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The journey through grief: insights from a qualitative study of electronic health record implementation.

The use of full or partial electronic health record (EHR) systems--also referred to as electronic medical records (EMRs)--in physicians' offices is increasing (Burt, Hing, and Woodwell 2006; Hsiao et al. 2011). However, by 2012, only 40 percent of providers used a fully functional system, or "Basic EHR," defined by the U.S. National Center for Health Statistics to include patient history and demographics, patient problem lists, physician clinical notes, comprehensive lists of patients' medications and allergies, computerized orders for prescriptions, and the ability to view laboratory and imaging results electronically (Blumenthal, DesRoches, and Donelan 2008; Hsiao et al. 2011). Meanwhile, only 27 percent of physicians intending to apply for meaningful use incentives reported having EHR systems in place with capabilities to actually meet the Stage 1 core objectives for meaningful use (Hsiao et al. 2011; Kokkonen et al. 2013). These facts suggest that transitioning from paper records to an EHR cannot be equated with complete integration of an EHR into the care process.

The slow pace of adoption and integration of fully functional EHR systems has typically been attributed to "barriers" at both the organizational and physician levels (Burt, Hing, and Woodwell 2006; DesRoches et al. 2008; Lorenzi et al. 2009; Hing, Hall, and Ashman 2010; Greiver et al. 2011; Kokkonen et al. 2013). Eight main categories of physician barriers were identified by a 2010 review of 22 research articles on barriers to EHR acceptance: financial, technical, time, psychological, social, legal, organizational, and change process (Boonstra and Broekhuis 2010). These physician barriers align to barriers identified at the organization level (Ash and Bates 2005; Lorenzi et al. 2009; Rao et al. 2011), and both types are well-understood by practitioners and researchers. Some view these barriers as the focal point of interventions--removing them will accelerate EHR adoption (Miller and Sim 2004; DesRoches et al. 2008; Boonstra and Broekhuis 2010). An alternative framing, however, is of EHR adoption as a change process that is slowed due to participant resistance (Ford et al. 2009).

In this article, we propose that EHR adoption is contingent not just on removing barriers but on addressing the change processes involved--at both the individual and organizational levels. Given this framing, there is a particular need to explore contextual factors related to the process of change to provide evidence-based guidance during implementation, a focus that is relatively absent from the current discourse on EHR adoption (Boonstra and Broekhuis 2010; Greiver et al. 2011; McAlearney et al. 2012). Our paper fills this gap by examining administrators' and physicians' perspectives about how adoption and implementation of an EHR system can be facilitated. Our research objective, shared with study participants, was to improve our collective understanding of EHR implementation strategies to advance the adoption and implementation of ambulatory EHRs, paying particular attention to opportunities to maximize physician adoption and use of such systems.

STUDY DESIGN AND METHODS

Site Selection

Our study was designed to learn from the experiences of physicians and administrators who had participated in EHR system implementations that had been widely reputed to be successful. We used several criteria to generate an initial list of successful sites including receipt of the Healthcare Information Management Systems Society Annual "Davies" Award for Ambulatory EHRs within the past 5 years combined with recognition as a "Most Wired" hospital by the Hospital and Health Network's annual benchmark survey. We then solicited feedback from a project advisory committee comprised of representatives from industry and academia with expertise in HIT implementation to allow the research team to finalize the list. From this list of 10 potential study sites, we refined our list to address considerations of geographic and organizational variability. Six health systems across the United States made our final study sample, with consideration of alternate sites given to allow for expansion if insufficient observed replication of themes across sites failed to allow the team to draw conclusions, consistent with our goal of saturation and the standards of case study research (Yin 2009). All target study sites agreed to participate in our research.

Data Collection and Study Participants

We conducted a total of 35 in-person or telephone interviews with administrative key informants, including organizational leaders and managers, information systems leaders and professionals, and staff (Table 1 provides a count of study participants by role). Interviews consisted of a series of open-ended questions and lasted 30-60 minutes. In addition, we held six focus groups comprised of 47 generalist and specialist physicians--physicians in practice, physicians in training, and physician leaders. We conducted focus groups using a standardized focus group guide that covered topics related to EHR implementation and use. Focus groups lasted 60-90 minutes. All interviews and focus groups were recorded and transcribed verbatim. Our data collection process also included a concomitant assessment of interview and focus group transcripts and discussion of preliminary findings to permit probing for new concepts and ensure that we reached saturation in data collection, consistent with standards for rigorous qualitative research (Strauss and Corbin 1998). This study was approved by the institutional review board of The Ohio State University. No informant approached for this study refused to participate.

