A PHYSICIAN GROUP S MOVEMENT TOWARD ELECTRONIC HEALTH RECORDS: A CASE STUDY USING THE TRANSTHEORETICAL MODEL FOR ORGANIZATIONAL CHANGE

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1 Consulting Psychology Journal: Practice and Research 2011 American Psychological Association 2011, Vol. 63, No. 2, /11/$12.00 DOI: /a A PHYSICIAN GROUP S MOVEMENT TOWARD ELECTRONIC HEALTH RECORDS: A CASE STUDY USING THE TRANSTHEORETICAL MODEL FOR ORGANIZATIONAL CHANGE Robert A. Boswell The Pennsylvania State University The American Recovery and Reinvestment Act (ARRA) of 2009 authorized the distribution of $34 billion through Medicare and Medicaid as adoption incentives to qualified providers to implement and use certified Electronic Health Records (EHR). In the case study presented here, which followed the transtheoretical model (TTM), employees of a multispecialty physician group were asked about their movement to EHR. The employees were part of a multispecialty physician group with 17 different offices and 73 providers in the greater south central Pennsylvania area. Sixteen employees from the physician group participated in a one-on-one interview. Interview questions were designed to identify actions that define successful EHR implementation, readiness to take actions toward successful EHR implementation, pros and cons of EHR implementation, and classification of change processes being utilized to move the multispecialty group toward successful EHR implementation. Interview data provided preliminary evidence of the applicability of the TTM to studies of EHR implementation. Keywords: organizational behavior change, transtheoretical model, stages of change Over the past three decades, the integration of electronic health records (EHR) has become a major organizational change objective in health care because of its promise of major improvements from paper records: freedom from paperwork, greater speed, remote access, improved patient safety, lower costs, even enhanced reimbursements (Allscripts Health care Solutions, 2005). For example, it has been reported that an EHR system helped to reduce medication administration errors, such as wrong person, wrong drug, or wrong route of administration, by 66% at a medical center (Health Care Information & Management Systems Society, 2009). That is, improved patient safety is attainable because EHR systems often store patient information more clearly and completely than Robert A. Boswell, School of Behavioral Sciences and Education, The Pennsylvania State University, Harrisburg. Robert A. Boswell is now at Department of Learning and Performance Systems, The Pennsylvania State University, University Park. Correspondence concerning this article should be addressed to Robert A. Boswell, Department of Learning and Performance Systems, The Pennsylvania State University, 301 Keller Building, University Park, PA [email protected] 138

2 MOVEMENT TO ELECTRONIC HEALTH RECORDS 139 traditional paper-based records and provide alerts for medication allergies or other problems. However, despite EHRs potential to improve patient care, very few physicians have actually used an EHR in their practices because they view the technology as troublesome, time-consuming, and expensive (as cited in Meinert, 2005). Recognizing the potential benefits associated with greater use of EHR systems, but also the cost of adoption, Congress authorized major funding to support the widespread adoption of health information technology (HIT) through the American Recovery and Reinvestment Act (ARRA) of The majority of these funds will be distributed as incentive payments to eligible professionals, eligible hospitals, and critical access hospitals (CAHs) as they adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology (Centers for Medicare & Medicaid Services, 2010). The ARRA act of 2009 outlined three main components of meaningful use: (a) the use of a certified EHR in a meaningful manner, (b) the use of certified EHR technology for electronic exchange of health information to improve quality of health care, and (c) the use of certified EHR technology in ways that can be measured significantly in quality and in quantity. The criteria for meaningful use will be staged in three steps over the course of the next 5 years. Stage 1 (2011 and 2012) sets the baseline for electronic data capture and informationsharing. Stage 2 (expected to be implemented in 2013) and Stage 3 (expected to be implemented in 2015) will continue to expand on this baseline and be developed through future rule-making. The requirements for stage one of meaningful use include both a core set and a menu set of objectives that are specific to eligible professionals or eligible hospitals and CAHs. There are a total of 25 meaningful use objectives for eligible professionals; to qualify for an incentive payment, 20 of these 25 objectives must be met. There are 15 required core objectives and the remaining 5 objectives may be chosen from the list of 10 menu set objectives. There are a total of 24 meaningful use objectives for eligible hospitals and CAHs. To qualify for an incentive payment, 19 of these 24 objectives must be met. There are 14 required core objectives and the remaining 5 objectives may be chosen from the list of 10 menu set objectives (Centers for Medicare & Medicaid Services, 2010). The main goal of the Medicare and Medicaid EHR Incentive Programs are to improve patient safety. This article presents results of a case study that explored the perceptions of employees at a multispecialty physician group regarding their readiness to implement EHR. This multispecialty physician group was making efforts to fulfill requirements for stage one of meaningful use as outlined by Medicare and Medicaid EHR Incentive Programs. The multispecialty physician group had 17 different offices and 73 providers in the greater south central Pennsylvania area. The framework used to evaluate this organizational change is the Transtheoretical Model of Change (TTM) (Prochaska & DiClemente, 1984). Transtheoretical Model of Change Over the past 25 years, the process of change has been the central focus of the TTM framework developed by Prochaska and DiClemente (1984). The model is an integrative biopsychosocial model that offers a systematic and empirically based approach to conceptualizing and assessing readiness to engage in intentional behavior change (Prochaska, Norcross, & DiClemente, 1994). Its primary assertion is that behavior change occurs in stages over time. Although TTM has been extensively tested with individual behavior change, its application to organizational behavior change has been limited. This study adapted the TTM for use within the context of organizational behavioral change. Research dealing with organizational change has been largely dominated by a systems-oriented focus (Judge, Thoresen, Pucik, & Welbourne, 1999). Neglected is the possibility that successful coping with change lies within the psychological predispositions of individuals experiencing the change (Judge et al., 1999). That is, change in organizational members behavior is the core of organizational change (Bartunek, 1984; Coloarelli, 1998; Ford & Ford, 1994, 1995; Porras & Robertson, 1992).

3 140 BOSWELL TTM research has been shown to be strong in its capability to explain and facilitate change in large populations of individuals for a broad range of behaviors, including smoking cessation (Prochaska et al., 1993, 2001; Velicer et al., 1999), dietary change (Greene et al., 1999), exercise adoption (Marcus et al., 1998), mammography screening (Rakowski et al., 1998), stress management (Evers et al., 2006), limited sun exposure (Weinstock et al., 2002), and multiple behaviors (Prochaska et al., 2005, 2004; Riebe et al., 2003). The model has also established empirical support across studies of intentional behavior change in organizational change areas including collaborative service delivery (Levesque, Prochaska, & Prochaska, 1999), time limited therapy (J. M. Prochaska, 2000), continuous quality improvement (Levesque et al., 2001), reducing the risks of musculoskeletal disorders (Whysall, Haslam, & Haslam, 2007), and advancing women scientist (J. M. Prochaska et al., 2006; Silver et al., 2007). Stages of Change The key organizing construct of the Transtheoretical Model is that behavior change studies have found that people move through a series of five stages when modifying behavior (Prochaska & DiClemente, 1983; Prochaska et al., 1992; Prochaska et al., 2001). The Stages of Change are typically described as: 1. Precontemplation not intending to take action within the next 6 months 2. Contemplation intending to take action within the next 6 months 3. Preparation intending to take action in the next 30 days 4. Action made overt changes less than 6 months ago 5. Maintenance made overt changes more than 6 months ago Decisional Balance A critical construct of the Transtheoretical Model that takes into consideration the potential gains and losses associated with a behavior s consequences (Velicer, DiClemente, Prochaska, & Brandenburg, 1985). Processes of Change This the most complex construct of the Transtheoretical Model that includes 10 fundamental covert and overt processes by which people change (Prochaska & DiClemente, 1984). These 10 processes are divided into two groups: experiential processes and behavioral processes. Experiential processes usually concern the organization s thoughts and feelings and are generally seen in the early stages of change. Behavioral processes are action-oriented and usually seen in the later stages of change. Experiential Processes 1. Consciousness Raising: Increasing awareness and information about EHR and Its benefits; 2. Dramatic Relief: Experiencing negative emotions associated with the failure to change and relief that comes with success; 3. Environmental Reevaluation: Considering how EHR Will have a positive impact on the social and work environment; 4. Self-Reevaluation: Considering how one s identity, happiness, and success can be enhanced by the adoption of EHR; and 5. Social Liberation: The organization empowering individuals to participate in EHR. Behavioral Processes 6. Self Liberation: The belief that one can change and commitment based on belief; 7. Stimulus Control: Restructuring the environment to remove cues for status quo and adding cues for EHR;

