While managing change is often challenging, the process is critical to the development of any organization. This requirement especially concerns healthcare facilities as the outcome of successful implementation of innovative approaches carries the potential for improving patients’ health and an increase in their satisfaction level. The present paper will include a review of literature related to success factors in change management, paying particular attention to Kotter’s change model. Much of the review will be dedicated to the challenges and opportunities of implementing EHRs.
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Change Management in Healthcare
Analysis of change management in healthcare is predominantly reflected in books or book chapters focused on strategic planning and organizational change. A book by Ginter, Duncan, and Swayne (2013) provides a general explanation of a strategic management system. The researchers dedicate one chapter to an assessment of strategic choice as a crucial component of management (Ginter, Duncan & Swayne 2013), noting the importance of evaluating possible options and implementing change in the case when a company perceives that it is losing its competitiveness and is not providing the necessary quality of services. The scholars also remark that managers should have an excellent understanding of the external environment to come up with successful change initiatives. Also, Ginter, Duncan, and Swayne (2013) note that a productive culture for organizational change should include the establishment of self-managed teams, a preference for simple rather than complex systems, a focus on the goals rather than the process and other features. Moreover, the authors emphasize that managers should not worry excessively about solutions, which are subject to frequent change. In these discussions, the book helps to identify the major aspects of change management.
Two other sources included in the review are primarily focused on change management (Hayes 2014; Matos & Clegg 2016). Hayes (2014) discusses such aspects of managing change as models and patterns while also paying particular attention to the recognition of the need for change. As Hayes (2014) notes, opportunities for change can be found not only in the external but also in the internal environment. Thus, this author’s views are contingent with those expressed by Ginter, Duncan, and Swayne (2013) who consider the environment a major trigger for change. In their analysis of the need for change, Matos and Clegg (2016) also pay due tribute to the role of the environment in this area. However, the latter authors argue that sustainability occupies a crucial place in the process of change management. Matos and Clegg (2016) mention that this factor should be given a high priority by any organization that is striving to improve its services. Therefore, it is possible to conclude that different scholars agree on the point that change management should be accompanied by a careful analysis of the external environment.
In chapters by Austin, Bentkover, and Chait (2016a; 2016b), the authors reflect on the role of management in healthcare. In their analysis of the need for change in the modern healthcare system, these scholars argue that the process as it stands is illogical. Austin, Bentkover, and Chait (2016a) remark that much information is being gathered with the help of modern technological advancements with no guarantee that these data will be supplied to the right people at the right time. Another aspect of the system’s deficiencies is that the healthcare economy is ‘chaotic’ (Austin, Bentkover & Chait 2016a, p. 18). Specific spheres requiring change, according to these authors, are healthcare organizations, delivery, and financing. With this view in mind, implementing EHRs is a crucial component of the change process.
Following Matos and Clegg (2016), Austin, Bentkover, and Chait (2016b) also support the idea that change management should involve sustainability. In particular, the scholars remark that in healthcare organizations, a major change strategy is creating a sustainable competitive impact (Austin, Bentkover & Chait 2016b). Low quality of healthcare services is regarded as a main obstacle in the modern healthcare system in the US. Thus, scholars believe that innovations in this area, such as EHRs, will promote better regulation of the services that healthcare organizations provide.
Kotter’s Change Model
Of all the available models of change implementation, the most widely-recognized and popular is Kotter’s model. This approach incorporates eight stages (Pollack & Pollack 2014; Small et al. 2016). These follow a logical order:
- creating a sense of urgency,
- forming a guiding coalition,
- developing the strategy and vision,
- communicating the change vision,
- empowering the change,
- generating quick wins,
- expanding on the change and
- institutionalizing the change (Small et al. 2016).
Some regard Kotter’s change model as highly efficient, but others have also criticized its ideas (Pollack & Pollack 2014). Some scholars argue that while the approach explains what is to be done, its author does not provide sufficient data on how to implement the necessary changes (Pollack & Pollack 2014). At the same time, others believe that no theory or model can be self-sufficient and that it is impossible to come up with a single solution to all problems (Pollack & Pollack 2014). Therefore, the present work will employ Kotter’s model as a positive example of change.
When implementing EHR, Kotter’s change approach will be useful since it involves distinct stages, each of which can help in promoting positive change. A modified version of Kotter’s model can be used in this case. As suggested by the ONCHIT (2016), a three-phased approach to managing change includes the following stages: (1) ‘creating a climate for change’, (2) ‘engaging and enabling the organization’ and (3) ‘implementing and sustaining the changes’ (p. 1). The reason for arranging a multi-step model is that its author believes that any change incorporates not only situational but also emotional components, thus requiring thorough and detailed consideration (ONCHIT 2016). It is noted that to make the process of implementing EHRs easier, the following issues must be understood by each member of the organization:
- reasons why the current state is not acceptable;
- reasons why the future state will be more suitable both for the organization and its patients;
- alterations that should be made in workflows;
- new skills and technologies that should be employed;
- methods by which employees will gain knowledge and learn new skills (ONCHIT 2016).
