Stages ofConcem for Implementing the Electronic Medical Records by Carrie Turk A Research Paper Submitted in Partial Fulfillment ofthe Requirements fur the Master ofScience Degree In Training and Development Approved: 4 Semester Credits KariDahl The Graduate School University ofWisconsin-Stout May, 2007 11 The Graduate School University of Wisconsin-Stout Menomonie, WI Author: Carrie Turk Title: Stages ofConcern for Implementing the Electronic Medical Records Graduate Degree! Major: MS Training and Development Research Adviser: Kari Dahl MonthfYear: May, 2007 Nnmber of Pages: Style Manual Used: American Psychological Association, sth edition ABSTRACT The Federal government is urging the health care industry to convert to Electronic Medical Records (EMR) in order to improve the delivery ofpatient care. This study determined the Stages ofConcerns a healthcare organization's health information management department has regarding the implementation of an Electronic Medical Record. It is difficult to utilize organizational learning and have a clear understanding ofa persons psyche. TIllS study examines change theories such as Kotter's Change Theory, Lewin's Change Process and the Stages of Concerns. These theories help guide people through the change process. The goal ofthis study is to determine how involved the health information managment department wants to be in the decision making regarding the implementation. The research also provides the Electronic Medical Records Implementation Team with data on whether the Health Information Management 111 Department has knowledge of the change, or if they will take action to learn more about the change. Using a survey based offofthe Stages ofConcern Model, the researcher was able to categorize the results and place the concerns into four different categories. The results showed that the healthcare organization has valid concerns that can be addressed by using sections from Kotter's Change Theory, Lewin's Change Process and the Stages of Concern Model. iv TABLE OF CONTENTS .............................................................................................................................Page ABSTRACT ii List ofTables vii Chapter I: Introduction I Statement ofthe Problem 1 Purpose ofthe Study '" I Assumptions ofthe Study 2 Definition ofTerms 2 Limitations ofthe Study 2 Methodology 3 Chapter II: Literature Review 4 Introduction 4 Organizational Learning 5 Organizational learning and Information Technology 5 Kotter's Eight Stepsfor Successful Large-Scale Change Process 5 Lewin's Change Process 7 Stages ofConcern Model 8 History ofthe Stages ofConcern Model 9 Limitations ofthe Stages ofConcern Model 10 The effectiveness ofthe Stages ofConcern Model.: 10 Change in Longevity's Health Information Management Department 10 Characteristics ofthe HIM Departmentpre-EMR II Expected Characteristics ofthe HIM Department Post-EMR 11 v Personal Health Records 12 Healthcare Information and Management Systems Society 12 Conclusion 13 Chapter 111: Methodology 14 Subject Selection and Description 14 Instrumentation 15 Data Collection Procedures 15 Data Analysis 16 Limitations 16 Summary 17 Chapter IV: Results................................................................................................. 18 Health Information Management Role and Years ofEmployment 18 Unrelated Concerns 19 SelfConcerns 20 Task Concerns 2I Impact Concerns 21 Concerns from the Open-Ended Question 23 Chapter V: Discussion 25 Limitations ofthe Study 25 Conclusions 25 Recommendations 26 Unrelated Concerns 26 SelfConcerns 26 Task Concerns 26 vi Impact Concerns 27 Concerns/rom the Open-Ended Question 27 References 29 Appendix A: The Survey 31 Appendix B: Survey Results 33 Appendix C: The Original Survey 34 vii List ofTables Table I: Health Information Management Role and Years ofEmployment.. 19 Table 2: Median of Unrelated Concerns- HIM Management 20 Table 3: Median ofSelf Concems- all Longevity HIM Partners and HIM Management.20 Table 4: Median ofTask Concems- all HIM Partners and HIM Management.. 21 Table 5: Median ofImpact Concerns- all Longevity HIM Partners and HIM Management. 22 Chapter I: Introduction The Federal government is urging the health care industry to convert to Electronic Medical Records (EMR) in order to improve the delivery ofpatient care. This includes implementing an Electronic Medical Record (EMR) within Longevity Health Systems Clinics. With the implementation ofthe Electronic Medical Record (EMR), the Health Information Management Department (HIM) at Health Systems will initiate a lot of changes. Statement ofthe Problem Converting from paper medical records to an Electronic Medical Record (EMR) can be very challenging. Some ofthe Health Information Management (HIM) staffat Longevity Health Systems have been filing paper charts for several decades and are unfamiliar with computers. Based on past experience, research concludes that it is important to include those who are going to be affected by the change, in the change process. Purpose ofthe Study The purpose ofthis study is to determine the Stages ofConcerns the Health Information Management Department (HIM) have regarding the implementation ofthe EMR. It will also help determine how involved the HIM Department wants to be in the decision making regarding the implementation. The research results will provide the EMR implementation team with data on whether the Health Information Management (HIM) Department has knowledge ofthe change, or ifthey will take action to learn more about the change. 2 Assumptions ofthe Study This research recognizes that not all 0 f the 29 Longevity Clinics that are included in this study have a HIM manager on site at all times. This research assumes that the HIM managers are conununicating the same information to all ofthe HIM clinic partners. This research also assumes that the different clinics will not be implementing the EMR at the same time therefore each clinic will have a HIM manager present during the implementation. It is also to be assumed that management will have detailed know ledge of the EMR implementation process and able to provide assistance. Definition orTerms Electronic Medical Record (EMR) is the "electronic version of a legal health record" and "the definition is constantly changing as the programs change (Thomas, 2006, p. 100)." It is also considered to be apart of an Electronic Health Record (Schroeder, 2006). Personal Health Record (PHR) is a "health record that is owned, updated and controlled by the patient. It may include a record of immunizations, family health history, and personal health history. It is typically web portal-based." (Thomas, 2006, p. 10I). Concerned is to be "in a mentally aroused state about something." (Hord & Hall, 2006, p. 139) Limitations ofthe Study This research is limited to site-specific criteria and cannot be generalized to other healthcare systems. This research recognizes that out of Longevity's 30 clinics, one clinic was not surveyed because the staffemployed at this clinic is union members. 