Change Management in Health Informatics

There are generally four kinds of changes that all kinds of organizations might encounter, with
the likelihood of overlap among the conceivable outcomes:

a. Operational changes can influence the way dynamic business tasks are led, including the
computerization of a particular business segment.
b. Strategic changes occur when the business direction, in relation to its vision, mission, and
philosophy, is altered. For instance, changing the business technique from business growth
to increasing market share in the overall industry is a case of strategic change.
c. Cultural changes influence the internal organizational culture, for example, the way the
business is conducted, such as actualizing a CQI (continuous quality improvement)
framework.
d. Political changes in human resources occur primarily due to political reasons of varying
types, commonly changes that happen on top patronage levels in the government agencies.

Different sorts of changes typically have dissimilar impacts on different organizational levels. For
instance, the operational changes tend to have the highest impacts on the lower organizational
levels, because the frontline employees are mostly affected. Employees working at the upper-
levels might be indifferent as to the changes, which may cause significant distress to those
attempting the implementation of change.
Conversely, the effect of the political changes is more strongly felt on the higher levels of the
organization. When change occurs relatively in a bureaucratic organization, those working on the
bottom level often notice the change at the top (Lorenzi& Riley, 2000).
There is no denying that organizational changes have varying degrees of impact on both the
organization, and in effect, its clientele. This chapter discusses Change Management
contextualized in Health Informatics, which is increasingly becoming a course of action that
health institutions avail of in order to improve their services.

Overview of Change Management

Change is inevitable and pervasive. Organizations are driven to change in order to respond to the
many pressures they encounter from their environment. These pressures usually include:

a. Global competition;
b. Changes in customer demand;
c. Technological advances; and
d. New legislation.

More often that not, these pressures require organizations to change the way they operate. This
can involve minor incremental changes that redefine roles, eliminate ineffective processes or
initiate new ways of working. At other times, these pressures necessitate major disruptions
within the organization, which transform the culture, re-organize people, process and systems,
and radically change the organization’s strategy. Research indicates that organizations
implement a major change approximately once every three years, while smaller changes happen
almost continually.
A 2007 survey on change management involving over 400 senior HR managers in the US
revealed the reasons behind the percentages of organizations implementing or planning change
over the previous two years include the following events:

a. New performance management process (58%)

b. Relocation or facility closure (57%)
c. Organizational culture changes (54%)
d. New IT systems (51%)
e. Change of strategy (45%)
f. New financial/accounting systems (41%)
g. Downsizing, layoffs (40%)
h. Operational changes resulting from new legislation, economic conditions or
national/international events (30%)
i. Product rebranding (26%)
j. Acquisition (25%)
k. Offshoring or outsourcing (16%)
l. Merger (10%)
m. Corporate ownership change (8%).
n. In the healthcare industry, however, regulatory adjustments, shifts in consumer behavior
patterns, and the accelerated pace of IT development are all factors that contribute to
the aggressive rate of changes in its environment.
o. For decades, various industries have been enticing consumers with the promise of a
more customized experience. Similarly, healthcare consumers want more participation in
their healthcare decisions, which entails the acquisition of more innovative technology,
and the implementation of informed patient engagement strategies and different
organizational structures to drive better patient experiences. These factors might result
in numerous, disruptive, and rapid changes (Quinn, 2017).
p. In addition, for decades, marketers in other industries have been appealing to the
consumer by making their experience more connected and more personalized. It's no
surprise that health care consumers expect similar engagement strategies from
providers.Increasingly, consumers want to be more involved in their health care
decisions, and that means providers are looking to innovative technology, informed
patient engagement strategies and different organizational structures to drive better
patient experiences. These factors can result in disruptive, voluminous and rapid change
(Quinn, 2017).
q. However, technology is not enough on its own. The fact of the matter is that no
technology can be successful after implementation without the people. The human
factor intensifies the overhaul of work processes and gives it the proper guidance.
 Striking the right balance between technology and human factor creates an effective
roadmap for organizational changes.
r. Communication can alsoplay avital role for developing the change initiatives and
implementation. Information sharing is afundamental function in the communication of
change. Stakeholders should be kept in touch with the possible changes in the timing,
nature and importance of business decisions. To conduct a successful change,
participation from management at several levels is crucial. Any change can only be
successful when the employees are motivated towards the change and are willing to
accept the vision presented by the organization’s leadership (Aljohani, 2016).
This is where the concept of change management comes into the picture. There are multiple
types of change and different approaches to manage it. Organizations most capable of managing
change are ultimately the ones which survive and thrive. Managers need to direct and control
change in a manner which satisfies organization objectives. They must ensure that their staff are
committed during and after implementation, while continuing business as usual (Downey, 2008).
Change management has been an evolving science for over 100 years, with its earliest
beginnings rooted in health and job-related grief studies. Today, most change management
processes, especially those designed to drive business transformation, draw inspiration from
fields such as behavioral and social sciences and IT and business solutions.
There are a wide range of change management process models to explore and consider—each
with their own strategic approaches based on the expertise and experiences of their developers.
A few of the more common change practice examples include:

