6 IT - From Cacophony To Harmony-A Case Study About The Is Implementation-2011

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From cacophony to harmony: A case study

about the IS implementation process as an
opportunity for organizational
transformation at Sentara Healthcare
ARTICLE in THE JOURNAL OF STRATEGIC INFORMATION SYSTEMS JUNE 2011
Impact Factor: 2.57 DOI: 10.1016/j.jsis.2011.03.005 Source: DBLP
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2 AUTHORS:
Chon Abraham
Iris A. Junglas
College of William and Mary
Florida State University
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Journal of Strategic Information Systems 20 (2011) 177197
Contents lists available at ScienceDirect
Journal of Strategic Information Systems

journal homepage: www.elsevier.com/locate/jsis
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
b
College of William and Mary, Williamsburg, VA 23187, United States

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
a b s t r a c t
The cacophony of criticisms emanating from an organization facing an information technology-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 organizational transformation in terms of changes in coordination, culture, and learning at a successful 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) implementation 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 organizational transformation literature, as a framework to describe the steps Sentara followed in implementation of eCare, a comprehensive 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
Corresponding author. Tel.: +1 757 221 2803; fax: +1 757 221 2884.
E-mail addresses: Chon.Abraham@business.wm.edu (C. Abraham), iris.a.junglas@accenture.com (I. Junglas).
Tel.: +1 617 488 7304; fax: +1 617 488 4001.
2
The Healthcare Information Management Systems Society (HIMSS) maintains diffusion statistics for healthcare IS and nationally recognizes healthcare
organizations for reaching the highest level (i.e., HIMSS level 7) of demonstrated technology embeddedness (HIMSS, 2010). Sentara Healthcare is an HIMSS
Level 7 designee and has won the coveted 2010 Davies Award for Excellence recipient for superlative implementation and demonstration of value from health
information technology (Sentara Healthcare, 2010).
1
0963-8687/$ - see front matter 2011 Elsevier B.V. All rights reserved.
doi:10.1016/j.jsis.2011.03.005
178
C. Abraham, I. Junglas / Journal of Strategic Information Systems 20 (2011) 177197
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 attempt to transform with IS is considered essential, yet most difcult, due to the lack of prescripts for effective implementation 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 Organization 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 workow. IOM and
other IS supporter consortiums also prescribe the use of IS to aid in transforming medical institutions into more efcient 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 Association, 2009; Chiasson et al., 2007; Davidson and Chismar, 2007; Hillestad et al., 2005). In the US, a national strategy to promote 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 functionalities, 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 answers this call in the healthcare context by describing how the IS implementation process has successfully impacted an organizational 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 workow. 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 communication 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 ramications, 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 capabilities in healthcare organizational change (Reardon and Davidson, 2007; Davidson and Chismar, 2007; Chiasson and Davidson, 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 business process reengineering as an effective tool in transformation (Christensen et al., 2004; Ho et al., 1999). Seminal IS research in business process reengineering asserts that facilitating change via technology requires the identication of
strategic value, assessing the learning capacity of the organization and cultural readiness, and the inclusion of IT and knowledge sharing (Kettinger et al., 1997). IS research also states that change within the organization is inuenced 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 implementations 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, specic 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 rms 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 qualitative 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 contributes 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 validity and reliability) of the ndings (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 characteristics 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 Ofcer (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 accessible 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 medical protocols, an integrated retrieval system for lab and test results, interfaces with a medication dispensary system and
patient identication 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 difcult to justify and thus often neglected in
healthcare organizations (Grieger et al., 2007). But Sentara undertook a thorough cost benet analysis, estimating return and
qualitative benets. eCare was estimated to cost 237 million USD over ten years. During their strategic planning in 2006, the
expected benets of eCare would not produce a positive cash ow 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 nancial leadership at
Sentara could not recommend the project to the Board of Directors based on nancial return. Rather, the board felt that eCare
would signicantly progress Sentara towards a desired standard of care. The project was approved. The rst hospital went
live in February 2008, with subsequent implementations staggered, based on hospital size and complexity of services provided, 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 nancial returns, the cost savings and revenue generation from process efciencies and quality improvements
would exceed clinician and managerial expectations as well as nancial forecasts within ve years of project conception.
3.2. Data collection and analysis
Data were collected longitudinally spanning Sentaras milestone progression for eCares 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 Sentaras efforts in the implementation, 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 predened 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 Sentaras activities in each phase of the framework. These insights provide the structure for our ndings.
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Data were collected both during and after milestones were completed. As in many eld research activities, it was infeasible to collect all data simultaneously as Sentara reached each of its milestones. We greatly tried to collect data during the
step in which Sentaras milestones were taking place and aligned it with a BPCM phase. There were instances when interviewees 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 multistakeholder 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
ofces 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 implementation, 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 leadership 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 specic 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 business strategy to become the most accessible healthcare provider in all service sectors in the northern North Carolina and
Southern Virginia region. This contributed to Sentaras 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. Sentaras 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 oor that
might be slightly different, maybe not as intense, as what the patient got in ICU. . . the patients 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 dont get that detail of information when the patient arrives on the oor with their transfer paperwork. We nd
out later that the patient is a drug user. We need that input to treat better.