4 MOVEMENT TO ELECTRONIC HEALTH RECORDS Counter conditioning: Substituting new behaviors and cognitions for the old ways of working; 9. Reinforcement Management: Finding intrinsic and extrinsic rewards for new ways of working; and 10. Helping Relationships: Seeking and using social support to facilitate change. Application of the TTM to EHR The purpose of this study was to explore the Transtheoretical Model in assessing the readiness of employees at a multispecialty physician group to take action regarding their movement to EHR. This particular group was chosen by the primary investigator after learning of their EHR implementation initiative. The multispecialty physician group had 17 different offices and 73 providers in the greater south central Pennsylvania area. More specifically, this study was intended to identify readiness to change, potential gains and losses related to the change, and strategies utilized to bring about such change as perceived by the employees of the multispecialty physician group. The TTM framework was used in this case study to guide the explanation and facilitation of the physician group s readiness to implement EHR through semistructured interviews. Research Questions Accordingly, the following questions were addressed: 1. How is successful implementation of electronic health records (EHR) defined behaviorally by the physician s group members? 2. What stage of change is the physician group in toward implementing EHR? 3. What are the pros and cons of implementing EHR as perceived by the physician s group members? 4. What processes of change are utilized by the physician group to change to EHR as perceived by its members? Method A single-case study design was utilized for this study. The rationale was that the TTM is a well formulated model with a specified clear set of propositions regarding its constructs. A single-case study design can confirm, challenge, or extend the model (Yin, 2009). In addition, the single-case study design enables the researcher to study the constructs of the TTM such as stages of change, decisional balance, and processes of change at different points in time (Yin, 2009). For instance, if an organization is assessed as being in the precontemplation stage at one point in time, and, after applying processes of change such as consciousness-raising, dramatic relief, and environmental reevaluation, the organization s stage of change may vary. Participants A sample consisting of members of a multispecialty physician group in south central Pennsylvania was invited to participate in a one-on-one interview. To recruit participants, the organization s was utilized as well the organization s newsletter. The medical director of the organization sent out the and copied the principal investigator. The newsletter was used because all organization members do not have access to . Volunteers for the study contacted the principal investigator directly to participate in study. Each participant met with the researcher on a specified day and time at the organization site. Participants were informed that the purpose of the research was to explore how change occurred in organizations. There were a total number of 477 employees in the physician group. Sixteen participants were interviewed for this study. They had the following job classifications: three executive committee members, three EHR implementation team members, two physician partners, billing supervisor, payroll specialist, practice manager, physician, physician assistant, LPN, front-

5 142 BOSWELL office supervisor, and back-office supervisor. Participants included in the interviews did hold significant roles in the choice of EHR system and its implementation as the system needed to be customized for each office. The numbers in this study s sample job classifications do not represent the job classification proportions in the multispecialty physician group. The small sample size could be attributed to the fact that this relatively large physician group that included providers of varied specialties were implementing EHR in multiple phases. For instance, the first phase included only two of the group s family practices who represent the majority of the sample in this study. Another rationale for the small sample size could be resistance to EHR implementation. A demographic sheet was also given to participants before the interview so the researcher had information on several of the participants characteristics, such as positions within the organization, educational levels, and years of experience with the organization. The employees who participated in this study varied according to job classification, education levels, and years of experience with the organization. Table 1 contains the job classifications and number of employees interviewed in this study. Table 2 summarizes the level of education of the participants. Table 3 provides details about the participants years of professional experience and years of experience with the medical group. Instrumentation Participants were asked four sets of semistructured questions that were geared to identifying actions that define successful EHR implementation, stage of change, pros and cons of EHR implementation, and processes of change utilized to move the multispecialty to successful EHR implementation. There were a total of 29 semistructured interview questions that required the participants to orally answer each question. However, the participants did not confine their responses to these questions as additional