Analysis

We used a grounded theory approach including both inductive and deductive methods to analyze interview and focus group data. A coding team, established by the lead investigator, created a preliminary coding dictionary defining broad categories of findings from the transcripts. This coding dictionary included the code "physician perspective," defined as physician's views on how an EHR changes their work and/or relationship with patients. We further classified data in this broad code into themes, following Constas's constant comparison methods (Constas 1992). Coders met periodically throughout the coding process to ensure consistency in coding and review any new codes or themes that emerged, consistent with a grounded theory approach (Glaser and Strauss 1967; Strauss and Corbin 1998). We used the Atlas.ti software program (Scientific Software Development 2008) to support the coding process. The themes associated with change principles that we describe here emerged from this iterative approach to coding and analysis.

STUDY FINDINGS

Through our analyses we found three important opportunities to facilitate physicians' adoption and use of EHR systems in clinical practice. These opportunities involved (1) conceptualizing EHR adoption as personal change through a metaphor of loss and grief; (2) framing EHR implementation using an organizational change management model; and (3) mapping these two approaches together to develop 10 EHR deployment strategies. These deployment strategies can serve a useful function to management by linking specific interventions to each of the stages of grief. In the following sections we describe each of these opportunities in further detail and offer evidence from our analyses to support these findings.

Conceptualizing EHR Adoption as Personal Change Involving Loss

In synthesizing our findings about physicians' personal reactions to EHR implementation, we identified a theme of loss among the participants. One administrator characterized the transition to an EHR as "the death of their old record into their new record," while physicians often commented on the changes needed for them to use the new system. As one physician explained, "So in the good old days, well there's a chart. You pick it up and we all knew how to flip the tabs and you know we could deal with that."

The extant literature provides examples of these types of professional losses inherent in organizational change, including the loss of valued expert knowledge when new technology replaces old, and the loss of power when organizations are restructured (Harvey 2002). We found that both of these types of loss were noted by the physician interviewees when describing the EHR introduction and implementation. For instance, physicians described the EHR introduction as "really so destructive to my flow and my interaction with my patients," while another was concerned about how to work with the new system: "How do I access these old records, the x-rays, all this stuff? And order my labs and then discharge them and do the follow-up letter?" At the same time, administrators reported that physicians often clung to the past because they did not want to lose their sense of expertise and comfort with the way they did things. One administrator noted, "They're really trying to do their old work in an EHR, as opposed to innovating, using that new functionality to innovate and change the way they practice."

With respect to loss of power, two areas of power loss were of particular note among study participants. First, interviewees noted that having junior physicians more comfortable with computers than the average established physician involved a shift in power. As one physician explained, "It can turn the whole relationship we have upside down. The old model was senior physicians have more knowledge, more wisdom, more experience and they taught the younger ... And an EMR in my mind flips it on its head because it's no longer simply about experience, right?" A second area of power loss was in the ability for physicians to shift their work to others. With the EHR implemented, physicians were now required to use the computers and input their orders rather than delegating these tasks to junior physicians or nurses. An IT director described how this played out in one EHR implementation describing, "We had some doctors who said, 'I don't need to do that, my nurse is going to do that for me.'" At another site an interviewee explained, "In the old world, the nurse was in getting the vitals on a sticky and the doc was outside looking at the chart refreshing him or herself," thus not needing to spend time recording the vitals. Similarly, an administrator noted, "Well, in the old world if a doc did a visit and scribbled, forgot to sign his or her name and it just went back in the shelf and we'd bill for it," but now the physician has to spend time signing records and ensuring compliance.

We propose that this theme of loss is associated with a sense of grief, akin to the type of employee grief identified in studies of corporate layoffs (Vickers 2009; Davey, Fearon, and McLaughlin 2013). This led us to conceptualize the EHR adoption process using Elisabeth Kubler-Ross's model categorizing the five stages of grief (Kubler-Ross and Kessler 2005). While admittedly not as profoundly personal as dealing with the loss of a loved one, framing EHR adoption in terms of loss and grief was surprisingly appropriate for characterizing the change process required for physicians to adopt and use an EHR system, and our data supported this classification. Specifically, we found that the five stages of Kubler-Ross's model--denial, anger, bargaining, depression, and acceptance--can be articulated as required phases of personal change for physicians adopting and integrating an EHR system. We describe this characterization further next and provide additional supporting evidence in Table 2, presenting representative quotations from both physician and administrator study participants.

Denial. Kubler-Ross identifies the first stage of grief, denial, as one where individuals may experience shock and/or feel overwhelmed. In the context of EHR implementation, we characterized this stage from comments indicating physicians struggle with loss. For instance, as one interviewee described of physicians' reactions to the EHR implementation, "They were just overwhelmed," while another noted, "the culture shock for implementation is significant." An information technology professional reflected about physicians in this early phase explaining, "In every provider meeting I go to, there is someone who says 'Leave it alone, I know what I am doing now.'" Also important was the notion that this denial stage had to be acknowledged and addressed. One administrator commented, "If you don't do it fast, people say, 'Hmm, they'll never get to me. This is a passing fad. A couple years from now they'll have a new CEO and they'll have something else they'll be working on.'"

