Practice owners seeking better solutions often start with a vision of increased practice profitability while treating reasonable patient volumes. Their vision spans multiple aspects, including better reach to prospective patients, better reimbursement rates, full and timely payments by insurance companies, less time spent on visit documentation, improved documentation quality for better clinical follow-up and lower audit risk, and more free time for family. However, that vision conflicts directly with the payers’ goals to reduce costs and increase revenues. Payers’ goals directly conflict with a provider’s vision because cost savings for payers simply mean that providers treat more patients at lower reimbursement rates—or, in other words, providers work harder for less money.
In addition to the basic payer-provider conflict, visionary practice owners must face the resistance of their office managers and colleagues. These people may be skeptical because they don’t trust the owner, have seen five other failed initiatives, or think they might lose something with the change. Significant time, enthusiasm, and resources are needed to change practice processes and technology and to retrain personnel while simultaneously managing the practice and treating patients. The challenge of overcoming resistance to change and implementing it in your practice is akin to enhancing airplane engineering while keeping the plane in the air. Thus, medical practice owners often find themselves in a dilemma between adopting new solutions or compromising the vision and returning to the old ways, along with shrinking revenues and growing frustration. One key area of medical practice that requires a huge transition is shifting from paper-based records to an electronic health record (EHR) system. Shifting from one EHR system to another is also burdensome and requires a systematic approach to achieve results. Several internet-based software and tools can aid medical practices in transitioning to electronic records successfully, leading to maximized outputs and better service delivery to patients. We shall look at how to adopt this change using a change model.
EHR and billing processes can help providers cut costs, improve the quality and safety of care, and enhance the productivity of the employees. Most practices have adopted EHR and electronic billing systems to achieve the above goals, whereas some have stuck to using paper documentation and filing systems. Paper-based records are often tiresome to retrieve, prone to errors and misplacements in addition to being bulky and space-consuming to store. Paper-based billing systems have also been shown to take longer claims processing times than EHR due to the time taken to verify manually. To fully realize change and adopt it into practice, a stepwise approach has to be taken, failure to which frustrations and complacencies are bound to occur, leading to regression to previous ways.
John Kotter, a Harvard Business School professor and the world’s foremost authority on leadership and change, discovered that transformation challenges span multiple industries and share the same characteristics. His book Leading Change lists an eight-step process for implementing successful transformations. The eight steps can be divided into 3 phases: creating the climate for change, energizing & enabling them, and implementing and sustaining the change (National Learning Consortium, 2013). The figure below illustrates these three phases.
Figure 1: The three phases of Kotter’s eight-step change management model
This model has successfully been used to help transition into an electronic health records system in clinical practices. For instance, North Shore Medical Center in Chicago, Illinois, successfully transitioned from 100 percent paper-based medical records to 100 percent electronic records in 2013 using Kotter’s eight-step model (Martin and Voynov, 2014). An orthopedic practice group in Ontario, Canada, also successfully transitioned from paper records to electronic records, achieving more than a 95% threshold using Kotter’s change model (Auguste, 2013). We shall look into the eight steps in detail using an example of a healthcare practice that desires to transition from paper-based records to electronic health records and billing.
Step 1: Create a sense of urgency.
In this step, a health practice can provide evidence to its employees on the need for an EHR. This can include faster claims processing, less bulky storage space, easy records retrieval, and better security. At this stage, the aim is for employees to buy into EHR and keep talking about the proposed change.
Step 2: Form a powerful coalition.
To help convince employees that change is necessary, the practice can develop a committee of committed and passionate individuals who constantly champion EHR. These individuals can work as a team to help identify barriers to implementation as well as help remind other employees of the need for EHR constantly.
Step 3- Create a vision for change.
The practice can develop a clear and concise vision through the committee, which motivates transition. An example of a vision would be establishing the most secure health records for clinic patients.
Step 4: Communicate the vision for buy-in.
Once the vision is created, it must be communicated to the employees clearly explaining the benefits to encourage buy-in. This can be achieved through face-to-face meetings, sending email reminders on the transition from paper to EHR, and individual interviews.
Step 5: Remove obstacles.
There are 5 categories of barriers hinder any change from occurring in an organization, the biggest of which are complacency and resistance to change (IvyPanda, 2020). The 5 categories include complacency, Limited sharing of the vision, Different obstacles to the vision, Inability to accomplish short-term wins, and failure to solidify the change in the practice culture. Let’s briefly talk about the five categories of barriers.
1. Complacency–
This is the most deadly of practice change management problems. Suppose you just plunge ahead with a new electronic medical records (EMR) system or billing process without first establishing a shared sense of immediate need or urgency because of increased audit risk or shrinking revenue. In that case, natural complacency takes over—and the entire change effort fails. It’s hard to drive people out of their comfort zones. Past failures, the lack of a visible crisis, low-performance standards, and insufficient feedback from doctors, office personnel, and patients—all add up to turning the best-intended change initiatives into talk without substance.
2. Limited sharing of the vision –
Don’t underestimate the need for and power of a shared vision. Running a practice is a complex balancing act between multiple priorities, competing demands for shared resources, and crisis management. Vision is required to align the multiple and often conflicting initiatives toward the common goal and to maintain the right priorities. Without an articulated vision of better payments, reduced workload, improved practice workflow, and better billing process control, the decision-making process drowns in endless details and unresolved conflicts.
