Wk 3 Team Assignment: Information System Briefing

Journal of Strategic Information Systems 20 (2011) 177–197

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Journal of Strategic Information Systems

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / j s i s

From cacophony to harmony: A case study about the IS implementation process as an opportunity for organizational transformation at Sentara Healthcare

Chon Abraham a,⇑, Iris Junglas b,1 a College of William and Mary, Williamsburg, VA 23187, United States b Accenture Research Institute for High Performance, Boston, MA 02199, United States

a r t i c l e i n f o

Article history: Available online 6 May 2011

Keywords: Case study IS implementation Organizational transformation Business process change model (BPCM) Healthcare

0963-8687/$ - see front matter � 2011 Elsevier B.V doi:10.1016/j.jsis.2011.03.005

⇑ Corresponding author. Tel.: +1 757 221 2803; fa E-mail addresses: [email protected]

1 Tel.: +1 617 488 7304; fax: +1 617 488 4001. 2 The Healthcare Information Management System

organizations for reaching the highest level (i.e., HIM Level 7 designee and has won the coveted 2010 Davie information technology (Sentara Healthcare, 2010).

a b s t r a c t

The cacophony of criticisms emanating from an organization facing an information tech- nology-enabled transformation can be deafening and deleterious. This is especially true in healthcare in the US, where information systems investments are typically huge and often perceived by change resistant stakeholders as disruptive or even potentially life threatening. We describe how the IS implementation process itself contributed to organi- zational transformation in terms of changes in coordination, culture, and learning at a suc- cessful organization, Sentara Healthcare, which transformed the discordant cacophony of the change process into a harmonious implementation.

� 2011 Elsevier B.V. All rights reserved.

1. Introduction

Organizational transformation in any industry involves fundamentally reshaping behaviors within the organization and, now more than ever, instituting technology-enabled processes – something desperately needed in US healthcare (Bohmer, 2010; Blumenthal, 2009; Moreton, 1995). The aim of this research is to describe how the information systems (IS) imple- mentation process aids in organizational transformation, a business context that is rapidly moving to the center stage of societal importance. We exhibit this transformation via a case study of a healthcare organization, Sentara Healthcare, which has been nationally recognized for its superlative efforts in instituting technology-enabled processes.2 We use the business process change model (BPCM) (Kettinger and Teng, 2000), one of the most comprehensive frames steeply couched in the orga- nizational transformation literature, as a framework to describe the steps Sentara followed in implementation of eCare, a com- prehensive healthcare information system. We also use BPCM as a framework for structuring our analysis and insights that are applicable in resolving the cacophony associated with how to manage the technology-enabled transformation.

The cacophony of critics emanating from organizational transformation efforts enabled by well-intentioned information systems has long been a perplexing topic, especially in healthcare (Devadoss and Pan, 2007; Crowston and Myers, 2004; Kohli and Devaraj, 2004; Brynjolfsson and Hitt, 2000, 1998; Brynjolfsson, 1993). The reengineering of business processes

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x: +1 757 221 2884. du (C. Abraham), [email protected] (I. Junglas).

s Society (HIMSS) maintains diffusion statistics for healthcare IS and nationally recognizes healthcare SS level 7) of demonstrated technology embeddedness (HIMSS, 2010). Sentara Healthcare is an HIMSS s Award for Excellence recipient for superlative implementation and demonstration of value from health

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is deemed essential for organizational transformation, but further complicated when conducted in conjunction with IS implementations (Igira and Aanestad, 2009; Avgerou and McGrath, 2007). Healthcare is one such industry in which this at- tempt to transform with IS is considered essential, yet most difficult, due to the lack of prescripts for effective implementa- tion in the company of business process change as well as inhibitors, such as cost factors and institutional and social structures (Bohmer, 2010; Adler-Milstein and Bates, 2010; Angst and Agarwal, 2009).

While the US has made technological strides in many industries, as measured by the performance gauges of the Organi- zation of Economic Cooperation and Development (OECD, 2009), it lags far behind other developed countries in terms of healthcare service quality based on indicators, such as workforce shortages, life expectancy and mortality rates, and medical complication indexes. Organizations, such as the Institute of Medicine (IOM, 2000, 2001), have recognized an association in treatment errors with the lack of patient and medical information at the point of care amidst clinician workflow. IOM and other IS supporter consortiums also prescribe the use of IS to aid in transforming medical institutions into more efficient and effective organizations (IOM, 2010; Blumenthal, 2009).

Today, in healthcare there is a plethora of disparate factions who often lack the needed information at the point of care to adequately treat and avoid life threatening errors, but, nevertheless, regularly perform processes with antiquated methods for information transfer and communication amongst stakeholders across the continuum of care (i.e., from practitioner to practitioner, practitioner to patient, and practitioner to administrator in all care environments) (American Hospital Associ- ation, 2009; Chiasson et al., 2007; Davidson and Chismar, 2007; Hillestad et al., 2005). In the US, a national strategy to pro- mote diffusion of IS within organizations to provide necessary information to stakeholders regarding care has emerged as formalized in the ‘‘Health Information Technology for Economic and Clinical Health Act of 2009’’ (HITECH). As of the second quarter of 2010, only 0.8% of the 5217 US healthcare organizations have implemented a comprehensive IS that includes func- tionalities, such as electronic medical records, computer physician order entry, and decision support (HIMSS, 2010). National healthcare IS strategist and researchers (e.g., Angst et al., 2010; Blumenthal, 2010; Maxson et al., 2010) suggest that diffusion can be accelerated by demonstration of successful implementations in prominent healthcare organizations. This study an- swers this call in the healthcare context by describing how the IS implementation process has successfully impacted an orga- nizational transformation through changes in coordination, culture, and learning.

2. IS transformation in healthcare

Mostly driven by a political agenda, the healthcare industry has recognized the importance of patient centricity, a concept that puts at center stage the patient and the associated procedural workflow. This idea theoretically moves away from the concept of a fragmented, physician-centric care delivery organization (Porter and Teisberg, 2007). However, implementing IS based on this patient-centric concept and managing the transformation is a formidable challenge organizations (Harrison and Kimani, 2009; Szydlowski and Smith, 2009; Carr et al., 2009; Day and Norris, 2007; Porter and Teisberg, 2007). In fact, IS implementations are a perturbation in any organization, whether it is a change in processes or in organizational commu- nication and learning (Edmondson et al., 2001; Davenport, 1998). In healthcare however there are higher stakes for failure than in traditional businesses as the slightest disruption caused by the IS can have detrimental consequences (Christensen et al., 2009, 2004). The perturbation is felt more closely by the caregivers in operations who have a high degree of autonomy and can resist usage, without ramifications, if they deem the IS to pose unsafe conditions for the patient or their ability to render care (Bohmer et al., 2002). As a result, transformations with enterprise IS require extensive managerial prowess in the transformation effort (Luftman and Kempaiah, 2008; Kohli and Kettinger, 2004), typically with a focus on the social design, inclusive of emphasizing human agency, as opposed to technological determinism (Boudreau and Robey, 2005; Teng et al., 1998).

Prior research has explored some of these issues. One theme is the aligning of social structures and technology capabil- ities in healthcare organizational change (Reardon and Davidson, 2007; Davidson and Chismar, 2007; Chiasson and David- son, 2004) and another theme involves changing clinician behaviors (Kohli and Kettinger, 2004; Wilcocks and Smith, 1995). But both types of studies that examine transformational efforts with enterprise IS are rather rare as it is a fairly new concept to the healthcare industry (Rahimi and Vimarlund, 2007), made evident by its laggard state (Houser and Johnson, 2008). Thus, theoretical guidance on transformational efforts via enterprise IS in the healthcare context remains sketchy and recent calls from both academia and practice support this assumption (DHHS, 2010).

Despite the lack of research, some studies have found that hospital executives are particularly interested in viewing busi- ness process reengineering as an effective tool in transformation (Christensen et al., 2004; Ho et al., 1999). Seminal IS re- search in business process reengineering asserts that facilitating change via technology requires the identification of strategic value, assessing the learning capacity of the organization and cultural readiness, and the inclusion of IT and knowl- edge sharing (Kettinger et al., 1997). IS research also states that change within the organization is influenced by managerial styles, information technology, structures, and people that ultimately impact viability of products, services, and performance (Mohrmann et al., 2009; Chiasson et al., 2007; Kettinger et al., 1997; Guha et al., 1997; Kotter, 1995; Davenport, 1993). Other research reveals that enterprise IS implementations in healthcare organizations or networks are akin to ERP implementa- tions across integrated business units of traditional organizations (MacKinnon and Wasserman, 2009; Yoo et al., 2008). In this context, the BPCM represents a comprehensive framework in the organizational transformation literature, specific for IS implementations. Its steps, that include (1) link with strategy, (2) plan the change, (3) analyze problems in the process, (4) process re-generation, and (5) continue improvement (see Appendix A for a more detailed description), have been

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established as a result of examining proprietary business process reengineering (BPR) practices among a set of 25 leading consulting firms and analyzing their communalities. We understand that the BPCM framework is considered to be a model to identify ‘‘best practices’’ for reengineering efforts. We made use of BPCM to explore the IS implementation that took place at Sentara.