probing questions were necessary at times in different interviews. Each interview was tape-recorded and later transcribed for analysis in NVivo8, a qualitative data analysis software program. Data Analysis This analysis served to answer the present study s questions. The pattern matching analytic technique was applied in this study to explore the medical group s behavior change process with the predicted patterns of the TTM (Yin, 2009). Participant responses to interview questions were coded to determine how they fit into TTM constructs. The specific procedures used are described below. The data analysis software included an initial codebook that consisted of a defined set of 13 codes grounded in the TTM. Transcriptions of interview responses to each question were read through five to six times by the researcher and coded as one of the 13 codes. Within each code, preliminary themes were identified and labels were developed to represent the themes. Themes and labels were refined and similar themes combined to create a more useful organization of the data. Table 1 Job Classifications and Number of Employees Interviewed Job classifications Number of employees Back office supervisors 1 Billing supervisors 1 EHR implementation team 3 Executive committee 3 Front office supervisors 1 Licensed practical nurses 1 Non-partner physicians/providers 1 Office managers 1 Partner physicians/providers 2 Payroll specialist 1 Physician assistants 1

6 MOVEMENT TO ELECTRONIC HEALTH RECORDS 143 Table 2 Participants Level of Education Level of education (n 16) Number Percent of sample Some college or technical school Associate degree Bachelor s degree Master s degree or higher In this process, patterns and themes provided the answers to this study s research questions (Creswell & Plano Clark, 2007). Table 4 presents the 13 codes used and the number of times each code was referenced in this study. Results Actions for EHR Data analysis revealed that four behaviors were identified and defined by the physician group employees. These behaviors were: (a) support aiding the cause or interest of EHR, (b) managing directing the affairs or interest of EHR, (c) training making proficient with instruction and practice of EHR, and (d) collaboration working together to successfully implement EHR, respectively. Stage of Change for EHR Nearly 70% (11 employees) indicated that their organization was in a preparatory stage for EHR implementation. Nineteen percent (3 employees) categorized the organization as in the contemplation stage. Twelve percent (2 employees) categorized the organization as in either the action or the maintenance stage. Figure 1 depicts the medical group s stage of change as perceived by participants in this study. Pros and Cons for EHR A total of five benefits and eight drawbacks in implementing EHR were cited by physician group employees who participated in this study, as listed in Table 5. Some of these themes included subthemes, such as improve patient care and safety, which was the most referenced benefit (146 mentions) while fear was the most referenced drawback (75 mentions). Processes of Change for EHR Data analysis revealed that the physician group utilized the following nine processes of change to implement EHR: (a) consciousness raising increasing awareness and information about EHR and its benefits (extensive), (b) helping relationships seeking and using social support to facilitate change (extensive), (c) dramatic relief experiencing negative emotions associated with the failure to change and relief that comes with success (extensive), (d) environmental reevaluation Table 3 Years of Professional Experience and Years of Experience in the Organization n 16 Mean Median SD Min Max Professional experience yrs Experience with organization 7.1 yrs months 24 Note. Min minimum professional experience or minimum experience with organization; Max maximum professional experience or maximum experience with organization.

7 144 BOSWELL Table 4 Codes and References Codes References EHR actions defined 226 Pros 227 Cons 201 Consciousness raising 75 Dramatic relief 48 Environmental reevaluation 31 Self reevaluation 34 Social liberation 21 Self liberation 23 Stimulus control 43 Counter conditioning 25 Reinforcement management 24 Helping relationships 55 considering how EHR will have a positive impact on the social and work environment (extensive), (e) self-reevaluation considering how one s identity, happiness, and success can be enhanced by the adoption of EHR (moderate), (f) social liberation the organization empowering individuals to participate in EHR (moderate), (g) self liberation the belief that one can change and commitment based on belief (moderate), (h) stimulus control restructuring the environment to remove cues for status quo and adding cues for EHR (minimal), and (i) reinforcement management finding intrinsic and extrinsic rewards for new ways of working (minimal). Discussion Study results supported the application of the TTM in explaining and facilitating EHR implementation. Four behavioral markers were identified to define action for successful EHR implementation: Figure 1. Stage of change as perceived by the medical group participants. None of the participants perceived the medical group as being in the precontemplation stage.

