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For other articles and previous issues click here. March 8, 2004 Change
Management: A Critical Factor in EMR Implementation According to Harvard Business School professors Michael Beer and Nitin Nohria, PhD, 70% of all change initiatives fail. They attribute this failure rate to the way in which organizations approach change. Their research indicates that organizations, based on their culture, choose an “either-or” approach. Some organizations choose an approach that tries to create a quick return on investment based on economics. Others approach change in an open, trusting culture based on results over time. While the professors recommend a blend of the approaches as most effective, some organizations do not consider change management strategies as part of the transition to the electronic medical record (EMR). Business strategist Peter Senge says, “People don’t resist change. They resist being changed!” Moving to an EMR requires a change in employee attitudes and behaviors. Healthcare organizations that address change management issues and help their users prepare for the impact of an EMR may increase their odds of being part of the 30% who complete successful change initiatives. What is change management? Jeff Hiatt, author of The Employee’s Survival Guide to Change, and Tim Creasy, editor of the Change Management Learning Center, define it as “the process, tools, and techniques to manage the people-side of business change to achieve the required business outcome and realize that business change effectively within the social infrastructure of the workplace.” They also recognize that the term change management takes on a variety of meanings for different organizations. Affecting behavior is a critical success factor in the implementation of an EMR. The implementation team must assign someone to work with potential users in the planning and design stages to ensure that the people who are supposed to use the system actually understand the process and will, in fact, use it. Everyone has heard horror stories of EMR implementations with physicians who are not consulted during the design and planning phases but are then expected to use the system when it goes “live.” For all of the talk about change management, many organizations do not address it in a formal way during the transformation from paper records to an EMR. Park Nicollet Health Services in St. Louis Park, Minn., took a strategic, formal approach, providing change management initiatives as part of the implementation of the IDX LastWord enterprise clinical system. Linda Bauermeister, director of organizational change management, led an effort to gain clinician buy-in throughout the process. Park Nicollet implemented clinician order entry and online medication administration as part of an initiative to create a lifetime EMR. The initiative has a second phase targeting online prescribing at ambulatory clinics and incorporating scheduling and administrative information into the IDX LastWord system. According to Bauermeister, “This was a massive process change, and we approached it in phases.” Park Nicollet is a large, integrated care system with more than 6,000 employees, featuring Methodist Hospital, a 426-bed facility; Park Nicollet Clinic with 25 locations throughout the Twin Cities; Park Nicollet Foundation; and Park Nicollet Institute. Goals for phase 1 of the implementation included visit planning to provide clinicians with information about other services a patient might need while in Park Nicollet’s care. For example, Bauermeister explained that if a patient was in for one service and a physician noticed she was overdue for a mammogram, it could be scheduled during that time. Phase 1 also included combining the clinic information with hospital information, patient tracking, and notification of the patient’s arrival to clinic staff. “There were classes and preclass sessions to help ensure that staff understood the workflow. For some employees, we offered basic computer training because they didn’t feel comfortable operating a computer,” says Bauermeister. Before her team attended any classes, Bauermeister says the most important training element was to develop an infrastructure for change that was connected with the operations. “One of the most important elements in the implementation was the involvement of senior management, and I think some organizations gain senior management’s support but don’t get them involved,” she explains. The approach at Park Nicollet addressed organizational needs, but it also concentrated on the individual needs of the people being affected by the change. “We tried to make the classes convenient,” Bauermeister says. “Classes were at the hospital or clinic, and people didn’t have to worry about getting to a class. The classes came to them. We had ‘super-users’ in most areas, and if a person had problems using the system, they called them first.” The clinician super-users champion the system during unit-by-unit rollout. Operational people were subject matter experts and their phone calls went to a specific person at the help desk. Bauermeister estimates that 500 calls were averted from the help desk because an infrastructure was put in place to help individuals feel successful working with a system. “The clinic implementation went smoothly by the end of the first week,” she says. Impact sheets were created for 98 different job categories. This tool explains how the online medication administration or clinician order entry would affect specific individuals and their roles. “It was just an 81/2 X 11 piece of paper on which a process was explained along one side, and it mapped out a ‘before and after’ of how the system impacted how a [particular] person approached his or her work,” Bauermeister says. “The