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European Journal of Operational Research 146 (2003) 352–364 www.elsevier.com/locate/dsw Enterprise resource planning: A taxonomy of critical factors Majed Al-Mashari a a,* , Abdullah Al-Mudimigh a, Mohamed Zairi b Department of Information Systems, College of Computer and Information Sciences, King Saud University, P.O. Box 51178, Riyadh 11543, Saudi Arabia b ECTQM, University of Bradford, Emm Lane, Bradford B094JL, West Yorkshire, UK Received 27 June 2002; accepted 27 June 2002 Abstract This paper presents a novel taxonomy of the critical success factors in enterprise resource planning (ERP) implementation process. ERP beneﬁts cannot be fully realised unless a strong alignment and reconciliation mechanism is established between technical and organisational imperatives based on the principles of process orientation. It is suggested in the taxonomy that measurement takes place in a balanced perspective, and for the purpose of providing useful information that can enable the decision making process and, which can help deliver the corporate objectives and therefore lead the business competitively forward. Upon this premise, the taxonomy is based on a comprehensive analysis of ERP literature combining research studies and organisational experiences. The taxonomy reﬂects the essential features of ERP systems, as being built based on the principles of business process management. Furthermore, it illustrates that ERP beneﬁts are realised when a tight link is established between implementation approach and business process performance measures. 2002 Elsevier Science B.V. All rights reserved. Keywords: ERP; Critical success factors; Taxonomy; Deployment; Evaluation 1. Introduction Today, one of the major sources of competitive advantage has been the ability to speed up the supply-chain process (Gumaer, 1996). This demand led to a signiﬁcant development in information systems (IS) known as enterprise resource planning (ERP) systems. Instead of developing IT * Corresponding author. E-mail addresses: firstname.lastname@example.org (M. Al-Mashari), email@example.com (A. Al-Mudimigh), m.zairi@ bradford.ac.uk (M. Zairi). system in-house, more and more companies are turning to oﬀ-the-shelf ERP solutions to plan their IT resources more eﬀectively and manage their legacy systems (Holland and Light, 1999). Various ﬁgures have pointed to the fact that ERP systems have become one of the largest IT investment in the 1990s (Chung and Snyder, 1999). In fact, the implementation of an ERP system can be considered as one of the most eﬀective ways towards traceability, since it facilitates integration between modules, data storing/retrieving processes and management and analysis functionalities, combined with the typical functionalities of standalone applications (Rizzi and Zamboni, 1999). The 0377-2217/03/$ – see front matter 2002 Elsevier Science B.V. All rights reserved. PII: S 0 3 7 7 – 2 2 1 7 ( 0 2 ) 0 0 5 5 4 – 4 M. Al-Mashari et al. / European Journal of Operational Research 146 (2003) 352–364 notion of ‘‘integration’’ can be traced back to the early days of computing in organisations, when Blumenthal (1969) developed a framework and integrated architecture for organizational IS (Kumar and Hillegersberg, 2000). Even if an organization could, over a short period of time, conﬁrm ﬁnal success of implementation of ERP, the real business value may not be realised as quick. The realisation of a lasting commitment has begun to dawn upon many organisations. For instance, some of the early implementers of SAP who installed the R/2 system version face a costly, time-consuming upgrade process to R/3 (Davenport, 1998a,b). The complexity of ERP and its associated high costs and implementation problems are forcing many organisations to rethink their plans for acquiring and implementing such enterprise systems (Kumar and Hillegersberg, 2000). Despite the signiﬁcant beneﬁts that ERP software packages provide in managing and integrating cross-functional business processes, they often cost millions of dollars to buy, several time as much to install, and, more importantly, they result in disruptive organizational changes (Volkoﬀ, 1999). It is on this basis that some companies have enjoyed considerable improvements whilst others have had to scale back their initiatives and to accept minimum payoﬀs, or even decide to give up on ERP implementation (Soh et al., 2000). This paper discusses the theoretical basis of ERP systems in relation to the beneﬁts realization process. A theoretically and practically grounded taxonomy of ERP critical success factors is therefore developed. The taxonomy demonstrates the linkages between ERP critical factors of success, ERP success and ERP beneﬁts. It should therefore contribute to an enhanced process of ERP beneﬁts realization, where critical factors bridge the link between ERP implementation and improvement in business performance across strategy, business processes, IT, structure, culture and management systems. 2. ERP deﬁnitions and drivers Like many newer ﬁelds in IS, the deﬁnition of ERP software, synonyms are integrated stan- 353 dard software packages, enterprise systems, enterprise wide-systems, enterprise business-systems, integrated vendor software, and enterprise application systems (Gable, 1998; Holsapple and Sena, 1999; Rosemann, 1999), has been deﬁned by various authors but with not much diﬀerences. Rosemann (1999) deﬁnes ERP system as a customizable, standard application software which includes integrated business solutions for the core processes (e.g. production planning and control, warehouse management) and the main administrative functions (e.g., accounting, human resource management) of an enterprise. Slight diﬀerently, Gable (1998), however, deﬁnes it as a comprehensive package software solutions seek to integrate the complete range of a business processes and functions in order to present a holistic view of the business from a single information and IT architecture. Since the focus of manufacturing systems in the 1960s was on traditional inventory control concepts, most of the software packages were limited generally to inventory based on traditional inventory processes (Gumaer, 1996; S, 2000). Due to the need for software designed speciﬁcally for manufacturing operations, the focus of manufacturing systems have moved to material requirement planning (MRP) systems which translated the Master Schedule built for the end items into timephased net requirements for the sub-assemblies, components and raw materials planning and procurement (Gumaer, 1996; S, 2000). Since 1975, the MRP system has been extended from a simple MRP tool to become the standard manufacturing resource planning (MRPII) (Chung and Snyder, 1999). In addition, Shtub (1999) states that the MRP systems, which trade with resource capacities, are known as MRPII systems. However, the shortcomings of MRPII in managing a production facilityÕs orders, production plans, and inventories, and the need to integrate these new techniques led together to the development of a rather more integrated solution called ERP (Chung and Snyder, 1999). ERP systems work essentially at integrating inventory data with ﬁnancial, sales, and human resources data, allowing organisations to price their products, produce ﬁnancial statements, and manage eﬀectively their resources of people, 354 M. Al-Mashari et al. / European Journal of Operational Research 146 (2003) 352–364 materials, and money (Markus et al., 2000). The emergence of ERP in the early 1990s led to the inclusion of other functions such as accounting and sales management (Gupta, 2000). In fact, ERP advocates believe that ERP could combine both business processes in the organization and IT into one integrated solution, which MRP and MRP II were not able to provide (Chung and Snyder, 1999). In recent years, while the rise of the Internet has been the subject of most of the mediaÕs attention, the business worldÕs focus on enterprise systems may in fact be the most signiﬁcant shift in the organisational use of IT in the 1990s (Davenport, 1998a,b; Holsapple and Sena, 1999). In the software market, the ERP software is the fastest growing market, as its growth is expected to increase from $15 billion to $50 billion in the coming ﬁve years (Bingi et al., 1999). By the year 2002, AMR Research expects the ERP systems market to jump from $15.68 billion (in 1997) to $72.63 billion (Holland and Light, 1999). This is comparable to the predication of some industry analysts that the worldwide ERP systems market is expected to reach $50 billion by 2002 (Computer Technology Research Corporation, 1990). An important feature of ERP is that it is the ﬁrst approach that integrally combines business management and IT concepts. (Slooten and Yap, 1999). Its strength stems from its ability to provide a comprehensive business functionality in an integrated way using a state-of-the-art IT infrastructure (Waston et al., 1999). In one example, SAPÕs client/server software package, R/3, oﬀers the potential to integrate the complete range of an organisationÕs operations in order to present a holistic view of the business functions from a single information and IT architecture perspective (Gable et al., 1998). Indeed, enterprise systems have improved the organisational information ﬂow through the supply chain to such a degree that they have become an eﬀective operating standard (Davenport, 1998a,b). One signiﬁcant feature of an ERP software is that core corporate activities, such as manufacturing, human resources, ﬁnance, and supply chain management are automated and improved considerably by incorporating best practices, so as to facilitate greater managerial control, speedy decisionmaking and huge reduction of business operational cost (Bancroft et al., 1998; Holland and Light, 1999). The basic architecture of an ERP system builds upon one database, one application, and a uniﬁed interface across the entire enterprise. An entire organisation is therefore able to operate under one application standard where all applications serving human resources, accounting, sales, manufacturing, distribution, and supply-chain management aspects are ﬁrmly integrated. An ERP software is also beneﬁcial in that it can speed decision-making, reduce costs and give managers control over a globally distributed business operations (Gibson et al., 1999; Holsapple and Sena, 1999). A study by Benchmarking Partners for Deloitte & Touche Consulting (Computer Technology Research Corporation, 1999) classiﬁes companiesÕ motivations for ERP implementation into two groups, technological and operational. Technological drivers relate mainly to the Year 2000 (Y2K) compliance requirements, replacement of disparate system, improvement of quality and visibility of information, integration of business processes and systems, simpliﬁcation of integration of business acquisitions into the existing technology infrastructure, replacement of older, obsolete systems, and the acquirement of system that can support business growth. Operational drivers, on the other hand, are related to improving inadequate business performance, reducing high-cost structures, improving responsiveness to customers, simplifying ineﬀective, complex business processes, supporting new business strategies, expanding business globally, and standardising business process throughout the enterprise. 