Anger. The second stage of grief requires acknowledgment of the underlying pain. As one administrator explained of the implementation process, "It's so painful for some of these folks that you could pay them anything and they wouldn't do it. And when they start doing it, it's painful." Another explained how the physicians "were angry for the first 3 months." More specifically, one interviewee described "anger on the part of physicians that they actually had to type and document and place orders and do histories and physicals themselves and meds." Physicians acknowledged this anger and frustration. As one lamented, "So, I don't know what has changed in the last couple months that I'm no longer allowed to give verbal orders to my MAs [medical assistants]. But now it's more focused on just put the order in instead of actually listening to what I say. That's a little frustrating." Another physician commented about this shared anger sentiment explaining, "It's because we're going from 'thinking folks' to 'data-entry folks' and that is painful on so many levels."

Bargaining. The third stage of grief, bargaining, encompasses aspects of negotiation and attempts to construct trade-offs to avoid the change or legitimate contingency approaches. An obvious bargaining approach indicating implementation failure for an individual was seen when physicians chose to retire rather than adopt a new EHR system. One administrator explained, "The ones who were close to retirement were like 'You know, I'm not going through this pain, it's been nice, see ya.'" When physicians outwardly adopted the EHR, several found ways to avoid actually interacting with the system. As one physician leader reflected, "The whole myth was that it was this fully wired, integrated system. But in fact what happened was the attendings weren't actually touching the computers. So, they could ask ... go find a resident 'pull this up for me,' whatever. So they didn't actually have to touch the computers." In confirmation of this approach, a different physician proudly reported, "I don't know how to place an order. I don't even know what my password is." Physicians also manifested this contingency behavior as one where they acknowledged the positive potential of the EHR system, but only when described along with the drawbacks of the system. One physician noted, "I think that we all recognize the positives of the system and we all recognize the frustrations perhaps with the implementation or the roll-out or the difficulty in getting things done that may be more inefficient now than they were when we had a paper system," thus offering the positive comment only in conjunction with negative feedback as well.

Depression. The depression stage of grief, when individuals deal with feelings of hopelessness and inadequacy, was evident in both physicians' comments and administrators' reports about how new users would cry and express a desire to either quit their present position or retire. As one physician recalled, "I started crying and could not quit! ... I would click in my sleep and I mean, to that point ... I had nightmares of clicking and clicking and not getting it right." Administrators recognized this stage and further described it as a low point. One noted, "You really have to make up a celebration, because during the first couple of days everyone is on the high, by about day three they are crying." Another administrator explained of this stage, "Yeah they haven't gotten to the point where, 'Ooh!' Like the light bulb hasn't quite come off of some of them for what the system can do for them." Interviewees' descriptions of this stage reflected how physicians indeed felt disheartened and empty, and did not suggest any sense of hope for the future.

Acceptance. In contrast, the fifth stage of grief, acceptance, was characterized in this context by comments indicating realistic acceptance of a changed reality --and, ideally, a better future that included the EHR system. As a physician leader described of this phase, "Now it's not something that somebody has to do to make sure it happens. It happens naturally in our system so we get less errors and much better flow. And in paper, you just can't physically do things in paper. It just is the way it is." An administrator summarized, "Basically it was, 'Well, this is going to take much more time out of my day, it's clunky, I'm not having eye contact with my patient' and now it's, 'Wow this is great!' ... And plus, having the disease registry piece really has made a difference in ... you know, you focus on diabetes, COPD [chronic obstructive pulmonary disease], cardiovascular disease and you can tell each provider's patients exactly how they stand relative to the quality indicators."

However, not all users truly accepted the change. As one administrator noted, "They're really trying to do their old work in an EMR, as opposed to innovating, using that new functionality to innovate and change the way they practice." Similarly, not all physician participants appeared convinced. One complained, "I'm not having eye contact with my patient," while another begrudgingly commented, "I think for the most part, physicians are adaptable to change. I guess." Administrators characterized this lack of acceptance by describing remaining issues they needed to address. As one noted, "Now one of the challenges we have post go-live is for them to really take ownership of this application and to have it become part of their culture there and part of their work world." Another explained, "We're going to reinvest in you whether you like it or not because we don't want garbage in. We want a pretty high standard for our EMR here and so we want to make sure you're contributing all the material to the EMR." Thus, while the acceptance phase appeared an appropriate way to characterize EHR implementation, similar to acceptance of grief, the time frame for acceptance of the EHR was not predictable, and there was considerable variability in users' perspectives about the new system.