The aforementioned reects the need for a more integrated information picture, coded as reveal information interdependence 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 ofce, 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 environments and that was deemed to be most inefcient 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 patients overall health, as described here:
Physician: I can see the same patient in my ofce, 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 patients record was available (e.g., not locked
up in someones ofce). I could call back to my ofce, have them faxed from referring physicians ofces, 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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Sentaras integrated structure offered the opportunity to provide the consolidated view necessary to improve care. However, 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 information across the disparate systems, in manual records, or even from someones 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 without some mechanism for consolidating the information. Without properly documenting and historically tracking care steps
in a standardized format across care services, there was no efcient 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 justiable cost).
Thus, Sentaras 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 Sentaras CIO:
CIO: We are self-sufcient but that comes with a cost if your organization has inherent inefciencies in the way that
work gets done. We lose time in turning around a diagnosis because faxes are ying from one docs ofce, 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 wellWe have multiple doctors ordering duplicate tests themselves to try and articially hurry up the lab results, or they order
because they dont know some other doctor the patient saw already ordered it and the results are available. Our operational processes were inefcient 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 comprehensive operational strategy, beginning with the two main environments of care, the hospital and the physician ofces,
and incrementally phasing in each of the other care environments. Our insight regarding this nding is as follows:
Insight 1 Linking the IS implementation with the organizational strategy forefronts the need and requirements for information
interdependence and efcient 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 providing 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 research 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 supporters, such as the Ofce 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 efciency improvements for poor work conditions, 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 workows, 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 sponsored project or even a top-down initiative. The process involved would require nesse 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 environments. These stakeholders had a common goal of quality care delivery to patients and were deemed principal players in
182
bringing about change in the organization. But getting them engaged to even form the coalition across disciplines was difcult 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: Its really easy to get a coalition of supporters who believe. Its 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 dont 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 rst, 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 specic to health information technology adoption. One of the main issues was economically justifying the comprehensive strategy. While eCare may have been spawned from the CIOs vision for integrating the
organization through information, it was because of the efforts of the thought partners that the project was nally
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 transitioned into informatics roles. These members of the eCare team were integrated with the medical staff governance structures 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 nding:
Physician and Chief Medical Information Ofcer: 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 rst 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 identied 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
Sentaras processes for reengineering.
1
2
3
4
5
6
7
8
9
Arrival management
Bed management
Case management
Charge capture
Claims processing
Clinical communications
Disease management
Emergency department
Home health
10
11
12
13
14
15
16
17
18
MD processes
Medical records
Meds management
Monitoring/recording
Order sets
Patient care transformation
Patient/member satisfaction
Physician practice
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 workows and identied a baseline for the process 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 inefciencies were the result of the manual and individualized
methods for hunting, gathering, and documenting patient information. The problem analysis exercises and drills for reengineering workows were done collectively by the clinician and administrative stakeholders (e.g., physicians, nurses, registration, 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 transparency 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 dont 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 nd out exactly what they
mean. . . whether its because you cant read their writing or its just not detailed enough. Sometimes you just have to
interpret and hope that its right. . .its 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 contributed to how dysfunctional the process had become for getting and exchanging information. We made it difcult for
ourselves by not at least considering each others needs for patient information. We regarded the record as our own
little memo device and its other peoples jobs to gure out what we intend. I didnt even know that some of the specialists, technicians, and nurses would benet from me adding even certain information. I realized that its not their
jobs nor should it be to have to gure out what I want. . . when they have the information they need from me and dont
have to guess at it then they can better act on my intent for the care of the patient. This could help ease the frustrations we sometimes have with each other. We revised these workows 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 handoffs between medical factions (i.e., discharge and receiving a patient from one unit, or transfer of a patient from one providers 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 analysis 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 Ofcer: 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 exceptionally 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 processes. This effort was painful for some because we exposed the good with the bad but its critical to do this because you
cant 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 functional expertise. The IS leadership employed process management consultants that used a lean methodology (i.e., process
denition, 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 ows regarding patient care touch points across a variety of
care environments (e.g., primary care physician ofces, emergency departments, in-hospital units, back ofce operations,
and the patients home). The scripts involved scenarios that a patient would typically encounter, ranging from scheduling
their own primary care physician ofce 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 perspective, 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 benets of real
time access to data across all environments of care not just their respective portion of the care process. The vendor demonstrations were made accessible via Sentaras 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 workow. . . 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 oor. It was to
help us be able to operate better as a team and realize how we as nurses affect patient ow and outcomes. . .we got a
