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

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


In their 2014 article titled The Journey through Grief: Insights from a Qualitative Study of Electronic Health Record Implementation [1], McAlearney, Hefner, Sieck, and Huerta explore the relevance of loss to clinicians and support staff adopting a new EHR. They refine this thinking through the application of Kübler-Ross’s five stages of grief and consider how EHR implementations might be facilitated by employing support strategies known to be effective in this context [2]. In a related vein, McAlearney et al. consider Kotter’s eight-step change management framework [3] as a source of guidance for EHR implementation professionals. The authors assert that successful adoption depends not only on overcoming barriers to the deployment of a new information system (e.g. financial, technical, impact on service capacity, legal, etc.), but also on the effective management of the changes that are a key factor in the clinicians’ inclination to adopt the new processes that the system brings with it.


The authors’ intent was to evaluate the experiences of physicians and administrators who had participated in EHR implementations that were recognized as being successful. One key selection criteria was the receipt of the HIMSS “Davies” award for ambulatory EHRs within 5 years of the study. Another criteria for inclusion was recognition by the Hospital and Health Network as a “Most Wired” hospital. For final selections, the authors report including commentary from an advisory committee made up of industrial and academic experts in the area of EHR implementation. A field of 10 qualifying sites was narrow to six in order to achieve a balanced representation of geographic and organizational diversity. Measures were derived from 35 individual interviews lasting 30-60 minutes and six focus group sessions lasting 60-90 minutes. A coding team created a dictionary of terms to structure the data for inductive and deductive analysis of data from the interview and focus group transcripts.


McAlearney et al. summarize their findings into "three opportunities to facilitate physicians' adoption and use of EHR systems in clinical practice." [2] These are:

  • (A) Address the related personal change through processes that support loss and grief
    • Examples are given of statements reflective of loss through Kübler-Ross’s five stages of grief; [2]
      • (1) denial
      • (2) anger
      • (3) bargaining
      • (4) depression and
      • (5) acceptance
  • (B) Address the management of personal change through an organizational change model
    • Examples are given that present evidence of Kotter’s eight steps guiding change management [3]
      • (1) Establish a sense of urgency
      • (2) Form a powerful guiding coalition
      • (3) Create a vision
      • (4) Communicate the vision
      • (5) empower others to act on that vision
      • (6) plan for and create short term wins
      • (7) consolidate improvements and create still more change and
      • (8) institutionalize new approaches
  • (C) integrating the two
    • Based on these findings, the authors present 10 EHR deployment strategies that combine these two domains. These are summarized in the table below.
Adapted from McAlearney et al. (2014) Table 4.
EHR Deployment Strategy Personal Change Organizational Change
1. Manage Expectations Denial Stage Establish sense of urgency
2. Make the case for quality Denial Stage Create a vision
3. Recruit Champions Anger Stage Form a powerful guiding coalition
4. Communicate Anger Stage Communicate the Vision
5. Acknowledge that it’s a painful transition Anger Stage Communicate the Vision
6. Provide Good Training Bargaining Stage Empower others to act
7. Improve functionality when possible Bargaining Stage Plan for and create short-term wins
8. Acknowledge competing priorities Bargaining Stage Plan for and create short-term wins
9. Allow time to adapt Depression stage Consolidate improvements and produce still more change
10. Promote a better, but not changed future Acceptance stage Institutionalize new approaches


It isn’t unusual for implementation consultants to assert some of Kotter’s change management teachings (e.g. “create the vision”, short-term wins) as key to the process. However, when implementation discussions reference the stages of grief, it is more likely to be as a humorous interjection than a strategic analysis. This study lends credibility to the importance of deliberate management of the aspects of loss involved in displacing existing processes and roles with a new EHR. Acknowledged limitations of the study include the small number of organizations included, and the inability to correlate strategies to clinical or financial outcomes. For the purposes of this study, success was determined by professional recognition (specifically the Davies award + “Most Wired” recognition). This had a limiting influence on the possible sample size.


  1. 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.
  2. 2.0 2.1 2.2 Kübler-Ross, E. 1969. On Death and Dying. New York: MacMillan.
  3. 3.0 3.1 Kotter, J. P. 1995. Leading Change: Why Transformation Efforts Fail. Harvard Business Review 73 (2): 59–67.