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However, effective leadership can sharply reduce the behavioral resistance to change—including to new technologies—to achieve a more rapid and productive introduction of informatics technology. This paper looks at four major areas—why information system failures occur, the core theories supporting change management, the practical applications of change management, and the change management efforts in informatics.

It's not the progress I mind, it's the change I don't like. Along with the inevitable failures, medical informatics has had many successes—probably more than should have been expected, given the challenges of the hardware, software, and infrastructure that faced us in the past.

However, many of the successful systems were implemented as stand-alone systems that involved a modest number of people. Furthermore, the systems were often implemented in specific, limited areas that could see potential direct benefits from the systems. Typically, there were local champions, who made major and personal commitments to the success of the systems, and the enthusiasm of these champions was readily transmitted to the people with whom they worked directly.

In turn, most of the people working on these systems felt like pioneers, and the literature of medical informatics is filled with their accomplishments. When we embark today on designing, developing, and implementing more complex systems that have wider impact, a new set of challenges looms even larger.

Managing in A Time of Great Change

Certainly, technical challenges still exist; they always will. However, as our new systems affect larger, more heterogeneous groups of people and more organizational areas, the major challenges to systems success often become more behavioral than technical. It has become apparent in recent years that successfully introducing major information systems into complex health care organizations requires an effective blend of good technical and good organizational skills. The leader who knows how to manage the organizational impact of information systems can sharply reduce the behavioral resistance to change, including to new technology, to achieve a more rapid and productive introduction of information technology.

Knowledge of the significance of people and organizational issues is not new.

One of our informatics pioneers, Octo Barnett, identified political and organizational factors as being important 30 years ago. We are seeing a shift in the balance of the people and organizational issues as opposed to the technical issues. An effective medical informatics change strategy can help convert what health care organizations are experiencing today—technology-centered tension—into welcomed opportunities that will lead to improvement in all phases of the health care process.

The content that supports both the intellectual content and strategy for this cornerstone comes from multiple disciplines, e. This paper discusses four major topics—why information system failures occur, the core theories supporting change management, the practical applications of change management, and the change management efforts in informatics. If only it weren't for the people, those awful people, always getting tangled up with the systems. If it weren't for them, the health care area would be an informatician's paradise. Complex problems rarely have simple solutions.

During the many stages of the solution process, there are numerous opportunities to go wrong, whether the solution tends to be a technical one or not. As we delve into increasingly complex medical informatics problems, we will increasingly face this challenge. In reviewing information system failures cited in the literature as well as drawing on our personal observations and experiences, we have seen the rising importance of the human issues that are often referred to as people and organizational issues.

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

Technology has indeed taken a place next to war, death, divorce, and taxes as a prime cause of bone-shuddering anxiety. Change is a constant in both our professional and our private lives. Our children grow up taking for granted such things as powerful personal computers that we could not envision at their ages.

The idea that human beings naturally resist change is deeply embedded in our thinking about change. Our language e.

Using the ADKAR Model as a Common Language for Change

However, it is easy to find examples of human beings, from childhood on through old age, actively seeking out change of all sorts. Human beings do not necessarily resist change automatically; however, many people do resist being changed, i. Organizational change normally involves some threat, real or perceived, of personal loss for those involved.

This threat may vary from job security to simply the disruption of an established routine. Furthermore, there may be tradeoffs between the long and short run.

1. Leverage technology to advance education

As an individual, I may clearly perceive that a particular proposed change is, in the long run, in my own best interests, and I may be very interested in seeing it happen, yet I may have short-run concerns that lead me to oppose particular aspects of the change or even the entire change project. The rate of change is escalating in virtually all organizations.

The pressure is intense on anybody connected with the health-related world to focus time and attention on understanding the forces driving the changing environment and develop or implement the information systems needed to support the altered environment. The phrase change management is very common in management articles as well as newspapers. Nevertheless, using the traditional terminology, what is meant by change management, how did it evolve, and why has this concept become so important?