3. Research design and methods

This study provides an in-depth case regarding the IS implementation at a healthcare organization. Our application of a case study design using an established framework (e.g., the BPCM) from theoretical literature merged with analysis of qual- itative data from multi-level stakeholders is consistent with a soft-positivistic approach similar to Kirsch (2004) and others (Demetrion, 2004; Hughes and Jones, 2004). We seek to enrich the understanding of how the IS implementation process con- tributes to our understanding of how organizations transform, rather than how BPCM is used to describe IS implementations. The aforementioned methods are necessary to promote credibility and applicability (akin to positivists’ evaluations of valid- ity and reliability) of the findings (Corbin and Strauss, 2008; Leininger, 1994).

3.1. Site selection

Demetrion (2004) suggests that the research design (e.g., site selection and criteria) depends on the needs of the issue being investigated. The site was purposefully chosen as the successful organization worthy of study because its character- istics met the following sampling criteria: (1) implementing an integrated, cross-functional enterprise information system in healthcare offering the potential to demonstrate success on a large scale, while (2) embarking on IS implementation, yet demonstrating some very early successes which enabled assessing the occurrence of change and the managerial practices in the progression of the implementation, and (3) possessing strong IT leadership with the forethought to employ business process change. Sentara was one of the few accessible organizations that met those criteria at the outset of this research.

Sentara is a networked healthcare organization in the US made up of 87 care giving sites; among these are seven hospitals totaling 1729 beds, three outpatient care campuses, seven nursing homes, three assisted living facilities, and 360 primary care and multi-specialty physicians. Additionally, Sentara covers 319,000 Sentara Health Plan members via its own insurance plan and provides 2500 community physicians with facilities (e.g., home health services, hospice services, physical therapy, and rehabilitation services).

In 2005, the Chief Information Officer (CIO) initiated a vision implementing IS, titled the eCare health network, which was intended to transform its existing insular information systems into an integrated, all-encompassing central repository acces- sible from any care environment across the healthcare system. eCare provides a single electronic medical record (EMR) for each patient and computerized physician order entry (CPOE) support. It also provides decision support tools, access to med- ical protocols, an integrated retrieval system for lab and test results, interfaces with a medication dispensary system and patient identification devices, billing administration, and a portal for patients to access some personal medical information, to schedule appointments, and to receive educational information.

Calculating the total cost of ownership for large scale IS implementations is difficult to justify and thus often neglected in healthcare organizations (Grieger et al., 2007). But Sentara undertook a thorough cost benefit analysis, estimating return and qualitative benefits. eCare was estimated to cost 237 million USD over ten years. During their strategic planning in 2006, the expected benefits of eCare would not produce a positive cash flow for two years (beyond the required 5 years) and offered less than the 15% return on assets threshold normally required by Sentara for capital investments. The financial leadership at Sentara could not recommend the project to the Board of Directors based on financial return. Rather, the board felt that eCare would significantly progress Sentara towards a desired standard of care. The project was approved. The first hospital went live in February 2008, with subsequent implementations staggered, based on hospital size and complexity of services pro- vided, as well as the availability of champions for change. Implementations for the 42 Sentara physician group practices, at a rate of one per day, took place simultaneously with the hospital implementations. Despite initially being below the threshold for expected financial returns, the cost savings and revenue generation from process efficiencies and quality improvements would exceed clinician and managerial expectations as well as financial forecasts within five years of project conception.

3.2. Data collection and analysis

Data were collected longitudinally spanning Sentara’s milestone progression for eCare’s implementation (see Appendix A for details). The typical IS implementation schedule at Sentara was planned in accordance to a generic series of steps they devised in-house resembling the BPCM. For academic rigor in framing our understanding of Sentara’s efforts in the imple- mentation, we relied on our theoretical repertoires to aid in identifying a theoretically grounded framework, which is the BPCM. The BPCM framework served a twofold purpose. First, it was used as a timeline reference to ascertain how Sentara accomplished its predefined milestones, which was important for the data collection protocol. Second, it provided the means to make sense of our data by providing a guide for data collection and pattern matching from which insights emerged in exploring Sentara’s activities in each phase of the framework. These insights provide the structure for our findings.

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Data were collected both during and after milestones were completed. As in many field research activities, it was infea- sible to collect all data simultaneously as Sentara reached each of its milestones. We greatly tried to collect data during the step in which Sentara’s milestones were taking place and aligned it with a BPCM phase. There were instances when inter- viewees would mention aspects of the implementation that were aligned with prior points in the implementation. If deemed insightful, we added this data to the pool of data with which it most aptly aligned.

Interviews entailed asking open-ended questions of 137 members of the Sentara community representing the multi- stakeholder perspective. Interviews with top management and implementation team members typically lasted for 1.5 h, were all audio recorded and transcribed, and occurred in either one on one or group session either in their respective offices or on site; interviews performed with medical, administrative and registration personnel typically lasted from 15 to 20 min and were conducted either in conference rooms of the respective facility or, if post implementation, at their work location in the midst of system use. Archival documents comprised more than 400 pages, including, for example, feasibility reports, marketing videos transcripts, press releases, project description materials prior to and post imple- mentation, project status presentations, and daily and monthly performance indicators. Observations entailed studying interactions between the eCare implementation team and user groups, and between top management, physician lead- ership and clinicians, as well as and surveying training sessions with clinicians and actual clinician usage post implementation.

4. Findings

We describe the implementation at Sentara according to phases of the BPCM framework. In our description, we include our assigned codes, indicating specific standout process activities (i.e., actions of stakeholders) relative to what was emphasized or what emerged during a particular step of the implementation process. The insights provided at the end of each section result from the analysis of these codes and contribute to an understanding of how the organization transformed.

4.1. BPCM phase – link with strategy

At the time planning began for the IS implementation, Sentara leadership was expanding the network through building facilities, adding units to existing facilities and acquiring a plethora of healthcare environments as part of the overall busi- ness strategy to become the most accessible healthcare provider in all service sectors in the northern North Carolina and Southern Virginia region. This contributed to Sentara’s goal of vast vertical and horizontal integration. It became apparent that while these environments expanded the Sentara brand, each facility functionally operated as a disparate faction, and so did the care units within these facilities. Sentara’s IT leadership began assessing the need for information by polling its healthcare professionals in order to determine how to best meet their needs across these disparate environments of care. Sentiments of a nurse regarding the prior methods of information retrieval across various care environments were as follows:

Acute Care Charge Nurse: ‘‘I want to be able to see what was done for a patient in the other units, especially ICU so I know what to expect even before the patient is transferred into my unit. It helps to coordinate care. . .like with assigning a nurse that has the best skills for dealing with them. For example, a doc prescribes a typical med for pain maybe on the floor that might be slightly different, maybe not as intense, as what the patient got in ICU. . . the patient’s not responding to the med. We call ICU to ask why this med may not be working or what their exact regimen was because a lot of times you don’t get that detail of information when the patient arrives on the floor with their transfer paperwork. We find out later that the patient is a drug user. We need that input to treat better.’’

The aforementioned reflects the need for a more integrated information picture, coded as reveal information interdepen- dence for coordination. The Sentara IT leadership found it necessary to consider the entire organizational structure and how it operated as a whole in providing care across a continuum of environments (e.g., services across the hospital-acute care, clinical, physician office, emergent and urgent, nursing, and home care environments). The intent of the implementation strategy initially was to focus on improving the one main process in the administration of care that occurred in all environ- ments and that was deemed to be most inefficient and a source of the inability to provide a consolidated view of services for patients. A typical scenario entailed a patient seeing multiple primary care providers (not merely physicians) and having in-hospital visits, home care visits, labs, and possibly nursing care stays, all of which were part of the Sentara network – integrated only by brand name. Individual providers held local manual, or partially automated, records for each medical encounter that were rarely integrated into a composite view of the patient’s overall health, as described here:

Physician: ‘‘I can see the same patient in my office, in any of the hospitals and other facilities, but I could only see certain type of information on that patient based on where I was located and if the patient’s record was available (e.g., not locked up in someone’s office). I could call back to my office, have them faxed from referring physicians’ offices, or bring records with me but you have to piece the information together that way. There is always a chance of not having the complete record. It took time to consolidate and often you end up having to make timely decisions based on partial information. The information should not be location dependent but rather patient dependent.’’

