Section 2.6 Plan
Change Management
This overview describes change management, including change stages, transformation, agents of
change, and possible barriers to making changes in your local public health (LPH) department as you
adopt electronic health records (EHR), health information exchange (HIE), and other health
information technology (HIT).
Time needed: 4 hours
Suggested other tools: NA
Introduction
Change is one of the most difficult behaviors to affect. While few people are willing to articulate
why change is so difficult for them on a personal level, change is frequently viewed as shifting the
balance of power. Even if this is never articulated, no one likes giving up control. An impending
change such as adoption of EHR and HIE often results in fear, resistance, and sometimes even
sabotage.
How to Use
Use this tool to learn about change management strategies. Use the force field analysis tool,
described below, to have a discussion about these issues with your staff and prepare for the changes
that new HIT may bring.
Stages of Change
As health professionals know well, there is no magic wand available to affect change. Some studies
suggest that change requires progression through stages, such as the five stages of the grieving
process in death (denial, anger, bargaining, depression, and acceptance), where loss of the familiar
paper and pen are often accompanied by denying the need to learn to use a computer, becoming
angry with those requiring use of HIT, seeking incentives or other means of getting something in
return, becoming depressed about one’s own inadequacies, and ultimately accepting that this is the
way of the future.
Several studies support the idea that change requires pre-contemplation, contemplation, preparation,
action, and maintenance—often over a fairly significant amount of time, or at least more time than is
often devoted to HIT acclimation. Other change management experts describe a process that entails:
unfreezing old habits by pointing out deficiencies in paper records and the value of the new
technology in improving productivity, decision-making, and quality of services provided; making the
change through engagement, education, training, and support; and then refreezing the change into
new habits through continual reminders, reinforcement, enforcement, support, and celebration of the
new technology’s results.
All of these suggest a common theme—that change is complex and people progress through multiple
stages before real change occurs.
Practice Transformation
Practice transformation ultimately means changing the practice of medicine in order to improve the
quality, experience, and cost of health care. Clinical transformation can be achieved without HIT, but
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generally is improved with use of HIT—and EHR and HIE in particular. Regulations, staffing,
reimbursement, cost, malpractice, report cards, and other issues have catapulted organizations to seek
a significant revamping of their workflows and processes to meet new requirements and mandates,
recruit and retain good staff members, optimize reimbursement, reduce waste, reduce errors, and
address public concerns. Quality of care, experience of care, and cost are now at the forefront of all
health care organizations’ concerns.
Clinical transformation suggests some hallmarks that are different from previous approaches to
changes in health care organizations:

Clinically-focused. Changing the practice of medicine requires new approaches that engage
patients so they share in clinical decision making. New models of care are needed to focus on
patients’ needs. Care must also be evidence-based. Providers must be keep current with the
massive amount of new information that is continuously available (to providers and patients
alike) and use such evidence to work with patients to making decisions.

Integrated. In the very near past, financial, administrative, and operational/departmental
processes were not integrated with clinical processes. To this day, very few hospitals can tell
a mother how much it will cost to deliver her baby. The industry has been reluctant to take a
hard look at quality with respect to individual providers. HIT has reflected these standalone
processes, where data are retained in separate databases and are not able to be integrated and
well-aggregated to reveal the information needed to transform health care.

Comprehensive. Clinical transformation relies on having access to all information about an
individual, in relationship to clinical evidence. For example, the association between
depression and unnecessary re-hospitalization has just come to be recognized—primarily
because medical and behavioral health were often siloed. The heart failure patient was
viewed only as a “heart,” not a whole person. Formal clinical trials and other research took a
long time to produce clinical evidence, with virtually no access to experiential data that might
be more timely and responsive to rapid changes. Knowing all of a person’s health issues—
before, during, and after an episode of care—should be essential.

Knowledge-based. LPH professionals are knowledge workers and demand that processes
intended to support them be as knowledge-based as they are. Knowledge is continually
evolving and changing. But knowledge must also be trustworthy—gained by applying
experience to sufficient information.

Coordinated. LPH departments have served as care coordinators for a long time, but many
health care providers have only recently recognized this important function. It is now
understood that discharging a patient from a hospital with no follow-up results in more
avoidable re-hospitalizations. Even something as simple as a client not having transportation
for follow-up care is now recognized as everyone’s concern. In the United States, health care
has not done well transitioning patients from one provider to another, or coordinating care
across multiple specialists, or providing needed social services. Clinical transformation
requires breaking down silos and building up community.