Change management is the process by which an organization gets to its future state, its vision. While traditional planning processes delineate the steps on the journey, change management attempts to facilitate that journey. Therefore, creating change starts with creating a vision for change and then empowering individuals to act as change agents to attain that vision. The empowered change management agents need plans that provide a total systems approach, are realistic, and are future oriented.

Change management encompasses the effective strategies and programs to enable those change agents to achieve the new vision. Today's change management strategies and techniques derive from the theoretic work of a number of early researchers. However, Watzlawick et al. Watzlawick et al. They selected the theory of groups and the theory of logical types. Their goal of reviewing the theories of change was to explain the accelerated phenomenon of change that they were witnessing.

First-order change is a variation in the way processes and procedures have been done in a given system, leaving the system itself relatively unchanged. Some examples are creating new reports, creating new ways to collect the same data, and refining existing processes and procedures. Second-order change occurs when the system itself is changed. This type of change usually occurs as the result of a strategic change or a major crisis such as a threat against system survival. Second-order change involves a redefinition or reconceptualization of the business of the organization and the way it is to be conducted.

In the medical area, changing from a paper medical record to an electronic medical record represents a second-order change, just as automated teller machines redefined the way that many banking functions are conducted worldwide. These two orders of change represent extremes. First-order change involves doing better what we already do, while second-order change alters the core ways we conduct business or even the basic business itself. Golembiewski, Billingsley, and Yeager 8 subsequently added another level of change, defining middle-order change as lying somewhere between the extremes of first- and second-order change.

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Kurt Lewin is credited with combining theories from psychology and sociology into the field theory in social psychology. Lewin believed that there is tension in a person whenever a psychological need or an intention exists, and the tension is released only when the need or intention is fulfilled. The tension may be positive or negative.

Individuals stand midway between two positive goals of approximately equal strength. A classic metaphor is the donkey starving between two stacks of hay because of the inability to choose. Individuals find themselves between two approximately equal negative goals. This certainly has been a conflict in many organizations that wish to purchase or build a health informatics system.

A combination of the economics, the available technologies, the organizational issues, among other factors, may well mean that the organization's informatics needs cannot be satisfied with any available products, whether purchased or developed in-house. Thus, the decision makers must make a choice of an information system that they know will not completely meet their needs. Their choice will probably be the lesser of two evils.

Individuals are exposed to opposing positive and negative forces. This conflict is very common in health care organizations today, especially regarding health informatics. This conflict usually occurs between the system users and the information technology or financial people. Kurt Lewin's field theory allows the types of conflict situations commonly found in health care to be diagrammed and analyzed. Small-group theory is another tool that is highly applicable to health informatics because of the way that health care environments and activities are organized.

Caring for patients and educating students typically involves many small groups of people. Small-group theory can help us understand why there are such wide ranges of effectiveness among these groups. These are just a few examples of the social science theories that can help the change management leader understand some of the underlying behavioral issues that need to be faced as health informatics technology is brought into today's complex health systems. There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things.

One of the most difficult problems organizations face is dealing with change.

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In today's rapidly changing, highly competitive environment, the ability to change rapidly, efficiently, and almost continually will distinguish the winners from the losers. Many health-related organizations will disappear because they find themselves unable to adapt. Furthermore, many of the pressures for change in health care organizations are independent of technologic change. This means that informaticians working for change are doing so in organizations that are already highly stressed by other pressures.

Major organizational changes typically involve many different types and levels of personal loss for the people in the organization.


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For example, change always requires the effort to learn the new, which is a loss in terms of time and energy that could have been used elsewhere. Although some may welcome the learning opportunity, many of us don't want to invest that time and energy unless we are dissatisfied with the current arrangements or see powerful advantages to the proposed change.

Upgrading to new software is a common example, in which the future benefits may not be seen as sufficient to outweigh the short-term investment required to learn the new programs. Second, people want to feel good about themselves. Ideally, people are able to take pride in their work, feel responsible for a job well done, feel they are part of a high-quality enterprise, and feel that their time has some significance.

In many work situations, the work itself and the organizational culture make it difficult for people to feel good about themselves.