On-the-job training of health professionals for electronic health record and electronic medical record use: A scoping review

The implementation of electronic health records (EHRs) or electronic medical records (EMRs) is well documented in health informatics literature yet, very few studies focus primarily on how health professionals in direct clinical care are trained for EHR or EMR use. Purpose: To investigate how health professionals in direct clinical care are trained to prepare them for EHR or EMR use. Methods: Systematic searches were conducted in CINAHL, EMBASE, Ovid MEDLINE, PsycINFO, PubMed and ISI WoS and, the Arksey and O’Malley scoping methodological framework was used to collect the data and analyze the results. Results: Training was done at implementation, orientation and post-implementation. Implementation and orientation training had a broader scope while post-implementation training focused on proficiency, efficiency and improvement. The multiplicity of training methods, types and levels of training identified appear to suggest that training is more effective when a combination of training methods are used.


Introduction
The implementation of EHRs or EMRs is supported with many written evidence in health informatics literature yet, very few studies focus predominantly on how health professionals in direct clinical care are trained for EHR or EMR use. Using the "P" and "R" labels of the "PQR" 1 formula in soft systems methodology to create a definition of training (Checkland & Scholes, 1999): Training in this paper is defined as, the process of teaching or learning that is provided by employers to employees -whether on-the-job or, in collaboration with external agencies like academic institutions, consultancies, other healthcare organizations, professional associations or vendors, for the purpose of educating, developing and equipping staff with the tools, skills, knowledge or behaviours required for their respective positions.
Historically, training has progressed dramatically over the past 30 years "in terms of both the science and practice of training". It is no longer a "stand-alone event" in organizations, but "a fully integrated strategic component" with new training-related approaches that include "action learning, just-in-time training, mentoring, coaching, organizational learning and managing skill portfolios" (Salas & Cannon-Bowers, 2001, p. 472).
Similarly, information technology (IT) has played an important role in health care for over 30 years -with the first use of computers in hospitals in the 1960's serving administrative and fiscal tasks (Berner, Detmer, & Simborg, 2005;Hammond, 2001). Later, this use was expanded to "collate and analyze patient data" (Otto & Kushniruk, 2009, p. 62). In Australia, Austin Health Victoria successfully implemented a bed management system that colour codes patients based on their estimated discharge date (Moritz, Scordel, Braitberg, & Hart, 2004). In the United States, Hartford Hospital Connecticut successfully implemented the bed management dashboard (Rosow, Adam, Coulombe, Race, & Anderson, 2003) and in the United Kingdom, the bed occupancy management and planning system was successfully used by a London teaching hospital for decision support on bed management (Wyatt, 1995).
In Canada, the organization mandated by the Canadian Government to ensure the establishment of a nationwide interoperable electronic health record system (iEHR) has been collaborating with Provinces, Territories, health care providers and technology solution providers to accelerate the use of EHRs and many Regional Health Authorities (RHAs) like the Regina Qu'Appelle Health Region (RQHR), Saskatoon Health Region (SHR), Alberta Health Services (AHS), Fraser Health and Island Health have several Canada Health Infoway projects either in progress or completed. Moreover, many of these RHAs are academic health sciences centres and provincial referral centres, serving local and non-local residents across Canada.
Irrespective the type of training to be undertaken, good practice dictates that organizations must decide prior to any training, who and what should be trained, where the intended training sits within the strategic goals and objectives of the organization, what the learning objectives of the training would be, the description of the work functions to be performed, the conditions under which the job will be performed and the knowledge, skills and attitudes required to perform those tasks (Goldstein & Ford, 2002). Furthermore, health informatics literature asserts that IT can potentially improve patient safety, organizational efficiency and overall quality of care (Poon et al., 2006;Warm, Thomas, Heard, Jones, & Hawkins-Brown, 2009;Smedley, 2005). Moreover, Southon, Sauer, and Dampney (1997) indicated that training was a contributing factor to a failed computer information systems (CIS) implementation while Jenet et al and Snyder-Halpern pointed to training as a "significant finding related to implementation readiness in other studies" (as cited in Piscotty & Tzeng, 2011, p. 652). In addition, other studies pointed to the potential unintended consequences the introduction and use of new technologies may pose (Kuperman & McGowan, 2013;Ash et al., 2007).
The purpose of this scoping review therefore is to investigate how health professionals in direct clinical care are trained to prepare them for EHR or EMR use, with a view to identifying what measures, if any, have been taken to ensure that healthcare professionals undergo the right level of training, so that they provide the right information for use at the right time.