3 Methodology This study uses the Stages of Concern Model to give a base line ofwhere the HIM Department is at regarding the implementation ofthe EMR. The Stages ofConcerns Model is based offofpeople's feelings and perceptions about the change process and how people's perceptions grow as the change process evolves. The Stages ofConcerns Model Instrument used in this study was revised to 28 questions. Questions one through five was added to the beginning ofthe survey and it will be sent out to both levels ofthe HIM staff. The HIM department is divided into two staffmg levels, the HIM management partners and HIM clinic partners. By surveying the different level ofpartners we hope to determine ifthere is a difference in the stages ofconcerns. The survey questionnaire also asks for the time ofemployment with in the organization. We hope to determine ifthere is a difference in the Stages ofConcerns based on time ofemployment. There is also an open ended question at the end ofthe survey to gain a better understanding ofwhat the concerns the HIM department has. 4 Chapter II: Literature Review Introduction When implementing change in a department, it is important to look at the overall picture ofthe department and have an understanding ofhow people go through change. John Kotter questions why managers fail to effectively manage change. He answers his question by explaining that "managers forget that it is not the organization that changes, but the people who are in that organization" (Gray, 2004, p. 2). Making a change in an organization means changing the behavior 0 f the people affected by the change. Changing the behavior of a single person can be extrernly difficult for an organization. If you look closly at how people react to change you can find patterns with how they react to change (Kotter, 2002). One theory on how people change is, Eight Steps for Successful Large-Scale Chage developed by John P. Kotter. Kotter's change process includes overlapping stages that people go through when encountering change in an organization. Another theory is Lewin's Change Process developed by Kurt Lewin. This theory includes three phases of the change process; unfreezing, changing, and refreezing. The Stages ofConcern Model includes seven stages that can be categoriezed into four groups: unrelated concerns, self concerns, task concerns about the change, and impact concerns. By recognizing these theories and using the Stages of Concern Model, we can gain an understanding ofhow the Health Information Management (HIM) Department at Longevity will progress through the implementation of the Electronic Medical Record (EMR) as well as people's feelings and perceptions about the change. 5 Organizational Learning An organization's ability to learn from its experiences or others experiences has been considered an essential component in helping to comprehend the reasons for success or failure (Senge, 1990; Levitt and March, 1988). Oris Ouksel and Ronald Vyheimister summarize organizationalleaming as using feedback from the enviornment in response to a specific contingency and its impact on an organizations decision making. (Ouksel & Vyheimister) Organizational Learning and Information Technology Organizationalleaming is continuous, and is needed when implementing change. Many companies have invested heavily in information technology (IT) in order to enhance their performance, and for some the investment pays off, other times it does not. Tippins and Sohi argue that organizationalleaming plays a significant role in determining the outcomes oflT. They explain that by utilizing organizational learning, organizations are in a better position to enhance their performance (Tippins & Shoi, 2003). Organizational learning has played a major role in management tool for coping with change (Gupta & Thomas, 2001). It is difficult to utilize organizational learning and have a clear understanding ofa persons psyche. Theories such as Kotter, Lewin and the Stages of Concerns help guide people through the change process. Kotter's Eight Steps for Successful Large-Scale Change Process Kotter explains, the first step in the Eight Steps for Successful Large-Scale Change Process is to "show people what the problem is and how to resolve the problem". He goes on to explain that organizations "provoke responses that reduce feelings that 6 slow and stifle needed change, and enhance their feelings that motivate change" (Kolter, 2002, p.8). One ofthe realities ofa successful team is that people must work with others to accomplish their goals. No matter how much people value and protect their individuality, almost all oftheir goals can be achieved by working together (Hersy, 2001; Blanchard, 2001; & Johnson, 2001). Kolter's Change Process second step includes building a guiding team. The importance ofthis step is to overcome group opposition and show honesty, trust and open behavior with in the team (Kolter, 2002). An optimal group might include people chosen to represent a cross-section ofthe organization as it relates to the vision (Senge, 1999). The third step in Kolter's Process is vision (Kolter, 2002). Vision is the capacity to hold a shared picture ofthe future the organization seeks to create. When there is a genuine vision, people excel and learn, not because they are told to but because they want to (Natemeyer & McMahon, 2001). Kolter's fourth step is communication. The goal of this step is to "get as many people as possible acting to make the vision a reality" (Kolter, 2002, p.83). Lack of communication could result in frustration, lack of motivation, resentment, low aspiration, and failure (Natemeyer & McMahon, 2001). Kolter's fitth change is empowerment; where people facing change need to remove the barriers that are in their way. The first step to remove the barrier is by confronting the issues. An analagy from Kolter, "You take a wind in their faces and create a wind at their backs. You take away a pessimistic skipper and give the crew an optimistic boss" (Kolter, 2002, p.3). 