The Journey through Grief-Insights from a Qualitative Study of Electronic Health Record Implementation

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This is a review for McAlearney, A. S., Hefner, J. L., Sieck, C. J. and Huerta, T. R. (2015), The Journey through Grief: Insights from a Qualitative Study of electronic health record Implementation. Health Services Research, 50: 462–488. doi: 10.1111/1475-6773.12227.


McAlearney et al. contends that going from paper records to an EHR cannot be equated with complete integration of an EHR into the care process. Both organizational and physician barriers have typically been blamed for slow uptake of EHR systems into workflows. They also state, eight main categories of physician barriers were identified by a 2010 review of 22 research articles on barriers to EHR acceptance: financial, technical, time, psychological, social, legal, organizational, and change process. These physician barriers align to barriers identified at the organization level, and both types are well-understood by practitioners and researchers. Some view these barriers as the focal point of interventions—removing them will accelerate EHR adoption. An alternative framing, however, is of EHR adoption as a change process that is slowed due to participant resistance, according to McAlearney et al.[1]


In the article, McAlearney et al. proposed that EHR adoption is contingent not just on removing barriers but on addressing the change processes involved—at both the individual and organizational levels. The researchers set out to examine administrators' and physicians' perspectives about how adoption and implementation of an EHR system can be facilitated. research objective, shared with study participants, was to improve our collective understanding of EHR implementation strategies to advance the adoption and implementation of ambulatory EHRs, paying particular attention to opportunities to maximize physician adoption and use of such systems.[1]

Data Sources/Study Setting

Primary data collected from 47 physician and 35 administrative key informants from six U.S. health care organizations identified because of purported success with EHR implementation. Interviews consisted of a series of open-ended questions and lasted 30–60 minutes. In addition, McAlearney et al. held six focus groups comprised of 47 generalist and specialist physicians. All interviews and focus groups were recorded and transcribed verbatim. The researchers’ data collection process also included a concomitant assessment of interview and focus group transcripts and discussion of preliminary findings to permit probing for new concepts and ensure that we reached saturation in data collection, consistent with standards for rigorous qualitative research. This study was approved by the institutional review board of The Ohio State University. No informant approached for this study refused to participate.[1]

Study Design

This extensive qualitative study consisted of interviews and focus groups. It was designed to learn from the experiences of successful EHR implementers. McAlearney et al. had several criteria to generate an initial list of successful sites. The criteria included receipt of the HIMSS “Davies” Award[1] for Ambulatory EHRs within the past 5 years, recognition as a “Most Wired” hospital[2] by the Hospital and Health Network's annual benchmark survey. We then solicited feedback from a project advisory committee comprised of representatives from industry and academia with expertise in HIT implementation to allow McAlearney et finalize the list. From this list of 10 potential study sites, we refined our list to address considerations of geographic and organizational variability. Six health systems across the United States made our final study sample with others assigned as alternates.[1]

Data Collection/Extraction Methods

McAlearney et al. used a grounded theory approach including both inductive and deductive methods to analyze interview and focus group data. A coding team, established by the lead investigator, created a preliminary coding dictionary defining broad categories of findings from the transcripts. This coding dictionary included the code “physician perspective,” defined as physician's views on how an EHR changes their work and/or relationship with patients. Coders further classified data in this broad code into themes. The themes associated with change principles that we describe here emerged from an iterative approach to coding and analysis. Verbatim transcripts of the interviews were analyzed both deductively and inductively using the constant comparative method.[1]

Principal Findings

Conceptualizing EHR adoption as loss through the lens of Kübler-Ross's[3] five stages of grief model may help individuals and organizations more effectively orient to the challenge of change. Coupled with Kotter's eight-step Change management framework, we offer a structure to facilitate organizations' movement through the EHR implementation journey. Combining insights from these frameworks, we identify 10 EHR strategies that can help address EHR implementation barriers.[1] The five stages of Kübler-Ross's model—denial, anger, bargaining, depression, and acceptance—can be articulated as required phases of personal change for physicians adopting and integrating an EHR system.[1] McAlearney et al. identified Kotter's eight-step change framework[4] as a good example of a change management model that appears to resonate among those challenged by the need to promote change in health care organizations. Kotter's eight-steps to guiding change includes, establishing a sense of urgency, form a powerful guiding coalition, creating a vision, communicating the vision, empowering others to act on the vision, plan for and create short-term wins, consolidate improvements and produce still more change, and institutionalize new approaches. [1] Combining insights from the individual and organizational change models, we identified 10 EHR deployment strategies based on study participants' recommendations to facilitate EHR adoption:

  • Manage expectations
  • Make the case for quality
  • Recruit champions
  • Communicate
  • Acknowledge that it is a painful transition
  • Provide good training
  • Improve functionality, when possible
  • Acknowledge competing priorities
  • Allow time to adapt to the new system and
  • Promote a better, but changed, future.[1]


Loss is one part of change often overlooked, according to McAlearney et al. Addressing it directly and compassionately can potentially facilitate the EHR implementation journey. We offer a summarized list of deployment strategies that are sensitive to these issues to support physician transition to new technologies that will bring value to clinical practice.[1]

Reviewer’s Comments

Jonzy’s Comments

I have reviewed the most enlightening article in McAlearney et al’s work. The three frameworks for conceptualizing change management should be framed and posted on every change manager’s office wall, in my opinion.

Related Articles

McAlearney, A. S., Robbins, J., Kowalczyk, N., Chisolm, D. J., & Song, P. H. (2012). The role of cognitive and learning theories in supporting successful EHR system implementation training: A qualitative study


  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 McAlearney, A. S., Hefner, J. L., Sieck, C. J. and Huerta, T. R. (2014), The Journey through Grief: Insights from a Qualitative Study of Electronic Health Record Implementation.