Methods
The Scoping Framework: We used the Arksey and O'Malley (2005) scoping methodological framework to collect the data and to analyze the results in this paper. The five stages and an optional sixth stage in the framework are summarized in Table 1 below and they provided a useful way to identify the "extent, range and nature" of all relevant literature irrespective of study design (p. 21).

Stage 1
Identifying the research questions in order to determine which aspects of the questions are important for the literature search.

Stage 2
Identifying relevant studies that would comprehensively answer the central research question(s) and for which consideration would have to be given to time, budgetary constraints, publication dates, language and the range of available literature sources.

Stage 3
Study selection -adopts methods similar to the systematic review process but with greater flexibility for inclusion and exclusion criteria as researchers may, based on increasing familiarity with research data, redefine their search terms.

Stage 4
"Charting" the data in terms of key issues and themes via a "narrative, descriptive-analytical" framework.

Stage 5
Collating, summarizing and reporting the results through an analytic or thematic framework but with no attempt to "weight" the evidence.

Stage 6
Optional consultation exercise with key stakeholders for potential added value such as additional references and valuable insights to the literature review.

Research questions
This scoping review sought to answer the following research questions: (1)

Literature search and search strategy
We used the research topic and research questions to determine the main concepts for the search and conducted systematic searches in CINAHL, EMBASE, Ovid MEDLINE, PsycINFO, PubMed and ISI WoS. We based our search strategy on four concepts -"training", "health professionals", "electronic health records" and "electronic medical records". We combined similar concepts with OR, must-have concepts with AND, and excluded search results that were not needed with NOT. There was no publication year limit set in this search.
We conducted an advanced search and a basic keyword search for each database. We performed an advanced multi-field search in ISI WoS and an advanced thesaurus search in the remaining five databases where search terms mapped to the controlled terms of the respective databases. The actual search terms used in the advanced thesaurus search varied slightly as not all databases use the exact same subject term. We checked the scope notes in the respective databases to confirm the semantic meaning of the terms and used wildcards to capture variations of the search terms in the advanced multi-field search performed in ISI WoS. An example of the search strings used in ISI WoS is shown below:  TS=(train*)  TS=(health professional* OR health personnel*)  TS=(electronic health record* OR electronic medical record*) We performed the exact same basic keyword search shown in Table 2 below, in all six databases and used the asterisk wildcard symbol to capture variations of the search terms, expand the search and increase the number of results retrieved. Screenshots of the search history of the six databases searched were captured in a word document and are included in Appendix A of this paper. We obtained additional references for background information and discussion by checking the reference lists of identified studies and locating resources in the business and education disciplines. We used the CADTH PRESS Checklist 2 (Canadian Agency for Drugs and Technologies in Health, 2013) to assess our search strategy for completeness and accuracy. Fig. 1 illustrates the types of searches done in this scoping review.
Studies were included if they (1) examined the training of health professionals for EHR or EMR use; (2) discussed and evaluated the training methods used in health professional EHR or EMR training; (3) focused on the content covered in health professional EHR or EMR training; (4) were qualitative and quantitative peer-reviewed studies. Studies were excluded if they (1) focused only on the design of the EHR or EMR; (2) did not have an evaluation component; (3) were an editorial, a comment, a letter to the editor, a survey, an abstract, a book review or a case report; (4) were in non-English language; (5) did not focus on health professional EHR or EMR training; (6) were not peer-reviewed.

