title: A mixed methods study of how clinician 'super users' influence others during the implementation of electronic health records.
abstract: BACKGROUND
  Despite the potential for electronic health records (EHRs) to improve patient safety and quality of care, the intended benefits of EHRs are not always realized because of implementation-related challenges. Enlisting clinician super users to provide frontline support to employees has been recommended to foster EHR implementation success. In some instances, their enlistment has been associated with implementation success; in other cases, it has not. Little is known about why some super users are more effective than others. The purpose of this study was to identify super users' mechanisms of influence and examine their effects on EHR implementation outcomes.
  
  
  METHODS
  We conducted a longitudinal (October 2012 - June 2013), comparative case study of super users' behaviors on two medical units of a large, academic hospital implementing a new EHR system. We assessed super users' behaviors by observing 29 clinicians and conducting 24 in-depth interviews. The implementation outcome, clinicians' information systems (IS) proficiency, was assessed using longitudinal survey data collected from 43 clinicians before and after the EHR start-date. We used multivariable linear regression to estimate the relationship between clinicians' IS proficiency and the clinical unit in which they worked.
  
  
  RESULTS
  Super users on both units employed behaviors that supported and hindered implementation. Four super user behaviors differed between the two units: proactivity, depth of explanation, framing, and information-sharing. The unit in which super users were more proactive, provided more comprehensive explanations for their actions, used positive framing, and shared information more freely experienced significantly greater improvement in clinicians' IS proficiency (p =0.03). Use of the four behaviors varied as a function of super users' role engagement, which was influenced by how the two units' managers selected super users and shaped the implementation climate.
  
  
  CONCLUSIONS
  Super users' behaviors in implementing EHRs vary substantively and can have important influence on implementation success.
authors.affiliation: Department of Health Policy and Management, Yale School of Public Health, New Haven, USA. christina.yuan@yale.edu.
authors.forename: Christina T
authors.initials: CT
authors.lastname: Yuan
authors.affiliation: Department of Health Policy and Management, Yale School of Public Health, New Haven, USA.
authors.forename: Elizabeth H
authors.initials: EH
authors.lastname: Bradley
authors.affiliation: Department of Health Policy and Management, Yale School of Public Health, New Haven, USA.
authors.forename: Ingrid M
authors.initials: IM
authors.lastname: Nembhard
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D057286:Electronic Health Records / Q000706:statistics & numerical data; D006785:Hospitals, University; D006801:Humans; D007400:Interprofessional Relations; D008137:Longitudinal Studies; D011361:Professional Competence