sense that you wouldnt 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 information 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 doesnt 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 doesnt get implemented in the right place rst, 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 rst 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 associated with the rst 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 organizations 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 contribute to medical errors in actual care situations. The re-engineered processes called for use of the system amidst workow,
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 workow, supplemented by on-access web training and 24 h help desks. The aforementioned nding 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 workow in the units.
The training emphasized how using the computer makes you more detailed and less likely to miss something in the charting. I learned how to use the information now available in the electronic chart to help me do my own assessments of
whats 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 whats
being done for the patient. It just wasnt technical training. Even in the training I was being educated about how to work
smarter.
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Fig. 1. Optimization team structure (provided in archival document).
The previous quote also suggests that the edication 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 its 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 condent 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 implementation in which the quest to improve is never-ending, where learning and in-rm 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 teams responsibilities entailed tracking needed improvements as the implementation progressed by examining and soliciting 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 workow.
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 benet 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 ve 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 specied methods for discerning problems and rubrics for addressing
them. Specically, the optimization team used a variety of methods (e.g., user interview, observation of re-engineered workows, patient satisfaction surveys) to areas of improvement.
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 documents 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 formerly existed in the manual chart, as discussed here:
Administrative Technician: When we moved from paper to electronic records I dont think they realized how much
material doesnt t 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 cant make the judgment about if this material should stay or not, so we just scan everything that cant be
coded...We ask the docs and nurses for guidance, but they arent 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 electronic 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 rene 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 patient wait times for entering the unit, time to discharge, and average bed turnover. This lag in patient throughput was associated with users not adding needed data into the system for specic services, as discussed here:
Nurse Coordinator: Patients arent being discharged in the system, or there are big delays for them to be discharged. I
cant 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 its 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 ow. However, Im expected to do rounds, customer service, nurse education, especially when they need an expert on the oor to assist in something. Im whom the nurses call. . .this should be my rst
priority as a coordinatornot bed ow.
Apart from implementing system alerts, the corrective measures taken were to re-emphasize the new process for completing discharges to the unit nurses and educating them about the impact of patient discharge on bed ow. A redesign included 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 continuum, such as home-based heath care as a critical component to patient compliance. Obeying the physician-ordered regimen 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
specics and insight about the patients based on their experience dealing with them. Its hard to get that picture of a persons 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 dont
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 dont know if everything can be described in
codes. Im 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 its 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 thats not
all that I used it for and Im 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 havent used it yet. I still have some caution because Im used to writing my thoughts more
freely. Thats 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 preventing lengthy narratives that were less suitable for data analysis purposes. This was coded as rene codication that constrains
articulation of thought and contributes to the following insight:
Insight 7: Improvement is an opportunity to understand the limitations of codication of data and compromise system requirements 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 eCares 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 x whats wrong now but can really use the trends available
because of the data to help predict what will happen in the future. Its as if we have the means now to answer questions
we didnt even know we could pose before.
Improvement Lead: We form task forces to rene 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 practices 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 supporting Emergency Medical Services (EMS), a faction external to Sentara in the region, realized opportunities to impact (a) quality
of services for patients coming into Sentaras ED by EMS ambulance transport, and (b) quality of repeat services for subsequent encounters patients have with EMS during emergency situations in the community. As a consequence, Sentara personnel 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 benecial 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)) Weve partnered with
Sentara to actually follow our patients all the way through the hospital. Were 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. . .
Its 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 workow. . . or frequency of patients being readmitted for the same problems,
the nurses want to know about the link between stafng and quality, even medical transport wants to know how transport time impacts unit patient turnover. . . We [IT and business analytics] no longer are xated on just providing them
[information consumers] the standard reports that reect 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 implementation 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 ndings is depicted in Table 2, and an evaluation of this qualitative research appears 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 reects 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, culture, 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 context of the existing business environment. The need for change was brought about by the realization that growing the Sentara 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 Sentaras
case it indicated proactive behavior with the intentions to seize existing opportunities, such as expanding an organizations
reach (Guha et al., 1997). The proactive behavior was also reected in Sentaras activities in (a) understanding the information interdependence, (b) streamlining processes, (c) rening tasks to ensure appropriate process ownership, and (d) deterring 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 paradigm shift towards multidisciplinary care delivery that was unconned 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 materialized 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 outcomes 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
workows 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 efciency and effectiveness of the workow 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 approach). The point is akin to what others have argued. Knowledge does not solely come from making data commonly available 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.
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Table 2
Summary of ndings.
BPCM phase
Process activities codes
Insights
Concepts concerning changes