 Kurt Lewin’s three-step “Unfreeze-Change-Refreeze― model, proposed by the

universally recognized founder of social psychology in the 1950s. It is still highly relevant
today and often used as the basis for many change management strategies.
 Proski’s ADKAR® Model: an acronym for a strategy that encompasses:
“Awareness of the business reasons for change; Desire to engage and participate
in the change; Knowledge about how to change, Ability to implement change,
and Reinforcement to ensure change sticks―.
 Kotter’s 8-Step Model of Change, developed by Harvard Business School’s John
Kotter, focuses on efficient and effective change management in a competitive world.
Highlights include building a strong, collaborative team and a solid strategy; creating
effective communication channels; supporting staff empowerment; using a phased and
steady approach; and securing the change within an organization’s culture
(QuickBase, 2017).

Application of Change Management

Change management is a series of tools, techniques and processes aimed at successfully

effecting change. These tools and techniques can be implemented in a variety of contexts, but
often they support the application of other initiatives such as Six Sigma, CRM, Total Quality
Management or enterprise applications such as SAP.
Downey (2008) describes common tools and techniques that a change management practitioner
might use during a change initiative, which include:

 Questioning skills to gather information about the ‘as is’ and ‘to be’ status of
the business process
 Process mapping for both ‘as is’ and ‘to be’ processes
 Gap analysis
 Business case development
 Project management
 Problem solving
 Requirements elicitation techniques
 Negotiation skills.

In addition to these techniques, Downey also mentions that it is crucial that progress of the
change initiative can be quantified against the objectives set by the organization. For this to be
successful, the organization needs to set clear objectives and settle on key performance
indicators (KPIs) that can be used to track and evaluate the change initiative against its
objectives. These KPIs might include:

 Reducing rework by x%
 Improvement in stakeholder satisfaction, for example, customer/employee surveys
 Reduced time to market
 Enhanced speed of delivery
 The return on investment, that is, the total cost to implement the initiative versus total
savings gained from the initiative per period.

Unfortunately, in the world of healthcare, hospitals have had a hard time adjusting to change
and technological advancement, and have shown great aversion towards the idea of change. In
the case of health informatics, new software applications might dramatically change the way
business is conducted on a daily basis, and impact daily routines and work habits of employees,
and if unmanaged, this could lead to more harm than good for the health institutions.
For healthcare providers to be at the same pace with the business and consumer demand, and
to benefit from new technologies, they need to welcome change and approach information
technology with an open mind. Aziz (2007) highlights that thereshould be a mechanism for the
transformation of business and clinical processes to encourage the adoption of innovation in
healthcare information technology by clinicians, therapists, nurses, and physicians. In addition,
he enumerates key success factors from both the leadership and program, as provided for in
Table 15.1 below.
Working with Physicians-Physicians Adoption
Since most physicians are non-hospital employees-most have patients in other hospitals, under
different health systems that utilize varying technologies, and this complicates the situation. It is
therefore critical to have clear-cut adoption methodologies for the use of new information
technology. Aziz (2007), lists some ideas for the success of the transformation:

1. Communicate value and benefits of the change in terms of patient care and patient
safety
2. Involve physician leaders in the process early on
3. Provide multi-channel learning and training opportunities including web, CBT, labs, and
other
4. Be available to answer questions and provide quick fixed
5. Have a process to handle enhancements requests and other unusual developments