7 Creating short term wins is Kotter's sixth step. This includes achieving small goals that will build momentum to accomplish the vision. The people, motivated by the prior steps, now in Kotter's step seven, have the momentum to make the vision a reality. They do this by keeping urgency up and a feeling offalse pride down. Kotter's final step is making the change stick, since old habits are hard to break. Creating a new norm means the people need to change their old norm. We need to keep in mind that as people go through change they need to be reminded what the change does and why it works (Kotter, 2002). Lewin's Change Process Kurt Lewin identifies three phases ofthe change process; unfreezing, changing, and refreezing. Unfreezing is to motivate the people to change. He continues to explain that it is the "thawing-out process in which the forces acting on individuals are rearranged so now they see the need for change." Edgar Schein expands on this theory stating that the "individuals being changed are physically removed from their accustomed routines, sources ofinformation and social relationshiops." Schein continues with "all social supports are underrninded and destroyed and individuals being changed are demeaned and humiliated." Because ofthe unfreezing, organizations face two types ofanxiety. The first anxiety sterns from the fear ofchanging and in result people are inable or unwilling to learn something new. The second anxiety stems from the fear ofnot changing and in result people may continue to do something that leads to failure, Schein concludes that for an organization to unfreeze, the fear ofchange anxiety must be decreased and the fear ofnot changing needs to be increased (Hersy, 2001; Blanchard, 2001; & Johnson, 2001, p.381). 8 After the unfreezing phase is the changing phase, taken from Lewin's Change Process. During this phase, people have become motivated to change and are ready to be provided with new patterns ofbehavior. There are two mechanisms; identification and internalization. Internalization is a more common outcome since the change is left up to the individual. Identification is where the change is based offofa model that is trying to create a new behavior pattern for the individual to become more like them. However, there is a third process for inducing change. This process is compliencc, which occurs when an individual is forced to change by manipulation, rewards and punishment (Hersy, 2001; Blanchard, 2001; & Johnson, 2001). The final change process created by Lewin is refreezing. Refreezing is when people's patterned behavior has been fitted naturally into the person's personality. Schein reitterates how important it is for an individual engaged in a change process to be in an enviornment that continually reinforces the desired change. The Stages ofConcern Model Individual's concerns have an impact on how they implement innovations (Schaafsma & Athanasou, 1994). The Stages ofConcern Model will give a base line of where an organization is at regarding concerns during an innovation. The Stages of Concern Model includes seven stages. Stage zero is awareness, where the person affected by the change is aware ofthe change but not concerned about it. The second stage is informational, where the affected person would like to know more about the change. This is followed by the personal stage. In the personal stage the affected person wants to know how the change will affect them. The management stage is a task stage, where the affected person is busy getting materials ready for the change. This is followed 9 by the concequence stage where the person is questioning how the change is going to affect the clients or in this study, the patients. The fifth stage is the collaboration stage. This stage is when the affected person is concerned about relating what they are doing to what their co-workers are doing. The last stage is the refocusing stage. This stage is where the affected person comes up with ideas that would improve the change (Hall & Hord, 2006). These seven stages can be categoriezed into four groups: unrelated concerns, selfconcerns, task concerns about the change, and impact concerns. Stage zero is in the unrelated concerns category. Stages one and two are in the self category, stage three is in the task category and stages four, five, and six are in the impact category (Hall & Hord, 2001). History ofthe Stages ofConcern Model The concept ofdefining a person's feelings and perceptions as concerns was created by Frances Fuller from the University ofTexas. She was described as an exceptional educator who surveyed 100 students after they took her course. Ninety Seven Percent ofthe students rated her class as a waste oftime and irrelevant. Instead of focusing on the negative, Fuller looked at the three positive responses. After some investigating she found that the three students had prior experience with the topic ofher class. From this, Fuller concluded that these three student's concerns were different from the other students in her class (Hord & Hall, 2006). George Hall and is colleagues later modified Fuller's theory and developed the beginning stages ofthe Stages ofConcern model and in 1974 the developed the Stages ofConcern Questionairre (Cheung, 2001). 10 Limitations ofthe Stages ofConcern Model There has been minimal analysis or reliability ofthe Stages ofConcern Model since it was created in the 1970's. Cheung explains that users ofthe SoC forget about using other models that have been proven to be better than the Soc. He continues to explain that researchers have attempted to test the reliability of the data the collected using the SoC and found stages zero and six unreliable. Because ofthis, Cheung recommends that users ofthe SoC examine the reliabilty and test their own data against statistical methods (Cheung, 2001) It is also reccomended that the wording in the 35 Stages ofConcern Questionionairee not be changed (Hord & Hall, 2006). Part ofthe reason for the discrepency in the reliability ofthe study is because originally there were only six stages in the model and after testing their theory, stage zero was created. Cheung explains that the "inclusion of stage zero items in the Stages of Concern Questionairre was data driven, which might make responses to thos items unreliable and invalid (Cheung, 200 I, p. 2). " The effectiveness ofthe Stages ofConcern Model The Stages of Concern Model gives a base line of where an organization is at when implementing change. The Stages ofConcerns Model is based offofpeople's feelings and perceptions about the change process and how people's perceptions grow as the change process evolves. Hord and his colleagues have done extensive research proving the concepts and issues related to change are not limited to students as it was in Fuller's research. Hard explains that everyone involved with change have the same characteristics as the student's Fuller researched (Hord & Hall, 2001). 