3. ERP cost and impact The contribution that ERP packages, including those from SAP AG, PeopleSoft, Oracle, and Baan, have made to the business world has been remarkable. ERP systems have increased the eﬃciency of a wide range of businesses by providing them with seamless access to much of the information they need (Li, 1999). An ERP system can M. Al-Mashari et al. / European Journal of Operational Research 146 (2003) 352–364 be thought of as a business-wide integration mechanism of all organisational IS (Bingi et al., 1999). This integration makes organisations able (Bingi et al., 1999) to take quick reaction to competitive pressures and market opportunities, be more ﬂexible product conﬁgurations, achieve reduced inventory, and maintain tightened supplychain links. The study also identiﬁes the various beneﬁts of ERP implementation as perceived by the companies surveyed. ERP beneﬁts can be classiﬁed into tangible and intangible. According to the Deloitte & ToucheÕs survey (Computer Technology Research Corporation, 1999), tangible beneﬁts refer to inventory reduction, reduction of personnel, increased productivity, improvements in order management, more rapid closing of ﬁnancial cycles, reduction in IT and procurement costs, improvement of cash ﬂow management, increase of revenue and proﬁts, reduction in transportation and logistics costs, reduction in the need for system maintenance, and improvement in ontime delivery performance. Intangibles refer to the increased visibility of corporate data, new or improved business processes, improved responsiveness to customers, unanticipated reduction in cost, tighter integration between systems, standardization of computing platforms, increased ﬂexibility, global sharing of information, Y2K compliance, improved business performance, and improved visibility into SCM process. However, a study of 63 companies shows that it took eight months after the new system was in to see any beneﬁts. However, the median annual savings from the new ERP system was $1.6 million (Koch et al., 1999). Despite these signiﬁcant beneﬁts that ERP systems can provide, they are very expensive even under ideal circumstances. The cost of an ERP software itself can range from hundreds of thousands of dollars to several million dollars. This cost can further be escalated when considering hiring consultants to help in the selection, conﬁguration, and implementation of the system. According to an IT research ﬁrm, Gartner Group, companies may spend up to three times as much money on consultants as they do on the ERP system itself (Computer Technology Research Corporation, 1999). Other costs may include the 355 human resources needed to work full time on the implementation project. Additionally, an organisation may need to install new hardware to run the ERP software, and a new database to store the ERP data. Furthermore, integrating the ERP system with other types of applications is usually a necessity. It is also important that end-user training and change management costs are considered in the equation (Computer Technology Research Corporation, 1999). In fact, every company that implements an ERP system is faced with its cost and complexity. However, the disastrous problems are usually those which relate to implementing an ERP system without thinking through its full business implications (Davenport, 1998a,b). 4. Taxonomy of critical factors One major beneﬁt of ERP comes from its enabling role in reengineering the companyÕs existing way of doing business. All the processes in a company must conform to the ERP model. Organisations that do not adopt this philosophy are likely to face major diﬃculties (Gibson et al., 1999). This entails that the costs of aligning with an ERP model could be very high, especially when a company plans to roll out the system worldwide. However, ERP implementation results in signiﬁcant beneﬁts engendered from the integrated nature of the system as well as from reengineering business processes and the change in business culture (Bingi et al., 1999). This however results in the scale of business process reengineering (BPR) and customisation tasks involved in the software implementation process being the major reasons for ERP dissatisfaction (Scheer and Habermann, 2000). One useful approach to adopt when trying to answer the question on whether/how ERP systems implementation impact on business performance is to consider the levels of ambition of the organisations concerned and what it is that they aspire to achieve in terms of competitive results (AlMashari et al., 2001). It is often the case that well deployed visions and missions are the ones that are translated into critical factors of success that get communicated at all levels within the organisation. 356 M. Al-Mashari et al. / European Journal of Operational Research 146 (2003) 352–364 In a sense, one major condition for ERP systems to yield to the desired beneﬁts is how well they serve the delivery of CFs. In light of Lyytinen and HirschheimÕs (1987) deﬁnition of failure, success in IT projects can be seen as: • Correspondence success, where there is a match between IT systems and the speciﬁc planned objectives. • Process success, when IT project is completed within time and budget. • Interaction success, when usersÕ attitudes towards IT are positive. • Expectation success, where IT systems match usersÕ expectations. The link between ERP beneﬁts and strategic goals, objectives or CFs is therefore a relative one rather than absolute in terms of what speciﬁcally can be expected. Shang and Seddon (2000) classify ERP beneﬁts into ﬁve groups as follows: • Operational, relating to cost reduction, cycle time reduction, productivity improvement, quality improvement, and customer services improvement. • Managerial, relating to better resource management, improved decision making and planning, and performance improvement. • Strategic, concerning supporting business growth, supporting business alliance, building business innovations, building cost leadership, generating product diﬀerentiation, and building external linkages. • IT infrastructure, involving building business ﬂexibility, IT cost reduction, and increased IT infrastructure capability. • Organisational, relating to supporting organizational changes, facilitating business learning, empowering, and building common visions. In a sense, a balanced strategy will have CFs of a strategic, organisational and operational nature. The implementation of ERP systems will therefore be carried out to serve that particular purpose and to support the accomplishment of the various, multi-level CFs. Furthermore, ERP systems can yield to many intangible beneﬁts such as ﬂexibil- ity, integration, process orientation and synergy building. These very often-unexpected beneﬁts can therefore provide organisations with added capability and will ultimately enhance the latterÕs strategic planning eﬀorts and can boost future competitive results. The taxonomy represented in Fig. 1 is a means for illustrating on the one hand the inter-relationship between core business strategy aspects, and on the other, the role of IT and associated systems can play in supporting the eﬀective deployment of key business imperatives through process improvement and management and through regular performance monitoring and review. 5. Setting-up 5.1. Management and leadership A review of successful ERP implementations has shown that leadership and top management commitment are the most critical factors in organizations embarking on ERP implementation, as they ensure a smooth change management and system rollout (Bingi et al., 1999). Not only is the requirement for setting the vision and the direction for the business, it is also for harnessing the energy and creativity of employees, for enabling the business to perform, for implementing modern concepts such as BPM and for exploiting the technology capabilities of an ERP system. Furthermore, leadership is a propagated approach of individuals and champions who can eﬀectively implement change programs such as ERP systems and who are not averse to modern ideas, learning and growing the business through innovation and best practices (Al-Mashari et al., 2001). The experience of Microsoft highlights the importance of having top management directly involved in planning and implementing an ERP system. MicrosoftÕs top management was instrumental in overseeing its ERP project, and the entire board reviewed and approved the plans (Deloitte Consulting, 2000). At ALEVO, the decision to implement an ERP system was also made at the board level, and the senior management team input was very important when selecting a M. Al-Mashari et al. / European Journal of Operational Research 146 (2003) 352–364 357 Fig. 1. Taxonomy for ERP critical factors. suitable vendor (Welti, 1999). Top management support and commitment does not end with initiation and facilitation, but must extend to the full implementation of an ERP system. HP noted that ERP implementation is about people, not processes or technology. The organisation went through a major transformation, and the management of this change was carefully planned (from a strategic viewpoint) and meticulously implemented. All the case studies analysed have shown that the key to a smooth rollout is the effective change management from top. Intervention from management has been necessary to crucial for the adequate resourcing of the project, to taking fast and eﬀective decisions, resolve conﬂicts and bring everybody to the same thinking, to promote company-wide acceptance of the project, and to build co-operation among the diverse groups in the organisation, and in many times across national borders. Top management needs to constantly monitor the progress of the project and provide direction to the implementation teams. 