contributing to the
organizational transformation
Link with strategy
Reveal information
interdependence
Streamline processes
(1) Linking the IS implementation with the organizational

strategy forefronts the need and requirements for
information interdependence and efcient processes to
bring about changes in coordination
Coordination changes
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
Rene tasks so the

appropriate entity has
ownership of the process
Deter complacency with
the IS to replace all verbal
communication
Rene codication that
constrains articulation of
thought
(5) Improvement is an opportunity to ensure the

appropriateness of the process owners for enhanced
coordination
(6) Improvement is an opportunity to deter complacency or
reliance on the system as a complete replacement for
needed communication for enhanced coordination
(7) Improvement is an opportunity to understand the
limitations of codication of data and compromise system
requirements to afford better data analysis with the
necessity to articulate freely the art form of medicine
(8) Improvement is an opportunity to provide a means for
enriched and continual learning that can be the basis for
innovation
Foster continual learning
Cultural changes
Learning changes
Additionally, the IS implementation process, regarding continual improvement, aided in identifying problems in the IS
design that, while optimizing codication, challenged the physicians autonomy. Physicians autonomy expressed itself as
part of the professional culture, more specically in the way how physicians exercised their exibility 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 eld 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 insufcient 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 opportunity for optimization and to show how to combine technology functionality with the professional culture. Overall, this resulted in changing the propensity and appreciation for transparency in the workow by the clinicians. Sentaras approach
was consistent with Newell et al. (2003) who suggested fostering organizational efciency and exibility 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 process 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 workow that, through institutionalization in managerial practice, led to innovative activities for
rening awed 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 exchanges, tying stakeholders in the community much closer to Sentara and raising the collective medical acumen of the stakeholders 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 innovation, 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 benet 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 benecial to
the overall delivery of care, but it also made work more purposeful for the nurses. Additionally, the process of the improvement 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 ndings 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 transformation 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 perspective. 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 difcult 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 Sentaras network included its own closely afliated staff of physicians and its own insurance company, generalizations to different healthcare congurations 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 process 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 involved including: patient lives and well-being, professional certications, 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 ramications 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 process into harmony.
Acknowledgment
We sincerely thank Mr. Bertram Reese, Chief Information Ofcer at Sentara Healthcare, and all personnel at Sentara who
greatly contributed to development of this research effort.
191
Appendix A. Sentaras milestones and data collection protocol
Sentaras dened eCare

milestones
Corresponding BPCM
framework phase (Kettinger
and Teng, 2000)
Research activities timeline
SeptemberDecember 2005
Link with strategy