Framing EHR Implementation Using an Organizational Change Management Model

From an organizational perspective, change principles can also be applied to help guide EHR implementation and facilitate adoption and use of the EHR system. We identified Kotter's eight-step change framework as a good example of a change management model that appears to resonate among those challenged by the need to promote change in health care organizations (Kotter 1995). In Table 3 we show how study participants' suggestions for facilitating EHR implementation can be conceptualized using Kotter's framework, presenting representative quotes to characterize each of the eight change steps.

Facilitating EHR Implementation Using Change Principles

Combining insights from the individual and organizational change models, we identified 10 EHR deployment strategies based on study participants' recommendations to facilitate EHR adoption: (1) Manage expectations; (2) Make the case for quality; (3) Recruit champions; (4) Communicate; (5) Acknowledge that it is a painful transition; (6) Provide good training; (7) Improve functionality, when possible; (8) Acknowledge competing priorities; (9) Allow time to adapt to the new system; and (10) Promote a better, but changed, future. Below we further describe the development of these strategies from our analyses, using the first strategy as an example.

The first deployment strategy, "manage expectations," was based on recommendations made by both physicians and administrators in the form of suggestions about how to improve the EHR implementation process. For instance, one interviewee reflected about how the EHR was introduced to physicians in the context of their work by being straightforward about the EHR system and goals for its introduction. He explained that the message to physicians was: "We bought this system so that we would have good reporting, so that we would have the integration between different practices and between the hospital facilities. This is not about making your life easier." This message provided a good example of how "managing expectations" was reportedly a facilitator of the EHR implementation process. Then, in our analysis process considering individual change principles, we mapped this "manage expectations" strategy to the "denial" stage of grief because this facilitator reflected the need to acknowledge the change expected in spite of individuals' reluctance to change, and the hope that this recognition could help physicians move out of the denial stage. We also mapped this recommendation to the organizational change management step of "establishing a sense of urgency" because this strategy emphasizes the need for all participants involved in EHR implementation to acknowledge the reality of the change and move forward with the change process.

As another example, the recommendation to "acknowledge the pain" of the transition to a new EHR system was supported by numerous comments from both physician and administrative study participants. One commented, "This is absolutely an essential step and painful process to go through," and another lamented that "There is nothing that we can do in preparation that will make it pain free." Framing these comments using change principles, we mapped this facilitator to the "anger" stage of personal change and the "communicate the vision" stage of organizational change. Given that the anger stage of grief explicitly notes that this stage involves acknowledging the "underlying pain," numerous comments from interviewees describing pain made this matching process straightforward. Similarly, because participants typically acknowledged the pain in the context of communicating the changes involved in realizing a new vision involving an EHR system, considering this recommendation as part of the organizational "communicating the vision" stage of change also seemed appropriate. In Table 4, we provide evidence about how we categorized participants' recommended facilitators by change stage, using both the personal and organizational change models to categorize each of the 10 EHR deployment strategies.

DISCUSSION

EHR Implementation and the Challenges of Change

For physicians, the introduction and implementation of an EHR system involves changes in medical practice and behaviors that are reportedly difficult. These difficulties may stem in part from logistical issues involved in training and preparation for implementation. However, our study suggests that personal factors associated with the process of change may also play a part, including the loss of professional content knowledge and/or the loss of power. Paying attention to these personal factors may improve the EHR implementation process.

The five stages of grief proposed by Elisabeth Kubler-Ross (1969) provided an approach to categorizing steps involved in the personal change required as physicians adopt and develop the capacity to fully use a new EHR system. Kubler-Ross's model was originally developed in 1970 to characterize the process of accepting one's own death and grieving the loss of a loved one. Through the decades, Kubler-Ross's framework has emerged as an important model of the personal change process (Linney 1999), both for consideration of changes in one's home, such as divorce (Kruk 1991), and for organizational change (Perlman and Takacs 1990; Grant 1996; Elrod and Tippett 2002).

Kubler-Ross's model has been applied to change in many professional contexts, including employee reactions to layoffs and corporate closures (Blau 2008; Davey, Fearon, and McLaughlin 2013), organization changes required for staff nurses in an oncology practice (Schoolfield and Orduna 1994), change in secondary and university educational systems (Adrienne 2003; Zell 2003), and corporate compliance (Boerner 2010). Within the professional context, the Kubler-Ross model has been discussed as a way to identify and reduce the stress associated with organizational change (Vakola and Nikolaou 2005; Critchley 2012). In 1996 Henderson-Loney noted that "Kubler-Ross's griefwork model provides a guide for supervisors to manage the emotional response of their team members to organizational change" (Henderson-Loney 1996). Thus, prior work can support the appropriateness of framing EHR adoption using this personal change model, and acknowledging that the EHR implementation process may indeed involve aspects of grief given the changes required.