Outcome-oriented. Clinical transformation is about achieving better outcomes. Some of the
approaches relate to the fundamental infrastructure of the health care delivery system, its
reimbursement methodologies, medical education, and other factors that cannot be changed
overnight. However, it is possible to shift the focus from process to outcomes. All
stakeholders in health care, including patients, must be accountable for outcomes.

Technology-aided. HIT has largely been on the periphery of the core business of health care.
Financial, administrative, and operational systems have been widely implemented; clinical
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systems and HIE are the next frontier. Clinical information systems focus directly on the core
business of health care—taking care of individuals’ health needs. HIT systems are recognized
as significant contributors to improving patient safety and quality outcomes, reducing costs,
and improving the individual’s health care experience – the Triple Aim goals of the Centers
for Medicare and Medicaid Services (CMS). (See also
http://www.ihi.org/explore/tripleaim/pages/default.aspx.)
Change Strategies
Change management for EHR and HIE is not only about recognizing the stages required to accept
change and the clinical transformation that is needed, but about applying strategies to support
change. One element of developing a change management strategy is to understand your
organization’s innate change management style. Every organization has some way of introducing and
requiring even moderate amounts of change. Most effective change managers recognize the corporate
culture of the organization and either work within that culture or attempt to move the organization to
a more positive culture.
One or more of the following types of change management strategies is typically found in every
organization. Although each can be effective, given the characteristics of the organization, the
general school of thought is that the most effective and longest lasting change is achieved through a
behavioral norm-based strategy.

Behavioral norm-based strategy is when behavioral norms or expectations are changed by
organizational leadership and/or external factors. An example is the promotion of EHR and
HIE because it is recognized as an important contribution to clinical transformation. There is
complete transparency in reasons why change is needed and each stakeholder wants to
continuously improve. This approach helps everyone work together to make the change
happen. Early adopters of EHR and HIE found themselves using this change management
strategy. An excellent example is found in Minnesota where the MN Community
Measurement project has contributed to competitiveness, with each clinic continuously
striving to improve.

Incentive-based strategy is one in which conformance is rewarded. This is becoming more
popular as payers have announced pay-for-performance incentives for HIT adoption. The
most prominent incentive today is the federal meaningful use of EHR incentives for hospitals
and physicians. Some experts fear that once the incentive is removed, organizations will slip
back into old ways, or that forward progress will stop.

Sanction-based strategy may be viewed as the opposite of the incentive-based strategy, where
nonconformance is penalized. Payers may introduce disincentives, such as Medicare slowing
payment of claims that are not filed using the HIPAA-required electronic transactions,
withholding some payment from hospitals that do not participate in voluntary quality
reporting, or reducing the fee schedule for physicians who do not use e-prescribing. The
federal meaningful use incentive program for EHR adoption includes sanctions for not
adopting EHR by the specified date, although there is concern that some physicians will opt
out of the program, believing that its value does not offset the costs and effort needed to
achieve the requirements. (http://www.ihealthbeat.org/articles/2013/12/23/concern-growsabout-doctor-offices-opting-out-of-meaningful-use). ¹
__________________________________
Minnesota Community Measurement.
http://mncm.org/
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
Adoption-based strategy is one in which happens over time and voluntarily, such as giving
staff the option of whether they will use an EHR to document their assessments and notes.
This type of strategy may sometimes be useful, but with today’s focus on clinical
transformation and the need for health reform, most organizations find they do not have the
time or resources to accommodate it. The strategy essentially requires running dual
processes—paper records and electronic records—until everyone decides to adopt the new
technology. Such a strategy is costly and results in a hybrid record environment that not only
is confusing but potentially poses client safety issues.
Agents of Change
Another key strategy in managing change is to recognize that the administrator, project manager, or
IT staff is not the sole change agent. In fact, everyone involved in the process of HIT adoption needs
to be a change agent. Discussing the skills that change agents need with members of the HIT steering
committee and all staff can be well worth the time. Each person involved in the HIT project may
need to reflect upon the following skill requirements and hone them for the good of the organization:

People skills are essential to understand the diversity among all individuals, skill sets, and
positions that are impacted by HIT. Effective change managers are able to listen, restate,
reflect, clarify without interrogating, draw out the quiet, quiet the verbose, channel
discussion, plant ideas, and develop trust and confidence among users.