3. Different obstacles to the vision –
Smart and well-intentioned managers and practice owners often avoid confronting roadblocks created by misaligned personal incentives or wrong organizational structures. They end up disempowering employees and undermining the entire change process. Suppose better payments are part of your vision. In that case, you can’t let your billing manager get away with excuses for growing accounts receivable, undisciplined follow-up with your office staff or insurance companies, or ineffective appeal letters.
4. Inability to accomplish short-term wins –
Keeping the team motivated is hard without short-term wins. For instance, if better patient visit compliance is part of your vision, and you plan to implement it using technology for automated patient reminder calls, then you must count your no-shows daily and demonstrate reduced no-shows and increased revenue directly attributable to the shrinking no-shows.
5. Failure to solidify the change in the practice culture –
The new organization structure, processes, and technology platform used to implement the change— every practice component must be based on the changed reality. Otherwise, the old habits return, and the benefits disappear, thus shrinking practice revenues and increasing workload for the office manager and providers.
Step 6: Create short-term wins that provide momentum.
Rewarding the efforts towards change empowers and motivates employees to continue working towards the desired vision. A short-term win when transitioning from paper to EHR can be the instantaneous retrieval of patient records and remittance for claim processing without any incidences of lost or misplaced records.
Step 7. Consolidate and produce more change.
The transitions already made from paper to EHR need to be consolidated to prevent relapse. This can be achieved by having at least weekly meetings to discuss progress, any challenges, and new developments when working with the EHR systems. This will ensure sustained progress and transition.
Step 8. Incorporate change into the organizational culture.
Once there is a full transition from paper-based to electronic records, the workplace culture needs to be shifted towards electronic records. The systems can be updated by making small changes based on user feedback, which are incorporated to sustain efficiency and workflow.
The ancient Greek philosopher- Heraclitus is credited with the famous saying that change is the only constant in life. Even healthcare practices that have transitioned from paper to EHR systems still face the need for change from one EHR system to another. This is through constant user feedback and the organization’s shifting needs by the day. For instance, Plymouth Psych Group, a mental health clinic in Plymouth, has been using a Practice Fusion EHR. The clinic recently transitioned to EHR and billing platforms offered by ClinicMind for their workflow management and billing needs (ClinicMind Inc, 2023). Another example of the beneficial impact of transitioning from one EHR to another was seen in Vanderbilt University Medical Center, Nashville, Tennessee, where there was a reduction in the outpatient prescription rate of potentially inappropriate medications to the geriatric population. The transition incorporated helpful clinical decision support guides in the new EHR system (Friebe et al., 2020).
Such transitions are often faced with challenges, including high costs, challenges with data migration, the need for staff retraining, disruption of workflow, and challenges with interoperability (Boyles, 2021; Miake-Lye et al., 2023). Kotter’s eight steps of change management are still applicable in driving the transition from one EHR to another (National Learning Consortium, 2013) and addressing the challenges faced during the implementation of a transition.
Conclusion
By implementing Kotter’s eight steps, a billing service provider can successfully transition from a paper-based billing and records system to a purely electronic system that is faster and more efficient. Transitioning from one EHR to another is equally challenging, with unique barriers such as workflow disruption and data migration challenges. Kotter’s eight-step model is equally useful when transitioning from one EHR to another. Individuals need to be empowered to achieve and sustain any desirable change in organizational practice and their issues addressed during the process. All the barriers to change should be anticipated, identified, and addressed to enable change progress.
References
IvyPanda. 2020. Electronic Health Records and Change Management. https://ivypanda.com/essays/electronic-health-records-and-change-management/
Auguste, J. 2013. Applying Kotter’s 8-step process for leading change to the digital transformation of an orthopedic surgical practice group in Toronto, Canada. J Health Med Informat, 4(3), 129.
National Learning Consortium. 2013. Change Management in EHR implementation. https://www.healthit.gov/sites/default/files/resources/changemanagementprimer_feb2014.pdf
Martin, W., & Voynov, S. 2014. Electronic health records and change management. International Journal of Computer and Information Technology, 3(3), 626-630.
ClinicMind Inc, 2023. Plymouth Psych Group Transitions to ClinicMind – Mental Health Practice Adopts New Cutting Edge EHR for Clinical Workflow and Billing.https://www.prweb.com/releases/plymouth-psych-group-transitions-to-clinicmind—mental-health-practice-adopts-new-cutting-edge-ehr-for-clinical-workflow-and-billing-301915890.html
Bolyes O. 2021. The Benefits and Challenges of Adopting a New EHR Platform. Icanotes.com.https://www.icanotes.com/2021/12/09/benefits-challenges-adopting-new-ehr/
Miake-Lye, I., Cogan, A., Mak, S., et al. 2023. Transitioning from One Electronic Health Record to Another: A Systematic Review. Journal of General Internal Medicine, 1-9.
Friebe, M, LeGrand, J., Shepherd, B., et al. 2020. Reducing inappropriate outpatient medication prescribing in older adults across electronic health record systems. Applied clinical informatics, 11(05), 865-872.
A Future Book Publication Note:
This article is a chapter in the forthcoming 2nd Edition book “Medical Billing Networks and Processes,” authored by Dr. Yuval Lirov and planned for publication in 2024. We will post more chapters on this blog soon.