Moreover, in light of the well-documented barriers to EHR implementation, researchers have suggested applying organizational change models to the EHR adoption process (Bonner et al. 2010; Boonstra and Broekhuis 2010; Greiver et al. 2011), and our research findings support this proposition. Our study provides evidence that each of the eight steps of Kotter's (1995) change management model could help frame the EHR implementation process, and we found multiple examples of how those steps resonated with study participants' comments about dealing with EHR adoption. While the application of Kotter's model in health care is not unprecedented (Fernandez and Rainey 2006; Campbell 2008; Tsuyuki and Schindel 2008), its consistency and fit with our study data provides evidence for its applicability in ambulatory EHR implementation that has not been previously demonstrated.

Perhaps most striking was our finding that the recommendations study participants listed as key facilitators of the EHR implementation process could be framed by both the personal and organizational change models. In the gray literature guiding business and management executives, both Kubler-Ross's stages of grief and Kotter's change principles have been referenced as useful frameworks for understanding change implementation (Chapman 2012). Our explicit categorization of recommended facilitators into EHR deployment strategies by change stage, however, provides additional support for the salience of these models in EHR implementation.

Implications for Management and Policy

Change can have powerful benefits for care, cost, and populations. Yet change remains difficult for both individuals and organizations. By considering and explicitly acknowledging the personal change processes involved in EHR adoption in light of individual change principles, we may be better able to allow people to cope with the pressure to change in ways similar to how we allow people to grieve when they are dealing with loss. Furthermore, by guiding required organizational change processes using a change management framework, organizations may be better able to motivate, lead, and succeed with EHR adoption as a major change for the organization. Under the right conditions, implementation can lead people and organizations to champion change, but under the wrong ones, they may come to champion the way things used to be.

Addressing the implications of our results specifically, managers can use the deployment strategies we present to intervene to mitigate EHR implementation problems and potentially move employees to the next stage of change. At the level of individual physician intervention, managers can identify the stage of change the employee is dealing with and implement a strategy from the left-hand column shown in Table 4. When a physician is determined to be in the Anger stage, for example, a corresponding deployment strategy is to acknowledge that it's a painful transition, thereby helping this individual to move past anger in the change process. At the level of the organization, however, managers can be guided by Kotter's framework and select the EHR deployment strategy that corresponds to the stage of change appropriate for the organization in its transition to use of a fully functional EHR system.

Study Limitations

One important limitation of this study is the small number of organizations involved. Given the resource constraints of qualitative studies, there are significant barriers to large-scale studies. Future work can include the development of surveys based on this research to explore and validate our findings in large samples. An additional limitation is the inability of our study to link EHR implementation strategies to either clinical or financial outcomes. However, previous research has established the link between successful EHR implementation and positive patient and provider outcomes (Shekelle, Morton, and Keeler 2006; Bonner et al. 2010; Adler-Milstein et al. 2013; Bar-Dayan et al. 2013); we selected the health systems in our study based on these accepted measures of successful implementation, thus attempting to mitigate this potential limitation.

Future Work

The EHR adoption process is often described as a journey. We submit that practice transformation efforts such as the introduction of the patient-centered medical home model and meaningful use requirements have created an unexpected and unexplored frontier. To this point, much of physicians' focus had been on the care of patients within an incident framework of episodic care. The health care delivery system is now asking physicians to "dance on shifting sands"--to meet moving targets, dispose of practice habits, build new data collection protocols, and learn new skills. In the context of EHR implementation, further work is needed to understand this complex system change from the perspective of physicians on the front line. The theoretical models highlighted by our work can serve as frameworks to organize future EHR implementation efforts and study their impact on physicians.

CONCLUSION

For both the organization and the individual, the introduction, adoption, implementation, and use of EHRs involve change. As the changes involved are both personal and organizational, our findings suggest that change principles can help clarify the steps involved and facilitate physicians' adoption and optimal use of EHR systems. Framing EHR implementation in stages using the lenses of both personal and organizational change models may be useful to physicians struggling to progress through the required steps of personal change, as well as to organizations challenged to maximize physicians' adoption and use of the new system.

DOI: 10.1111/1475-6773.12227

ACKNOWLEDGMENTS

Joint Acknowledgment/Disclosure Statement The authors are extremely grateful to the organizations and informants who participated in this study, and to the health system members of our Project Advisory Team. We also thank our research team members, Drs. Paula Song and Julie Robbins, our research assistants, and our research consultants, all of whom were affiliated with The Ohio State University during the study. This research was funded in part by the Center for Health Management Research, but the study sponsors had no involvement in the study design; in the collection, analysis, and interpretation of data; in the writing of the manuscript; or in the decision to submit the manuscript for publication.

Disclosures: None.

Disclaimers: None.

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SUPPORTING INFORMATION

Additional supporting information may be found in the online version of this article:

Appendix SA1: Author Matrix.

