This document summarizes the situation at Saint Vincent Health System regarding the potential adoption of an electronic medical record (EMR) system. The new CEO, Dr. Johnson, is a proponent of EMRs but faces resistance from some key stakeholders. He discusses EMRs with the head of the information services department, who supports the idea, and the director of medical records and a physician leader, who oppose changes that could reduce their control. Dr. Johnson recognizes the challenges of gaining acceptance for a major technological change at the traditionally paper-based health system.

1. Introduction
Saint Vincent Health System is a large academic medical center
based in Bolder Colorado. Saint Vincent Health Systems is
associated with the state university, and includes three
hospitals, a medical clinic facility, a medical research complex,
and affiliated primary and specialty group practices spread
throughout the region. Saint Vincent University Hospital is the
main hospital campus with 500 inpatient beds and equipment
and facilities that are considered state of the art. Saint Vincent
Health System is well known for its cancer and rehabilitation
service lines, and has recently expanded its cardiac service line
in an attempt to keep up with the increasing demand.
Despite strong clinical services lines and an excellent
reputation, Saint Vincent Health System has been reluctant to
adopt new clinical information technologies (IT) such as
computerized provider order entry (CPOE) systems or a more
comprehensive electronic health record (EHR) system. Instead,
Saint Vincent Health System’s services are mainly supported by
paper-based processes, and a strong team in the medical records
department that has been able to expand with the health
system’s growth.
Changing Health System Leadership
Dr. Craig Johnson has just been appointed CEO of Saint
Vincent Health System, and has come to the Bolder area after
serving five years in his previous position as CEO of a 200-bed
community hospital. Dr. Johnson’s predecessor, Jeffrey Ash had
retired after serving 20 years as Saint Vincent Health System’s
CEO, while the announcement of a new CEO was not
unexpected, this change in leadership has left the organization
unsettled, and staff and affiliated physicians are anxious about

2. the new changes Dr. Johnson may bring to Saint Vincent Health
System.
Assessing the Situation
Dr. Johnson is a definite fan of EHR and electronic medical
record (EMR) systems, and is enthusiastic about the potential
for incorporating an EMR system with CPOE capabilities into
Saint Vincent Health System. In particular, he is aware of the
opportunities to use an EMR system to improve Saint Vincent’s
ability to provide care according to evidence-based guidelines,
and to capitalize on patient safety improvements that are
possible with an EMR system. Dr. Johnson knows that his
daughter, Ellen, uses a handheld computer, or digital tablet, to
help her keep track of her patients, check medications, and
access important clinical information in her internal medicine
practice, and has seen these tablets in the pockets of many of
the Saint Vincent physicians as well.
Yet Dr. Johnson is aware of the likely resistance he will face in
his efforts to introduce an EMR system throughout Saint
Vincent. He has followed some of the IT implementation
literature, and knows that common barriers to implementation,
such as physician resistance to changes in workflow and a
reluctance to use practice guidelines or “cookbook medicine,”
may 2 create challenges at Saint Vincent. He also predicts
resistance from the strong and capable medical records
department. Given that successful EMR implementations are
associated with a reduced need for space and personnel in
medical records, it is unlikely that such changes will be warmly
received. Dr. Johnson schedules a meeting with Ms. Leigh Rice,
director of information services, because he suspects Ms. Rice
might have some ideas about how to proceed.

3. Meeting with the Information Systems Department
Once Dr. Johnson scheduled his meeting with Ms. Rice,
excitement grew in the IS department. Ms. Rice and her
department had been enthusiastically following all of the
changes in the EMR systems, but had met with resistance when
they suggested that Saint Vincent consider adopting a new
system. The previous CEO had been decidedly “old school” and
had little interest in leading the charge to put Saint Vincent on
the EMR map. Instead, Ash chose to placate the established
physicians and the director of medical records, Ms. Amanda
Chapman. Even though he was aware that the newer physicians
were all carrying tablets and iPhones, he had no interest in
rocking the proverbial boat at Saint Vincent.
Ms. Rice knew this was her opportunity to make the case for a
system-wide EMR introduction at Saint Vincent. She had full
confidence in her IS team’s ability to carry out this initiative.
Ms. Rice had the group compile the information they had
collected from different vendors about the various systems and
capabilities, and summarize everything in an “issue brief”
document that would be easy to skim. She also had her summer
resident, Austin Mitchell, collect some of the key articles from
the research literature that highlighted the potential and pitfalls
of such a system-wide implementation. Ms. Rice’s meeting with
Dr. Johnson went even better than she had hoped. Armed with
the evidence, Ms. Rice laid out the various issues, pros and con,
for a system-wide implementation of an EMR, and then
explained the different vendor options that might be appropriate
for Saint Vincent. Already convinced that this was a good idea,
Dr. Johnson gave Ms. Rice the green light to develop a formal
proposal for presentation to the Saint Vincent board, and
directed her to Chase Aukland, Saint Vincent’s CFO, to make
sure the cost proposal IS developed would be appropriate for
Saint Vincent.