The National Research Council (1997) emphasizes that technological security tools are essential
components of modern distributed health care information systems, and that they serve five key
functions:

1. Availability—ensuring that accurate and up-to-date information is available when

needed at appropriate places;
 2. Accountability—helping to ensure that health care providers are responsible for their
access to and use of information, based on a legitimate need and right to know;
3. Perimeter identification—knowing and controlling the boundaries of trusted access to
the information system, both physically and logically;
4. Controlling access—enabling access for health care providers only to information
essential to the performance of their jobs and limiting the real or perceived temptation
to access information beyond a legitimate need; and
5. Comprehensibility and control—ensuring that record owners, data stewards, and
patients understand and have effective control over appropriate aspects of information
privacy and access.

Training and Education in Health Informatics

Leaders of organizations must initiate a culture that emphasizes life-long learning as a central
element, especially in support of change initiatives, business improvement, and transformation
(Aziz, 2007).

1. Provide for different shifts (around the clock) instructor-led training classes
2. Provide for contemporary models of training
3. 24/7 open computer lab for practice available for all shift and on weekends
4. On the job/real-time training when rolling out new technology
5. Provide cheat-sheets/with summaries of steps easy to fit in pocket or stick by the computer
6. Develop colorful booklets – easy to carry and store in a pocket
7. Have a hard copy short manual with the key facts and how-to tips
8. Well prepared and equipped training rooms – convenient seats and handy printers
9. Train-the Trainer program – start early in the process and give enough time to practice
10. Recruit super-user early and keep them involved and motivated
11. Be prepared with the business process maps and new workflows
12. Have a day-in-the-life scenario prepared for exercises and simulation
13. Walk them through a patient flow in the system several times until in sticks
14. Answer questions in details, especially when it relates to the chart, where will the chart be?
How can we access information? What is the new patient chart? What can we print?
15. Prepare the users to some of the challenges and frustrations they will face in the early
stagesof rollout.

Aziz (2007) summarized that to be meritorious in change management in healthcare

organizations, there is a need to observe fundamental practices and embrace a well-rounded
strategy along the following lines:

1. Governance structure that aligns business leaders with clinical leaders

2. A relentless focus on business processes design and clear mapping of workflow
3. Due diligence for a thorough organizational and business impact analysis
4. Early involvement of clinicians at various levels (starting with requirements and design)
 5. Constantly communicate the vision, loudly and clearly, and show commitment to stay the
course
6. Have a strong, ongoing program for training and education – customized to different
needs
7. Have a well thought-of communication plan that takes feedback into the loop, and act on
it
8. Have a well structures maintenance and support program including a 24 x 7 Help Desk
9. Regular reporting using dashboards with simple statistics to grab people’s attention
10. Select a handful of measurement criteria for benchmarking and system evaluation

Health Information Profession

15.3.1 The Role of Health Information Management Professionals

Health Information Management (HIM) professionals, credentialed with their academic
preparation, work experience, commitment to patient advocacy, and professional code of ethics,
have a specialized skillset that uniquely qualifies them to assume the role both of privacy official
and/or security official. store, protect, and transmit information in all media and formats (May,
2014). A Health Information Management professional:

 Collects, aggregates, analyzes, and disseminates patient health information.

 Committed to the timely and accurate collection of health information and its
maintenance, storage, retentions, and disclosure.
 Represents patients’ interest in matters of privacy and security, information release,
and issues and guidelines regarding record access.
 Certified by the American Health Information Management Association.
 Ensures confidential patient information is kept private, secure, and in accordance with
federal and state laws.