Implementing an EHR: Critical Success Factors
Change Management and EHR Adoption
Many scholars have dedicated their efforts to investigate the process of adopting EHRs in healthcare settings. Sinha et al. (2013) offer an extensive analysis of the standards, frameworks, and infrastructures involved in the process of implementing EHRs. Baumann, Baker, and Elshaug (2018), Charles, Gabriel, and Searcy (2015), and Nguyen, Bellucci, and Nguyen (2014) examine the effect of EHR adoption on different aspects of healthcare facilities’ work. The ONCHIT (2016) discusses change management in EHR implementation.
In their analysis of EHR implementation during the period 2008–2014, Charles, Gabriel, and Searcy (2015) remark that the primary demand for EHRs is that they meet specific functionality and security expectations, as well as the technical requirements set by the Department of Health and Human Services. The authors note that the use of EHRs has sufficiently increased since the introduction of this technology in the U.S. healthcare system (Charles, Gabriel & Searcy 2015). In 2014, almost all hospitals in the United States owned a certified EHR system. The growth in EHR use has caused a rise in overall technology adoption by hospitals (Charles, Gabriel & Searcy 2015). The ONCHIT primer on EHR implementation further discusses the process of introducing innovation and suggests dividing change implementation into three phases (ONCHIT 2016). In particular, recommendations include creating a suitable climate for change, engaging the participants, and introducing and promoting change. In addition to these steps, the ONCHIT (2016) offers advice on preparing the change process and analyses the influence of this process on an organization’s workers.
For a healthcare organization, it is crucial to engage all stakeholders in change implementation. Thus, the ONCHIT (2016) explains how to encourage meaningful patient engagement in addition to employee participation. It is also noted that some supplementary measures can be taken to support the successful use of EHRs in healthcare facilities. According to the ONCHIT (2016), such new care models as patient-centered medical homes and alternative payment approaches can be of great help. Nguyen, Bellucci, and Nguyen (2014) also investigate additional factors involved in the process of introducing EHRs, as well as the positive and negative implications of this process. The authors note that EHR technology has a positive impact on the arrangement of clinical documentation and providing patient care. Such aspects as enhanced administrative efficiency, upgraded quality of documentation, and better coordination and quality of care are established as the most positive outcomes of EHRs (Nguyen, Bellucci & Nguyen 2014). Data quality factors that can be reached with the help of EHRs, as outlined by Nguyen, Bellucci, and Nguyen (2014), include accuracy, availability, legibility, data overload management, and completeness.
Baumann, Baker, and Elshaug (2018) provide insight into the effect of EHRs on clinical documentation time frames, remarking on the considerable effect produced by the use of EHRs on the time it takes healthcare professionals to perform their duties. Having analyzed several articles focused on EHR use, the scholars conclude that documentation time generally increases when EHRs are employed (Baumann, Baker & Elshaug 2018). However, it is noted that as employees become more familiar with the system, they can work more quickly with it. This conclusion correlates well with research by the ONCHIT (2016) that proposes using several phases for better implementation of an EHR. By paying more time to educate their staff, hospital managers are more likely to reach the goal of increased time efficiency.
The source by Sinha et al. (2013) is a substantial investigation of EHR use. The authors outline the following aspects of EHRs’ significance: efficiency in complex environments, ease of maintaining patients’ health data, improved patient care and its quality, eliminated healthcare costs, increased safety, and promotion of effective medical practices (Sinha et al. 2013). When identifying the factors influencing EHR implementation, Sinha et al. (2013) single out the following: crucial changes in hospitals’ workflow, unique identification, security and privacy, consistent application of standards, interoperability, legal and ethical concerns, and additional costs. Thus, it is possible to conclude that all the authors here consider EHRs to be a positive change in healthcare settings that can lead to many crucial adjustments. At the same time, the scholars admit that some additional help and guidance is needed for the most successful EHR implementation.
Major Considerations for the Successful Implementation of EHRs
Benefits and success criteria for EHR introduction and use are discussed in articles by Ancker et al. (2013), Cresswell, Bates, and Sheikh (2013), Fritz, Tilahun, and Dugas (2015), and King et al. (2013). A book by Bercaw, Knoth, and Snedaker (2018) presents an analysis of care optimization due to the use of EHRs. Cresswell, Bates, and Sheikh (2013) suggest considering the following ten aspects when implementing health information technology:
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- clarifying the problematic issues that the technology will help to manage;
- creating a consensus;
- considering the organization’s options;
- selecting affordable systems that meet the facility’s needs;
- designing an appropriate plan;
- paying attention to the infrastructure;
- training employees;
- assessing progress constantly;
- maintaining the system;
- keeping to the selected course.