Study identification, selection and review
Three researchers reviewed and discussed the titles and abstracts of the studies identified in the literature search to determine whether the inclusion criteria have been met. All disagreements between the reviewers regarding the articles were resolved through discussion and a consensus on each article. Articles that met the inclusion criteria were pulled for full manuscript review. The full text of the articles was obtained and the full manuscripts reviewed by the three reviewers for a final decision on which studies to include.
Selection of studies was based on the criteria indicated above and the determination by the three researchers on whether the inclusion criteria have been met. The selected studies were also examined for redundancy and duplicates were removed. Again all disagreements were resolved through discussion and a consensus on each article. RefWorks Citation Manager was used to manage the included and excluded studies retrieved.

Analysis
The three reviewers extracted relevant data and themes from the included studies. These themes are outlined in greater detail in the results section of this paper.

Results
Search Statistics and Included Studies: The literature search produced 3335 results with the following breakdown -601 from CINAHL, 609 from EMBASE, 342 from MEDLINE, 249 from PsycINFO, 634 from PubMed and 900 from ISI WoS. 214 duplicates were removed and a further 3079 studies were excluded, based on a review of the titles and abstracts of the studies. Of the 42 remaining studies, 27 were excluded and 15 studies met the inclusion criteria set for this research (see Fig. 2). Table 3a, 3b, 3c, and 3d presents the findings from the included studies and the references of the included studies are in Appendix B of this document. The median publication year for the included studies is 2011 (with a publication year range of 2004 -2013). Fig. 3a and 3b illustrate the included studies retrieved per publication year.     Individual counselling (i.e., one-on-one training) and feedback most effective to improve meaningful use