Health Information Management professionals are the stewards and guardians of patient health
information. They represent the patient’s interests in matters of privacy and security,
information release, issues and guidelines regarding record access, and general consumer
education about personal health records.
They specialize in managing patient health information and medical records, administering
computer information systems, and classifying using standard coding systems, the diagnoses,
and procedures for health care services provided to patients.
Those with health information management and health information technology careers manage
all aspects of the content of patient medical records and patient information systems. Job
responsibilities can include aspects of clinical information documentation capture and
maintenance, data analytics and interpretation, as well as designing, implementing, and
maintaining health information technology systems.
 Health Information Profession

Committed to the timely and accurate collection of health information and its maintenance,
storage, retention, and disclosure, Health Information Management Professionals ensure that
such information is kept private, secure, and in accordance with federal and state laws.
Health Information Management Professionals fall into many job categories with varied titles,
including:

 Health Information Management Department Director

 Health Information Management System Manager
 Information Security Officer
 Chief Privacy Officer
 Health Data Analyst
 Health Record Technician Specialist
 Clinical Coding Specialist
 Patient Information Coordinator
 Physician Practice Manager
 Health Information Administrator
 Revenue Cycle Specialist
 Director of Quality Management
 Health Information Manager
 Health Information Technologist/Technician

The typical day-to-day activities of a Health Information Management Professional include:

 collecting, aggregating, analyzing, and disseminating patient health information for

doctors’ offices, hospitals, managed care organizations, insurance companies, research
and policy agencies, and other health care facilities and related industries
 providing accurate coding of diagnoses and procedures from patient visits with health care
providers, ensuring accurate patient billing and proper reimbursement to health care
providers
 compiling and analyzing health care data from patients, assisting with the identification of
ways to better utilize health care resources, uncovering public health patterns, improving
patient care, and providing critical information for health care research
 developing policies to support the delivery of high quality health care by ensuring the
availability of quality information for accurate health care decision making (May, 2014).

15.3.2The Philippine Health Information Profession

Advancements in ICT (information and communication technology) are upsetting not only
traditional businesses, but even those not immediately thought of as probable
beneficiaries—such as the healthcare sector. From electronic patient records to the wireless
transmittal of patient files for remote diagnosis, improvements in communication and
technology will lead to better delivery of healthcare services. Telemedicine, or the use of
electronic communications to transmit and exchange medical information and data to provide
patient treatment, is quickly gaining momentum within the country and the rest of the ASEAN
region.
With the increasing popularity of smartphones, wireless tools and other comparable technology,
primary care and specialist referral services, as well as remote patient monitoring and patient
medical health information are undeniably improved with the help of telemedicine.
Thailand, Singapore, and Malaysia have started adopting healthcare IT solutions to bring the
sector to the next level. In 2009, Singapore developed its National Electronic Health Record
initiative, which permitted healthcare practitioners in the island state access to a patient’s
records across the healthcare continuum.
Malaysia initiated a Hospital Implementation System in 1993, with its first telemedicine project
in 1996, and Thailand created its National Health Information Committee in 2010.
Likewise, the Philippines has developed an eHealth Strategic Framework and Plan for 2014 to
2020, whose objective is to utilize information and communication technologies in the health
sector. This will assist in the delivery of health services and manage health systems for greater
efficacy, with the ultimate goal of providing universal healthcare for the Filipinos.
One of the strategic goals of this framework is to establish unified and coherent health and
management information systems, and also to take advantage of ICT to reach and provide better
health services and support the attainment of the UN’s Sustainable Development Goals.
In line with this, the Department of Health (DOH) in Region 4Bhas launched the first interactive
telemedicine system in Marinduque, and seemingly the entire country, at the Dr. Damian J.
Reyes Provincial Hospital. The system currently provides medical consultations and diagnostics
through video calls (De Dios, 2016).