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Sentara’s integrated structure offered the opportunity to provide the consolidated view necessary to improve care. How- ever, the CIO noted that the strategic opportunity would be unachievable without the supporting IS capabilities for providing a comprehensive view of information. Rather, the current process required hunting, gathering, and then consolidating infor- mation across the disparate systems, in manual records, or even from someone’s memory. As noted by the CIO, something as critical as tracking the impact of prescribed medications on patients’ cholesterol levels was almost impossible to follow with- out some mechanism for consolidating the information. Without properly documenting and historically tracking care steps in a standardized format across care services, there was no efficient means of analyzing what clinical procedures would be most effective, a capability vital for practicing evidence-based medicine (i.e., using proven regimens that present the least torment for the patient while delivering high quality at a justifiable cost).

Thus, Sentara’s IT leadership expanded the scope of the strategy to include the documentation of the entire care process, spurring inclusion of a single electronic medical record accessible to all factions within the Sentara network. Planning for implementing a comprehensive strategy also entailed decreasing redundancies in information inquiry and use, coded as streamlining processes for coordination, and described by Sentara’s CIO:

CIO: ‘‘We are self-sufficient but that comes with a cost if your organization has inherent inefficiencies in the way that work gets done. We lose time in turning around a diagnosis because faxes are flying from one doc’s office, to an outpatient clinic, from an ER and so on. All of this paper costs . . .in materials and manpower but in service time and quality as well- We have multiple doctors ordering duplicate tests themselves to try and artificially hurry up the lab results, or they order because they don’t know some other doctor the patient saw already ordered it and the results are available. Our opera- tional processes were inefficient in information consolidation and delivery, which costs us, the payer, and the patient in delays in service. . .the game changer here is the information availability in our operations. . .but getting to that point is like trying to make music out of noise.’’

The latter point in the quote attests to the many social and institutional factors at play that convoluted and were revealed by the IS implementation process. The scope of the IS implementation for eCare was planned to facilitate fruition of a com- prehensive operational strategy, beginning with the two main environments of care, the hospital and the physician offices, and incrementally phasing in each of the other care environments. Our insight regarding this finding is as follows:

Insight 1 Linking the IS implementation with the organizational strategy forefronts the need and requirements for information interdependence and efficient processes to bring about changes in coordination.

4.2. BPCM phase – plan the change

At the time of planning, the national impetus for healthcare IS (HIS) was just beginning to increase in intensity with a focus on interoperability across healthcare institutions (HIMSS, 2009). However, there were very few examples of pro- viding guidance for how to go about an IS implementation for a comprehensive strategy, integrating care environments aside from computerized physician order entry (CPOE) for physicians. In fact, much of the trade press and academic re- search at the time discussed failures due to patient safety concerns and bankrupted projects in healthcare networks, attempting to automate the electronic medical records and especially nursing documentation. However, national sup- porters, such as the Office of National Coordination, urged a comprehensive IS use by all types of clinicians as critical amidst massive skepticism from clinicians and clinician leadership and little guidance for implementation (HL7 2007; Christman, 2006). Nursing, at the time, was a major area needing great efficiency improvements for poor work condi- tions, including laborious manual documentation taxing staff that was already suffering from dire shortages (Buerhaus et al., 2005; Lynn and Redman, 2005). Much of the anxiety about IS implementations was predicated on oversights in the planning process regarding: (1) not including representations from all clinician stakeholders, such as in nursing and rehabilitative services, (2) the lack of support from frontline caregivers whose primary deterrence from IS usage stemmed from fear of increased patient safety issues and their associated accountability from reliance on information in the system, and (3) the overall lack of feasible implementation strategies with laudable outcomes (Anderson, 2007). While the CIO envisioned expanding the computerized physician order entry (CPOE) concept to automate other care workflows, such as in nursing, there was a lack of widely accepted proof of concepts nationally to engender grassroots support from clinicians – the primary user group. Therefore, the comprehensiveness of the implementation required greater commitment across the executive leadership, top management, and especially all professional levels (managerial and frontline) of the organization.

The difference in healthcare organizations, despite having paid employees, is that these clinicians, physicians, nurses, etc. are credentialed, allotting them autonomy to various degrees for how they deliver care. In essence, the CIO understood that the planning activities for the IS implementation would require a concerted effort that could not be envisioned as an IT spon- sored project or even a top-down initiative. The process involved would require finesse and would be impacted by a number of social and political dynamics through the entire implementation effort.

The CIO developed two coalitions based on function and purpose of organizational stakeholders who could help, plan, champion, and govern compliance for the transformation effort. Prior to the eCare implementation effort, there had not been a concerted effort of this magnitude for an IS implementation to incorporate stakeholders at all levels across all care envi- ronments. These stakeholders had a common goal of quality care delivery to patients and were deemed principal players in

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bringing about change in the organization. But getting them engaged to even form the coalition across disciplines was dif- ficult because clinicians tended to not understand the value in focusing on any area other than their own.

The CIO sought to form a coalition with representatives from these stakeholder groups. Part of the coalition was formed for the ‘‘prelude-to-acquisition’’ phase, and the other half for the ‘‘prelude-to-implementation’’ phase, but with the intent of engendering support across all levels. This demonstrated true collaboration that could transcend from planning throughout the entire implementation effort, as described below:

CIO: ‘‘It’s really easy to get a coalition of supporters who believe. It’s better to have a coalition of doers who are going to be touched by this - the clinicians in operations, the community physicians, the payers, and the patients. I build this coalition so I can get a 360 view – so we don’t get caught up drinking our own Kool-aid [referring to deterrence of technology determinism]. . .I was deliberate in making sure that they thought of themselves as a coalition for joint planning and not just merely as the stakeholder representing their own peer groups.’’

At first, the IS leadership focused on developing a coalition of ‘‘thought partners’’ at the executive and managerial level for funding to move forward with the effort. As the business case for the effort suggested, the total investment was steep with the project not expected to produce the usual benchmark returns within the typical payback period. The ‘‘thought partners’’’ role was to ensure the sustained commitment from the top leadership. This entailed keeping top management abreast of the relevance of eCare at the time with regard to capitalizing on industry-wide changes on the horizon, governmental mandates, and subsidies in healthcare reform specific to health information technology adoption. One of the main issues was econom- ically justifying the comprehensive strategy. While eCare may have been spawned from the CIO’s vision for integrating the organization through information, it was because of the efforts of the ‘‘thought partners’’ that the project was finally approved.

The focus of the coalition development then shifted to frontline users (i.e., nurses, physicians, patients, pharmacist, and other medical staff). This coalition of ‘‘doers’’ had a vested interest and enough clout to promote the use of the IS amongst the highly autonomous professional medical staff. Interestingly, many members of the coalition of ‘‘doers’’ also became part of the process reengineering team, ‘‘the clinician guidance group,’’ an integral component of the overall eCare team. The eCare team, up to then, exclusively consisted of IS managers internal to the IT department who were medical staff that had tran- sitioned into informatics roles. These members of the eCare team were integrated with the medical staff governance struc- tures of physicians, nurses, and ancillary units in each hospital in the hopes of promoting acceptance amongst all stakeholder groups to bridge professional barriers, coded as use joint planning activities to foster collaboration, which had not been a part of institutionalizing professional or organizational culture prior to eCare, as discussed here followed by our insight regarding this finding:

Physician and Chief Medical Information Officer: ‘‘The culture of healthcare has always been very disjointed. Everyone tends to be in the own lanes, doing for the patient, especially physicians. Our medical training is set up to first provide broad based knowledge and then specialize. We are rewarded and compensated more for specialization. That sometimes predisposes us to tunnel vision and working like lone rangers. We often forget that care is an input output system. In just getting people together from the different disciplines, who would probably never have ever sat together to talk about how they each care for a patient, was really a remarkable change and step in the right direction.’’

Insight 2: The planning strategy that stresses collaboration and involvement at all stakeholder levels is foundational for changes to come in professional and organizational culture.

4.3. BPCM phase – analyzing problems in the process

The coalition of ‘‘doers’’ possessed the functional knowledge of the care processes across the continuum and identified 18 mission critical processes that they deemed to align with the comprehensive strategy as indicated in Table 1.

The eCare team consisted mostly of staff that had a wealth of clinical experience. However, they did not rely on their own recollections of the processes involved in patient care when specifying requirements for the IS. Instead, external consultants were hired to document the ‘‘day in the life’’ of each stakeholder group, such as the physicians’ responsibilities in rounding

Table 1 Sentara’s processes for reengineering.

1 Arrival management 10 MD processes 2 Bed management 11 Medical records 3 Case management 12 Meds management 4 Charge capture 13 Monitoring/recording 5 Claims processing 14 Order sets 6 Clinical communications 15 Patient care transformation 7 Disease management 16 Patient/member satisfaction 8 Emergency department 17 Physician practice 9 Home health 18 Scheduling

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and communication of orders and the nurses’ efforts in medication administration, charting, and consolidation of patient information.