5.2. Visioning and planning ERP systems are essentially considered as process-oriented IT tools for improving business performance. One of the most fundamental elements in business improvement is having a clearly deﬁned vision/mission and the formulation of the right policies/strategies that can serve as the blueprint for any organisational success (Mitchell and Zmud, 1995). It is also important to emphasise at this juncture that successful visions/missions are those that are translated into measurable goals and targets. The visioning and planning stage can then serve as Ôthe precursorÕ for putting in place an enabling IT strategy, based on mapping and determining the key requirements that can support 358 M. Al-Mashari et al. / European Journal of Operational Research 146 (2003) 352–364 the eﬀective deployment and delivery of the key business imperatives (Al-Mashari et al., 2001). In fact, an IT vision/mission process is developed as a sub-set of the business strategic formulation process (Henderson and Venkatraman, 1993). It addresses similar issues that are considered from a technical, enabling and supporting perspective (AlMashari et al., 2001), and be shaped through a comprehensive gap analysis as well as capturing leading practices form similar competent organizations (Al-Mashari and Zairi, 1999). Luftman and Brier (1999) point out that IT managers must be knowledgeable about how new technologies (such as ERP systems) can be integrated into every component of their business, including tactical and strategic plans, management systems, culture, human resources, organisational structure, current technologies and business architecture. It is therefore imperative that business strategy formulation process be conducted with the presence of both IT and business executives. Alignment of IT strategy with the organizationÕs business strategy is also considered a fundamental principle that has been advocated for over a decade (Rockart et al., 1996). Luftman and Brier (1999) ﬁnd out that the IT/Business strategic alignment process is enabled by senior executive support for IT, involvement of IT people in strategy development and the level of IT peopleÕs understanding of the business. He also recommends that maximizing the role of alignment enablers can be achieved through setting clear goals and establishing strong teams, establishing strong communication plans, understanding the business–IT linkage, analysing and prioritising performance gaps, specifying actions and deﬁning project-management infrastructure, choosing and evaluating success criteria, and sustaining alignment through continuous improvement. In ERP implementation, the same principles of IT strategic alignment apply. If an organization strives to install a system without establishing a clear vision and understanding of the business propositions, the integration eﬀorts can quickly turn into a disaster, no matter how competent is the software package selected (Davenport, 1998a,b). Indeed, without a clear direction and meticulous strategic planning, the ERP implementation initiative can suﬀer a huge failure (Deloitte Consulting, 2000). Well-deﬁned strategic targets help to keep the project team on track throughout the entire implementation process (Welti, 1999). Project frameworking through planning is important as it identiﬁes the extent and type of beneﬁts that can be derived from an ERP systems (Markus et al., 2000). In reality, the logic of an ERP system may conﬂict with the logic of the business, and either of two results will come out, an implementation failure, or a weakened competitive position (Davenport, 1998a,b). In the past, ERP projectsÕ failures are found to be the result of inadequately deﬁned business goals and the lack of strong and adequate sponsorship (Deloitte Consulting, 2000). 6. Deployment This group of factors concerns moving from the what to the how issue of implementation, and converting the ÔblueprintsÕ into real actions that focus on the value chain aspects. From a business perspective, the deployment stage includes the deﬁnition of the documentation, analysis, improvement, control and redesign/reengineering opportunities of all the most critical processes and core activities. These activities are coupled with the management of the people (skills, competencies, etc.); the change management (preparing the organisation for change, dealing with resistance, for putting in communication, awareness, etc.); teambuilding (training brieﬁng, reward, recognition, etc.); the use of tools and techniques (problemsolving tools, measurement tools, need analysis tools, etc.); and project-management competencies (Al-Mashari et al., 2001). In fact, ERP systems are a natural progression from the logic described hitherto (Al-Mashari et al., 2001). They are derived from a true business need and requirement, their purpose is clearly deﬁned through the IT vision/mission, their role is fundamentally to support all aspects of process management. The role itself is very encompassing and will cover strategic, tactical and operational aspects and the beneﬁts to be accrued will therefore be very diverse. M. Al-Mashari et al. / European Journal of Operational Research 146 (2003) 352–364 6.1. ERP package selection Companies often fail to consider whether the system they are evaluating will match their overall business strategy (Davenport, 1998a,b). It is therefore prudent that the characteristics of an ERP software are matching the criteria used by an organisation to select an IS. The results of a survey of the criteria used by organisations in selecting their current IS shows that the best ﬁt with current business procedures is the most important one (Everdingen et al., 2000). Clarkston Potomac (Computer Technology Research Corporation, 1999) suggests several practices to ensure a successful ERP selection process, including staying on schedule, including human resources representatives in the assessment of IT capabilities, not allowing vendors to drive the presentations of demos, entering product presentations or demos with a clear agenda and communicate that agenda to the providers, ensuring that test scenarios represent a variety of departments, building test scenarios that represent current and future processes, documenting assumptions about what the ERP system will accomplish, recording all conclusions reached about each vendor and system, respecting dissenting options, scheduling breaks between product reviews, resisting the temptation to rank candidates, eliminating clear losers immediately, using experienced negotiators, and maintaining site of original plans. On the other hand, Rao (2000a,b) believes that small and medium enterprises should check for ﬁve important criteria when selecting an ERP package. These are aﬀordability, domain knowledge of suppliers, level of local support, software upgradability and use of latest technology. 6.2. Communication Indeed, communication is one of most challenging and diﬃcult tasks in any ERP project (Welti, 1999). The communication plan has to detail several areas including the rationale for the ERP implementation, details of the business process management change, demonstration of applicable software modules, brieﬁngs of change management strategies and tactics and establish- 359 ment of contact points (Bancroft et al., 1998). Communication has to cover the scope, objectives, and tasks of an ERP implementation project (Sumner, 1999). In a way to avoid the various communication failures, an open information policy has to be maintained for the project. For example, a good e-mailer system can help promote this policy, but serious problems need to be discussed by telephone or, preferably, face to face (Welti, 1999). 6.3. Process management To take full advantage of an ERP software, business process redesign is a prerequisite (Holland and Light, 1999). Because ERP systems are essentially developed as instruments for improving business processes such as manufacturing, purchasing, or distribution, ERP implementation and BPR activities should be closely connected (Al-Mashari and Zairi, 1999). This is achieved through an exhaustive analysis of current business processes to identify the potential chances of reengineering, rather than designing an application system that makes only the best of bad processes (Scheer and Habermann, 2000). 6.4. Training and education Inadequate training has been one of the signiﬁcant reasons of many ERP systems failure (Gupta, 2000). In ERP implementation projects, despite millions of dollars and hundreds of deployment hours, many projects fail because of the lack of adequate training (Kelley et al., 1999). A particular challenge in ERP implementation is to select an appropriate plan for end-user training and education. It is however important to stress that the main goal of ERP training should be the eﬀective understanding of the various business processes behind the ERP applications (Gupta, 2000). ERP training should address all aspects of the system, be continuous and based on knowledge transfer principles wherever consultants are involved (Davenport, 1998a,b). 360 M. Al-Mashari et al. / European Journal of Operational Research 146 (2003) 352–364 6.5. Project management Approximately 90% of ERP implementations are late or over budget (Martin, 1998), which may be due to poor cost and schedule estimations or changes in project scope, rather than projectmanagement failure (Holland et al., 1998). Slevin and Pinto (1987) argue that in order to manage a project successfully, project managers must be capable both in strategic and tactical projectmanagement activities. They propose ten projectmanagement critical success factors that fall in either the strategic or tactical phases of a project. The strategic factors are: project mission, top management support and project schedule/plan; while tactical factors are: client consultation, personnel recruitment, technical task, client acceptance, monitoring and feedback, communication, and troubleshooting (Slevin and Pinto, 1987). With new technology, it is often critical to acquire external expertise, including vendor support, to facilitate successful implementation. (Sumner, 1999). Hundreds of companies provide ERP services, which may include all or some combination of ERP selection, business process planning or reengineering, ERP implementation, End-user training and ERP maintenance and support. With the growth of the ERP market being fast and huge, there has been a lack of competent consultants. One of the challenges with ERP implementation is that it demands multiple skills covering functional, technical, and inter-personal areas. If these skills are found in a consulting ﬁrm, it is another challenge for an organisation to manage such a consultant (Bingi et al., 1999). However, an important success factor here is for the organisation to establish a knowledge transfer mechanism by which consultantsÕ role is deﬁned clearly and their skills and expertise are acquired and transferred adequately. 