The authors note that by observing these considerations, healthcare facility managers will be able to gain the desired change and reach positive outcomes (Cresswell, Bates & Sheikh 2013). This opinion is relevant to the subject of EHR implementation because this technology involves a variety of requirements. In their analysis of the clinical advantages of EHRs, King et al. (2013) also emphasize the need for a systematic approach when introducing and maintaining the use of EHRs. As a result of their investigation, the scholars conclude that 78% of doctors reported improved patient care overall due to the use of EHRs (King et al. 2013). Another benefit of this technology, according to King et al. (2013), is that 81% of physicians can access their patients’ charts remotely. Furthermore, in 65% of cases, EHRs have helped doctors to prevent a potential medication error (King et al. 2013). In general, research by King et al. (2013) indicates that between 30% and 50% of doctors relate the use of EHRs to clinical benefits associated with better care provision.
While the previously analyzed scholarly works are focused on the advantages of EHR use, studies are also available that concentrate on the success criteria necessary in the implementation process. Ancker et al. (2013) remark that a major factor associated with the beneficial introduction of EHRs is the size of the healthcare facility. Other crucial criteria, according to these scholars, include the number of providers, the location of the organization, the number of patients in general, and the number of uninsured and Medicaid customers. Also, Ancker et al. (2013) emphasize that the following issues play an important role in EHRs’ success in a facility: experience with software, the time of enrolment, and the choice of an EHR practice approach. Ancker et al. (2013) remark that the success of the implementation can be enhanced through the inclusion of federal programs.
Another article defining success criteria was written by Fritz, Tilahun, and Dugas (2015). First, the authors outline seven categories for establishing success or failure criteria: ethical, organizational, financial, political, functionality, technical, and training (Fritz, Tilahun & Dugas 2015). Second, the scholars identify those factors that are most frequently mentioned in academic literature: functionality, along with organizational and technical issues. They also note that the category of functionality incorporates the possibility of handling various types of data with the help of EHRs (Fritz, Tilahun & Dugas 2015). In terms of organizational criteria, the majority of issues are related to human resource management, employees’ skills, and commitment. Finally, the scholars remark that the attitudes of healthcare workers towards the use of EHRs play a highly significant role in the implementation’s success.
In a book by Bercaw, Knoth, and Snedaker (2018), the possibilities of optimizing care with the help of EHRs are described. The authors remark that the first consideration is that innovation should offer a benefit for patients. Second, the implementation should help to arrange a more positive working environment for healthcare employees. In particular, existing methods of data collection tend to lead to burnout for nurses, whereas the introduction of innovative EHRs can mitigate this problem (Bercaw, Knoth & Snedaker 2018). Moreover, the scholars emphasize that the implementation of an EHR system can lead to a considerable improvement in patient outcomes. Therefore, it can be concluded that numerous success factors are involved in EHR establishment. Along with these are many benefits that organizations can gain if they implement the program successfully.
Challenges in the Process of EHR Adoption
Along with several advantages brought by an EHR system, some barriers to its adoption must also be considered. Adler-Milstein et al. (2015), Ajami and Bagheri-Tadi (2013), Heisey-Grove et al. (2014), and Nguyen, Bellucci, and Nguyen (2014) analyze these obstacles in their studies. The main issues that these authors have noted as occurring in the implementation process include the following: time, cost, lack of computer skills, workflow disruption, problems in patient-doctor relationships, interoperability, complexity, the need for additional training, and the lack of physical space (Ajami & Bagheri-Tadi 2013; Nguyen, Bellucci & Nguyen 2014). Research by Adler-Milstein et al. (2015) also identifies financial costs, both upfront and ongoing, as a major complication in the process of EHR adoption. Also, the scholars mention that the complexity of corresponding to the meaningful-use criteria and the attainment of physician cooperation constitute other significant challenges. Research by Heisey-Grove et al. (2014) indicates that administrative issues and provider engagement can cause problems for organizations that are adopting EHRs. All scholars note that despite the existence of these obstacles, healthcare facilities can mitigate potential problems by using appropriate methods and relevant management techniques.
Adopting new technology presents a challenging but rewarding step in any organization’s development. The present review of literature offers an analysis of research findings obtained by many scholars that have investigated change management in general and the implementation of EHRs in particular. It has been concluded that the EHR introduction in healthcare organizations offers both benefits and limitations, but the former significantly outnumber the latter. The major advantages of EHRs are a decreased number of medication errors and an enhanced patient satisfaction level. The biggest disadvantages concern the cost of new equipment, along with the need for training and the time involved in implementation. Taking into consideration the critical factors outlined by scholars will allow the successful implementation of EHRs.
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