8 MOVEMENT TO ELECTRONIC HEALTH RECORDS 145 Table 5 Pros and Cons of EHR Implementation Pros Improve patient care and safety Reduce frustration Generate revenue Remain competitive Excitement Cons Fear Learning curve Reduced productivity Resistance Back loading Cost Impersonal Increased frustration (a) support, (b) managing, (c) training, and (d) collaborating. Findings suggested that these four behaviors are necessary for successful EHR implementation at a medical office. In addition, these four behavior change targets could help change leaders to clarify the goals of the change initiative and then communicate them to the rest of the medical group. For instance, these behaviors may be the basis of an incentive program that rewards employees who exemplify the behaviors. There appears to be validation for the theoretical relationship between stages of change and the decisional balance inventory. Previous research has shown that in the middle stages, the pros of the new behavior begin to outweigh its cons (Hall, 2004; Prochaska, 1994). Nearly 70% (11 employees) indicated that their organization s stage of change was exactly in the middle (preparation) for EHR implementation. Overall, the pros were referenced 227 times compared to the cons, which were referenced 201 times. The most frequently mentioned benefit of EHR implementation improve patient care and safety was referenced 146 times. The most frequently mentioned drawback of EHR implementation fear was referenced 75 times. Overall, more cons were identified than pros. After EHR implementation, most of the cons identified may gradually fade away. There also seems to be validation for the theoretical relationship between the stages of change and the processes of change. That is, organizations in the later stages engaged in more processes of change than organizations in the earlier stages (Levesque et al., 2001; J. M. Prochaska, 2000). In this study the physician group was found to be in the preparation stage. Furthermore, the physician group used at least 8 of 10 processes of change. That s more than an organization in the precontemplation or contemplation stages and less than an organization in the action or maintenance stages. The two processes of change that the organization was not using included reinforcement management and counter conditioning. Some degree of reinforcement management was being used by the physician group because of the potential increase in job satisfaction, individual fulfillment, and potential monetary rewards that attend EHR implementation. The physician group was using counterconditioning even less often because no new behaviors/activities had been substituted for old behaviors/activities. However, the physician group did provide pretraining and demonstrations. Based on study findings, it seems reasonable to suggest that this medical group will move further along with its implementation of EHR if it utilizes more action-oriented strategies, including: (a) implementation of the action plan for EHR by substituting the desired EHR behavior for the current paper chart behavior, (b) reward desired EHR behavior with either monetary or nonmonetary incentives, (c) restructure the medical office by removing cues for paper chart tasks and adding cues for electronic chart tasks, and (d) provide the necessary support from leadership, peers, and the industry for the change to EHR behavior. Utilization of these strategies should help to minimize the perceived drawbacks and enhance the perceived benefits of EHR implementation. An executive summary was provided to the medical director of the physician group. The medical director indicated that the summary was shared with their management team and executive board. Practitioners should become acquainted with TTM because of its ability to describe an organization s readiness for change and its ability to focus on activities and events that successfully modify behavior based on stage of readiness. This study s findings provide further implications for

9 146 BOSWELL stage-matched interventions designed to increase organizations readiness to implement behavior changes that is, tailoring change initiatives more closely to the organization s readiness for change. This approach shows more promise than a one-size-fit-all intervention that may result in resistance to change and other negative consequences. The population for this study was limited to a physician group that is implementing or planning to implement EHR. This population is not representative of all medical offices implementing EHR, nor is it representative of other types of organizations. In addition, results from participants may not be reflective of those for nonparticipants. This study only investigated the multispecialty physician group s actions regarding EHR implementation, stage of change, pros and cons related to the change, and processes of change utilized to move it forward to successful EHR implementation. The causes of expected differences between participants who hold a different job classification were not examined. The researcher was only able to conclude from the present situation, which makes it difficult to generalize the results to other organizations at other times. No reliability and validity measures were used to assess stage of change, decisional