully complete online coursework before being allowed to register for live classes, or conversely may require that learners sign onto the HealthStream system to complete competency assessments and evaluations following the completion of the live workshops. Any number of required or optional learning and/or assessment modules may be included in a single assignment, which must have a specific final due date referenced in the assignment.

System administrators may also assign coursework purchased from HealthStream’s courseware library. Hundreds of professionally produced programs on numerous clinical, human resources, financial, personal development, and administrative topics are available. Many of these programs include the granting of continuing educational credits upon completion of an included competency assessment.

Upon receiving notice of a required assignment, employees can log onto the system to complete online coursework asynchronously at an opportune time before the due date. The system continuously tracks course completion progress, and will automatically resume coursework at the last viewed position if the learner is interrupted and returns to the system later. Learners may also choose to sign onto the system at any time to examine and print their transcripts, retake previously completed courses, or take any coursework in the HealthStream library. Learners have the ability to take online courses from home, but are routinely discouraged from doing so because of overtime and support issues.

Perhaps one of the most useful features of the HealthStream platform is the ease with which the system can generate completion reports. While individual transcripts and certificates of completion may be printed and filed in department records, administrators can readily generate electronic reports at a moment’s notice that satisfy regulatory agencies such as state inspectors or the Joint Commission, both of whom require that all hospital employees receive regular training on a variety of subject areas. Individual departments often must also show course completion data to clinical accreditation agencies on demand. The standard systems administrator interface facilitates the generation of custom reports, and currently lists 51 available standard report types, each customizable with multiple criteria reporting options (HealthStream Learning Center Administration Center, 2010).

HealthStream has many practical benefits to organizations that make it worthy of consideration as a tool to address an organization’s educational challenges. Because HealthStream is a subscription-based service, healthcare organizations do not need to invest in new educational hardware, software, or support infrastructure to launch, maintain, or update the learning management system. The platform can be made operational in days, and its interfaces for learners, administrators, and authors is intuitive, easily trained, and readily managed by employees at all levels. Electronic records reduce reliance upon paper files and realize savings from any associated cost reductions. According to HealthStream, their customers report that system utilization decreases operational risks associated with untrained staff while improving educational compliance by 20% to 30% (HealthStream, 2010). Online learning is also an appropriate tool for utilization by young employees entering the workforce, since Hopkins (2008) identifies e-learning modalities as a preferred educational choice of new millennial generation nurses.

Limitations of the HealthStream platform are primarily in its inflexibility to assimilate standard webpages and associated tools often incorporated in commercial Internet sites. Administrators who desire these features cannot readily employ local Internet page designers, but must purchase software from HealthStream’s courseware library, upgrade to paying for the enhanced authoring tool, or limit themselves to the basic functionality of the standard authoring tool.

Rogers (2003) defines one of the measures of success of an innovation in an organization as a function of its sustainability, which is related to the degree of participation in the innovation by the members of the organization over time. By these criteria, the innovation of e-learning as introduced into the educational culture of a vibrant western Connecticut healthcare organization via the HealthStream platform has been very successful (see Table 1). Utilization of HealthStream at Danbury Health Systems began slowly after the system was operationalized in 2003, but continues to gain momentum and increased utilization as some department managers begin to understand its potential in leveraging online education as a cost-effective and practical instructional tool.

While the HealthStream system was originally contracted primarily as a costsaving, convenient utility for the completion of annual Danbury Health Systems mandatory training, management now sees employee education, development, and communication opportunities provided by the platform as an efficient way to help them achieve many of their clinical and operational goals. Online coursework at Danbury Hospital consists of education on patient privacy regulations, nursing quality, new drug interactions, equipment operation, safety procedures, cost-savings processes, coding management, surgical techniques, new infection control protocols, and numerous other clinical topics requested by administrators and managers to meet the demands of a changing healthcare world.

The HealthStream system is being prepared for new innovative educational strategies for the near future. Nursing has purchased electronic mannequins that integrate into HealthStream via wireless Internet connections to provide nursing staff with asynchronous opportunities to complete the practical components of online CPR and ACLS coursework. While physicians have been slow to get on board, exploration has begun to consider the platform for use of meeting new medical educational goals, with the possible expansion of system availability to 450 community physicians by the fall of 2010 (M. Miller, Danbury Health Systems Vice President of Medical Affairs, personal communication, March 19, 2010).

Cornish (2005) predicted that technological advances have helped people live longer, and, if trends continue, that our life spans will continue to grow as technologies and associated knowledge continue to develop. If true, our longer lives will require newer medical technologies to maintain and enhance our quality of life in later years, and the successful implementation of these technologies will require trained and dedicated healthcare staff to bring them to our bedsides. Technology provides us with new problems to solve, and concurrently with the opportunities to solve those problems. HealthStream is a technology-based educational tool that integrates well into solving the needs of twenty-first century organizations and employees.