Secure management
commitment
January 2006May 2006

Interviewed three top management personnel
about the strategic plan for eCare
Business case validated and

vendor contract signed
Discover reengineering
opportunities
Identify IT levers by
reviewing IT plans and
current IT assets
Select processes and
dene project scope
MayDecember 2006
Project team planning phase
Plan the change

Inform stakeholders
Organize reengineering
team
Conduct project planning
Reviewed archived documents such as the

internally prepared business case and description
of vendor contract
Interviewed ten senior IT architects about the IT
implementation plan
MayDecember 2006
Interviewed top IT management (i.e., CIO and ve
VPs) about forming coalitions and informing
stakeholder
Interviewed twenty-ve hospital implementation
team and ve members of the physician group
practice implementation team about project
planning and setting performance goals
Interviewed and observed medical staff in-hospital
and doctors ofces concerning their preimplementation perceptions of eCare
Set performance goals of

the re-designed process
December 2006May 2007
Dened current processes
Designed, built, and

validated new processes
Analyzing problems in the

process
Document existing
processes
Uncover pathologies that
are problematic
Explore alternative
process designs
Design new processes
Design human resource
architecture
Design IT architecture
Conduct holistic process
prototype
Construct information
systems
Select conversion process
August 2007: First MD ofce
implemented (150 MDs First
Year)
Process re-generation
December 2006May 2007

Reviewed archival documentation from external
consultants hired to document existing processes
that revealed inconsistencies in processes
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
Interviewed IT personnel about new IT architecture
for supporting re-engineered processes
August 2007October 2008
(continued on next page)
192
Appendix A (continued)
Sentaras dened eCare
milestones
February 2008:
First hospital implemented,
all but CPOM
May 2008:
First hospital implemented
CPOM
SeptemberOctober 2008:
2nd and 3rd hospital Go Live
MarchNovember 2009:
4th, 5th and 6th hospital Go
Lives
October 2008continuous
Corresponding BPCM
framework phase (Kettinger
and Teng, 2000)
Deploy IT
Research activities timeline
Interviewed and observed implementations pre

and post (i.e., Go Live periods for Hospitals 13 and
select physician ofces)
Reorganize
AugustNovember 2009
Interviewed and observed implementations pre
and post (i.e., Go Live periods for Hospitals 46)
Continuous improvement
Measure performance
Link to quality program
October 2008December 2009

Interviewed business analyst and top management
concerning
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 (rst
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 68 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 indenitely
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 ofce personnel with
insights on expected benets (e.g., expect easier referral), which serve as
reminders to the impending implementation
193
Appendix B (continued)
Time
Activities
Two to four weeks prior to Go Live:
Follow-up training
On site training and support at physician ofce 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 fth 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 rst year.
Appendix C. Examples of value on investment since implementing eCare
eCare metric description
Process efciency
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%)
Increase in outpatient procedures (by
nearly 12%)
Associated with decreasing inefcient

processes in care delivery such as
errors or delays in services that require
the patient to stay in-hospital longer
than anticipated
Increase in unit efciency 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 workow)
Reduction in transcription expense (by

42%)
Associated with expenses paid to

outsourced transcribers (i.e., reduction
in unnecessary processes)
Reduction in medical records supply

costs (by 38%)
Associated with expenses maintaining

records (i.e., reduction in unnecessary
processes)
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 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
Associated with not having to admit
patients for procedures that can be
sufciently conducted in outpatient
care, lessening the chances of
exposure to other conditions and
diseases in the acute care setting
Associated with the likelihood of
patients receiving better care from
experienced nurses who are
enabled to be more procient in
their duties
Associated with less likelihood of
misinterpretation of instructions for
care and more thorough
documentation because fewer nonclinicians transcribing
Associated with availability of
medical information at the point of
care via the IS lessening the
likelihood of erroneous care
Associated with number of times a
persons condition does not warrant
admissions but they are admitted
anyway, exposing them to harmful
health conditions in the acute care
setting
Associated with increased ease in

