EHR Best Practices And Challenges

16 LORENZI, RILEY, Managing Change

Review Paper n

Managing Change: An Overview

NANCY M. LORENZI, PHD, ROBERT T. RILEY, PHD

A b s t r a c t As increasingly powerful informatics systems are designed, developed, and implemented, they inevitably affect larger, more heterogeneous groups of people and more organizational areas. In turn, the major challenges to system success are often more behavioral than technical. Successfully introducing such systems into complex health care organizations requires an effective blend of good technical and good organizational skills. People who have low psychological ownership in a system and who vigorously resist its implementation can bring a ‘‘technically best’’ system to its knees. However, effective leadership can sharply reduce the behavioral resistance to change—including to new technologies—to achieve a more rapid and productive introduction of informatics technology. This paper looks at four major areas—why information system failures occur, the core theories supporting change management, the practical applications of change management, and the change management efforts in informatics.

n JAMIA. 2000;7:116–124.

It’s not the progress I mind, it’s the change I don’t like. —MARK TWAIN

Along with the inevitable failures, medical informat- ics has had many successes—probably more than should have been expected, given the challenges of the hardware, software, and infrastructure that faced us in the past. However, many of the successful sys- tems were implemented as stand-alone systems that involved a modest number of people. Furthermore, the systems were often implemented in specific, lim- ited areas that could see potential direct benefits from

Affiliations of the authors: University of Cincinnati, Cincinnati, Ohio (NML); Riley Associates, Cincinnati (RTR).

This paper was the basis of a presentation by Dr. Lorenzi that was part of the Cornerstone on Managing Change, one of four Cornerstone sessions included in the program of the AMIA An- nual Fall Symposium, Washington, DC, November 6–10, 1999.

Correspondence and reprints: Nancy M. Lorenzi, PhD, Univer- sity of Cincinnati Medical Center, P.O. Box 0663, 250 Health Professions Building, Cincinnati, OH 45267-0663. e-mail ^lorenzi@uc.edu&.

Received for publication: 11/1/99; accepted for publication: 11/18/99.

the systems. Typically, there were local champions, who made major and personal commitments to the success of the systems, and the enthusiasm of these champions was readily transmitted to the people with whom they worked directly. In turn, most of the peo- ple working on these systems felt like pioneers, and the literature of medical informatics is filled with their accomplishments.

When we embark today on designing, developing, and implementing more complex systems that have wider impact, a new set of challenges looms even larger. Certainly, technical challenges still exist; they always will. However, as our new systems affect larger, more heterogeneous groups of people and more organizational areas, the major challenges to systems success often become more behavioral than technical.

It has become apparent in recent years that success- fully introducing major information systems into complex health care organizations requires an effec- tive blend of good technical and good organizational skills. A ‘‘technically best’’ system can be brought to its knees by people who have low psychological own-

Journal of the American Medical Informatics Association Volume 7 Number 2 Mar / Apr 2000 117

ership in the system and who vigorously resist its im- plementation. The leader who knows how to manage the organizational impact of information systems can sharply reduce the behavioral resistance to change, in- cluding to new technology, to achieve a more rapid and productive introduction of information technol- ogy.

Knowledge of the significance of people and organi- zational issues is not new. One of our informatics pi- oneers, Octo Barnett, identified political and organi- zational factors as being important 30 years ago.1

However, given the realities of that era, they were ‘‘well down the list.’’ By 1998, Reed Gardner, another definite pioneer, stated in his Davies Lecture2:

In my opinion, the success of a project is perhaps 80 percent dependent on the development of the social and political interaction skills of the devel- oper and 20 percent or less on the implementation of the hardware and software technology!

We are seeing a shift in the balance of the people and organizational issues as opposed to the technical is- sues. An effective medical informatics change strategy can help convert what health care organizations are experiencing today—technology-centered tension— into welcomed opportunities that will lead to im- provement in all phases of the health care process.

The content that supports both the intellectual content and strategy for this cornerstone comes from multiple disciplines, e.g. psychology, sociology, management, and anthropology. This paper discusses four major topics—why information system failures occur, the core theories supporting change management, the practical applications of change management, and the change management efforts in informatics.

Why Do Information System Failures Occur?

If only it weren’t for the people, those awful people, al- ways getting tangled up with the systems. If it weren’t for them, the health care area would be an informati- cian’s paradise.*

Complex problems rarely have simple solutions. Dur- ing the many stages of the solution process, there are numerous opportunities to go wrong, whether the so- lution tends to be a technical one or not. As we delve

*Paraphrased from Kurt Vonnegut, Jr., in Slaughterhouse-five: ‘‘ ‘If only it weren’t for the people, the goddamned people,’ said Finnerty, ‘always getting tangled up with the machinery. If it weren’t for them, earth would be an engineer’s paradise.’ ’’3

into increasingly complex medical informatics prob- lems, we will increasingly face this challenge. In reviewing information system failures cited in the lit- erature as well as drawing on our personal observa- tions and experiences, we have seen the rising impor- tance of the human issues that are often referred to as people and organizational issues.

Table 1 presents a categorized overview of the reasons for contemporary failures in implementing major in- formation systems. There is typically no one single cause in a given case. In fact, a snowball effect is often seen, with a shortcoming in one area leading to sub- sequent shortcomings in other areas. No precise sta- tistics exist for the relative importance of the causes; however, personal observation tells us that the two most important are communications deficiencies and the failure to develop user ownership.

Change and Change Management

Technology has indeed taken a place next to war, death, divorce, and taxes as a prime cause of bone-shuddering anxiety.—JOHN SEYMOUR

Change is a constant in both our professional and our private lives. Our children grow up taking for granted such things as powerful personal computers that we could not envision at their ages. The idea that human beings naturally resist change is deeply embedded in our thinking about change. Our language (e.g., ‘‘re- sistance to change’’), our assumptions, and our mental models about change all seem to imply that some- thing in our natures leads us to resist change. How- ever, it is easy to find examples of human beings, from childhood on through old age, actively seeking out change of all sorts. Human beings do not…