11 Change in Longevity's Health Information Management Department Longevity Health System's mission is to provide exceptional healthcare services, resulting in healing in the broadest sense. Evleyn Strobing, a Longevity Partner, explains that by "implementing an Electronic Medical Record process, Longevity will be following their mission." The Electronic Medical Record (EMR) will be implemented throughout 30 Longevity clinics in Southern Wisconsin and Northern Illinois. The Health Information Management Department at each ofthese sites will no longer have paper charts and will be expected to maintain the charts using the EMR. Characteristics ofthe HIM Department pre-EMR The HIM department consists oftwo different levels, the HIM management partners and HIM clinic partners. Some ofthe clinic partner's duties are to assign history numbers and file clinical reports along with correspondence and other pertinent information in the patient record. As stated in a personal interview with a current manager at Longevity, "they [HIM clinic partners] also retrieve and deliver charts for pre-scheduled appointments, collects reports daily from designated areas, monitor physicians signatures on reports daily, file clinic and hospital dictation reports." HIM clinic partners are also responsible for making sure that the appropriate information was documented into a patients chart after the patient was seen by a physician. The role of HIM management partners include conducting interviews, hiring, training, supervising the HIM clinic partners, and evaluate designated staff. Expected Characteristics ofthe HIM Department Post-EMR After the implementation ofthe EMR, paper charts will gradually be phased out. The HIM clinic partners will continue to check the medical record for appropriate 12 information documented in the patient's chart after they were seen by a physician. Both the HIM management partners and clinic partners will be trained on how to use the EMR. The HIM staffwillieam how to look up medical data from the EMR, print reports, and scan documents from outside Longevity System and attach the scanned files electronically and attach it to the Electronic Medical Record. In addition, the HIM staff will be responsible for abstracting previous medical information from a patients paper chart and entering it into the electronic medical record. Personal Health Records With the impending change ofthe EMR, not only will the HIM Department go paperless, the HIM Department will play an active role in Personal Health Records (PHR). PHR works in two directions. The first direction is when patients are new to Longevity Health System and are bringing their personal halth records with them for Longevity to use in that patient's care. The other direction is when a Longevity patient is reffered or transfer to another health system, the patient can access their personal heath record via the Internet or directly through a HIM partner. From a personal interview with a HIM management partner, " The HIM Department will be responsible for assisting in receiving and storing information from any number ofpatient PHR formats (paper, USB key, excel, other MyChart applications, etc)." Healthcare Information and Management Systems Society The Healthcare Information and Management Systems Society is a great resource for health care systems who have or are going to implement an Electronic Medical Record. According to Healthcare Information and Management Systems Society (HIMSS) website their focus is to "provide leadership for the optimal use ofhealthcare 13 ? information technology (IT) and management systems for betterment ofhealthcare." HIMSS directs and shapes the health care industry while encourageing new technology and promoting public policies that improve healthcare (Lieber, 2002) The organization has over 20,000 individual members and 300 coportate members (Healthcare Information Systems Society, 2007) with 41 chapters and 20 special interest groups (Lieber, 2002). Some ofHIMSS work includes sponsoring programs that encourage and recognize excellence in the implementation ofEMR systems. Some ofthe topics include; getting started with an EMR, selecting the right EMR along with step by step plans on how to find and evaluate the EMR vendors, standards ofthe EMR, and news regarding legislation related to heaIthcare. By providing this information members of HIMSS hope to achieve a common goal: The use ofEMR will be 80% ofheaIthcare organizations and 50% ofphysician practices by 2010 (Healthcare Information Systems Society, 2007). Taken from a personal interview with a former manager at Longevity states that "In addition to the resources provided by HIMSS regarding the EMR implementation it also important to look at the situation from the points ofview ofthe people who will be affected by the changes." Conclusion Because ofthe changes occuring with in Longevity's Health Information Management Department including the implementation ofthe Electronic Medical Record the HIM staffwere asked to complete the Stages of Coneem Questionairee. The results ofthe SoC Questionaire will determine where they are at in the Stages ofConcern Model. 14 Chapter III: Methodology The purpose ofthis study is to determine the Stages ofConcerns the Health Information Management Department (HIM) have regarding the implementation ofthe Electronic Medical Record. By using the Stages of Concern (SoC) Survey it was determined how involved the Health Information Management (HIM) Department wants to be in the decision making regarding the implementation. Questions one through five was added to the beginning ofthe survey and was sent to all ofthe HIM staff. The HIM department consists oftwo different levels, the HIM management partners and HIM clinic partners. By surveying the different levels we determined ifthere is a difference in the SoC's (Appendix: A). There is an open ended question included in the survey to gain a better understanding ofwhat the concerns the HIM Department has. The survey questionnaire also asks for the time of employment with in the organization. We hope to determine if there is a difference in the Stages of Concerns based on time ofemployment. Subject Selection and Description There are several departments at Longevity Health Systems that will be affected by the implementation ofthe Electronic Medical Record (EMR). There has been a lot of time and resources preparing the front-end staffor the physicians and nurses to change their medical record documentation practices. It was decided to survey the HIM Department because they playa major role in the documentation process by maintaining the records. There are 35 employees in the HIM Department 6 ofthem are management partners and 29 ofthem are clinic partners. 