balance, or processes of change in this study. Future research should include the development of reliability and validity measures for stage of change, decisional balance, and processes of change using behaviors that define successful EHR implementation. Such measures can be valuable in facilitating the development of TTM-based interventions for implementing EHR. This research may be applicable to other types of changes that involve behaviors. If further research replicates the relationships found in the TTM on a variety of organizational changes, practitioners may be able to forecast those interventions that exert the most impact based on readiness to change. The initial challenge, regardless of type of organizational change, is clearly identifying the target behavior(s) and the contextual problem(s). This case study provides preliminary evidence of the applicability of the TTM to a broader variety of consulting situations in organizations. The TTM provides an overarching framework that increases clarity and direction and guides the development of stage-matched change management programs. However, the TTM approach appears most suitable when the change is psychological or behavioral. That is, change related to specific readiness to take action. For example, an organization working collaboratively to successfully implement electronic health records defines behaviorally what an organization would be doing if they were in action. Furthermore, consulting psychologists could utilize the TTM for tailoring or targeting interventions to employees in an organization by their readiness to do an organizational change. References Allscripts Healthcare Solutions. (2005). The electronic physician: Guidelines for implementing a paperless practice. Chicago: Author. Bartunek, J. M. (1984). Changing interpretive schemas and organizational restructuring: The example of a religious order. Administrative Science Quarterly, 29, Centers for Medicare & Medicaid Services. (2010). Medicare and medicaid EHR incentive programs. Retrieved from MU_Stage1_ReqSummary.pdf Colarelli, S. M. (1998). Psychological interventions in organizations: An evolutionary perspective. American Psychologist, 53, Creswell, J. W., & Plano Clark, V. L. (2007). Designing and conducting mixed methods research. Thousand Oaks, CA: Sage. Evers, K. E., Prochaska, J. O., Johnson, J. L., Mauriello, L. M., Padula, J. A., & Prochaska, J. M. (2006). A randomized clinical trial of a population and transtheoretical based stress management intervention. Health Psychology, 25, Ford, J. D., & Ford, L. W. (1994). Logics of identity, contradiction, and attraction in change. Academy of Management Review, 19, Ford, J. D., & Ford, L. W. (1995). The role of conversations in producing intentional change in organizations. Academy of Management Review, 20, Greene, G. W., Rossi, S. R., Rossi, J. S., Velicer, W. F., Fava, J. L., & Prochaska, J. O. (1999). Dietary applications of the stages of change model. Journal of the American Dietetic Association, 99,

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11 148 BOSWELL trial of the efficacy of a multi-component stage-matched intervention to increase sun protection among beachgoers. Preventive Medicine, 35, Whysall, Z. J., Haslam, C., & Haslam, R. (2007). Developing the stage of change approach for the reduction of work related musculoskeletal disorders. Journal of Health Psychology, 12, Yin, R. K. (2009). Case study research: Design and methods (4th ed.). Thousand Oaks, CA: Sage. Received March 31, 2011 Revision received May 6, 2011 Accepted May 13, 2011 Members of Underrepresented Groups: Reviewers for Journal Manuscripts Wanted If you are interested in reviewing manuscripts for APA journals, the APA Publications and Communications Board would like to invite your participation. Manuscript reviewers are vital to the publications process. As a reviewer, you would gain valuable experience in publishing. The P&C Board is particularly interested in encouraging members of underrepresented groups to participate more in this process. If you are interested in reviewing manuscripts, please write APA Journals at [email protected]. Please note the following important points: To be selected as a reviewer, you must have published articles in peer-reviewed journals. The experience of publishing provides a reviewer with the basis for preparing a thorough, objective review. To be selected, it is critical to be a regular reader of the five to six empirical journals that are most central to the area or journal for which you would like to review. Current knowledge of recently published research provides a reviewer with the knowledge base to evaluate a new submission within the context of existing research. To select the appropriate reviewers for each manuscript, the editor needs detailed information. Please include with your letter your vita. In the letter, please identify which APA journal(s) you are interested in, and describe your area of expertise. Be as specific as possible. For example, social psychology is not sufficient you would need to specify social cognition or attitude change as well. Reviewing a manuscript takes time (1 4 hours per manuscript reviewed). If you are selected to review a manuscript, be prepared to invest the necessary time to evaluate the manuscript thoroughly.