6.6. Legacy systems management Roberts and Barrar (1992) and Adolph (1996) note that legacy systems include the existing information technology infrastructure (hardware and software), business processes, organisational structure and culture. In ERP implementation, existing legacy systems have to be carefully deﬁned and evaluated to determine the nature and scale of problems that an organisation may encounter during implementation (Holland and Light, 1999). As it is important that an adequate infrastructure should be planned for so that it becomes reliably available and well in time (Rao, 2000a,b); Holland and Light (1999) stress the need to carefully manage legacy systems in ERP implementation. They suggest that if organizational legacy systems are very complex (with multiple platforms and a variety of procedures to manage processes), then the amount of technical and organisational changes required is likely to be high, and vise versa. Indeed, the problem of legacy systems centers on the fact that in most companies, data are not kept in a single repository, but rather spread across dozens or even hundreds of separate computer systems, each housed in an individual function, business unit, region, factory, or oﬃce. Each of these legacy systems may provide valuable support for a particular business task. However, when they are considered in combination, they represent one of the heaviest hindrances on business productivity and performance (Davenport, 1998a,b). It is important, therefore, that an organisation approaches the transition of legacy system carefully and with a comprehensive plan. 6.7. System integration One of the complexities associated with ERP implementation is related to the cross-module integration nature of the system (Soh et al., 2000). Though there are middleware technologies that can be used to integrate software applications from several vendors to the ERP backbone, they are not available for all ERP systems (Bingi et al., 1999). Moreover, middleware vendors often tend to focus on the technical aspects of application inter-operability rather than linking business processes together, and, in many times, organisations have to develop their own interfaces for commercial software applications. Even maintaining the integration mix requires an excessive and ongoing expenditure of resources (Bingi et al., 1999). It is found that organisations spend up to 50 percent of their IT budgets on application integration (Rad- M. Al-Mashari et al. / European Journal of Operational Research 146 (2003) 352–364 ding, 1998). When it comes to maintaining the system, IS personnel are faced with the challenge of managing and keeping it integrated with other organizational systems (Bingi et al., 1999). 361 Therefore, it is important that an organisation goes through a carefully planned transformation that is based on adequate strategy and well-deﬁned methodology of implementation (Bingi et al., 1999). 6.8. System testing As the implementation of any application system cannot be realised in a single step, the new functionalities are better tested both alone and in conjunction with the existing functionalities (Apperlrath and Ritter, 2000). In ERP implementation, going live on the system without adequate and planned testing is a recipe for an organisational disaster (Computer Technology Research Corporation, 1999). The testing and validation of an ERP system is important to ensure that the software works technically and that the business process conﬁgurations are practical. When business processes are up and running, an important test is of whether the processes described and represented in the application system actually match with the processes taking place in the organisation (Apperlrath and Ritter, 2000). In the case of Guilbert, testing was considered important because the new system were found not working in parallel with the companyÕs old systems. A testing process was undertaken as the system was conﬁgured, and then the entire system was tested by user trials (Gibson et al., 1999). 7. Evaluation 6.9. Cultural and structural changes 7.1. Performance evaluation and management It is estimated that about half of enterprise system projects fail to achieve hoped-for beneﬁts, because managers signiﬁcantly underestimate the eﬀorts required to manage eﬀectively the wide range of changes involved (Pawlowsiki and Boudreau, 1999). ERP systems are designed such that they support a variety of logical organisational structures. Consequently, customising and conﬁguring an ERP software involves creating a logical structure that in turn involves one or more ﬁnancial entities and one or more operational entities (manufacturing and/or sales and distribution units) (Markus et al., 2000). This requires a massive change in an organizationÕs structure and affects the way people use to do work and interact. Measuring and evaluating performance is a very critical factor for ensuring the success of any business organisation and indeed for making IT systems such as ERP pay back. Performance management in this context is therefore an integrated holistic concept. It has to embody the whole organisation and capture tangible and intangible aspects, cover soft and hard elements and include aspects of synergy through integration. Sinclair and Zairi (2000) argue that such measurement is not widely pervasive as an integrated practice and its implementation is not a straightforward process. It is suggested in the taxonomy that measurement takes place in a balanced perspective and for the purpose of providing useful information For the purpose of measuring and improving business performance, several costing techniques have been developed to provide more accurate cost information, primarily by cutting the link between internal management reporting and the demands of external regulations (Dixon et al., 1990). However, several authors such as McKinnon and Bruns (1992) suggest that management accountants must pass responsibility for performance measurement to those responsible for achieving the performance (i.e., process owners). This led to the development of non-ﬁnancial measures of performance to achieve a balanced between both ﬁnancial and operational measures. Grady (1991) supports this balanced perspective and Kaplan and Norton (1992) propose a ‘‘Balanced Scorecard’’ of measures along ﬁve perspectives, namely strategic planning, ﬁnancial, customer, internal business, and innovation and learning. This approach appears to become more popular as its applicability continues to spread across diﬀerent ﬁelds. 362 M. Al-Mashari et al. / European Journal of Operational Research 146 (2003) 352–364 that can enable the decision making process and, which can help deliver the corporate objectives and therefore lead the business competitively forward. In ERP contexts, the performance management has got to reﬂect a holistic and balanced perspective. In addition to technical performance such as reliability of the system, other aspects on ﬂexibility, speed, timeliness, costs, etc. can also be added on. The value-added contribution is in the form of the tangible and intangible beneﬁts, covering the strategic and operational aspects of business organizations (Al-Mashari, 2000). Furthermore, competitive measurement could cover the added capability provided by ERP systems to the business for ÔstretchingÕ the competitive and strategic agenda. To complement this system, it is advisable that regular auditing and benchmarking are considered for optimisation of the potential available to businesses in all aspects. Furthermore, external benchmarking can bring in new ideas, knowledge and best practices on dealing with deﬁciencies in ERP systems, de-bottlenecking, streamlining process, optimising and redesigning for more extensive beneﬁts (Al-Mashari, 2002). Such audits can take advantage of an array of existing tools that can be applied to ÔscanÕ both the organisational, managerial and technical sides of the business. 8. Conclusion This paper has presented a novel taxonomy of realising and maximising ERP beneﬁts though a critical factor approach. The paper argues that ERP beneﬁts are realised when a tight link is established between implementation approach and business-wide performance measures. The paper has discussed the concept of ERP as a pioneering, enabling and support system that is compatible with the requirements of modules business and that can help the eﬀective implementation of the business process management principles. The paper agreed the ERP systems can yield to a wide array of beneﬁts that are of a tangible and intangible nature. These are, however, heavily dependant on the approach adopted for the evaluation, selection and project manage- ment of ERP systems. To this end, a several critical factors have been identiﬁed and have been eluded to individually, within the paper. The taxonomy presented in this paper emphasizes that a clear vision and business director is fundamental for the success of ERP system implementation. It also considers IT strategic process a sub-set of the business strategy planning process where it sets the architecture and requirement for the short, medium and long-term requirements. The taxonomy also focuses on the business process management as a core requirement for business success in the creation of a value chain approach. The ERP system strategic is then become out of a clear IT strategy, which in turn, is supporting the core business strategy. A stage of performance review and evaluation is based on the premise that the evaluation and performance monitoring of ERP systemÕs implementation can in turn lead to the achievement of all the business desired goal and objectives. 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To improve understanding of facilitators of EHR system implementation, paying particular attention to opportunities to maximize physician adoption and effective deployment. Data Sources/Study Setting. Primary data collected from 47 physician and 35 administrative key informants from six U.S. health care organizations identiﬁed because of purported success with EHR implementation. Study Design. We conducted interviews and focus groups in an extensive qualitative study. Data Collection/Extraction Methods. Verbatim transcripts were analyzed both deductively and inductively using the constant comparative method. Principal Findings. Conceptualizing EHR adoption as loss through the lens of K€ ubler-Ross’s ﬁve stages of grief model may help individuals and organizations more effectively orient to the challenge of change. Coupled with Kotter’s eight-step change management framework, we offer a structure to facilitate organizations’ movement through the EHR implementation journey. Combining insights from these frameworks, we identify 10 EHR strategies that can help address EHR implementation barriers. Conclusions. Loss is one part of change often overlooked. Addressing it directly and compassionately can potentially facilitate the EHR implementation journey. We offer a summarized list of deployment strategies that are sensitive to these issues to support physician transition to new technologies that will bring value to clinical practice. Key Words. Electronic health records, medical informatics, information systems, information management/systems/computerization ambulatory/physician ofﬁce health information technology, EHR/EMR implementation, organizational change, change management, stages of grief The use of full or partial electronic health record (EHR) systems—also referred to as electronic medical records (EMRs)—in physicians’ ofﬁces is increasing (Burt, Hing, and Woodwell 2006; Hsiao et al. 2011). However, by 462 The Journey through Grief 463 2012, only 40 percent of providers used a fully functional system, or “Basic EHR,” deﬁned by the U.S. National Center for Health Statistics to include patient history and demographics, patient problem lists, physician clinical notes, comprehensive lists of patients’ medications and allergies, computerized orders for prescriptions, and the ability to view laboratory and imaging results electronically (Blumenthal, DesRoches, and Donelan 2008; Hsiao et al. 2011). Meanwhile, only 27 percent of physicians intending to apply for meaningful use incentives reported having EHR systems in place with