Address correspondence to Ann Scheck McAlearney, Sc.D., M.S., Department of Family Medicine, Ohio State University, 273 Northwood and High Building, 2231 North High Street, Columbus, OH 43201; e-mail: ann.mcalearney@osumc.edu. Jennifer L. Hefner, Ph.D., M.P.H., Cynthia J. Sieck, Ph.D., M.P.H., and Timothy R. Huerta, Ph.D., M.S., are with the Department of Family Medicine, College of Medicine, The Ohio State University, Columbus, OH. Timothy R. Huerta, Ph.D., M.S., is also with the Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH.
Table 1: Study Participants, by Role

Administrative            Number   Physician Participants    Number
Participants

Leaders/managers            18     Physicians in practice      26
                                   (attending and private
                                   practice physicians)

Information technology      13     Physicians in training      17
(IT) professionals                 (interns, residents)
and leaders

Staff                        4     Physician leaders            4

Total                       35     Total                       47

Table 2: Conceptualizing EHR Adoption as Personal Change Involving
Loss

Stages of Grief        Representative Quotations Characterizing
(Kubler-Ross,             Stage of Grief in Change Process
1969)
                     Physicians' Comments        Administrators'
                                                     Comments

Denial

* Shock             * "It's been probably     * "The docs were just
                    one of the most           overwhelmed. Not just
* Feeling           unsettling things that    the docs, but the
overwhelmed         I've seen for             clinical staff could
                    physicians throughout     easily be overwhelmed
                    our entire system."       with that stuff."

                    * ... it was an           * "There was no gray;
                    overwhelming amount of    it was very black and
                    information."             white and that was
                                              shocking and upsetting
                                              at first."

Anger

* Underlying        * "It was a fairly        * "We're asking the
pain                painful process           clinical people to do
                    getting on top of it."    more and more ... so
                                              you end up having very
                    * "By the time you've     highly paid, high
                    actually done all         thought process people
                    that, your patient        doing data entry--bad
                    encounter is half way     idea. And that's
                    over and then it is       painful for a lot of
                    not even worth            people."
                    documenting in the
                    patient room."            * "... anger on the
                                              part of physicians
                                              that they actually had
                                              to type and document
                                              and place orders and
                                              do histories and
                                              physicals themselves
                                              and meds."

Bargaining

* Negotiation       * "Everyone has mixed     * "... the ones that
                    feelings. I mean there    have already the
                    are a few that have       little negative
                    all favorable but even    thoughts in their
                    those people              heads--that it's not
                    acknowledge the issues    going to work, I am
                    and the problems that     not going to be as
                    we have."                 productive, I don't
                                              want to share my
                    * "And I went all the     notes."
                    way to even less
                    personal ... why do       * "We did lose
                    they need that cover      physicians over this
                    letter? It's obvious I    ... There were doctors
                    saw the patient. Just     that left because they
                    give them the progress    could not adapt ...
                    note. They can read       they did not know how
                    the note."                to type."

Depression

* Feeling           * "The first 2 weeks,     * "We can't make them
empty               I could have quit         feel bad, they'll
                    medicine. It was          start crying. I had a
                    really so destructive     provider cry on me
                    to my flow and my         once."
                    interaction with my
                    patients."                * "... they just want
                                              to go back to doing
                    * "It was too much        work the way they used
                    information ... and       to do work."
                    then all of the
                    sudden, the next
                    day, ... we were
                    thrown in the clinics
                    ... which stressed me
                    out for like 2
                    months!"

Acceptance

* Of changed        * "When you have          * "[They say] ...
reality             somebody who is a very    while I used to have
                    medically complex         to take a stack of
* New reality       patient who sees a lot    charts home to review
is permanent        of different              them, now I can just
reality             specialists, who has a    dial in from home and
                    lot of different          do all of that stuff
                    outpatient visits and     before I even come
                    those clinics are         in.'"
                    within the EMR system
                    and you can really use    * "Actually our
                    it to the best of its     biggest critic is ...
                    ability ... You are       the staunchest
                    able to have all of       advocate of the EMR."
                    that at your
                    fingertips and ... so
                    at its best, I think
                    that it is a great
                    system and it really
                    ... it changes the way
                    that you manage
                    people."

                    * "... the ability to
                    share information
                    within our practice,
                    very critical
                    information that
                    somebody knows
                    something that
                    somebody else needs to
                    know, the ability to
                    shift work to where it
                    can be done better or
                    more efficiently like
                    off-site of to the
                    right person.
                    Definitely the ability
                    to follow things we
                    couldn't in the past
                    because we can't do it
                    on paper."

Table 3: Framing EHR Implementation as Organizational Change
Management

Kotter's Eight-Steps       Representative Quotations Describing
Guiding Change             Facilitators of EHR Implementation
Management (1995)          Characterized as Steps Toward Change

1. Establish a sense of    * "I mean it was really part of the
urgency                    burning platform ... just to try to get
                           people to recognize that status quo was
                           not acceptable. We couldn't keep doing
                           what we were doing and sustain it."