15 Instrumentation The survey used in this study was adapted from Implementing Change Patterns, Principles. and Potholes (Hord & Hall, 2006). The original Stages ofConcerns (SoC) Model Instrument (~ix--.J used in this study was revised from 35 questions to 28 questions. Also, some ofthe wording was changed so the questions would be easier to understand by the HIM department staff. The SoC survey uses a "Likert-type instrument that is designed to measure the relative intensity of seven distinct stages ofconcern. Answers range from irrelevant (0), to "not true ofme now" (I -2); "somewhat true ofme now" (3-5) and (6-7) being "very true ofme now"(Schaafsma & Athanasou, 1994, p.18). Questions one through five was added to the beginning of the survey and it was sent out to both HIM Management and HIM Clinic Partners. By surveying the different levels we hoped to determine ifthere is a difference in the SoC's. The survey questionnaire also asked for the time of employment with in the organization. We hope to determine if there is a difference in the Stages ofConcerns based on time ofemployment. There is an open ended question included in the modified survey (Appendix A) to gain a better understanding ofwhat the concerns the HIM Department has. Data Collection Procedures A 28-question survey was sent to the Health Information Management management partners on April19'h, 2007. The managers then distributed the survey to each oftheir staff. Instructions on the survey asked that the surveys be sent by inter department mail by May I st to the researcher to insure confidentiality. Completion ofthe survey was confidential and voluntary. The survey was also exernpt from the University ofWisconsin Stout Internal Review Board. 16 Data Analysis After the survey data was compiled, the results for each question were tallied. The median for each question was determined for all ofthe HIM Partners and the HIM Management Partners. All ofthe HIM Partner data was then divided by length of employment at Longevity. The open ended question was then evaluated. Limitations A limitation ofthis study is that the Stages of Concern survey only included one health system and to the researchers know ledge there is no other study in the health care system to compare the results to. Another limitation is that out ofLongevity's 30 clinics one clinic was not surveyed do to the clinic employees belonging to a union. Even though the survey questions where changed to make it easier for the HIM staffto understand it is still possible that the staff answered the question with out fully understanding the question. During the course ofdividing that data by length ofemployment, it was found that several participants answered all yes or all no to questions three, four, and five. There were also several participants who did not answer these three questions. Because ofthis, the researcher was unable to accurately determine the length ofemployment at Longevity. The data used in the study was based offofperception. Because ofthis, the data could be skewed because of the partner's current attitude towards Longevity at the time they took the survey. Summary 17 After surveying the Health Information Management Department based offthe Stages of Concern Model, we were able to determine a base line ofwhere the HIM Department is at regarding the implementation ofthe EMR. 18 Chapter IV: Results The purpose ofthis study is to determine the Stages of Concerns the Health Information Management Department (HIM) have regarding the implementation ofthe Electronic Medical Record (EMR). The questions used in the survey are based off of the Stages of Concerns Model. Each question is asking a concern that the participants may have regarding the implementation. The first part ofthe results discusses the results ofthe HIM roles and the years of employment the partners have worked at Longevity. The second part divides the results ofquestions six to thirty-three into four categories of the Stages of Concerns Model. Stage zero is in the unrelated concerns category. Stages one and two are in the self category, stage three is in the task category and stages four, five, and six are in the impact category (Hall & Hord, 200 I). 35 surveys were sent out to the HIM Department and 31 surveys were returned. The participants were to answer the first five questions as yes or no. They were to answer questions six to thirty-three based of a seven point Likert Scale. The answers ranging from irrelevant (0), to "not true of me now" (1-2); "somewhat true of me now" (3-5) and (6-7) being "very true of me now"(Schaafsma & Athanasou, 1994, p.18). Health Information Management Role and Years ofEmployment Along with determining the Stages ofConcerns ofthe HIM Department staff, we hoped to distinguish the findings between the management partners and the clinic partners. The first five questions of the survey determined if the HIM partner was a manager partner, a clinic partner and if they worked for Longevity Health Systems for less than a year, greater than a year, less than five years, or greater than 5 years. Some of the participants answered all yes, all no or not at all to questions three, four, and five. 19 Therefore there is in accurate data when determining the years ofemployment at Longevity. Ofthe 31 surveys returned, four of the participants are management partners and 27 ofthem are clinic partners (Table Il. Table I Health Information Management Role and Years ofEmployment Yes No Health Information Management- Management Partner 4 27 Health Information Management- Clinic Partner 27 4 Employed in the HIM Department for less than a year? 22 2 Employed in the HIM Department for more than I year but less than 5. 17 8 Employed in the HIM Department for more than 5 years. 