capabilities to actually meet the Stage 1 core objectives for meaningful use (Hsiao et al. 2011; Kokkonen et al. 2013). These facts suggest that transitioning from paper records to an EHR cannot be equated with complete integration of an EHR into the care process. The slow pace of adoption and integration of fully functional EHR systems has typically been attributed to “barriers” at both the organizational and physician levels (Burt, Hing, and Woodwell 2006; DesRoches et al. 2008; Lorenzi et al. 2009; Hing, Hall, and Ashman 2010; Greiver et al. 2011; Kokkonen et al. 2013). Eight main categories of physician barriers were identiﬁed by a 2010 review of 22 research articles on barriers to EHR acceptance: ﬁnancial, technical, time, psychological, social, legal, organizational, and change process (Boonstra and Broekhuis 2010). These physician barriers align to barriers identiﬁed at the organization level (Ash and Bates 2005; Lorenzi et al. 2009; Rao et al. 2011), and both types are well-understood by practitioners and researchers. Some view these barriers as the focal point of interventions— removing them will accelerate EHR adoption (Miller and Sim 2004; DesRoches et al. 2008; Boonstra and Broekhuis 2010). An alternative framing, however, is of EHR adoption as a change process that is slowed due to participant resistance (Ford et al. 2009). In this article, we propose that EHR adoption is contingent not just on removing barriers but on addressing the change processes involved—at both the individual and organizational levels. Given this framing, there is a particular need to explore contextual factors related to the process of change to provide evidence-based guidance during implementation, a focus that is Address correspondence to Ann Scheck McAlearney, Sc.D., M.S., Department of Family Medicine, Ohio State University, 273 Northwood and High Building, 2231 North High Street, Columbus, OH 43201; e-mail: firstname.lastname@example.org. Jennifer L. Hefner, Ph.D., M.P.H., Cynthia J. Sieck, Ph.D., M.P.H., and Timothy R. Huerta, Ph.D., M.S., are with the Department of Family Medicine, College of Medicine, The Ohio State University, Columbus, OH. Timothy R. Huerta, Ph.D., M.S., is also with the Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH. 464 HSR: Health Services Research 50:2 (April 2015) relatively absent from the current discourse on EHR adoption (Boonstra and Broekhuis 2010; Greiver et al. 2011; McAlearney et al. 2012). Our paper ﬁlls this gap by examining administrators’ and physicians’ perspectives about how adoption and implementation of an EHR system can be facilitated. Our research objective, shared with study participants, was to improve our collective understanding of EHR implementation strategies to advance the adoption and implementation of ambulatory EHRs, paying particular attention to opportunities to maximize physician adoption and use of such systems. STUDY DESIGN AND M ETHODS Site Selection Our study was designed to learn from the experiences of physicians and administrators who had participated in EHR system implementations that had been widely reputed to be successful. We used several criteria to generate an initial list of successful sites including receipt of the Healthcare Information Management Systems Society Annual “Davies” Award for Ambulatory EHRs within the past 5 years combined with recognition as a “Most Wired” hospital by the Hospital and Health Network’s annual benchmark survey. We then solicited feedback from a project advisory committee comprised of representatives from industry and academia with expertise in HIT implementation to allow the research team to ﬁnalize the list. From this list of 10 potential study sites, we reﬁned our list to address considerations of geographic and organizational variability. Six health systems across the United States made our ﬁnal study sample, with consideration of alternate sites given to allow for expansion if insufﬁcient observed replication of themes across sites failed to allow the team to draw conclusions, consistent with our goal of saturation and the standards of case study research (Yin 2009). All target study sites agreed to participate in our research. Data Collection and Study Participants We conducted a total of 35 in-person or telephone interviews with administrative key informants, including organizational leaders and managers, information systems leaders and professionals, and staff (Table 1 provides a count of study participants by role). Interviews consisted of a series of open-ended questions and lasted 30–60 minutes. In addition, we held six focus groups comprised of 47 generalist and specialist physicians—physicians in practice, The Journey through Grief 465 Table 1: Study Participants, by Role Administrative Participants Number Physician Participants Number Leaders/managers 18 26 Information technology (IT) professionals and leaders Staff Total 13 Physicians in practice (attending and private practice physicians) Physicians in training (interns, residents) Physician leaders Total 4 47 4 35 17 physicians in training, and physician leaders. We conducted focus groups using a standardized focus group guide that covered topics related to EHR implementation and use. Focus groups lasted 60–90 minutes. All interviews and focus groups were recorded and transcribed verbatim. Our data collection process also included a concomitant assessment of interview and focus group transcripts and discussion of preliminary ﬁndings to permit probing for new concepts and ensure that we reached saturation in data collection, consistent with standards for rigorous qualitative research (Strauss and Corbin 1998). This study was approved by the institutional review board of The Ohio State University. No informant approached for this study refused to participate. Analysis We used a grounded theory approach including both inductive and deductive methods to analyze interview and focus group data. A coding team, established by the lead investigator, created a preliminary coding dictionary deﬁning broad categories of ﬁndings from the transcripts. This coding dictionary included the code “physician perspective,” deﬁned as physician’s views on how an EHR changes their work and/or relationship with patients. We further classiﬁed data in this broad code into themes, following Constas’s constant comparison methods (Constas 1992). Coders met periodically throughout the coding process to ensure consistency in coding and review any new codes or themes that emerged, consistent with a grounded theory approach (Glaser and Strauss 1967; Strauss and Corbin 1998). We used the Atlas.ti software program (Scientiﬁc Software Development 2008) to support the coding process. The themes associated with change principles that we describe here emerged from this iterative approach to coding and analysis. 466 HSR: Health Services Research 50:2 (April 2015) STUDY F INDINGS Through our analyses we found three important opportunities to facilitate physicians’ adoption and use of EHR systems in clinical practice. These opportunities involved (1) conceptualizing EHR adoption as personal change through a metaphor of loss and grief; (2) framing EHR implementation using an organizational change management model; and (3) mapping these two approaches together to develop 10 EHR deployment strategies. These deployment strategies can serve a useful function to management by linking speciﬁc interventions to each of the stages of grief. In the following sections we describe each of these opportunities in further detail and offer evidence from our analyses to support these ﬁndings. Conceptualizing EHR Adoption as Personal Change Involving Loss In synthesizing our ﬁndings about physicians’ personal reactions to EHR implementation, we identiﬁed a theme of loss among the participants. One administrator characterized the transition to an EHR as “the death of their old record into their new record,” while physicians often commented on the changes needed for them to use the new system. As one physician explained, “So in the good old days, well there’s a chart. You pick it up and we all knew how to ﬂip the tabs and you know we could deal with that.” The extant literature provides examples of these types of professional losses inherent in organizational change, including the loss of valued expert knowledge when new technology replaces old, and the loss of power when organizations are restructured (Harvey 2002). We found that both of these types of loss were noted by the physician interviewees when describing the EHR introduction and implementation. For instance, physicians described the EHR introduction as “really so destructive to my ﬂow and my interaction with my patients,” while another was concerned about how to work with the new system: “How do I access these old records, the x-rays, all this stuff? And order my labs and then discharge them and do the follow-up letter?” At the same time, administrators reported that physicians often clung to the past because they did not want to lose their sense of expertise and comfort with the way they did things. One administrator noted, “They’re really trying to do their old work in an EHR, as opposed to innovating, using that new functionality to innovate and change the way they practice.” The Journey through Grief 467 With respect to loss of power, two areas of power loss were of particular note among study participants. First, interviewees noted that having junior physicians more comfortable with computers than the average established physician involved a shift in power. As one physician explained, “It can turn the whole relationship we have upside down. The old model was senior physicians have more knowledge, more wisdom, more experience and they taught the younger . . . And an EMR in my mind ﬂips it on its head because it’s no longer simply about experience, right?” A second area of power loss was in the ability for physicians to shift their work to others. With the EHR implemented, physicians were now required to use the computers and input their orders rather than delegating these tasks to junior physicians or nurses. An IT director described how this played out in one EHR implementation describing, “We had some doctors who said, ‘I don’t need to do that, my nurse is going to do that for me.’” At another site an interviewee explained, “In the old world, the nurse was in getting the vitals on a sticky and the doc was outside looking at the chart refreshing him or herself,” thus not needing to spend time recording the vitals. Similarly, an administrator noted, “Well, in the old world if a doc did a visit and scribbled, forgot to sign his or her name and it just went back in the shelf and we’d bill for it,” but now the physician has to spend time signing records and ensuring compliance. We propose that this theme of loss is associated with a sense of grief, akin to the type of employee grief identiﬁed in studies of corporate layoffs (Vickers 2009; Davey, Fearon, and McLaughlin 2013). This led us to conceptualize the EHR adoption process using Elisabeth Kübler-Ross’s model categorizing the ﬁve stages of grief (Kübler-Ross and