                           * "So you've got to go quickly and
                           you've got to make it the exclusive
                           focus if you really have a
                           transformational type situation."

2. Form a powerful         * "I think that there's a leadership ...
guiding coalition          the administration and the medical staff
                           leadership and with the support of the
                           boards."

                           * "We had 12 physician leaders that were
                           all part of the physician coalition to
                           lead the vision from a medical staff
                           perspective."

3. Create a vision         * "We established a vision in our EHR
                           adoption and set out a plan about 5
                           years ago."

                           * "So that vision is what's really
                           driving all of our attention and
                           willingness to go along with this."

4. Communicate the         * "This was the focus and that's all we
vision                     talked about and everybody's goals and
                           compensation were all aligned to what
                           the vision was."

                           * "So, if management is saying this is
                           why we are doing it, this is the reason
                           we are doing it, this is how much money
                           we are going to make, this is how much
                           we are going to save, etc., and these
                           people are going to act on our behalf to
                           do that, then that's the way to be
                           successful."

5. Empower others to       * "... strong steering committee, strong
act on the vision          work group meetings, and then as you're
                           working through the workflow at the
                           clinic level, making sure that
                           participation, people are showing up,
                           that they're doing their tasks ...
                           strong project management."

                           * "We took anything else of major
                           substance off of the plate that cut
                           across institutional lines." continued

6. Plan for and create     * "So when we started doing this roll
short-term wins            out on medications for patients and we
                           were able to demonstrate reductions in
                           medication errors and you get some of
                           those 'wow' moments where a nurse is
                           barcoding this medication before they
                           administer it and it comes up in the
                           electronic medical record that there
                           could be this fatal complication, you
                           literally save a life there."

                           * "It was about the wins ... at one of
                           our practices, there were seven docs ...
                           A doc was on call, got a call over the
                           weekend from a hospital in [Name], for a
                           patient that wasn't his, and had to do
                           with [a problem] ... And this doc was
                           able to bring up the chart and see
                           everything that he needed to see to give
                           the answer. So needless to say, he was
                           now less resistant to [the EHR,
                           thinking,] 'this might be worth it.'"

7. Consolidate             * "Once you started producing results
improvements and           and getting where you wanted to get to,
produce still more         then you could start being a little more
change                     focused on sub-areas or things that you
                           needed to get at and you could start
                           bringing other key goals for the
                           institution back into play."

                           * "The next phase is to go 'ok, now you
                           got the basics, now, how can we leverage
                           some of this? What's taking you the most
                           time?' And stay with them to work with
                           them to get processes in the whole
                           practice and then get them rolling in
                           the whole practice."

8. Institutionalize        * "Now it's not something that somebody
new approaches             has to do to make sure it happens. It
                           happens naturally in our system so we
                           get less errors and much better flow and
                           in paper, you just can't physically do
                           things in paper. It just is the way it
                           is."

                           * "I think it's now an absolute part of
                           the culture and who we are and how we do
                           things here."

Table 4: Characterizing Ten EHR Deployment Strategies: Linking
Recommended Facilitators of EHR Implementation to Stages of Personal
and Organizational Change

                                                    Link to
EHR Deployment           Link to Personal        Organizational
Strategy                   Change Stage           Change Stage

1. Manage              Denial stage           Establish a sense
expectations                                  of urgency

2. Make the case       Denial stage           Create a vision
for quality

3. Recruit             Anger stage            Form a powerful
champions                                     guiding coalition

4. Communicate         Anger stage            Communicate
                                              the vision

5. Acknowledge         Anger stage            Communicate
that it is a                                  the vision
painful transition

6. Provide             Bargaining stage       Empower others
good training                                 to act

7. Improve             Bargaining stage       Plan for and create
functionality,                                short-term wins
when possible

8. Acknowledge         Bargaining stage       Plan for and create
competing                                     short-term wins
priorities

9. Allow time to       Depression stage       Consolidate
adapt                                         improvements
                                              and produce still
                                              more change

10. Promote a          Acceptance             Institutionalize
better, but            stage                  new approaches
changed, future

EHR Deployment           Representative Quotations Characterizing
Strategy               Recommended Facilitator of EHR Implementation

1. Manage              * "And I just ... I guess someone needs to
expectations           sit them down and sort of say, 'The party's
                       over,' in a way. You kind of have to."

                       * "... try and set expectations as much as
                       you can upfront."

                       * "... building an understanding of what it
                       really is going to take I think is really
                       essential."

2. Make the case       * "There is a vision that people just buy
for quality            into that it's better if it's an electronic
                       record. It's more accessible, there are
                       alerts for safety and you can make sure
                       people get their mammograms and get their
                       whatever blood tests for diabetes and
                       whatever else you need to remind them to do
                       and remind the doctors to do."

                       * "The Institute of Medicine Report says
                       we're killing people, we've got to get on
                       this."