Key Themes
Tailor training to trainee needs; Self-paced hands-on practice

Themes
Several key themes emerged from our review of the included studies namely, (1) types of study design; (2) location of training; (3) types of training; (4) types of training content covered; and (5) perception of training. The themes were extracted after study inclusion and are discussed below.
Theme 1: Study Design. The included studies in this scoping review employed a range of qualitative and quantitative research methods. Of the 15 studies reviewed, five were observational, five descriptive, two were mixed methods, one a review, one a qualitative case study and one an experimental randomized control trial, with physicians in primary care practices as the unit of randomization . There were six case series in the included studies -two observational and four descriptive (among which two used a survey to measure training outcomes). The outstanding descriptive study was a survey , while the remaining observational studies included one comparative ethnographic study , one cross-sectional study (Kirshner, Salmon, & Chin, 2004) and one longitudinal prospective study (Carayon, Smith, Hundt, Kuruchittham, & Li, 2009). In the mixed method studies, one study used case-control survey (Bredfeldt, Award, Joseph, & Snyder, 2013) while the other employed "retrospective, comparative, descriptive, secondary data analysis" (Edwards, Kitzmiller, & Breckenbridge-Sproat, 2012, p. 106).
Theme 2: Location of Training. Training locations varied in size and type. For example, training was held in "small family practice clinics including rural, urban and small town" (Carayon et al., 2009;). One training location was that of an EMR vendor who discussed support provided to a "small solo specialist practice with three EMR users in a small town" . Training was also provided in primary care practices paired by practice size and GP (General Practitioner) .
One study compared training in three different health care systems -a HMO with 421 clinics, a private and publicly subsidized system with a medical university and eight primary care clinics and several specialty clinics and, an open full-spectrum health service provider with over 20 primary care clinics and approximately 30 hospitals in five western states . Another study individually reviewed training in seven settings namely, physician groups in a primary care network, primary care members of the mediplus database, physicians in an internal medicine department, a HMO, and three hospitals mentioned below .
One service provider -Kaiser Permanente, held training in different states and specific departments or settings namely, non-specific outpatient primary and specialty care, ambulatory and hospital settings and, clinician office settings (Bredfeldt et al., 2013;.
Finally, training was held in at least five hospitals -the largest of which was a quaternary hospital in New Delhi, India . Other hospital settings included a general hospital and an acute care hospital , and hospitals for which no specific type of care was indicated that is, "Mission Hospitals" and a "Central Finland Hospital" .
Theme 3: Types of Training. Training was conducted at the orientation of new hires, at EHR implementation and at post-implementation. Types of training is further divided into training period and training methods.
Training Period. Of the 15 studies included in this research, five were done at implementation (Carayon et al., 2009;): four at post-implementation (Bredfeldt et al., 2013; and three at orientation . There were two studies for which the training period was not stated but which could potentially have been either orientation or continuing education training . One study did not indicate the training period though four of the seven articles reviewed in that study are part of the 15 included studies that are included in this paper . Implementation and orientation training appeared to have a broader scope and with a focus on getting participants trained in key areas that would allow them to begin using the system. The post-implementation training built on the existing knowledge of trainees who were generally advanced EHR/EMR users and so the level of training given was more targeted, in-depth, intensive and with a focus on proficiency, effectiveness, efficiency and improvement (Bredfeldt et al., 2013;. Training Methods. Seven types of training methods were identified in these studies -traditional instructor-led classroom training, one-on-one training, familiarization, CBT, blended learning, feedback and support. 12 studies offered some form of classroom training among which 4 offered only classroom training (Carayon et al., 2009;. Eight studies offered a mix of classroom and CBT or some form of blended learning while one study offered both traditional classroom training and blended learning independently at specific times in the year . Terry et al. (2008) did not indicate the type of training methods used in their study.  indicated one-on-one training held in clinician offices. One study provided training from the vendor perspective . This training, called support, offered onsite classroom training, telephone consultations for ongoing support, the Help menu within the EMR, the vendor website, the EMR user manual, annual users' conference and follow up training after system updates or at the request of the client.
The length of training sessions varied in terms of the type of training and the methods of training. Training methods varied between two to four hours per session to 6 and 8 hour training days and one study had a 45 day time completion limit for training . Classroom sessions appeared to have a longer duration while attendee roles also seemed a factor in the length of training sessions. For example in one study, super-users were trained for eight hours (Carayon et al., 2009), nurses, 23 hours over four days  and physicians, physician assistants and nurse practitioners, five sessions in three days .
In summary, the multiplicity of training methods, types and levels of training used in these studies would appear to suggest that training is more effective when a combination of training methods are used. This would include methods mentioned earlier in this section and those discussed later on in this section of the paper such as, hands-on training, self-paced training and customized training.
Theme 4: Training Content. Six studies provided no details of training content covered (Carayon et al., 2009;. One study  provided partial content by indicating details of three out of the seven studies reviewed in their paper. Of the 15 studies included in this research, only eight studies indicated the types of content covered in their training (Bredfeldt et al., 2013;. The types of content covered are:  "Problem list management, medication list management, patient history, efficient chart review, documentation, efficiency tools, order entry and preference list" (Bredfeldt et al., 2013, pp. 2-3).  "Various functions of the EHR including computerized physician order entry, physician documentation, lab results retrieval, etc." (Dastagir et al., 2012, p. 137).
 "Logging in to the system, documenting and reviewing office visit data, placing orders and documenting a complex visit … perform specific EHR tasks such as documenting patient history, entering medication, writing orders, checking alerts and adding notes and letters" .