Political skills are needed to understand the various viewpoints and counterpoints that may
arise during discussion about HIT.

System skills help organize and manage the technology while translating this into language
that users will understand and respect.

Analytical skills ensure that workflow and processes are not only understood and
appropriately improved upon, but also are used to assess and manage the financial impact of
change.

Business skills are needed to understand the underlying way the health care organization
works and the underlying clinical processes. Change agents need be able to “talk the talk”
and “walk the walk” related to their roles.
Recognizing and Responding to Resistance to Change
Reading people and preparing to respond to their concerns about change is an important task as we
all act as change agents. People react and adapt to change in different ways—from threatening to
leave to actively supporting the change. Reading reactions and responding appropriately is very
important. This is especially true for those known to be “informal leaders” or “opinion leaders” who
you want to support the change and not sabotage it. Common reactions to change and how leadership
may need to respond include:

Leaving. Some people indicate that they will retire before adopting EHR or HIE. Some can
be convinced to stay and serve the organization well if their active resistance can be
channeled into representing a resister’s viewpoint for the good of the project. However, if this
is not possible, it may be necessary to simply acknowledge these individuals’
accomplishments and let them make their own decisions.

Active resistance. In active resistance, the individuals are clear about how they feel and can
benefit an HIT project if their resistance can be channeled into representing a resister’s
viewpoint for the good of the project. Once active resisters are turned around, they can be
equally active in their support. Active resisters often do not threaten to leave, either because
they are not old enough to retire or know other organizations are also adopting EHR and HIE.
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They are easier to influence than those threatening to leave. It is important to turn them
around because their resistance can be infectious.

Opposition. A person who opposes EHR and HIE but is not overtly resistant can be the most
difficult to identify and turn around. Often this is a person who is negative about everything.
Offering counseling to such individuals can yields substantial benefits for the EHR and HIE
projects and for the individual.

Acquiescence. An individual who grudgingly accepts HIT is someone who could swing to
either opposition or acceptance. Monitor these individuals closely and involve them with
specific tasks and recognition for work well done.

Acceptance/modification. An individual who claims to accept the project but continuously
offers modifications can put a project at risk for delay or going over budget. Often, a person
with such a reaction actually opposes the project and is trying to avoid using the system or
any change it may be designed to impose. This exuberance for modifying the new system
back to old ways absolutely needs to be managed immediately.

Acceptance. A person who quietly accepts the change is certainly one to be appreciated.
However, such individuals can contribute more to the process of turning others around if they
are more actively supportive. They should be encouraged, if not called upon, to describe their
interest.

Active support. Genuinely active supporters should be greatly appreciated. Their energy and
enthusiasm should be channeled into constructive help.
Reading People
One way of both reading people and starting the change management process is to engage them in
visioning (see Section 2.3 Visioning, Goal Setting, and Strategic Planning) or to use a force field
analysis that helps everyone put driving forces and restraining forces for the EHR and HIE projects
on the table. If done in a way that is not personal, but instructive to the organization, the force field
analysis process can be revealing and help to educate everyone.
Force Field Analysis Tool
The following provides the structure for force field analysis. When using this technique, let
participants articulate driving and restraining forces themselves (see example table below). Avoid
judging any of the comments. A facilitator should record them as they are described. Capture how
people feel about the issues—not whether you think they are right or wrong. Start asking for
national/state factors driving HIT and progress down to institutional and then personal factors. This
helps participants recognize this is not focused just on them or intended to be punitive. Ask the group
to describe the strength or importance of the force and illustrate this by the length with which the
arrow extends into the Key Factors field. Repeat these steps with the restraining forces.
Next, hold a discussion about what the responses mean. Hopefully any myths that surface can be
debunked. Keep the focus positive but realistic, acknowledging risk factors to be addressed. Change
is much more likely to be accepted when perfection is not expected.
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Force Field Analysis Example (Do not include the example “forces” when using this tool.)
Copyright © 2014, Margret\A Consulting, LLC. Used with permission of author
Use the following template to conduct a force field analysis in your agency. Note, you might wish to
keep the analysis and periodically review it or even conduct the process afresh to see if change is
taking place.
Force Field Analysis Template
Driving Forces
Key Factors
Restraining Forces
National/State Factors
Institutional
Personal
Copyright © 2014 Stratis Health.
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Updated 03-10-14