These consultants aided the eCare team by mapping the ‘‘as-is’’ state for workflows and identified a baseline for the pro- cess reengineering with eCare. From the analysis, the team learned that many of the steps taken across processes were redundant, similar processes were not consistently performed across the care environment, and some were not consistent with typical standard operating procedures. Many of the inefficiencies were the result of the manual and individualized methods for hunting, gathering, and documenting patient information. The problem analysis exercises and drills for reengi- neering workflows were done collectively by the clinician and administrative stakeholders (e.g., physicians, nurses, registra- tion, accounting, and other technicians) revealing where, when, and how information was needed for each. Unbeknownst to the physicians, the lack of clarity in their guidance resulted in misinterpretation or unintended decision-making by the other clinicians. This lack of clarity contributed to the blurring of clinical roles and brought into question who was accountable for consequences resulting from misinterpretation of physician guidance. This was coded as unearth role and process transpar- ency inclusive of accountability, as described here:

Acute Care Nurse: ‘‘In the mapping of the new processes, it was apparent how hard it really is for us nurses to gather all the information we need for our charting, e.g., docs scripts and orders, written on slips of paper or sticky notes, patient transfer sheets, etc. The paper trail for the patient is hard to follow. . .and you don’t want to appear stupid or bothersome to the docs when you have to keep asking them questions if you can get a hold of them, to find out exactly what they mean. . . whether it’s because you can’t read their writing or it’s just not detailed enough. Sometimes you just have to interpret and hope that it’s right. . .it’s an uncomfortable feeling because you know regardless of what I think the doc meant I am still accountable too for whatever I do for the patient.’’

Physician: ‘‘In these process redesign exercises that we all did together, we came to see that we individually contrib- uted to how dysfunctional the process had become for getting and exchanging information. We made it difficult for ourselves by not at least considering each others’ needs for patient information. We regarded the record as our own little memo device and it’s other peoples’ jobs to figure out what we intend. I didn’t even know that some of the spe- cialists, technicians, and nurses would benefit from me adding even certain information. I realized that it’s not their jobs nor should it be to have to figure out what I want. . . when they have the information they need from me and don’t have to guess at it then they can better act on my intent for the care of the patient. This could help ease the frustra- tions we sometimes have with each other. We revised these workflows with this in mind to lift the barriers between our disciplines.’’

Additionally, problems resulted from the lack of collaboration in the care process, especially in regards to patient hand- offs between medical factions (i.e., discharge and receiving a patient from one unit, or transfer of a patient from one pro- vider’s care to another). Information was lost or not communicated, resulting in possible errors. All factions recognized the fragmentation of care delivery across the Sentara network and the lack of information transparency. The thorough anal- ysis of the current processes and their redesign for eCare presented an opportunity for internal process transparency, which was not always part of the culture of the organization, as described in the following quote:

Physician and Chief Medical Information Officer: ‘‘In the analysis we found a few things that were down-right scary, we discovered we are even less integrated than we thought, but we also found people doing things that were working excep- tionally well and should be replicated across the entire organization and incorporated in the new design of processes to work with eCare. The analysis allowed us to go into eCare with eyes wide open and not replicate or reinforce broken pro- cesses. This effort was painful for some because we exposed the good with the bad but it’s critical to do this because you can’t bring about change unless you know what needs to be changed.’’

After the processes were analyzed, the coalition of doers separated to form a process reengineering team based on func- tional expertise. The IS leadership employed process management consultants that used a lean methodology (i.e., process definition, measurement, analysis, redesign, and validation) to help guide the teams through the reengineering activities. These re-engineered processes were thoroughly vetted by the coalition.

Scripts were developed to detail daily work and information flows regarding patient care touch points across a variety of care environments (e.g., primary care physician offices, emergency departments, in-hospital units, back office operations, and the patient’s home). The scripts involved scenarios that a patient would typically encounter, ranging from scheduling their own primary care physician office appointment to emergent situations, in-hospital stays, home care, and billing. The scripts were then given to a selected group of vendors whom Sentara solicited to provide a technological solution for eCare. The eCare team videotaped the vendor presentations and evaluated collectively with other stakeholders and a sample of users in the target group the ability of the vendor software to seamlessly perform the task at hand. From an engineering per- spective, the coalition faction for implementation could see exactly how each vendor product performed (e.g., how many clicks and screens users have to go through to complete a task). The sampled users in the target user group were able to visualize how their daily work lives would change with eCare. Additionally, they were able to envision the benefits of real time access to data across all environments of care – not just their respective portion of the care process. The vendor dem- onstrations were made accessible via Sentara’s website and Sentara personnel were encouraged to look at them. Hundreds of personnel provided feedback, thus fostering user buy-in, making the transformation effort salient for the frontline users. This

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was thought to help change the previous culture by engendering mutual respect amongst all clinicians, as illustrated in the following quotes followed by our insight:

Nurse: ‘‘The new care scenarios show how to incorporate eCare in workflow. . . we [nurses] learned how to function more like pit crews when we get a patient in. It demonstrated how we could use the information that was put in on patients prior to them coming to the unit to understand what we need to do for the patient when they come on the floor. It was to help us be able to operate better as a team and realize how we as nurses affect patient flow and outcomes. . .we got a sense that you wouldn’t just be there waiting to follow the physician orders.’’

Physician: ‘‘In the scripts it was very apparent exactly what each person does in the care of patients and how the infor- mation was to be used. We really never had a forum like that where we stepped though all the processes to see who does what and how each of us impacts care overall from the docs, to the nurses, to the technician, on to specialists etc. It made us appreciate what each of us contributes. . . and as docs we should use these other people as resources more often. . . as opposed to acting like line rangers. . .because care doesn’t happen in a vacuum.’’

Insight 3: Analyzing problems collectively amongst stakeholders uncovers role and process transparency that needs to be addressed to change culture.

4.4. BPCM phase – process re-generation

The CIO noted that implementation failures in general either stem from poor planning or from haphazard strategies for putting the new processes into place, which is especially true for large scale implementations. The core implementation team thought it was necessary to be deliberate in planning the schedule for the conversion, resulting in the development of new selection criteria. Applying the criteria was thought to be useful in minimizing inhibitors to change:

eCare Implementation Lead: ‘‘You can have an awesome plan but if it doesn’t get implemented in the right place first, it can taint how things will go later on for the other hospitals or areas where we want to go live [system rollout] with eCare. We had a lot of discussions and were very deliberate about our selections that would give us some good wins to show and be a size that was manageable enough to let us work out kinks.’’

The implementation team approached conversion more strategically than during past implementations prior to the eCare initiative. They generated the following selection criteria for the conversion schedule of the hospitals: (1) existence and power of potential champions in the hospital leadership to provide top management support, (2) existence and power of potential champions in the physician leadership to provide referent support, (3) consistency of physician referrals and actual admissions to indicate hospitals utilization, (4) degree of senior staff tenure representing those less prone to adapting to new technology, and (5) degree of complexity in case mix (i.e., minimal, moderate, high).

The implementation team selected the hospital that ranked highest on criteria 1 through 3 and moderate on 4 and 5, with the rationale that the first hospital should have strong internal support for change, demonstrate senior staff adaptability, and be an environment with a manageable but somewhat challenging case mix (i.e., level of acuity and variation in conditions treated). Tackling the most complex hospital with the most challenging staff would consume all personnel resources of the implementation team. The IT management had to be mindful to simultaneously implement the physician practices associ- ated with the first hospital scheduled for conversion. The rationale for simultaneous implementation in the hospital and the associated physician practices was to provide a seamless view of the system from the hospital environment to the physician practice. Additionally, the goal was to convert to the new system in one day at the hospitals and not to run parallel systems with any of the legacy applications that could introduce error and prove costly in terms of maintenance. At Hospital number one, this applied only to the nursing component, after which direct conversion for the physician component was applied.

The in-house eCare training team, with assistance from the primary electronic medical record (EMR) vendor, developed a training plan (see Appendix B) that kept particulars of the healthcare environment in mind. For example, healthcare orga- nizations cannot stop the delivery of services in order to train. Instead, training needs to be conducted in an environment in which there is little distraction to using the system, otherwise resulting in misinformation that potentially would contrib- ute to medical errors in actual care situations. The re-engineered processes called for use of the system amidst workflow, which was a fundamental change for how documentation and information inquiry occurred prior to eCare. Training was deemed critical for the aggressive conversion plan that provided exposure to the system in a classroom setting, then onsite instruction amidst workflow, supplemented by on-access web training and 24 h help desks. The aforementioned finding was coded as ensure training appropriateness to aid in learning new processes. Clinician sentiments are expressed here:

Nurse: ‘‘We learned the mechanics of the system in the classroom, then how to incorporate it into workflow in the units. The training emphasized how using the computer makes you more detailed and less likely to miss something in the chart- ing. I learned how to use the information now available in the electronic chart to help me do my own assessments of what’s going on with the patient. . .like rationalizing why a doc wants something done. Before, I would often do it blindly. . .without really understanding why. I see now the plan and feel like I have more of a place and purpose in what’s being done for the patient. It just wasn’t technical training. Even in the training I was being educated about how to work smarter.’’