 Order entry (single and complex), key EMR topics, medication reconciliation, pharmacy system and medication dispensing, documentation of medication profile, admission history and assessment, online references, guides, additional information retrieval, electronic medication administration record session with self-paced examples and related scenarios, "restraint orders/documentation, nutritional documentation, shift documentation, special notations, … integrating knowledge of the documentation system to include the care plan, problem list, discharge instructions, patient education documentation and related topics" and with an option for remediation or practice following a completed assessment (Harton et al., 2009, pp. 231-232).  "Basic core competency evaluations … (and) tailored instruction about features and functions of CIS applications with which they are unfamiliar". The four CIS components were "the EMR, data retrieval results reporting, e-mail, and medical library" (Kirshner et al., 2004, p. 342).
 EHR features such as order entry, patient information look up, "documentation and communicating with other clinicians within EHR", and in one system, videos showing the "right" and "wrong" way to use computers in the examination room (Lynott et al., 2012, p. 9).
 Feedback on physicians' current level of preventive care, hands-on training on "how to query their EMR database to generate lists of patients eligible for preventive care tests … a toolkit with step-by-step instructions and software screen shots" for reference (Maddocks et al., 2011, p. 149).
 Functions for patient data entry such as setting up patients' appointments for the administrative staff, and with the doctors -notes, prescriptions and letters. Special functions such as billing, "more advanced features for the doctors … messaging for the whole office … scanning and … (getting) their labs working". A last one-day lesson that teaches how to "reconcile their books with the Ministry" and advanced functions including conducting practice-wide searches and reminders "which let them … know how to … deal with the patients in a variety of ways" (Shachak et al., 2012, p. 188).
 System basics like signing on and signing off, "clinical terminology associated with the HCIS (Health Care Information System)", password management; initiating and editing care plans, entering and editing data on allergies, navigating the electronic chart, simulated admission scenarios requiring "assessment findings, patient history, laboratory values, diagnosis and other facts critical to the care plan"; intervention documentation, electronic medication administration record, barcode scanning in medication administration; keyboard shortcuts, order entry, "order sets such as cardiac enzymes and insulin algorithms, medication orders, laboratory tests, radiological procedures, diets, and consultations"; order edits, documenting the collection of specimens ordered and electronically signing off orders, medication reconciliation including the documentation and editing of home medication lists (Stromberg, 2011, pp. 322 -324).  was the only study that indicated medical library applications as a core component of the CIS applications of the organization. In spite of this difference, there appears to be some similarity in the types of content taught in EHR or EMR training. , documents these types of EHR training content as pertaining to "meaningful use" of EHR: that is, the adoption and use of certified EHRs technologies by healthcare providers "in ways that would improve quality, safety and efficiency" in patient care (Classen & Bates, 2011, p. 855). Criteria developed in the United States for meaningful use included core objectives like patient and medication list management, CPOE, the implementation and use of clinical decision support, additional criteria like the implementation and use of drug formulary checks, the incorporation into EHRs of clinical laboratory tests as structured data and the use of EHRs for quality improvement (Blumenthal & Tavenner, 2010, pp. 502-503).
Theme 5: Perception of Training. Evidence of training perceptions was obtained from the results indicated in the studies -many of which used either quantitative, qualitative or a combination of both instruments to measure training effectiveness or satisfaction. For example, five studies used a survey and five others, a combination of instruments. One study used semi-structured interviews ) and another, participant observation ). Yet one more study used an evaluation form (Bredfeldt et al., 2013), while Stromberg (2011) measured satisfaction with informal reports from unit managers, staff and nurses -a tool that may potentially create room for bias.
Dissatisfaction was expressed in some studies and training perceived as a challenge prior to the change in training format. Comments referred to the constant daily geographical movement between training locations as physically and mentally exhausting , while others indicated that the long training hours and class times were unconducive to their needs . Other criticisms included too much information in too short a time , "documentation class too long, shorten pharmacy lecture" .
Overall, feedback from training participants in all the studies was generally positive. Common perceptions were that training was successful, hands-on exercises were most useful and for Carayon et al. (2009), user training was thoroughly planned and delivered and the EHR system was easy to learn. In one study, training material was being incorporated enterprise-wide (Bredfeldt et al., 2013). Trainees also appreciated receiving support materials pertaining to the training sessions Carayon et al., 2009). In studies where training methods included blended learning, trainees recognized the flexibility afforded by this method and expressed their appreciation for self-paced learning and the ability to work on their own . Other training methods for which participants expressed satisfaction were one-on-one training , offsite classroom training  and onsite classroom training .
Participants also recognized the need for more training and suggested that more hands-on practice and interactive learning was needed. This recommendation potentially addresses a recurrent theme found in the majority of the studies namely, participant level of computer literacy, which also relates to trainee ability regarding the ease or difficulty of use of the technology.  advised to consider several issues including trainer and trainee constraints.  indicated a 45% rate of trainee preference for personal guidance. In the McCain (2008) study, participants under the old training method commented on being slowed down or receiving too much content too fast. From the vendor support perspective, Shachak et al. (2013) indicated that client population profile changes reflected different needs with varying levels of computer experience.  on discovering training and time as barriers in their study, concluded that providers should pay attention to computer literacy, commit to protected time for EHR implementation and adoption, engage in training activities and support in house facilitators, as barriers and facilitators influenced participants' level of EHR adoption.
The blended learning methods adopted in the studies and the feedback from participants of same appear to suggest that participant learning cycles and styles (MacKeracher, 2004) were targeted -and with the potential outcome variables of satisfaction and user acceptance, improvement in staff knowledge and skill , resource availability and enhanced learner retention .

