Inside IT

Margret Amatayakul

Prochaska's six stages of change could be applied in striving for meaningful use of EHRs.

With the federal incentives for demonstrated meaningful use of electronic health records (EHRs) looming, it is likely that most hospitals and healthcare organizations have opted to enhance their healthcare IT capabilities with the components that contribute to an EHR. Typically these applications focus on the use of applications such as computerized provider order entry, electronic medication administration record, point-of-care charting, clinical decision support, results management, quality measurement and improvement, and health information exchange by physicians, nurses, and other clinicians.

So now the challenge is to successfully implement these applications, not just to earn the meaningful use incentives, but to gain value for patient care. Although a particular organization's environment and the products it acquires will heavily influence how rapidly it will be able to move through an implementation of this magnitude, it is important to be aware that in the past, full implementation of such applications has typically taken several years. The time required reflects time needed for "change" to take effect. The work of James Prochaska, who developed a theory describing how six stages of change can take from two to five years to complete, is frequently cited when considering how long changes relating to personal well-being may take. Because implementing an EHR is not just about automating the paper chart, but also, automating how clinicians use information in healthcare practice, there is some evidence that these stages of change are applicable to EHR implementations.

Six Stages of Change in EHR Implementation

The following six key elements for EHR implementation closely reflect Prochaska's stages of change.

Stage No. 1: Preparation. Preparation, or what Prochaska refers to as the "pre-contemplation" stage of change, is both an organizational and personal decision-making process, often taking at least six months. During this stage, it is vital to engage representatives of all clinician stakeholders in envisioning how an EHR will be used. During this phase, provider organizations should create "demand" for an EHR by analyzing workflows, processes, current quality benchmarks, and other elements that would suggest the need for EHR. This is the phase in which clinicians recognize that the EHR is a clinical transformation-not just a new form of charting and not just learning how to use a computer. During this phase, the organization should also ramp up its resources to fully support an EHR, such as by hiring a full-time project manager and designating a physician champion.

Stage No. 2: Planning. Planning, or what Prochaska calls the "contemplation" stage, is a more active process of engaging the ultimate end users directly in product selection (if applicable) and planning associated with work flow and process changes to be made. This phase often takes another six months. During this phase, clinicians should be asked to review templates, clinical decision support rules, and practice guidelines. Most vendors do not provide very much support for work flow and process redesign and improvement. However, this is the area where clinicians need the most help. They know the processes they perform today, often do not appreciate how these processes can be changed for the better, and frequently do not see the ramifications of their processes downstream for other users or even patients. Contemplating how such changes can and will need to be made is vital to success. This part of the change process is most frequently overlooked or short-changed.

Stage No. 3: Installation. Usually it takes a very short time to actually install EHR software, but a more intensive system-build process follows. Here, the model for EHR implementation differs from the six stages of change described by Prochaska, as he suggests allowing one month for a "preparation" stage such as this, whereas the system-build process for an EHR takes longer. During this period of time, end users should continue to be engaged, refining templates, tuning clinical decision support, and evaluating workflow and process changes.

Stage No. 4: Action. Action is the stage when people are actively making the change. In an EHR implementation, this generally includes testing, one-on-one training, "dress rehearsal," go-live, and steps toward beginning to use the system with patients. Prochaska suggests that this process take yet another six months-and that is certainly the estimate that rings true for most EHR implementations. This is the stage in which a lot of at-the-elbow support is needed.

Stage No. 5: Maintenance. Maintenance is the term Prochaska uses to describe the period of time during which new behaviors (i.e., work flows and processes) are solidified. Prochaska suggests that this process could take anywhere from six months to five years. This is an especially critical time in an EHR implementation, because often the EHR implementation team is moving on to the next phase of the project, during which they are busy with new users and/or a new application. The result is often that those in "maintenance" are not attended to and easily slip back into old ways while no one is noticing. Critical to successfully maintaining the change to an EHR system are regular monitoring, continued celebration of positive results, and immediate course correction, where necessary, to avoid workarounds or a return to old ways.

Stage No. 6: Termination. Termination is the final stage in Prochaska's model-and it would reflect the fact that paper processes are terminated and electronic processes are ingrained in clinician behavior.

Involvement of End Users Is Critical

Regardless of whether one subscribes to the stages of change described by Prochaska or does not quite see the connection, it cannot be denied that engaging end users in the process of making change-in this case, in implementing an EHR-is critical. Doing so takes time, resources, and a lot of hand-holding, cajoling, celebrating, patience, and stamina. Today, many organizations are opting to reduce their engagement of clinicians in the EHR implementation process with the idea that this will speed up the process. Unfortunately, while the time to reach "go-live" might be less with such a strategy, the time to achieve positive results-the "maintenance" phase-could take much longer than it would have if the optimal time for clinician engagement had been invested from the start.

Margret Amatayakul, RHIA, FHIMSS, is president, Margret\A Consulting, LLC, Schaumburg, Ill. (

Publication Date: Wednesday, December 01, 2010

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