Fig. 1. Optimization team structure (provided in archival document).

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The previous quote also suggests that the edification of the clinicians enabled an enriched verbal exchange, as discussed here followed by our insight:

Physician: ‘‘The dialogue with nurses is richer now than before. I think it’s due to the wealth of information that they have access to eCare. They really ask some detailed questions now more than before and they seem more confident in giving me helpful insight on the patient. . .we complement each others’ skills. . . also I know now how I can make better use of the historical information in the system in addition to what I see for myself and hear from the patient, nurses or other clinicians. . .to synthesize it all to diagnose and treat.’’

Insight 4: Process-re-generation is an opportunity for educating and raising the collective medical acumen to promote changes in learning.

4.5. BPCM phase – continuous improvement

The IS leadership understood that transformation would be a gradual, proactive, and journey in a long term implemen- tation in which the quest to improve is never-ending, where learning and in-firm capabilities build overtime as does the capabilities of the IS. The ‘‘optimization3 team’’ (see Fig. 1) consisted of internal IT personnel, most of whom were part of the initial design team that had expert functional knowledge of how the system should operate in the care environments. The team’s responsibilities entailed tracking needed improvements as the implementation progressed by examining and solic- iting feedback from the users on the type of issue encountered (i.e., either technical or process-oriented). For technical issues, the team determined its criticality and its potential threat to patient safety as well as the level of vendor support required for software updates. For process issues, the improvement team worked with users in order to determine necessary adjustments in the new workflow.

The scheduling of the implementations allowed for realization of problems based on the type of care environment, which was helpful in categorizing and prioritizing issues to address. The stated goals of the improvement or ‘‘optimization’’ team, as referred to by Sentara personnel, were to overcome implementation issues and to ensure benefit realization, articulated as: (1) establish an optimization dashboard to track expected return on investment (ROI) as well as value on investment (VOI) to validate that the metric goals are being met (see also Appendix C), (2) identify the improvement project selection criteria, (3) select, initiate, and complete three to five subprojects based on analyzed eCare data per quarter, (4) establish a baseline of system functionality, set goals, track utilization, and (5) establish a baseline for the customer experience, set goals, and track progress.

The efforts in improvements were more comprehensive and proactive when compared to implementations prior to eCare in that with the eCare implementation there were specified methods for discerning problems and rubrics for addressing them. Specifically, the optimization team used a variety of methods (e.g., user interview, observation of re-engineered work- flows, patient satisfaction surveys) to areas of improvement.

3 Sentara personnel used the term ‘‘optimization’’ to mean continuous improvement.

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One noted issue following the assessment at Hospital 1 was that despite the decrease in manual documentation for care combined with a drop in man-hours required for records creation due to eCare functionality, the scanning volume for doc- uments as part of the electronic medical record (EMR) was marginally increasing. Inquiry by the optimization team revealed problems with clinicians and administrative assistants not having clear direction on what to exclude from the EMR that for- merly existed in the manual chart, as discussed here:

Administrative Technician: ‘‘When we moved from paper to electronic records I don’t think they realized how much material doesn’t fit into the coding categories like certain images that are held in the record and now require scanning. We spend a lot of time scanning materials that are in the patients’ paper chart to get it into the records at least in pdf format. We can’t make the judgment about if this material should stay or not, so we just scan everything that can’t be coded...We ask the docs and nurses for guidance, but they aren’t sure either sometimes. . .so when in doubt, we just scan it in.’’

The corrective measures the improvement team took in this case were to enlist some medical staff, evaluate sample elec- tronic records, and determine the relevance of materials that had been scanned into the record. From this insight, a rubric was created to aid the technicians in discerning relevant materials as well as providing a standard for codifying some of the detail for analysis, which was not possible before from merely having the image of a scanned document. The aforementioned example, represented by the code refine tasks so the appropriate entity has ownership of the process, suggests the following:

Insight 5: Improvement is an opportunity to ensure the appropriateness of the process owners for enhanced coordination.

Another example of improvement opportunities discovered involved the patient throughput in units that impacted pa- tient wait times for entering the unit, time to discharge, and average bed turnover. This lag in patient throughput was asso- ciated with users not adding needed data into the system for specific services, as discussed here:

Nurse Coordinator: ‘‘Patients aren’t being discharged in the system, or there are big delays for them to be discharged. I can’t turnover a bed until the system indicates that the bed is free. I think the delays are due to nurses just not getting to the charting until later and/or neglecting to ensure that they complete the discharge as soon as a patient leaves. So, I believe it’s more of making sure they understand the new process and not as much about the technology not working properly.. . .All I do right now is bed flow. However, I’m expected to do rounds, customer service, nurse education, espe- cially when they need an expert on the floor to assist in something. I’m whom the nurses call. . .this should be my first priority as a coordinator—not bed flow.’’

Apart from implementing system alerts, the corrective measures taken were to re-emphasize the new process for com- pleting discharges to the unit nurses and educating them about the impact of patient discharge on bed flow. A redesign in- cluded undergoing a shift in responsibilities for the nurse coordinators in order to allow them to focus on providing expert knowledge for complex cases to unit nurses onsite. The redesign involved (a) shifting some tasks to the unit nurses and administrative assistants and (b) designing software capabilities inclusive of decision support to assist the coordinator in how to place patients based on factors, such as acuity level, current capacity, and experience of unit clinicians for dealing with the patient under these situational circumstances.

Incompletely recorded discharges in the system also had an impact on the coordination of other services in the care con- tinuum, such as home-based heath care as a critical component to patient compliance. Obeying the physician-ordered reg- imen not only contributed to successful rehabilitation, but also allays complications requiring repeat or emergent visits. The associated code, deter complacency with the IS to replace all verbal communication, is discussed below and was viewed as an improvement compared to the prior eCare process:

Home Care Nurse and Coordinator: They [nurses] use to call us before eCare to make sure we come to set up the home care schedule [based on the physician guidance for post acute hospital care] before they discharge. They would give me specifics and insight about the patients based on their experience dealing with them. It’s hard to get that picture of a per- son’s demeanor from the computer. The process is automated now and they [nurses] rely on it too much. I think we still need that verbal communication. More often now since eCare, I will go to visit the patient and give the guidance and they are already gone. The chance of patients having emergent problems and ending up right back here is higher if we don’t provide the care at home.’’

The aforementioned quote contributes to the following insight:

Insight 6: Improvement is an opportunity to deter complacency or reliance on the system as a complete replacement for needed communication for enhanced coordination.

Another area of concern was that the system constrained the manner in which the clinicians articulated their diagnoses and thoughts concerning their care process. This is alluded to in the following:

Gastroenterologist: ‘‘Medicine is a lot more art sometimes than science and I don’t know if everything can be described in codes. I’m being forced to change my process of how I document care and make sense of what I see. Everything is not

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clearly understood from just selecting codes. I understand it’s better to have the codes than long narratives for analysis but I need my narrative to get a clear picture of the patient. I do a lot of narrative dictation about my patients and have those transcribed into the record. The notes section is supposed to be used to document anomalies in care but that’s not all that I used it for and I’m afraid that I lose too much on my thoughts documenting this way in the EMR. . .I heard there are things like Smart text but I haven’t used it yet. I still have some caution because I’m used to writing my thoughts more freely. That’s just how I do it.’’

Similar sentiments were also voiced by nurses who wanted to be more descriptive in how they entered notes on patient care. As a result, the optimization team incorporated clinicians in the redesign of the notes functionality. This included, for example, the use of ‘‘smart tags’’ for key descriptive phrases that allowed for the desired autonomy in writing while prevent- ing lengthy narratives that were less suitable for data analysis purposes. This was coded as refine codification that constrains articulation of thought and contributes to the following insight:

Insight 7: Improvement is an opportunity to understand the limitations of codification of data and compromise system require- ments to afford better data analysis with the necessity to articulate freely the art form of medicine.

Sentara recognized that improvement of processes is recurrent and that there is a need to continue learning from the eCare data and improving eCare’s functionality as new requirements and opportunities unfolded, coded as foster continual learning. The following alludes to this latter point:

Physician: ‘‘Once the mechanics are working properly, we can move on from being focused only in the past and present state of the patient. We are no longer limited to just trying to fix what’s wrong now but can really use the trends available because of the data to help predict what will happen in the future. It’s as if we have the means now to answer questions we didn’t even know we could pose before.’’

Improvement Lead: ‘‘We form task forces to refine processes to help us be more sustainable, like tracking charge captures better to reduce waste of medical supplies. In optimization we are learning that we want to change how we do things like giving a basic med earlier in a regimen to help out ward off other problems. We turn this insight into actionable best prac- tices and be innovative in how we approach care to reduce the likelihood of patient complications. We advise other healthcare networks about what you can learn from just doing the implementation as well as what the data can provide as a result of the having the system in place.’’