20 5 Unrelated Concerns The unrelated concerns category includes stage zero from the Stages ofConcern Model. The questions that fall into this stage and the median score determined by the both HIM Management Partner and HIM Clinic partner participants are shown in Table 2. There were no unrelated concerns when looking at the entire HIM Department. We then looked at the HIM Management Staff regarding their unrelated concerns. The HIM Management has little or no concern about other projects they are working on affecting the EMR. They also are not concerned about patient feedback to the EMR. They are also not worried about tasks and other people taking too much oftheir time. 20 Table 2 Median ofUnrelated Concerns- HIM Management Concern HIM Management Median Am completely occupied with other things 0.5 At this time, I am not interested in learning about the EMR 0.5 I would like to use feedback from patient's to change the program 0.5 Coordination oftasks and people is taking too much ofmy time 0 SelfConcerns The selfconcerns category includes stages one and two from the Stages of Concern Model. The questions that fall into this stage and the median score determined by the both HIM Management Partner and HIM Clinic partner participants are shown in Table 3. Table 3 Median ofSelfConcerns- all Longevity HIM Partners and HIM Management Concern All HIM HIM Partner Management Median Median Know ofother approaches that might work better 1 1.5 Don't know what the Electronic Medical Record is Concern about not having enough time to use the EMR 2 21 Completely occupied by other things Would like to modify the use ofthe EMR based on 2 1.5 experiences Don't know about the EMR, but concerned about other issues I in the HIM Department. At this time, not interested in learning about the EMR I I would like to determine how to supplement, enhance, or 2 replace the EMR Coordination oftasks and people is taking too much time I I am not concerned about the EMR Task Concerns The tasks concerns category includes stage three from the Stages ofConcern Model. The questions that fall into this stage and the median score determined by the participants are shown in Table 4. Table 4 Median ofTask Concems- all Longevity HIM Partners and HIM Management Concern AU HIM HIM Partner Management Median Median Concerned about the patient's attitude toward the EMR 3 3 Would like to use feedback from patient's to change the 3 program 22 3.5Concerned about not having enough time to use the EMR Impact Concerns The impact concerns category includes stages four, five and six from the Stages of Concern Model. The questions that fall into this stage and the median score determined by the participants are shown in Table 5. Table 5 Median ofImpact Concerns- all Longevity HIM Partners and HIM Management Concern All HIM HIM Partner Management Median Median Would like to help other Longevity Partners in their use of 4 5.5 the EMR Having limited knowledge about the EMR 5 4.5 Would like to develop a working relationship with both 5 7 Longevity Partners and Longevity Health Systems Concerned about how the EMR affects Longevity Health 5 6.5 Systems Not concerned about the EMR 4 Would like to know who will make the decisions with the 4 5 EMR Would like to discuss the possibility ofusing the EMR 5 4 Would like to know what resources are available for the 6 5 23 EMR Concerned about inability to complete all ofthe EMR 4 4.5 responsibilities Would like to familiarize other departments or persons with 4 5.5 the progress ofthe EMR Would like to excite Longevity Partners about their part in 4 7 theEMR Would like to know what the use ofthe EMR will require in 6 7 the immediate future Like to coordinate efforts with others to maximize the 6 7 EMR's success Would like to have more information on time and energy 6 7 commitments required by the EMR Would like to know what other Health Systems are doing in 5 6.5 this area Would like to determine how to supplement, enhance or 4 replace the EMR Would like to know how my role will change when I am 7 7 using the EMR Like to know that the EMR is better than the paper medical 6 7 records 24 Concerns/rom the Open-Ended Question The last question in the survey asked, "What other concerns do you have at this time". There were five responses to this question, they are: I. When this happens, will we have jobs or will someone lose their jobs due to the new system? 2. What is the time frame and training process to re-educate employee. 3. How many people this will take to employ in each medical records department? Will the department cut down on the employees? 4. What effects will this have on the entire department? How long will we keep the paper records? Will paper records also be used in case of an emergency? (I.e. electricity is lost, system breaks down, etc. 5. I am afraid this EMR will be too complicated for me to learn, being that I am not full time. 25 Chapter V: Discussion The purpose ofthis study is to determine the Stages ofConcerns the Health Information Management Department (HIM) have regarding the implementation ofthe EMR. Making a change in an organization means changing the behavior ofthe people affected by the change. Changing the behavior of a single person can be extrernly difficult for an organization. Ifyou look closly at how people react to change you can find patterns with how they react to change (Kotter, 2002). Because ofthis, the study examined the importance and need for change theories such as Kotter's Theory, Lewin's Theory, and the Stages of Concern Model. Limitations of the Study The limitations ofthis study include: I. Site-specific criteria and cannot be generalized to other healthcare systems. 2. Not all of Longevity's 30 clinics were surveyed due to one clinic was not surveyed because the staff employed at this clinic is union members. 3. The survey questions where changed to make it easier for the HIM staffto understand but it is still possible that the staffanswered the question with out fully understanding the question. 