                       * "I'm trying to help improve the quality of
                       care given to the patients and if you have to
                       go abstract paper charts, it's just not going
                       to get done."

3. Recruit             * "Managing the culture, it is what it is.
champions              The most you can do is find, like a good
                       physician champion, find a strong practice
                       leader."

                       * "The key role there was to identify
                       physician champions: physicians who were
                       incredible individuals but who also knew that
                       the status quo was unacceptable ... And to
                       develop additional physician champions to
                       help provide the leadership to get there for
                       all the doctors."

4. Communicate         * "There is a vision that people just buy
                       into that it's better if it's an electronic
                       record. It's more accessible, there are
                       alerts for safety and you can make sure
                       people get their mammograms and get their
                       whatever blood tests for diabetes and
                       whatever else you need to remind them to do
                       and remind the doctors to do."

                       * "You can't deny that because you're not
                       making their j ob easier, and you're not
                       saving them time."

                       * "Any major change requires a
                       communication."

5. Acknowledge         * "It was a painful transition and some of
that it is a           that might be because it's just hard to go
painful transition     from paper charts to electronic no matter
                       what you do."

                       * "So don't even try to sell that
                       [efficiencies gained argument] out of the
                       door because the first 6 months are so
                       painful ..."

                       * "They just complain, you know. But they
                       will never, they never regret it. They always
                       say it's great but they just go kicking and
                       screaming through the whole thing."

6. Provide             * "We'll give you a great experience and in
good training          fact we'll throw in ... we threw in some CMEs
                       and a briefcase and stuff like that ..."
                       "We'll give you this great stuff and you have
                       to turn around and use it and then we're
                       going to reinvest in you whether you like it
                       or not."

                       * "When you're training this, you're teaching
                       several things: you're teaching new software,
                       you're teaching new workflow, and you're
                       dealing with all their anxieties about their
                       job, their own personal abilities to learn
                       this, their fear of losing their job."

                       * "One of the things that we have learned is
                       that sometimes we need to go and give
                       computer training to people before we even
                       start the EMR. We have to have the trainers
                       go out and show them how to use a mouse and
                       show them how to you know, do things like
                       that."

7. Improve             * "Once you're in it and they're going
functionality,         through all that pain, you're trying to show
when possible          them little things to improve it."

                       * "It just may not be possible to create
                       smart phrases for some of the messy
                       psychosocial issues that we deal with in
                       primary care. But some of them could be
                       created I think."

                       * "Despite my own frustrations with the speed
                       of our current system and the mistakes that
                       that then causes, I think it is still a good
                       step in the right direction."

8. Acknowledge         * "You know people are already doing multiple
competing              things and have multiple responsibilities and
priorities             so they totally ... it's very hard to explain
                       to them how much time and energy it's going
                       to take to do an ambulatory implementation
                       and so they really need to understand what
                       that commitment is."

                       * "Just because we changed to an electronic
                       environment, doesn't mean the rest of the
                       world did. So you're living in a partially
                       electronic world, you're living in a
                       partially paper world."

                       * "They have a life and a job that they want
                       to do, don't make them decide. You know what
                       I mean? Because they chose health care, they
                       didn't choose technology. So come in ... and
                       work with them!"

9. Allow time to       * "Get comfortable with that and then we'll
adapt                  add other things."

                       * "You can frame it that this is about the
                       system of care, it's how we take care of
                       patients, not about just you and making your
                       life miserable with this one little piece so
                       you feel a little bit better about it."

                       * "And recognize, tell them that upfront:
                       this is a significant change in how you work
                       and don't expect to do it tomorrow. Don't get
                       angry that you can't operate this way. It'll
                       take time."

                       * "It wasn't a, 'let's look at the data
                       coming out of it at the same time' that was
                       more of a well, when we get to that it'll be
                       just gravy."

10. Promote a          * "It touched every individual in the
better, but            organization and changed every process.
changed, future        Everything that was always done by paper and
                       how we've done it and documented it and
                       reported on it and all of the metrics that we
                       used and all the ways we did it touched
                       literally every individual."

                       * "Today, you couldn't go backwards. You
                       could not take the system out of there.
                       People are used to it. They can't imagine not
                       having the benefits of the electronic medical
                       record like you can find the chart. You can
                       work from home. Patients can self-schedule or
                       get prescriptions renewed electronically. I
                       mean all the benefits that are there for the
                       physicians. You just can't go back."

                       * "I don't know how you can practice medicine
                       in the 21st century without electronic
                       medical records. I don't know how you can
                       practice safe, cost-effective medicine
                       without this tool."
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Title Annotation:RESEARCH ARTICLE
Author:McAlearney, Ann Scheck; Hefner, Jennifer L.; Sieck, Cynthia J.; Huerta, Timothy R.
Publication:Health Services Research
Date:Apr 1, 2015
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