Table 4.

Characterizing Ten EHR Deployment Strategies: Linking Recommended Facilitators of EHR Implementation to Stages of Personal and Organizational Change

EHR Deployment Strategy	Link to Personal Change Stage	Link to Organizational Change Stage	Representative Quotations Characterizing Recommended Facilitator of EHR Implementation
1. Manage expectations	Denial stage	Establish a sense of urgency	“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.”
2. Make the case for quality	Denial stage	Create a vision	“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.”
3. Recruit champions	Anger stage	Form a powerful guiding coalition	“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.”
4. Communicate	Anger stage	Communicate the vision	“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.”
5. Acknowledge that it is a painful transition	Anger stage	Communicate the vision	“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.”
6. Provide good training	Bargaining stage	Empower others to act	“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.”
7. Improve functionality, when possible	Bargaining stage	Plan for and create short-term wins	“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.”
8. Acknowledge competing priorities	Bargaining stage	Plan for and create short-term wins	“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!”
9. Allow time to adapt	Depression stage	Consolidate improvements and produce still more change	“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.”
10. Promote a better, but changed, future	Acceptance stage	Institutionalize new approaches	“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.”