Answers to research questions
(1) What types of training are typically done with health professionals for the EHR or EMR?
We noted that training was conducted at the orientation of new hires, at EHR or EMR implementation and at post-implementation. We further observed that implementation and orientation training appeared to have a broader scope, while post-implementation training generally targeted advanced EHR/EMR users and focused on proficiency, efficiency and improvement.
(2) What types of training methods are the right fit for health professionals in EHR or EMR training and what types of training methods or strategies do health professionals end up receiving?
We determined that there was not a consensus on this question as discussions in health informatics literature pointed to blended learning as a preferred method, a combination of training (namely, classroom, computer-based and feedback), custom and self-paced training and the best way being unclear. Healthcare professionals in this scoping review received a multiplicity of training methods that included traditional instructor-led classroom training, one-on-one training, familiarization, computer-based training, blended learning, feedback and support. We noted that the multiplicity of training methods, types and levels of training used in these studies would appear to suggest that training is more effective when a combination of training methods are used.
(3) What types of content are covered in EHR or EMR training?
We noted that six of the 15 studies in this scoping review provided no details of the content covered in the training and that in those studies that did provide details, similarities in content were identified that were ascribed to "meaningful use" . We also noted that basic training content included signing on/off the system, general navigation and review of the most common functions used, pre-defined data entry, entering / editing care plans, online reference guides, medication dispensing, reconciliation, medication profile documentation, keyboard shortcuts, order entry, edits, e-ordering, home medication list entry etc. Advanced training content included problem and medication list management, patient history, efficient chart review, order entry, documentation, preference list management, efficiency tools, lab results retrieval, practice-wide searches etc.