Telemedicine in the Philippines

For an archipelago such as the Philippines, the delivery of healthcare services might prove to be
challenging. Fortunately, the rise of Telemedicine within the region, as discussed above, has
been a beneficial turn of events for the Philippine Healthcare sector.
Multiple players in the Telemedicine scene in the Philippines currently exist, ranging from mobile
apps to call center services.
Some providers of over-the-phone telemedicine services are Medgate and Lifeline. Common
features include 24/7 call centers, diagnosis using images sent via email, medical certificates, and
treatment plan summaries. These kinds of telemedicine centers usually have a corresponding
mobile app to facilitate easier access. Unique to Lifeline, however, is video consultation with
doctors, patient education, free doctor or nurse home visits, and delivery of medication and
prescriptions in exchange for a fixed monthly subscription fee.
Mobile App-based Telemedicine centers, on the other hand, include MyPocketDoctor and
MyDocNow. These providers are usually in partnership with other international telemedicine
centers.
Medway Healthcare Inc., by far, offers the most comprehensive set of telemedicine services,
being the first medical clinic in the Philippines to mobilize its Pre-Employment Medical
Examination (PEME) arm into the path of delivering interactive healthcare. They offerTelefollow-
up and Teleconsultation procedures which are accessible online and through a specially-
designed computer program.
In Telefollow-up, patients are notified of the medical evaluation results via text messages on
their individual cell phones. Within 24 hours of PEME, patients will already know if they are fit to
work, unfit to work or still with pending workups. Follow-up visit to the clinic is then
advised.Follow-up of results using traditional landline call is also accommodated.
Meanwhile, Follow-up Teleconsultation establishes online communication between the MedWay
physician and the patient regarding follow-up of medical results in cases where the patient hails
from a distant location or is unable to immediately visit the clinic. The MedWay physician gives
the necessary medical advice and schedules the best day and time for the patient to come back
to the clinic for follow-up.
Specialist Teleconsultation, on the other hand, enables real-time consultation with the use of
appropriate telemedicine equipment and the assistance of a physician and nurse. In so doing,
teleconsultation ensues despite distance barrier. Should the specialist need to listen to the
patient’s breath, heart or bowel sounds, the physician or nurse would just place the
telephonic stethoscope on the appropriate areas of the patient's body and the sound would
instantly be transmitted to the specialist. High-definition cameras are also used when focusing
on specific body parts or lesions. Diagnostic test results are relayed to the specialist using the
store-and-forward technology or are made readily available using real-time electronic medical
records (Medway Health Inc., 2012).
Telemedicine efforts from the government and other non-profit organizations have also ensued.
The National Telehealth Center is the leading research unit in the University of the Philippines
responsible for developing cost effective tools and innovations in the realm of information and
communications technology (ICT) for improving health care. NTHC experienced a breakthrough,
when it first conducted telemedicine research-cum-service in remote and undeserved areas
from Batanes to Zamboanga through partners in the then Commission on Information and
Communications Technology’s (CICT, 2004―2008) and Department of Science and
Technology ― Philippine Council for Health Research and Development (DOST―PCHRD,
2008―2011). Today, the center partners with various government and non-government
institutions, engaging them on eHealth research, training, and service activities (National
Telehealth Center, n.d.).
The Department of Science & Technology (DOST)has also begun distributing the breakthrough
“RXBox― telemedicine device developed by engineers and researchers from University of
the Philippines (UP) Diliman and UP Manila to 1,000 far-flung municipalities in the country,
focusing on disadvantaged municipalities to benefit from having affordable health care in their
respective communities.
The RXBox was a collaboration between a team of engineers, doctors and researchers from UP
Diliman and UP Manila, led by electronics and communication engineer Nathaniel Cruz, who is
currently with the National Telehealth Center.
RXBoxhas features that enable teleconsultations via email, video call, or SMS. It has sensors that
can measure a patient’s blood pressure, temperature, oxygen saturation rate, pulse rate, and
even the electrocardiogram rate, and this information may all be sent to the specialist doctor via
email or SMS, aiding in patient care.Afterwards, the RXBox stores and files data into a
community health information system (Ronda, 2016).

KEY POINTS TO REMEMBER

 Change is inevitable and pervasive. Organizations are driven to change in order to respond
to the many pressures they encounter from their environment. These pressures include:
global competition, changes in customer demand, technological advances and new
legislation.
 Change management is a series of tools, techniques and processes aimed at successfully
effecting change.
 Health Information Management (HIM) professionals, credentialed with their academic
preparation, work experience, commitment to patient advocacy, and professional code of
ethics, have a specialized skillset that uniquely qualifies them to assume the role both of
privacy official and/or security official. store, protect, and transmit information in all media
and formats (May, 2014).
 One of the strategic goals of this framework is to establish unified and coherent health and
management information systems, and also to take advantage of ICT to reach and provide
better health services and support the attainment of the UN’s Sustainable Development
Goals.
 Telemedicine efforts from the government and other non-profit organizations have also
ensued. The National Telehealth Center is the leading research unit in the University of the
Philippines responsible for developing cost effective tools and innovations in the realm of
information and communications technology (ICT) for improving health care.