An example of this process of learning from improvement was epitomized by a new service in emergent care. Sentara realized decreasing times for patients waiting to be seen in the emergency departments (ED) because of better information and process changes enabled by eCare. However in improvement, the IT and ED leadership at Sentara as well as the support- ing Emergency Medical Services (EMS), a faction external to Sentara in the region, realized opportunities to impact (a) quality of services for patients coming into Sentara’s ED by EMS ambulance transport, and (b) quality of repeat services for subse- quent encounters patients have with EMS during emergency situations in the community. As a consequence, Sentara person- nel partnered with EMS to build a system that allowed for medics to have access to eCare whenever they arrived on site during emergent situations in the region. This increased the likelihood that a medic could treat more effectively due to the availability of critical patient information and that ED could prepare better to receive the patient. It also provided ED and EMS with information regarding the effectiveness of the medical intervention. The insight from these encounters was especially beneficial to the EMS, which had not been privy to that information prior to the visibility afforded by eCare, as discussed here:

EMS Division Chief: (excerpt taken from interview in Sentara Press release – see Adams (2010)) ‘‘We’ve partnered with Sentara to actually follow our patients all the way through the hospital. We’re able to track patient outcomes and alter the way we deliver care on the streets.’’

The aforementioned alludes to the engendering of the learning desire from the data provided via eCare that represented a change in the behavior of the stakeholders within and external to the organization, as discussed here:

CIO: ‘‘We continue to optimize the care process design . . .The desire to learn across the organization seems endless now. . . It’s not just the administrators asking us for new reports. . . the docs want to know more about what the data shows for effective disease regimen. . . the link with workflow. . . or frequency of patients being readmitted for the same problems, the nurses want to know about the link between staffing and quality, even medical transport wants to know how trans- port time impacts unit patient turnover. . . We [IT and business analytics] no longer are fixated on just providing them [information consumers] the standard reports that reflect what happened in retrospect. We can more deliberately act in real time to affect clinical outcomes. We can predict better, anticipate and plan for future problems and possibilities. eCare is the platform for this transformation. . . getting eCare implemented was just the starting point.’’

The aforementioned also suggests that continuous learning took place because of cross-fertilization inputs. Namely, the need to learn may be both: (a) a result of the activity of different coalitions and stakeholders participating in the implemen- tation process thereby exchanging diverse knowledge and (b) an impetus for innovation. Therefore, we suggest the following insight:

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Insight 8: Improvement is an opportunity to provide a means for enriched and continual learning that can be the basis for innovation.

By using the BPCM model as our guiding framework in analysis, we discerned how the activities undertaken during the process of IS implementation provided an understanding of how Sentara transformed in three crucial ways: via coordination, culture, and learning. The summary of our findings is depicted in Table 2, and an evaluation of this qualitative research ap- pears in Appendix D.

The contents of Table 2 indicate the relationship between: (a) the BPCM phases, (b) our codes for the process activities undertaken by Sentara in the implementation relative to each BPCM phase, (c) our insights to that reflects our sense-making of these coded process activities, and (d) the resulting concepts (i.e., coordination, culture, and learning) that are associated with the insights relative to the IS implementation process. We analyzed these concepts to be the manifestation of how the IS process contributed to organizational transformation at Sentara and elaborate on each in the following section.

5. Discussion

The insights gained from examining the IS implementation process suggest that this process itself, and not merely the resulting IS artifact, is associated with each of the three concepts contributing to transformation changes: coordination, cul- ture, and learning.

5.1. The IS implementation process and coordination

How to deploy an IS to align strategy with the objective to ‘‘informate’’ (Zuboff, 1985) and to integrate horizontally or vertically across disparate factions is an issue that has long challenged non-healthcare organizations (Avison et al., 2004; Chan et al., 1997; Brown and Magill, 1994; Hendersen and Venkatraman, 1993). According to Kettinger and Teng (2000), the phase ‘‘Link with Strategy’’ entails a high-level evaluation of the ‘‘need for change and feasibility for change’’ in the con- text of the existing business environment. The need for change was brought about by the realization that growing the Sent- ara brand effectively would require synergizing and integrating its current resources. While the need for change could have been based on reactive behavior due to extraneous pressures, such as the political agenda for healthcare reform, in Sentara’s case it indicated proactive behavior with the intentions to seize existing opportunities, such as expanding an organization’s reach (Guha et al., 1997). The proactive behavior was also reflected in Sentara’s activities in (a) understanding the informa- tion interdependence, (b) streamlining processes, (c) refining tasks to ensure appropriate process ownership, and (d) deter- ring complacency to rely on the IS as a replacement for communication and instead promoting the IS as a tool to help better synthesize verbal and non-verbal communication.

Sentara used the IS implementation to break open the organization and reveal its inner workings. This instituted a par- adigm shift towards multidisciplinary care delivery that was unconfined by the location of the provider. The understanding that having access to the same comprehensive information across all units, as a means for coordinating care, proved to be essential for management. They realized the strategic implications of coordination across the entire organization as materi- alized in ROI and VOI. The process of implementing eCare was the vehicle for that awareness and change to take place, which can be attributed to the promotion of project awareness created from common knowledge (Huang and Newell, 2007).

5.2. The IS implementation process and culture

The IS implementation process should seek to ensure a pairing of the technology-enabled processes with the desired out- comes of the business strategy (Henderson and Venkatraman, 1990; Thompson, 1967). However, this can be an arduous task complicated by clashes in cultural norms in the organization. At Sentara this was exhibited in the joint planning process for eCare, which demonstrated how little each stakeholder group (i.e., physicians, nurses, technicians, and administrators) knew about each others’ involvement in the care process. Researchers have noted this type of occurrence in various contexts (e.g., Adler-Milstein and Bates, 2010; Bohmer, 2009; Tarafdar and Gordon, 2007; Kanungo et al., 2001) and have pointed out that it is even more of an arduous task when the users do not appreciate or embrace the interdependent nature of the processes or workflows and are autonomous enough to warrant the status quo (Berg, 2001). The eCare implementation process unearthed just how interdependent and reciprocal tasks were in care. It also revealed how roles and professional cultures inhibited the overall efficiency and effectiveness of the workflow of all stakeholders and ultimately the care outcomes for the patient. In addition, the IS process itself was also used to bridge the professional gap between clinicians and administrators as well as amongst clinicians. This enabled more fruitful information exchanges and the realization that each stakeholder contributed to the care process, and not just physicians (i.e., the change from lone ranger style care to appreciating the pit crew ap- proach). The point is akin to what others have argued. Knowledge does not solely come from making data commonly avail- able to people, but from making the rationale for the different perspectives of the groups apparent to all involved in the information exchange (Newell and Edelman, 2008; Boland and Tenkasi, 1995). In essence explaining why a care practice is done a certain way and providing opportunities to unpack the impact for all involved unearths interdependent activities.

Table 2 Summary of findings.

BPCM phase Process activities’ codes Insights Concepts concerning changes contributing to the organizational transformation

Link with strategy Reveal information interdependence

(1) Linking the IS implementation with the organizational strategy forefronts the need and requirements for information interdependence and efficient processes to bring about changes in coordination

Coordination changes

Streamline processes

Plan the change Use joint planning activities to foster collaboration

(2) The planning strategy that stresses collaboration and involvement at all stakeholder levels is foundational for changes to come in professional and organizational culture

Cultural changes

Analyzing problems in the process

Unearth role and process transparency inclusive of accountability

(3) Analyzing problems collectively amongst stakeholders uncovers role and process transparency and accountability issues that need to be addressed to change culture

Culture changes

Process re-generation Ensure training appropriateness to aid in learning the new process

(4) Process-re-generation is an opportunity for educating and raising the collective medical acumen to promote changes in learning

Learning changes

Continuous improvement

Refine tasks so the appropriate entity has ownership of the process

(5) Improvement is an opportunity to ensure the appropriateness of the process owners for enhanced coordination

Coordination changes

Deter complacency with the IS to replace all verbal communication

(6) Improvement is an opportunity to deter complacency or reliance on the system as a complete replacement for needed communication for enhanced coordination

Coordination changes

Refine codification that constrains articulation of thought

(7) Improvement is an opportunity to understand the limitations of codification of data and compromise system requirements to afford better data analysis with the necessity to articulate freely the art form of medicine

Cultural changes

Foster continual learning (8) Improvement is an opportunity to provide a means for enriched and continual learning that can be the basis for innovation

Learning changes

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Additionally, the IS implementation process, regarding continual improvement, aided in identifying problems in the IS design that, while optimizing codification, challenged the physicians’ autonomy. Physicians’ autonomy expressed itself as part of the professional culture, more specifically in the way how physicians exercised their flexibility in documentation style for sense-making. At Sentara, viewing medicine as an art emphasized that medicine and medical encounters required improvisation (Haidet, 2007; Koppel et al., 2005; Berg, 2001) and compressing it into a text field would have degraded this perspective. Similar problems with system implementations have been noted by other researchers (e.g., Koppel et al., 2005; Ash et al., 2004; Jackson, 2004) in that knowledge creation needs to be understood at the individual level and that the IS, taken by itself, might be insufficient in enabling sense-making (Newell et al., 2002).