4. Questions three, four and five ofthe survey were not answered correctly, or not answered. Conclusions Overall Longevity's Health Information Management Department is encouraging, regarding the Stages of Concerns. Their concerns are valid concerns and can be 26 addressed by following sections from Kotter's theory, Lewin's theory and the Stages of Concern Model. Several of their concerns fall in the impact category indicating that they have thought a lot about the implementation of the EMR and that they are interested in discussing and are thinking proactively about the implementation. Recommendations Unrelated Concerns The unrelated category is to determine ifthe HIM department has little or no knowledge ofthe implementation, or is doing nothing toward becoming involved in the implementation. The few concerns that the HIM Management have regarding the EMR implementation are encouraging. A conclusion from this part ofthe study determines that Longevity has accomplished Kotter's stage one by informing the HIM Department what the change is. Self Concerns The self concerns category represent two key parts, the person know a little about the change and would like to know more. After looking at the concerns that Longevity HIM Department have in the self concerns category, it can be concluded that the HIM Department hasthought about the implementation and have concerns about it. It is important to remernber Kotter's stages three and four. If the vision ofthe implementation is communicated to the department Longevity Health Systems can make their vision a reality and possibly avoid frustration, lack of motivation and resentment in the department. Task Concerns 27 The task concerns category is where concerns are related to users (HIM partners) needs. It is recognized that the patients are valued but resources SJ.Ich as management, time and knowledge dictate what the user can do (Hord & Hall, 2006). The concerns from the HIM Department in the task concerns category concur with the Hall and Hord's (2006) theory. The HIM Department is concerned with patient's attitude regarding the EMR, are open to feedback from the patient's, but are concerned about not having enough time. Recognizing Kotter's fifth change, removing barriers is an important step. It is possible to remove barriers by confronting the issues (Kotter, 2002). It is recommended by Hord and Hall (2006) to discuss resources needed for the initial use of the implementation. By following these recommendations, Longevity Health Systems can avoid these concerns becoming a reality. Impact Concerns The concerns ofthe HIM Department in the impact concerns category determine that the participants ofthe survey are thinking ahead about the implementation and are thinking about management and logistical issues related to the EMR. They are concerned about not only their role in the EMR but other Longevity Partner's role in the EMR. They are showing a strong interest in the EMR and would like more information regarding it, would like to maximize the EMR's success and would like to know what other Health Systems are doing regarding EMRs. Concerns from the Open-Ended Question Ail ofthe responses from the open-ended question are valid concerns. These concerns show that the HIM Partners are being pro-active and thinking about not only their own job but other people's job in the HIM Department. They are concerned about 28 patient care in an emergency such as a power outage. Again, by removing barriers, taken from Kotter's step five, confronting issues, and communicating the vision to the HIM Partners will make the vision ofthe implementation a reality (Kotter, 2002). The Healthcare Information and Management Systems Society (HIMSS) is a great resource for health care systems who have or are going to implement an Electronic Medical Record. A lot ofbarriers can be eliminated by utilizing HIMSS. It is also recommended to remember that anxiety stems from the fear of changing (Hersy, 2001; Blanchard, 2001; & Johnson, 200!). Make sure the vision is communicated and the HIM Department is motivated to change as explained in Lewin's unfreezing stage. By creating an environment that is continually reinforcing the change it is easier to move into Lewin's freezing stage where the HIM Department will tum the changes in a norm The implementation ofthe EMR is only the first part of changes that the HIM Department will have to encounter. The theories used in this study can also be used when the Personal Health Records are implemented at Longevity Health Systems. 29 References Cheung, D., Hattie, J., & Ng, D. (2001). Reexamining the stages ofconcern questionnaire: a test ofalternative models. The Journal ofEducational Research (Washington, D.C.), 94(4), 226-36. Retrieved May 5, 2007 from Education Full Text database. Gray, J. (2004, July). Ch-ch-ch-changes, Canadian Business. 77( 14/15), 93-94. Retrieved May 5, 2007, from ABl/INFORM Global database. Hall, G.E., & Hord, S.M. (2006). Implementing change: Patterns, principles, and potholes (2nd ed.). Boston: Pearson. Hersey, P., & Blanchard, K.H., & Johnson, D.E. (2001). Management oforganizational behavior: Leading human resources (8th ed.). Upper Saddle River, NJ: Prentice Hall. Healthcare Information Management Systems Society. (2007). Retrieved April 25, 2007 from http://www.hirnss.orglaspllegal.asp Kotter, J.P., & Cohen, D.S. (2002). The heart ofchange: Real-life stories ofhow people change their organizations. Boston: Harvard Business School Press. Natemeyer, W.E., & McMahon, J.T., (2001). Classics oforganizational behavior (3rd ed.). Prospect Heights, IL: Waveland Press, Inc. Schaafsma, H., & Athanasour, J. (1994). Concerns about innovations in the workplace. Leadership & Organization Development Journal. 15(8), 16. Retrieved May 10, 2007, from ABIIlNFORM Global database. 30 Thomas, R.L. (2006, March). Learning the alphabet of healthcare IT. Healthcare Financial Management, 60(3), 100,102. Retrieved May 5,2007, from ABI/INFORM Global database. 31 Appendix A: The Survey Are you a Health Information Management- Management Partner? Y N Are you a Health Information Management- Clinic Partner? Y N Have you been employed in the Health Information Management Y N Department for less than 1 year. Have you been employed in the Health Information Management Y N Department for more than 1 year but less than 5. Have you been employed in the Health Information Management Y N Department for more than 5 years. Please circle the number that is the most appropriate regarding your involvement or potential involvement with the Electronic Medical Record. J I am concerned about patients' attitudes toward the Electronic 0 2 3 4 5 6 7 Medical Record (EMR). I now know of some other approaches that might work better. 0 2 3 4 5 6 7 I don't even know what the Electronic Medical Record is. 0 2 3 4 5 6 7 I am concerned about not having enough time to use the EMR. 0 1 2 3 4 5 6 7 I would like to help other Longevity Partners in their use of the 0 2 3 4 5 6 7 EMR. I have a very limited knowledge about the EMR. 0 1 2 3 4 5 6 7 I would like to develop working relationships with both Longevity 0 2 3 4 5 6 7 Partners and Longevity Health Systems. I am concemed about how the EMR affects Longevity Health 0 2 3 4 5 6 7 Systems. I am not concerned about the EMR. 0 1 2 3 4 5 6 7 32 I would like to know who will make the decisions with the EMR. 0 2 3 4 5 6 7 I would like to discuss the possibility of using the EMR. 0 2 3 4 5 6 7 I would like to know what resources are available for the EMR. 0 2 3 4 5 6 7 I am concemed about my inability to complete all of the EMR 0 2 3 4 5 6 7 responsibilities. I would like to familiarize other departments or persons with the 0 2 3 4 5 6 7 progress of the EMR. I am completely occupied with other things. 