Kessler 2005). While admittedly not as profoundly personal as dealing with the loss of a loved one, framing EHR adoption in terms of loss and grief was surprisingly appropriate for characterizing the change process required for physicians to adopt and use an EHR system, and our data supported this classiﬁcation. Speciﬁcally, we found that the ﬁve stages of Kübler-Ross’s model—denial, anger, bargaining, depression, and acceptance—can be articulated as required phases of personal change for physicians adopting and integrating an EHR system. We describe this characterization further next and provide additional supporting evidence in Table 2, presenting representative quotations from both physician and administrator study participants. Denial. Kübler-Ross identiﬁes the ﬁrst stage of grief, denial, as one where individuals may experience shock and/or feel overwhelmed. In the context of • Anger Underlying pain • • Denial Shock Feeling overwhelmed Stages of Grief (Kübler-Ross, 1969) • • • • “It was a fairly painful process getting on top of it.” “By the time you’ve actually done all that, your patient encounter is half way over and then it is not even worth documenting in the patient room.” “It’s been probably one of the most unsettling things that I’ve seen for physicians throughout our entire system.” “. . .it was an overwhelming amount of information.” Physicians’ Comments • • • • continued “We’re asking the clinical people to do more and more . . . so you end up having very highly paid, high thought process people doing data entry—bad idea. And that’s painful for a lot of people.” “. . .anger on the part of physicians that they actually had to type and document and place orders and do histories and physicals themselves and meds.” “The docs were just overwhelmed. Not just the docs, but the clinical staff could easily be overwhelmed with that stuff.” “There was no gray; it was very black and white and that was shocking and upsetting at ﬁrst.” Administrators’ Comments Representative Quotations Characterizing Stage of Grief in Change Process Table 2: Conceptualizing EHR Adoption as Personal Change Involving Loss 468 HSR: Health Services Research 50:2 (April 2015) • Depression Feeling empty • Bargaining Negotiation Stages of Grief (Kübler-Ross, 1969) Table 2. Continued • • • • “The ﬁrst 2 weeks, I could have quit medicine. It was really so destructive to my ﬂow and my interaction with my patients.” “It was too much information . . . and then all of the sudden, the next day,. . . we were thrown in the clinics . . . which stressed me out for like 2 months!” “Everyone has mixed feelings. I mean there are a few that have all favorable but even those people acknowledge the issues and the problems that we have.” “And I went all the way to even less personal . . . why do they need that cover letter? It’s obvious I saw the patient. Just give them the progress note. They can read the note.” Physicians’ Comments • • • • continued “We can’t make them feel bad, they’ll start crying. I had a provider cry on me once.” “. . .they just want to go back to doing work the way they used to do work.” “. . .the ones that have already the little negative thoughts in their heads—that it’s not going to work, I am not going to be as productive, I don’t want to share my notes.” “We did lose physicians over this . . . There were doctors that left because they could not adapt . . . they did not know how to type.” Administrators’ Comments Representative Quotations Characterizing Stage of Grief in Change Process The Journey through Grief 469 • • Acceptance Of changed reality New reality is permanent reality Stages of Grief (Kübler-Ross, 1969) Table 2. Continued • • “When you have somebody who is a very medically complex patient who sees a lot of different specialists, who has a lot of different outpatient visits and those clinics are within the EMR system and you can really use it to the best of its ability . . . You are able to have all of that at your ﬁngertips and . . . so at its best, I think that it is a great system and it really . . . it changes the way that you manage people.” “. . .the ability to share information within our practice, very critical information that somebody knows something that somebody else needs to know, the ability to shift work to where it can be done better or more efﬁciently like off-site of to the right person. Deﬁnitely the ability to follow things we couldn’t in the past because we can’t do it on paper.” Physicians’ Comments • • “[They say] . . . while I used to have to take a stack of charts home to review them, now I can just dial in from home and do all of that stuff before I even come in.’” “Actually our biggest critic is . . . the staunchest advocate of the EMR.” Administrators’ Comments Representative Quotations Characterizing Stage of Grief in Change Process 470 HSR: Health Services Research 50:2 (April 2015) The Journey through Grief 471 EHR implementation, we characterized this stage from comments indicating physicians struggle with loss. For instance, as one interviewee described of physicians’ reactions to the EHR implementation, “They were just overwhelmed,” while another noted, “the culture shock for implementation is signiﬁcant.” An information technology professional reﬂected about physicians in this early phase explaining, “In every provider meeting I go to, there is someone who says ‘Leave it alone, I know what I am doing now.’” Also important was the notion that this denial stage had to be acknowledged and addressed. One administrator commented, “If you don’t do it fast, people say, ‘Hmm, they’ll never get to me. This is a passing fad. A couple years from now they’ll have a new CEO and they’ll have something else they’ll be working on.’” Anger. The second stage of grief requires acknowledgment of the underlying pain. As one administrator explained of the implementation process, “It’s so painful for some of these folks that you could pay them anything and they wouldn’t do it. And when they start doing it, it’s painful.” Another explained how the physicians “were angry for the ﬁrst 3 months.” More speciﬁcally, one interviewee described “anger on the part of physicians that they actually had to type and document and place orders and do histories and physicals themselves and meds.” Physicians acknowledged this anger and frustration. As one lamented, “So, I don’t know what has changed in the last couple months that I’m no longer allowed to give verbal orders to my MAs [medical assistants]. But now it’s more focused on just put the order in instead of actually listening to what I say. That’s a little frustrating.” Another physician commented about this shared anger sentiment explaining, “It’s because we’re going from ‘thinking folks’ to ‘data-entry folks’ and that is painful on so many levels.” Bargaining. The third stage of grief, bargaining, encompasses aspects of negotiation and attempts to construct trade-offs to avoid the change or legitimate contingency approaches. An obvious bargaining approach indicating implementation failure for an individual was seen when physicians chose to retire rather than adopt a new EHR system. One administrator explained, “The ones who were close to retirement were like ‘You know, I’m not going through this pain, it’s been nice, see ya.’” When physicians outwardly adopted the EHR, several found ways to avoid actually interacting with the system. As one physician leader reﬂected, “The whole myth was that it was this fully wired, 472 HSR: Health Services Research 50:2 (April 2015) integrated system. But in fact what happened was the attendings weren’t actually touching the computers. So, they could ask . . . go ﬁnd a resident ‘pull this up for me,’ whatever. So they didn’t actually have to touch the computers.” In conﬁrmation of this approach, a different physician proudly reported, “I don’t know how to place an order. I don’t even know what my password is.” Physicians also manifested this contingency behavior as one where they acknowledged the positive potential of the EHR system, but only when described along with the drawbacks of the system. One physician noted, “I think that we all recognize the positives of the system and we all recognize the frustrations perhaps with the implementation or the roll-out or the difﬁculty in getting things done that may be more inefﬁcient now than they were when we had a paper system,” thus offering the positive comment only in conjunction with negative feedback as well. Depression. The depression stage of grief, when individuals deal with feelings of hopelessness and inadequacy, was evident in both physicians’ comments and administrators’ reports about how new users would cry and express a desire to either quit their present position or retire. As one physician recalled, “I started crying and could not quit! . . . I would click in my sleep and I mean, to that point . . . I had nightmares of clicking and clicking and not getting it right.” Administrators recognized this stage and further described it as a low point. One noted, “You really have to make up a celebration, because during the ﬁrst couple of days everyone is on the high, by about day three they are crying.” Another administrator explained of this stage, “Yeah they haven’t gotten to the point where, ‘Ooh!’ Like the light bulb hasn’t quite come off of some of them for what the system can do for them.” Interviewees’ descriptions of this stage reﬂected how physicians indeed felt disheartened and empty, and did not suggest any sense of hope for the future. Acceptance. In contrast, the ﬁfth stage of grief, acceptance, was characterized in this context by comments indicating realistic acceptance of a changed reality —and, ideally, a better future that included the EHR system. As a physician leader described of this phase, “Now it’s not something that somebody has to do to make sure it happens. It happens naturally in our system so we get less errors and much better ﬂow. And in paper, you just can’t physically do things in paper. It just is the way it is.” An administrator summarized, “Basically it was, ‘Well, this is going to take much more time out of my day, it’s clunky, I’m The Journey through Grief 473 not having eye contact with my patient’ and now it’s, ‘Wow this is great!’ . . . And plus, having the disease registry piece really has made a difference in . . . you know, you focus on diabetes, COPD [chronic obstructive pulmonary disease], cardiovascular disease and you can tell each provider’s patients exactly how they stand relative to the quality indicators.” However, not all users truly accepted the change. As one administrator noted, “They’re really trying to do their old work in an EMR, as opposed to innovating, using that new functionality to innovate and change the way they practice.” Similarly, not all physician participants appeared convinced. One complained, “I’m not having eye contact with my patient,” while another begrudgingly commented, “I think for the most part, physicians are adaptable to change. I guess.” Administrators characterized this lack of acceptance by describing remaining issues they needed to address. As one noted, “Now one of the challenges we have post go-live is for them to really take ownership of this application and to have it become part of their culture there and part of their work world.” Another explained, “We’re going to reinvest in you whether you like it or not because we don’t want garbage in. We want a pretty high standard for our EMR here and so we want to make sure you’re contributing all the material to the EMR.” Thus, while the acceptance phase appeared an appropriate way to characterize EHR implementation, similar to acceptance of grief, the time frame for acceptance of the EHR was not predictable, and there was considerable variability in users’ perspectives about the new system. Framing EHR Implementation Using an Organizational Change Management Model From an organizational perspective, change principles can also be applied to help guide EHR implementation and facilitate adoption and use of the EHR system. We identiﬁed Kotter’s eight-step change framework as a good example of a change management model that appears to resonate among those challenged by the need to promote change in health care organizations (Kotter 1995). In Table 3 we show how study participants’ suggestions for facilitating EHR implementation can be conceptualized using Kotter’s framework, presenting representative quotes to characterize each of the eight change steps. Facilitating EHR Implementation Using Change Principles Combining insights from the individual and organizational change models, we identiﬁed 10 EHR deployment strategies based on study participants’ 5. Empower others to act on the vision 4. Communicate the vision 3. Create a vision 2. Form a powerful guiding coalition 1. Establish a sense of urgency • • • • • • • • • • continued “. . .strong steering committee, strong work group meetings, and then as you’re working through the workﬂow at the clinic level, making sure that participation, people are showing up, that they’re doing their tasks . . . strong project management.” “We took anything else of major substance off of the plate that cut across institutional lines.” “This was the focus and that’s all we talked about and everybody’s goals and compensation were all aligned to what the vision was.” “So, if management is saying this is why we are doing it, this is the reason we are doing it, this is how much money we are going to make, this is how much we are going to save, etc., and these people are going to act on our behalf to do that, then that’s the way to be successful.” “We established a vision in our EHR adoption and set out a plan about 5 years ago.” “So that vision is what’s really driving all of our attention and willingness to go along with this.” “I think that there’s a leadership . . . the administration and the medical staff leadership and with the support of the boards.” “We had 12 physician leaders that were all part of the physician coalition to lead the vision from a medical staff perspective.” “I mean it was really part of the burning platform . . . just to try to get people to recognize that status quo was not acceptable. We couldn’t keep doing what we were doing and sustain it.” “So you’ve got to go quickly and you’ve got to make it the exclusive focus if you really have a transformational type situation.” Representative Quotations Describing Facilitators of EHR Implementation Characterized as Steps Toward Change Framing EHR Implementation as Organizational Change Management Kotter’s Eight-Steps Guiding Change Management (1995) Table 3: 474 HSR: Health Services Research 50:2 (April 2015) 8. Institutionalize new approaches 7. Consolidate improvements and produce still more change 6. Plan for and create short-term wins Kotter’s Eight-Steps Guiding Change Management (1995) Table 3. Continued • • • • • • “Now it’s not something that somebody has to do to make sure it happens. It happens naturally in our system so we get less errors and much better ﬂow and in paper, you just can’t physically do things in paper. It just is the way it is.” “I think it’s now an absolute part of the culture and who we are and how we do things here.” “Once you started producing results and getting where you wanted to get to, then you could start being a little more focused on sub-areas or things that you needed to get at and you could start bringing other key goals for the institution back into play.” “The next phase is to go ‘ok, now you got the basics, now, how can we leverage some of this? What’s taking you the most time?’ And stay with them to work with them to get processes in the whole practice and then get them rolling in the whole practice.” “So when we started doing this roll out on medications for patients and we were able to demonstrate reductions in medication errors and you get some of those ‘wow’ moments where a nurse is barcoding this medication before they administer it and it comes up in the electronic medical record that there could be this fatal complication, you literally save a life there.” “It was about the wins . . . at one of our practices, there were seven docs . . . A doc was on call, got a call over the weekend from a hospital in [Name], for a patient that wasn’t his, and had to do with [a problem] . . . And this doc was able to bring up the chart and see everything that he needed to see to give the answer. So needless to say, he was now less resistant to [the EHR, thinking,] ‘this might be worth it.’” Representative Quotations Describing Facilitators of EHR Implementation Characterized as Steps Toward Change The Journey through Grief 475 476 HSR: Health Services Research 50:2 (April 2015) recommendations to facilitate EHR adoption: (1) Manage expectations; (2) Make the case for quality; (3) Recruit champions; (4) Communicate; (5) Acknowledge that it is a painful transition; (6) Provide good training; (7) Improve functionality, when possible; (8) Acknowledge competing priorities; (9) Allow time to adapt to the new system; and (10) Promote a better, but changed, future. Below we further describe the development of these strategies from our analyses, using the ﬁrst strategy as an example. The ﬁrst deployment strategy, “manage expectations,” was based on recommendations made by both physicians and administrators in the form of suggestions about how to improve the EHR implementation process. For instance, one interviewee reﬂected about how the EHR was introduced to physicians in the context of their work by being straightforward about the EHR system and goals for its introduction. He explained that the message to physicians was: “We bought this system so that we would have good reporting, so that we would have the integration between different practices and between the hospital facilities. This is not about making your life easier.” This message provided a good example of how “managing expectations” was reportedly a facilitator of the EHR implementation process. Then, in our analysis process considering individual change principles, we mapped this “manage expectations” strategy to the “denial” stage of grief because this facilitator reﬂected the need to acknowledge the change expected in spite of individuals’ reluctance to change, and the hope that this recognition could help physicians move out of the denial stage. We also mapped this recommendation to the organizational change management step of “establishing a sense of urgency” because this strategy emphasizes the need for all participants involved in EHR implementation to acknowledge the reality of the change and move forward with the change process. As another example, the recommendation to “acknowledge the pain” of the transition to a new EHR system was supported by numerous comments from both physician and administrative study participants. One commented, “This is absolutely an essential step and painful process to go through,” and another lamented that “There is nothing that we can do in preparation that will make it pain free.” Framing these comments using change principles, we mapped this facilitator to the “anger” stage of personal change and the “communicate the vision” stage of organizational change. Given that the anger stage of grief explicitly notes that this stage involves acknowledging the “underlying pain,” numerous comments from interviewees describing pain made this matching process straightforward. Similarly, because participants typically acknowledged the pain in the The Journey through Grief 477 context of communicating the changes involved in realizing a new vision involving an EHR system, considering this recommendation as part of the organizational “communicating the vision” stage of change also seemed appropriate. In Table 4, we provide evidence about how we categorized participants’ recommended facilitators by change stage, using both the personal and organizational change models to categorize each of the 10 EHR deployment strategies. DISCUSSION EHR Implementation and the Challenges of Change For physicians, the introduction and implementation of an EHR system involves changes in medical practice and behaviors that are reportedly difﬁcult. These difﬁculties may stem in part from logistical issues involved in training and preparation for implementation. However, our study suggests that personal factors associated with the process of change may also play a part, including the loss of professional content knowledge and/or the loss of power. Paying attention to these personal factors may improve the EHR implementation process. The ﬁve stages of grief proposed by Elisabeth Kübler-Ross (1969) provided an approach to categorizing steps involved in the personal change required as physicians adopt and develop the capacity to fully use a new EHR system. Kübler-Ross’s model was originally developed in 1970 to characterize the process of accepting one’s own death and grieving the loss of a loved one. Through the decades, Kübler-Ross’s framework has emerged as an important model of the personal change process (Linney 1999), both for consideration of changes in one’s home, such as divorce (Kruk 1991), and for organizational change (Perlman and Takacs 1990; Grant 1996; Elrod and Tippett 2002). Kübler-Ross’s model has been applied to change in many professional contexts, including employee reactions to layoffs and corporate closures (Blau 2008; Davey, Fearon, and McLaughlin 2013), organization changes required for staff nurses in an oncology practice (Schoolﬁeld and Ordu~ na 1994), change in secondary and university educational systems (Adrienne 2003; Zell 2003), and corporate compliance (Boerner 2010). Within the professional context, the Kübler-Ross model has been discussed as a way to identify and reduce the stress associated with organizational change (Vakola and Nikolaou 2005; Critchley 2012). In 1996 Link to Personal Change Stage Denial stage Denial stage Anger stage EHR Deployment Strategy 1. Manage expectations 2. Make the case for quality 3. Recruit champions Form a powerful guiding coalition Create a vision Establish a sense of urgency • • • • • • • • Table 4: Characterizing Ten EHR Deployment Strategies: Linking Recommended Facilitators of EHR Implementation to Stages of Personal and Organizational