Underestimating medicine as an art form could have been an inhibitor to the success of eCare, but was used as an oppor- tunity for optimization and to show how to combine technology functionality with the professional culture. Overall, this re- sulted in changing the propensity and appreciation for transparency in the workflow by the clinicians. Sentara’s approach was consistent with Newell et al. (2003) who suggested fostering organizational efficiency and flexibility for the workforce simultaneously and in a complementary fashion with the enterprise IS. This later point is indicative of the interplay between the implementation process, culture, and organizational transformation. Understanding facets of the IS implementation pro- cess at Sentara revealed how culture (whether of a professional, organizational, or IT nature) responded to management activity, which contributed to needed clarity in this area (Walsh et al., 2010).

5.3. The IS implementation process and learning

The BPCM phase ‘‘Continuous Improvement’’ entails examining if the performance objectives were met and assessing what actions to take next (Kettinger and Teng, 2000). The Sentara approach was a never-ending cycle, targeting optimization of effective use of the IS in workflow that, through institutionalization in managerial practice, led to innovative activities for refining flawed processes in addition to producing new services. Participants were motivated to use this information and what they had learned during the improvement activities to create new services – services that offered new information ex- changes, tying stakeholders in the community much closer to Sentara and raising the collective medical acumen of the stake- holders in the community and not just within Sentara. Examples include consulting services for other healthcare organizations and needed partnerships with emergency medical services (i.e., ambulance transport) to build modules of eCare enabling medics to learn about patient prior to arriving on site of an emergent event and ascertain the effectiveness of their emergent care delivery. These services made it easier for these stakeholders to conduct business with Sentara, providing ‘‘sticky’’ services as labeled by the CIO. Thus, this information integration facilitated by the IS was not only

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foundational for other services, but it required organizational will to develop this foundation into a springboard for innova- tion, as has been suggested by others recently (e.g., Leidner et al., 2010; Kohli and Melville, 2009). It also aligns with what prior researchers have noted in their remarks about ambidextrous innovation processes (e.g., Newell et al., 2002; Benner and Tushman, 2003).

While this type of innovative implication and strategic value often goes underexplored in organizations (Baptisa et al., 2010; Kohli, 2007), Sentara realized the benefit of having data and process transparency of medical interventions between patients and clinicians for virtually every touch point across the continuum of care. This point is akin to the insight gained from understanding nuances in process changes when implementing IS in multi-sites (Markus et al., 2000).

Another objective of the improvement activities at Sentara was to promote learning for both the administration and users. The intent was to seek new areas to improve and to pass on baseline knowledge of IS capabilities learned during the initial or subsequent training sessions. The result was that the users regarded the IS as a means for learning and used it to answer equivocal or complex questions that were not previously raised. It even promoted empowerment of the nurses to use the available information to enrich their sense-making capabilities, much like the physicians, and enabled a better understanding of the physician guidance. This enabling of an enriched sense-making capability was not only beneficial to the overall delivery of care, but it also made work more purposeful for the nurses. Additionally, the process of the improve- ment activities provided a proactive means of learning problems and working through solutions before they could fester and become counterproductive to the entire implementation across the network, akin to findings made by Huysman et al. (1994).

5.4. Generalizability and future research

This study contributed to a more descriptive understanding of a mechanism by which successful organizational transfor- mation in a healthcare organization can occur – the IS implementation process as an opportunity for changing coordination, culture, and learning. Inferences from this research can be abstracted to draw conclusions about similar contexts, which is a component of generalizability (Lee and Baskerville, 2003; Klein and Myers, 1999). This case study describes a successful implementation of IS in healthcare and thus, provides important insights to help scholars and practitioners (e.g., CEOs, CIOs, hospital managers, IT managers in healthcare, etc.) who are keen to understand such transformation from a process perspec- tive. We suggest that the insights that emerged from this study would apply to any networked organization comprised of autonomous professionals that perform long-linked tasks in a somewhat unpredictable, transformational process facilitated via technology. However, it is difficult to discern any other context that has individuals with such a high degree of autonomy, but yet so interconnected in the functions they serve and pressured by the gravity of their outcomes. Even in this context, where Sentara’s network included its own closely affiliated staff of physicians and its own insurance company, generaliza- tions to different healthcare configurations must be done with care.

As a result, more research regarding transformational change processes and guidance is needed for various types of organizations with lesser degrees of organizational integration and size than Sentara. This is especially true since 81% of care, based on physician interaction, is conducted in non-acute care settings (i.e., ambulatory or clinical environments and post-acute long term/nursing facilities) that are stand-alone or minimally integrated (Schappert and Rechtsteiner, 2008). Future research might also consider discerning interactions between coordination, culture, learning changes. For example, examining in detail how the IS implementation process can promote coordination that may alter the culture is worthwhile as a separate study. Also, a separate study is warranted to show how coordination, culture, and learning changes contribute to determining how organizations transition from viewing IS as a means for transformation to a means for innovation.

6. Conclusion

The study demonstrates that prudent business process change management as part of a poignant IS implementation pro- cess is essential and that IS is a catalyst for changes in how an organization transforms in terms of coordination, culture, and learning. While true for any business, it is even more pronounced in the healthcare industry, because of the high stakes in- volved including: patient lives and well-being, professional certifications, and legal liabilities. Healthcare is peculiar and makes the task of incorporating IS complex, requiring great care and sensitivity for its productive inclusion in the process transformation tool kit. If the IS cannot inform properly then lives are lost, thus adding graveness far greater than that of most other business contexts. This perspective has ramifications for the way we study the healthcare context and how IS implementation processes are applied as agents for organizations to alchemize the disruptive cacophony of the change pro- cess into harmony.

Acknowledgment

We sincerely thank Mr. Bertram Reese, Chief Information Officer at Sentara Healthcare, and all personnel at Sentara who greatly contributed to development of this research effort.

C. Abraham, I. Junglas / Journal of Strategic Information Systems 20 (2011) 177–197 191

Appendix A. Sentara’s milestones and data collection protocol

Sentara’s defined eCare milestones

Corresponding BPCM framework phase (Kettinger and Teng, 2000)

Research activities timeline

September–December 2005

Link with strategy

January 2006–May 2006

� Secure management

commitment

� Interviewed three top management personnel

about the strategic plan for eCare

Business case validated and � Discover reengineering � Reviewed archived documents such as the

vendor contract signed

opportunities

internally prepared business case and description

of vendor contract

� Identify IT levers by

reviewing IT plans and current IT assets

� Interviewed ten senior IT architects about the IT implementation plan

� Select processes and define project scope

May–December 2006

Plan the change

May–December 2006

Project team planning phase

� Inform stakeholders

� Interviewed top IT management (i.e., CIO and five

VPs) about forming coalitions and informing stakeholder

� Organize reengineering team

� Interviewed twenty-five hospital implementation team and five members of the physician group practice implementation team about project planning and setting performance goals

� Conduct project planning

� Interviewed and observed medical staff in-hospital and doctors offices concerning their pre- implementation perceptions of eCare

� Set performance goals of the re-designed process

December 2006–May 2007 Analyzing problems in the December 2006–May 2007

process

� Defined current processes

� Document existing processes

� Reviewed archival documentation from external consultants hired to document existing processes that revealed inconsistencies in processes

� Designed, built, and validated new processes

� Uncover pathologies that are problematic

� Interviewed 40 physicians, 36 nurses, and nine registration/administrative assistants comprising the hospital implementation teams about discovering problematic pathologies, alternative processes and transfer of role responsibilities

� Explore alternative process designs

� Interviewed IT personnel about new IT architecture for supporting re-engineered processes

� Design new processes

� Design human resource

architecture

� Design IT architecture

� Conduct holistic process

prototype

� Construct information

systems

� Select conversion process

August 2007: First MD office implemented (150 MDs First Year)

Process re-generation

August 2007–October 2008

(continued on next page)

192 C. Abraham, I. Junglas / Journal of Strategic Information Systems 20 (2011) 177–197

Appendix A (continued)

Sentara’s defined eCare milestones

Corresponding BPCM framework phase (Kettinger and Teng, 2000)

Research activities timeline

February 2008: First hospital implemented, all but CPOM

� Deploy IT

� Interviewed and observed implementations pre and post (i.e., Go Live periods for Hospitals 1–3 and select physician offices)