impact sheets were part of the effort to individualize the experience and look at it from different points of view.” There were also employees designated as “resistance busters”—usually a peer or someone with a similar role in another part of the system. They worked with individuals who were having a tough time adapting to the new environment. According to Bauermeister, Park Nicollet’s team reviewed all angles of change management beyond just training. “We tried not to look just at the application,” she says. “We considered communication, rewards, and consequences, and created an infrastructure during the process to make this comprehensive.” The staff’s commitment to change management is demonstrated in the success of the phase 1 implementation. Phase 2 will include more functionality for documentation and the implementation of a phone module application, among other enhancements. Making the transition to an EMR requires individual behavior changes that many organizations do not take the time to address. According to Michael Hammer, PhD, president of Hammer and Company and coauthor of Reengineering the Corporation: A Manifesto for Business Revolution, organizations should “sell” their employees on change. Hammer explains that innumerable technology projects fall short of their goals because organizations failed to grasp this marketing reality. In the great majority of these cases, the critical problems weren’t technical. The hardware was capable, the software was adequate, and the network capacity was sufficient. However, the systems sank anyway because leaders introduced major change, and those who were affected rejected that change and the systems that went with it. Hammer recommends the use of sales and marketing strategies that include communicating, building a brand, and educating individuals to cope with change. The Park Nicollet resistance busters acted as a sales force for process change as well as champions of the new system. Using the organization’s marketing savvy as a way to engage employees in change may be a new way of thinking. Ideally, employees would see the benefits of an EMR and be delighted to adopt leading-edge technology that improves patient care. However, research indicates that employees are often resistant to change, and even when the change supposedly helps a person perform his or her job, it is nevertheless difficult to accept. The most common reasons employees resist change are concerns about learning something new, concerns about their ability to adapt to a new system, and fear that the EMR requires more effort than the old system. Some individuals have a low tolerance for change, even when they agree with the concept. Surprisingly, there are times in the EMR implementation when resistance to change can actually be helpful. An implementation team member may introduce information that the planning team or consultants are not aware of in the system design. Because this employee is closest to the process, he or she understands how it is performed and resists the implementation, knowing it will not work. There is a place for positive resistance throughout the selection, planning, designing, and implementation process. Insightful and well-intended criticism, debate, and disagreements are not necessarily counterproductive. In many cases, the employee may be trying to introduce additional options and solutions or a better understanding of the process. Some people view change as an opportunity while others view it as a problem. It’s important to note that it’s not a manager’s role to try to alter an employee’s outlook. What an organization can provide is a thoughtful strategy for change management that fits the work culture and environment. Commitment to change must include the budget and resources to make it work. Communication is important throughout the process because without a formal system, rumors will become the source of information. The communication cannot be intranet-based if all employees do not have computer access. Training must be convenient and regularly scheduled to include everyone. During training and other group meetings, it is important for management to diffuse negative comments without being defensive or it will prevent further discussion even if others have positive comments. Senior executives—including, whenever possible, the CEO—must be involved to demonstrate their own commitment and seriousness to keeping the EMR transition moving forward. It will also impress upon everyone in the organization that they are personally invested in seeing the project through to completion. Supervisors and managers have important roles to play as well because they’re the established lines of communication within the organization. If they don’t advocate a change, it will not happen. Senior management must also be able to educate employees on what the EMR means to the organization in terms of better patient care, efficiency, competitiveness in the market, and compliance. Employees will not support what they don’t understand. Some employees may give blind compliance as opposed to informed commitment. Merely getting people to follow orders isn’t the same as winning their full support. In a large-scale change, such as an EMR implementation, employees need to understand the project’s vision and their individual role before they can help make it happen. If the observations of Beer and Nohria are correct and 70% of all change initiatives do indeed fail, it is worth the time and money to be part of the other 30%. — Brenda L. Johnson, SPHR, is an Indianapolis-based writer, consultant, and public speaker. She can be reached through www.4innovations.com. — Valerie R. Davis, RHIA, is the director of health information and records at Provident Hospital of Cook County, Ill. |
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