Change continued “Managing the culture, it is what it is. The most you can do is ﬁnd, like a good physician champion, ﬁnd a strong practice leader.” “The key role there was to identify physician champions: physicians who were incredible individuals but who also knew that the status quo was unacceptable . . . And to develop additional physician champions to help provide the leadership to get there for all the doctors.” “There is a vision that people just buy into that it’s better if it’s an electronic record. It’s more accessible, there are alerts for safety and you can make sure people get their mammograms and get their whatever blood tests for diabetes and whatever else you need to remind them to do and remind the doctors to do.” “The Institute of Medicine Report says we’re killing people, we’ve got to get on this.” “I’m trying to help improve the quality of care given to the patients and if you have to go abstract paper charts, it’s just not going to get done.” “And I just . . . I guess someone needs to sit them down and sort of say, ‘The party’s over,’ in a way. You kind of have to.” “. . .try and set expectations as much as you can upfront.” “. . .building an understanding of what it really is going to take I think is really essential.” Representative Quotations Characterizing Recommended Facilitator of EHR Implementation HSR: Health Services Research 50:2 (April 2015) Link to Organizational Change Stage 478 Link to Personal Change Stage Anger stage Anger stage EHR Deployment Strategy 4. Communicate 5. Acknowledge that it is a painful transition Table 4. Continued Communicate the vision Communicate the vision Link to Organizational Change Stage • • • • • • continued “It was a painful transition and some of that might be because it’s just hard to go from paper charts to electronic no matter what you do.” “So don’t even try to sell that [efﬁciencies gained argument] out of the door because the ﬁrst 6 months are so painful. . .” “They just complain, you know. But they will never, they never regret it. They always say it’s great but they just go kicking and screaming through the whole thing.” “There is a vision that people just buy into that it’s better if it’s an electronic record. It’s more accessible, there are alerts for safety and you can make sure people get their mammograms and get their whatever blood tests for diabetes and whatever else you need to remind them to do and remind the doctors to do.” “You can’t deny that because you’re not making their job easier, and you’re not saving them time.” “Any major change requires a communication.” Representative Quotations Characterizing Recommended Facilitator of EHR Implementation The Journey through Grief 479 Link to Personal Change Stage Bargaining stage Bargaining stage EHR Deployment Strategy 6. Provide good training 7. Improve functionality, when possible Table 4. Continued Plan for and create short-term wins Empower others to act Link to Organizational Change Stage • • • • • • continued “Once you’re in it and they’re going through all that pain, you’re trying to show them little things to improve it.” “It just may not be possible to create smart phrases for some of the messy psychosocial issues that we deal with in primary care. But some of them could be created I think.” “Despite my own frustrations with the speed of our current system and the mistakes that that then causes, I think it is still a good step in the right direction.” “We’ll give you a great experience and in fact we’ll throw in. . . we threw in some CMEs and a briefcase and stuff like that. . .” “We’ll give you this great stuff and you have to turn around and use it and then we’re going to reinvest in you whether you like it or not.” “When you’re training this, you’re teaching several things: you’re teaching new software, you’re teaching new workﬂow, and you’re dealing with all their anxieties about their job, their own personal abilities to learn this, their fear of losing their job.” “One of the things that we have learned is that sometimes we need to go and give computer training to people before we even start the EMR. We have to have the trainers go out and show them how to use a mouse and show them how to you know, do things like that.” Representative Quotations Characterizing Recommended Facilitator of EHR Implementation 480 HSR: Health Services Research 50:2 (April 2015) Link to Personal Change Stage Bargaining stage Depression stage EHR Deployment Strategy 8. Acknowledge competing priorities 9. Allow time to adapt Table 4. Continued Consolidate improvements and produce still more change Plan for and create short-term wins Link to Organizational Change Stage • • • • • • • continued “Get comfortable with that and then we’ll add other things.” “You can frame it that this is about the system of care, it’s how we take care of patients, not about just you and making your life miserable with this one little piece so you feel a little bit better about it.” “And recognize, tell them that upfront: this is a signiﬁcant change in how you work and don’t expect to do it tomorrow. Don’t get angry that you can’t operate this way. It’ll take time.” “It wasn’t a, ‘let’s look at the data coming out of it at the same time’ that was more of a well, when we get to that it’ll be just gravy.” “You know people are already doing multiple things and have multiple responsibilities and so they totally . . . it’s very hard to explain to them how much time and energy it’s going to take to do an ambulatory implementation and so they really need to understand what that commitment is.” “Just because we changed to an electronic environment, doesn’t mean the rest of the world did. So you’re living in a partially electronic world, you’re living in a partially paper world.” “They have a life and a job that they want to do, don’t make them decide. You know what I mean? Because they chose health care, they didn’t choose technology. So come in . . . and work with them!” Representative Quotations Characterizing Recommended Facilitator of EHR Implementation The Journey through Grief 481 Link to Personal Change Stage Acceptance stage EHR Deployment Strategy 10. Promote a better, but changed, future Table 4. Continued Institutionalize new approaches Link to Organizational Change Stage • • • “It touched every individual in the organization and changed every process. Everything that was always done by paper and how we’ve done it and documented it and reported on it and all of the metrics that we used and all the ways we did it touched literally every individual.” “Today, you couldn’t go backwards. You could not take the system out of there. People are used to it. They can’t imagine not having the beneﬁts of the electronic medical record like you can ﬁnd the chart. You can work from home. Patients can self-schedule or get prescriptions renewed electronically. I mean all the beneﬁts that are there for the physicians. You just can’t go back.” “I don’t know how you can practice medicine in the 21st century without electronic medical records. I don’t know how you can practice safe, cost-effective medicine without this tool.” Representative Quotations Characterizing Recommended Facilitator of EHR Implementation 482 HSR: Health Services Research 50:2 (April 2015) The Journey through Grief 483 Henderson-Loney noted that “Kübler-Ross’s griefwork model provides a guide for supervisors to manage the emotional response of their team members to organizational change” (Henderson-Loney 1996). Thus, prior work can support the appropriateness of framing EHR adoption using this personal change model, and acknowledging that the EHR implementation process may indeed involve aspects of grief given the changes required. Moreover, in light of the well-documented barriers to EHR implementation, researchers have suggested applying organizational change models to the EHR adoption process (Bonner et al. 2010; Boonstra and Broekhuis 2010; Greiver et al. 2011), and our research ﬁndings support this proposition. Our study provides evidence that each of the eight steps of Kotter’s (1995) change management model could help frame the EHR implementation process, and we found multiple examples of how those steps resonated with study participants’ comments about dealing with EHR adoption. While the application of Kotter’s model in health care is not unprecedented (Fernandez and Rainey 2006; Campbell 2008; Tsuyuki and Schindel 2008), its consistency and ﬁt with our study data provides evidence for its applicability in ambulatory EHR implementation that has not been previously demonstrated. Perhaps most striking was our ﬁnding that the recommendations study participants listed as key facilitators of the EHR implementation process could be framed by both the personal and organizational change models. In the gray literature guiding business and management executives, both Kübler-Ross’s stages of grief and Kotter’s change principles have been referenced as useful frameworks for understanding change implementation (Chapman 2012). Our explicit categorization of recommended facilitators into EHR deployment strategies by change stage, however, provides additional support for the salience of these models in EHR implementation. Implications for Management and Policy Change can have powerful beneﬁts for care, cost, and populations. Yet change remains difﬁcult for both individuals and organizations. By considering and explicitly acknowledging the personal change processes involved in EHR adoption in light of individual change principles, we may be better able to allow people to cope with the pressure to change in ways similar to how we allow people to grieve when they are dealing with loss. Furthermore, by guiding required organizational change processes using a change management 484 HSR: Health Services Research 50:2 (April 2015) framework, organizations may be better able to motivate, lead, and succeed with EHR adoption as a major change for the organization. Under the right conditions, implementation can lead people and organizations to champion change, but under the wrong ones, they may come to champion the way things used to be. Addressing the implications of our results speciﬁcally, managers can use the deployment strategies we present to intervene to mitigate EHR implementation problems and potentially move employees to the next stage of change. At the level of individual physician intervention, managers can identify the stage of change the employee is dealing with and implement a strategy from the left-hand column shown in Table 4. When a physician is determined to be in the Anger stage, for example, a corresponding deployment strategy is to acknowledge that it’s a painful transition, thereby helping this individual to move past anger in the change process. At the level of the organization, however, managers can be guided by Kotter’s framework and select the EHR deployment strategy that corresponds to the stage of change appropriate for the organization in its transition to use of a fully functional EHR system. Study Limitations One important limitation of this study is the s…
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