May 2008: First hospital implemented CPOM

� Reorganize

September–October 2008: 2nd and 3rd hospital Go Live

August–November 2009

March–November 2009: 4th, 5th and 6th hospital Go Lives

� Interviewed and observed implementations pre and post (i.e., Go Live periods for Hospitals 4–6)

October 2008–continuous

Continuous improvement

October 2008–December 2009

� Measure performance

� Interviewed business analyst and top management

concerning

� Link to quality program

� Interviewed medical staff about process changes

and link to quality improvements

� Reviewed archival documents on performance

metrics

Appendix B. Training plan

Time

Activities

Hospital implementations

Three months prior to Go Live (first

day of implementation)

Initial training

� In-class training for super users (physicians and nurses) conducted 3 months prior to the Go Live date; super users then train other clinicians in their unit, but there were in-class training opportunities scheduled 6–8 weeks prior to Go Live for non-super users

� Users have access to the prototype or play environment at worksites or via Web

site with computer based training to allow training at the convenience of the user

Go Live through the following 6 months

Follow-up training

� Additional, remedial, or new employee training is conducted on site as needed Installation and support

� On the Go Live date, the eCare is available, and access to any legacy application is

prohibited

� Hands-on user support for nurses and physicians in the units, differentiated by

colored shirts (i.e., red-shirted team members to aid nurses and black for physicians); a command post providing 24/7 help via phone and email at the worksite is established to assist users with transition in the worksite for the entire duration of the scheduled implementation

� Subsequently, a reduced support echelon remains at the hospital indefinitely

Physician group implementations

Two months prior to Go Live:

Training

� In-class training for physicians at the corporate site

� Countdown calendar begins, and messages are sent to office personnel with

insights on expected benefits (e.g., expect easier referral), which serve as reminders to the impending implementation

C. Abraham, I. Junglas / Journal of Strategic Information Systems 20 (2011) 177–197 193

Appendix B (continued)

Time

Activities

Two to four weeks prior to Go Live: Follow-up training

� On site training and support at physician office through Go Live

Go Live:

Temporary reduction in caseload

� Clinical staff reduces patient scheduling to allay problems with prolonged wait

times as the physician and staff begin to use the system at the worksite

Notes: Implementation at Hospital Number 1 was scheduled for 6 months. Initially, the IT implementation team, consisting of 80 and then rising to 90 personnel, focused efforts at this site, but were split into 2 teams to handle nearly simultaneous implementations thereafter at Hospitals Number 2 and 3. These had similar case mixes and capacity until they reconvened into one team at Hospital Number 4 in order to handle the largest hospital and most complex case mix. At the height of the simultaneous conversions, the IT implementation team rose to 190 personnel who enabled acceleration of the implementation. The implementation team split again to support nearly simultaneous implementations at the fifth and sixth hospitals, which were also similar in case mix and capacity. After which, hospital seven and other care environments, such the outpatient and nursing homes, were scheduled. Initially, physician practices were implemented every 30 days when Hospital Number 1 went live, but increased in productivity to one practice every 10 days by the end of the first year.

Appendix C. Examples of value on investment since implementing eCare

eCare metric description

Process efficiency

Quality improvement

Reduced length of stay (by nearly 21% overall, 72% reduction in late medication administration, 67% remarkable reduction in stroke patients) and reduced adverse drug events due to medication error (by 96%)

Associated with decreasing inefficient processes in care delivery such as errors or delays in services that require the patient to stay in-hospital longer than anticipated

Associated with reduction in medication errors that cause harm or death or delays in receipt of medications that can cause a patient to have to remain in the hospital longer recovering or receiving care for avoidable errors or delays

Increase in outpatient procedures (by nearly 12%)

Associated with increased ease in scheduling procedures because of a streamlined process of information exchange between physician practices and the outpatient services

Associated with not having to admit patients for procedures that can be sufficiently conducted in outpatient care, lessening the chances of exposure to other conditions and diseases in the acute care setting

Increase in unit efficiency and retention of registered nurses (by nearly 38%)

Associated with nursing retention and decrease in overtime expenses much do to charting at the end of shifts (i.e., streamlining workflow)

Associated with the likelihood of patients receiving better care from experienced nurses who are enabled to be more proficient in their duties

Reduction in transcription expense (by 42%)

Associated with expenses paid to outsourced transcribers (i.e., reduction in unnecessary processes)

Associated with less likelihood of misinterpretation of instructions for care and more thorough documentation because fewer non- clinicians transcribing

Reduction in medical records supply costs (by 38%)

Associated with expenses maintaining records (i.e., reduction in unnecessary processes)

Associated with availability of medical information at the point of care via the IS lessening the likelihood of erroneous care

Reduced inappropriate admissions (by 38%)

Associated with streamlined or more effective process for identifying who truly needs to be admitted via decision support that helps with capacity management

Associated with number of times a person’s condition does not warrant admissions but they are admitted anyway, exposing them to harmful health conditions in the acute care setting

(continued on next page)

194 C. Abraham, I. Junglas / Journal of Strategic Information Systems 20 (2011) 177–197

Appendix C (continued)

eCare metric description

Process efficiency

Quality improvement

Reduction in pharmacist order entry (by 20%)

Associated with pharmacist units of service in hours for validating and preparing Rx doses (i.e., reduction in unnecessary processes)

Associated with a decrease in the unintentional prescription validations that can cause an unnecessary or erroneous medication delivery because the IS enables the physician to enter pharmacy orders directly based on their own guidance as opposed to the pharmacist having to interpret physician orders

Appendix D. Qualitative research evaluation

Most qualitative researchers are not comfortable using the terms ‘‘validity’’ and ‘‘reliability’’ for the assessment of their work as these terms carry many quantitative implications (Corbin and Strauss, 2008; Leininger, 1994). Moreover, it is impor- tant to select assessment criteria that are appropriate for a given qualitative methodology (Corbin and Strauss, 2008; Deme- trion, 2004) – there is not a set of criteria that fits all of them. In this spirit, we choose to use Glaser and Strauss’ (1967) recommendations to assess our work since we did apply grounded theory methods, under the auspices of a post-positivist paradigm, that afforded the emergence of concepts associated with changes in coordination, culture, and learning in the organization realized in a particular phase of the BPCM framework. Accordingly, the criteria of credibility and applicability are discussed below.

Criteria

Assessment

Credibility

Is there sufficient detail and description so that readers

feel that they were vicariously in the field?

While remaining within the scope expected from a journal article, we tried to provide sufficient details as descriptively as possible about the site, the IS project, the stakeholders, and the process activities for implementation. The detail was obtained from multi-level perspectives and archived documents that consistently associated the IS implementation process with coordination, culture, and learning demonstrating the ways in which the organization transformed. We provide multi-level stakeholders’ quotes in the text to give the reader real insight about the phenomenon. The overview of this description was approved by the CIO and key eCare team members

Credibility

Is there sufficient evidence on how the data were

gathered and how the analysis was conducted?

In the Research Approach section, we provided details of our selection criteria for the successful site akin with theoretical sampling. Triangulation (by way of different data collection techniques and from pre and post implementation) provided a means to validate the collected data. We used an established frame to code the data, which we later synthesize into insights for explaining how Sentara progressed through the implementation process. We then provide an understanding of how this insight about the process reveals that the organization transformed by (1) changing the way it coordinated, (2) changing its culture, and (3) changing the way it approach and appreciated learning about its own operations

C. Abraham, I. Junglas / Journal of Strategic Information Systems 20 (2011) 177–197 195

Appendix D (continued)

Criteria

Assessment

Applicability

Is the resulting insight readily understandable by laymen

and professionals?

Through the research effort, we periodically provided the analysis to the CIO and key eCare personnel for validation. We also presented the research in healthcare practitioner and academic forums and received confirmation that the findings were believable. The success status of the Sentara that was bestowed by a credentialing practitioner consortium adds credence to our claim that the explanation and understandings we surmise are sufficient

Applicability

Is the resulting explanation or insight sufficiently general

to be applicable to diverse situations and populations?

In the Generalizability and Future Research section, we discuss how our findings are sufficiently generalizable other contexts discerning any IS implementation process influence on coordination changes, culture changes, and learning changes and their collective influence on organizational transformation. While the discussion was developed based on explanation and understanding of phenomenon in healthcare, we provide explanation concerning how the insights are generic enough to apply to other context at the organizational level of analysis

Applicability

Does the resulting explanation or insight provides the

user with sufficient control to bring about change in situations?

The description of the process activities in each phase of BPCM for how Sentara engaged in implementing the IS is sufficient to provide the basis for replication in other organizations (healthcare or otherwise) implementing IS. The insights provide insight into what can possibly change that will ultimately impact organizational transformation. Other organizations can control how they change coordination (e.g., possibly indicated by time and service quality indexes), culture (e.g., possibly indicated by survey of staff), and learning (e.g., indicated by number of requests for new reports, new products or services offered) to prompt the transformation

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