Study limitations
We excluded grey literature studies from this scoping review and focused only on studies that were available via traditional publishing channels. While we thought that grey literature studies were important, this was not the focus of our search. For the same reason, we did not include studies that discussed the training of students in health professions. We conducted a very broad search and set no publication date limits for the search as we were unsure whether we would find any results. We noted that none of the studies in this scoping review were generalizable and that case series studies, ranked low on the hierarchy of health evidence (Duke University Medical Center Library & Archives, 2015; Glover, Izzo, Odato, & Wang, 2006) were the majority of the included studies in this paper. Studies were limited by demographics (namely rural versus urban and suburban) and by location (for example, emergency care, ambulatory care, specialty care and so on). One study  was limited by a parallel provincial program and another by a one-time occurrence (Kishner et al., 2004). Other studies were limited by sample size and the quality of the assessment tool for training -anecdotal feedback .

Recommendations
We made recommendations for detailed training content to be provided, for a consensus development on training methods, for engagement in collaborative opportunities and for the development of training as a core product / strategic asset in healthcare organizations. We recommended the use of strategic business concepts -"strategic networks", "distinctive capabilities" and "core competencies" (Jarillo, 1993;Kay, 1993;Hamel & Prahalad, 1994;Prahalad & Hamel, 1990) and based our recommendations on the fact that: 1. Six out of the 15 included studies reviewed in this paper provided no details about the content of training covered (Carayon et al., 2009;). Our position is that the inclusion of detailed training content would have helped to better assess the success or otherwise of the studies and to inform healthcare organizations of potential content for consideration or inclusion in actual EHR or EMR training. 2. There did not appear to be a consensus on the best way to train healthcare professionals in the use of health information technologies. We noted that there was a multiplicity of training methods in the studies and that they appeared to suggest that training was more effective when a combination of training methods are used. 3. We found very few research in health informatics literature, pertaining to this type of study, that six of the included studies in this paper were case series  and that case series studies rank very low on the evidence hierarchy in health and medical literature (Duke University Medical Center Library & Archives, 2015; Glover, Izzo, Odato, & Wang, 2006). 4. Only two of the 15 studies reviewed for this research indicated the application of continuing medical education credits to the training and both were postimplementation studies (Bredfeldt et al., 2013;. One of the two studies also indicated that the training material used in the study was being incorporated enterprise-wide (Bredfeldt et al., 2013). One study stated that the blended learning strategy was permanently included in the EMR training plan and that three classroom courses were to be moved to the blended format as next steps . Only one study indicated that library applications were part of the four core components of their computer information systems .

Directions for future research
In a systematic review of health informatics literature, the authors discovered that there was a paucity of results that addressed on-the-job training of health professionals for EHR and EMR use, although calls have been made for healthcare organizations to invest in the training of their employees (Ash, Stavri, & Kuperman, 2003;Lorenzi, Kouroubali, Detmer, & Bloomrosen, 2009;Goldberg, Kuzel, Feng, DeShazo, & Love, 2012;Janois, Lind, Göransson, & Sandblad, 2014). The authors also noted the contributions to health informatics practice by professional organizations like COACH (Canada's Health Informatics Association) and HIMSS (Healthcare Information and Management Systems Society) through program activities like certification and publication of white papers and other reports. Additionally, the authors noted the contribution to health informatics education where schools such as the University of Victoria, University of Arkansas for Medical Sciences and University Hospital "P. Giaccone" include or plan to include EHR/EMR training to students in health professions (Borycki et al., 2009;Hart, Newton, & Boone, 2010;Allegra, Messineo, Migliore, & Alessi, 2010). Potential research enquires could include investigating grey literature studies for this type of training and exploring further, the inclusion of EHR or EMR training to students in health professions.
Advances in health information technology warrant that healthcare organizations should be equipped with the necessary tools to deal with the turbulence that characterizes technology-rich environments and research into all aspects of technology training that prepares healthcare professionals for the changing nature of their work environments should be encouraged.

Conclusion
We reviewed 15 studies and used the Arksey and O'Malley (2005) scoping framework as the methodology for this project. Key themes were extracted and discussed and answers to the research questions were provided in the discussion section of this paper.
We conclude this scoping review with the observation that healthcare organizations are aware of the importance of having health professionals trained in health information technologies and that they may be working to close this gap in the continuing professional development of healthcare professionals. For example, in Canada, Prism Economics and Analysis (2014) projected hiring requirements for health informatics and health information management professionals and identified roles at high risk of skills shortages. The Prism report commissioned by Canada Health Infoway, CHIMA (Canadian Health Information Management Association), CIHI (Canadian Institute for Health Information), COACH, ICTC (Information and Communications Technology Council) and ITAC (Information Technology Association of Canada) Health, indicated that as a result of replacement and growth demand, hiring requirements over the next five years in Canada (i.e., 2014-2019) would range from approximately 6,200 to 12,200 persons with more than 70% of the hiring requirements projected to be in information technology and health information management (p.2). The report also revealed the need to "broaden the skills of current clinical professionals to better support them in clinical informatics roles" -given the dominant trend of the "intensification and optimization of usage of e-health systems and applications …" (p. 66). Furthermore, COACH, Canada's Health Informatics Association has several publications that directly address the skills, knowledge and types of training required for various health informatics roles. These publications include the Health Informatics Professional Core Competencies eBook (COACH, 2012)