scheduling procedures because of a
streamlined process of information
exchange between physician practices
and the outpatient services
(continued on next page)
194
Appendix C (continued)
eCare metric description
Process efciency
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 important to select assessment criteria that are appropriate for a given qualitative methodology (Corbin and Strauss, 2008; Demetrion, 2004) there is not a set of criteria that ts 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
Credibility
Is there sufcient detail and description so that readers
feel that they were vicariously in the eld?
Credibility
Is there sufcient evidence on how the data were
gathered and how the analysis was conducted?
Assessment
While remaining within the scope expected from a journal
article, we tried to provide sufcient 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
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
195
Appendix D (continued)
Criteria
Applicability
Is the resulting insight readily understandable by laymen
and professionals?
Applicability
Is the resulting explanation or insight sufciently general
to be applicable to diverse situations and populations?
Applicability
Does the resulting explanation or insight provides the
user with sufcient control to bring about change in
situations?
Assessment
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 conrmation that the
ndings 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 sufcient
In the Generalizability and Future Research section, we
discuss how our ndings are sufciently generalizable
other contexts discerning any IS implementation process
inuence on coordination changes, culture changes, and
learning changes and their collective inuence 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
The description of the process activities in each phase of
BPCM for how Sentara engaged in implementing the IS is
sufcient 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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6 IT - From Cacophony To Harmony-A Case Study About The Is Implementation-2011

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From cacophony to harmony: A case study

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Journal of Strategic Information Systems 20 (2011) 177197

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Journal of Strategic Information Systems

From cacophony to harmony: A case study about the IS implementation

College of William and Mary, Williamsburg, VA 23187, United States

C. Abraham, I. Junglas / Journal of Strategic Information Systems 20 (2011) 177197

C. Abraham, I. Junglas / Journal of Strategic Information Systems 20 (2011) 177197

3. Research design and methods

C. Abraham, I. Junglas / Journal of Strategic Information Systems 20 (2011) 177197

C. Abraham, I. Junglas / Journal of Strategic Information Systems 20 (2011) 177197

C. Abraham, I. Junglas / Journal of Strategic Information Systems 20 (2011) 177197

C. Abraham, I. Junglas / Journal of Strategic Information Systems 20 (2011) 177197

C. Abraham, I. Junglas / Journal of Strategic Information Systems 20 (2011) 177197

C. Abraham, I. Junglas / Journal of Strategic Information Systems 20 (2011) 177197

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

Sentara personnel used the term optimization to mean continuous improvement.

C. Abraham, I. Junglas / Journal of Strategic Information Systems 20 (2011) 177197

C. Abraham, I. Junglas / Journal of Strategic Information Systems 20 (2011) 177197

C. Abraham, I. Junglas / Journal of Strategic Information Systems 20 (2011) 177197

C. Abraham, I. Junglas / Journal of Strategic Information Systems 20 (2011) 177197

Process activities codes

Concepts concerning changes

Link with strategy

(1) Linking the IS implementation with the organizational

Plan the change

Use joint planning

(2) The planning strategy that stresses collaboration and

Unearth role and process

(3) Analyzing problems collectively amongst stakeholders

(4) Process-re-generation is an opportunity for educating

Rene tasks so the

(5) Improvement is an opportunity to ensure the

Foster continual learning

5.3. The IS implementation process and learning

C. Abraham, I. Junglas / Journal of Strategic Information Systems 20 (2011) 177197

C. Abraham, I. Junglas / Journal of Strategic Information Systems 20 (2011) 177197

Appendix A. Sentaras milestones and data collection protocol

Sentaras dened eCare

Research activities timeline

Link with strategy

January 2006May 2006

Business case validated and

Plan the change

 Conduct project planning

 Reviewed archived documents such as the

 Set performance goals of

 Designed, built, and

Analyzing problems in the

December 2006May 2007

August 2007October 2008

(continued on next page)

C. Abraham, I. Junglas / Journal of Strategic Information Systems 20 (2011) 177197

Research activities timeline

 Interviewed and observed implementations pre

October 2008December 2009

Conduct project planning

Reviewed archived documents such as the

Set performance goals of

Designed, built, and

Interviewed and observed implementations pre