0 2 3 4 5 6 7 I would like to modify our use of the EMR based on the experiences of Longevity. 0 2 3 4 5 6 7 Although I don't know about the EMR, I am concerned about other things in the area. 0 1 2 3 4 5 6 7 I would like to excite Longevity Partners about their part in the EMR. 0 1 2 3 4 5 6 7 I would like to know what the use of the EMR will require in the 0 1 2 3 4 5 6 7 immediate future. I would like to coordinate my efforts with others to maximize the 0 1 2 3 4 5 6 7 EMR's success. I would like to have more information on time and energy commitments required by the EMR. 0 1 2 3 4 5 6 7 I would like to know what other Health Systems are doing in this 0 2 3 4 5 6 7 area. At this time, I am not interested in learning about the EMR. 0 1 2 3 4 5 6 7 I would like to detenmine how to supplement, enhance, or replace 0 1 2 3 4 5 6 7 the EMR. I would like to use feedback from patient's to change the program. 0 1 2 3 4 5 6 7 I would like to know how my role will change when I am using the 0 1 2 3 4 5 6 7 EMR. Coordination of tasks and people is taking too much of my time. 0 2 3 4 5 6 7 I would like to know that the EMR is beller than the paper medical 0 1 2 3 4 5 6 7 records. What other concerns do you have at this time? 33 Appendix B: The results ofthe survey Median I am concerned about patients' attitudes toward the Electronic Medical Record (EMR). 3 I now know of some other approaches that might work. better. I don't even know what the Electronic Medical Record is. I am concerned about not having enough time to use the EMR. 2 I would like to help other Mercy Partners in their use of the EMR. 4 I have a very limited knowledge about the EMR. 5 I would like to develop working relationships with both Mercy Partners and Mercy Heatth Systems. 5 I am concerned about how the EMR affects Mercy Heatth Systems. 5 I am not concemed about the EMR. 4 I would like to know who will make the decisions with the EMR. 4 I would like to discuss the possibility of using the EMR. 5 I would like to know what resources are available for the EMR. 6 I am concerned about my inability to complete all of the EMR responsibilities. 4 I would like to familiarize other departments or persons with the progress of the EMR. 4 I am completely occupied with other things. I would like to modify our use of the EMR based on the experiences of Mercy. 2 Although I don't know about the EMR, I am concerned about other things in the area. I would like to excite Mercy Partners about their part in the EMR. 4 I would like to know what the use of the EMR will reqUire in the immediate future. 6 I would like to coordinate my efforts with others to maximize the EMR's success. 6 I woujd like to have more information on time and energy commitments required by the EMR. 6 I would like to know what other Health Systems are doing in this area. 5 At this time, I am not interested in learning about the EMR. I would like to determine how to supplement, enhance, or replace the EMR. 4 I would like to use feedback from patient's to change the program. 3 I would like to know how my role will change when I am using the EMR. 7 Coordination of tasks and people is taking too much of my time. I would like to know that the EMR is better than the paper medical records. 6 34 Appendix C: The Original Survey Instructions I am concerned about patients' attitudes toward this innovation. I now know of some other approaches that might work better. I don't even know what the innovation is. I am concerned about not having enough time to organize myself each day. I would like to help other Mercy Partners in their use of the innovation. I have a very limited knowledge about the innovation. , would like to know the effect of this reorganization on my professional status. I am concerned about conflict between my interests and my responsibilities. I am concerned about revising my use of the innovation. I would like to develop working relationships with both Mercy Partners and Mercy Health Systems. I am concerned about how the innovation affects Mercy Health Systems. I arn not concerned about this innovation. I would like to know who wiii make the decisions in the new system. I would like to discuss the possibility of using ht innovation. 1would like to know what resources are available if the decide to adopt this innovation. I am concerned about my inability to manage all the innovation requires. I would like to know how my teaching or administration is supposed to change. J 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 1 0 1 0 1 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 35 I would like to familiarize other departments or persons with the progress of this new approach. 0 2 3 4 5 6 7 I am concerned about evaluating my impact on Mercy Health Systems. 0 1 2 3 4 5 6 7 I would like to revise the innovation's instructional approach. 0 1 2 3 4 5 6 7 I am completely occupied with other things. 0 1 2 3 4 5 6 7 I would like to modify our use of the innovation based on the experiences of Mercy. 0 2 3 4 5 6 7 Although I don't know about this innovation, I am concerned about other things in the area. 0 2 3 4 5 6 7 I would like to excite Mercy Partners about their part in this approach. 0 2 3 4 5 6 7 I am concerned about my time spent working with nonacademic problems related to this innovation. 0 2 3 4 5 6 7 I would like to know what the use of the innovation will require in the immediate future. 0 2 3 4 5 6 7 I would like to coordinate my efforts with others to maximize the innovation's effects. 0 1 2 3 4 5 6 7 I would like to have more information on time and energy commitments required by this innovation. 0 1 2 3 4 5 6 7 I would like to know what other Health Systems are doing in this area. 0 1 2 3 4 5 6 7 At this time, I am not interested in learning about the innovation. 0 1 2 3 4 5 6 7 I would like to determine how to supplement, enhance, or replace the innovation. 0 1 2 3 4 5 6 7 I would like to use feedback from students to change the program. 0 1 2 3 4 5 6 7 I would like to know how my role will change when I am using the innovation. 0 2 3 4 5 6 7 Coordination of tasks and people is taking too much of my time. 0 1 2 3 4 5 6 7 I would like to know this innovation is better than what we have now. 0 1 2 3 4 5 6 7 What other concerns, if any, do you have at this time? Briefly describe your job function.