4. A Hallway Conversation
Dr. Johnson left the meeting with Ms. Rice smiling, but his
smile faded when he was stopped in the corridor by Amanda
Chapman, who was leaving the Medical Records Department.
Dr. Johnson: Hi, Ms. Chapman. How is everything going in
Medical Records? Ms. Chapman: Not well, Dr. Dr. Johnson. I
heard a rumor that you were considering bringing an electronic
medical record system to Saint Vincent, and that makes me very
concerned. Dr. Johnson: Well, Ms. Chapman, nothing has been
decided yet, but there is a strong push nationwide to introduce
EMR systems in all hospitals and we don’t want to be left
behind. 3 Ms. Chapman: I understand that, Dr. Dr. Johnson, but
I just don’t think we want to do any of this too quickly. Mr. Ash
had been very consistent in his message that Saint Vincent had
no reason to be an “early adopter” of such systems. As he
repeated said, “Let all those other health systems make the
mistakes first. Then we can learn from their mistakes and make
our own decision. And in the meantime, we can keep doing well
what we already do well.” Dr. Johnson: I appreciate that
perspective, Ms. Chapman, but I have to admit, I am a bit more
likely to push the envelope than Mr. Ash. I believe an EMR
system would be a great boost for Saint Vincent, helping us to
track everything electronically, and potentially helping us to
reduce medical errors in the process. Ms. Chapman: But don’t
we already have the ability to track everything? I’m just not
sure what’s wrong with paper. Out medical records team is very
capable and responsive. I certainly haven’t heard any
complaints about our ability to access patient records. Dr.
Johnson: That’s true, Ms. Chapman, but I don’t think that we
are looking far enough ahead. As other hospitals and health
systems go digital, we’re going to be left behind. I truly believe
we do not have a choice in this situation. It is not a matter of
“whether,” but a question of “when.” I think it would be in the
best interests of Saint Vincent to get this going on the sooner

5. side so that we can take advantage of the capabilities of an
electronic medical record system as soon as possible. Also, Ms.
Chapman, before we select a system, a task force will be created
which is charged with the analysis, selection, and
implementation of an EMR system. Ms. Chapman: Well, Dr. Dr.
Johnson, I disagree. I tend to believe “If it isn’t broke, don’t fix
it.” And the Medical Records Department “isn’t broke.” Dr.
Johnson: Thanks so much, Ms. Chapman. I appreciate your
time. As Dr. Johnson headed back to his office, he was once
more reminded that none of this was going to be easy. Even
though Ms. Rice and her IS department seemed fully capable
and on board with the idea, there were plenty of others
throughout the health system who might not share their
enthusiasm. He was especially concerned about resistance from
the physicians. While he was a physician himself, that did little
to improve his credibility when he was making a case “from the
dark side” of administration. He decided to seek out Dr. Jody
Smith, the chair of internal medicine, to begin to gauge some of
the sentiments from the physicians. He headed to her office to
see if he could catch her for a moment.
A Physician’s Perspective
Dr. Johnson (knocking as he enters Dr. Smith’s office): Hi Jody.
How’s everything going? Dr. Smith: Craig. Just the person I
wanted to see. I heard a rumor that you were considering an
EMR for Saint Vincent Dr. Johnson: Well, Jody, the rumor is
actually true. I just met with Ms. Leigh Rice, the head of IS, to
get her and her team to begin to develop some estimates and
plans for what an EMR adoption would mean for Saint Vincent .
Dr. Smith: But Craig! Have you been following the latest
research? Despite what the vendors claim, every place that puts
one of these systems in reports that it actually takes the docs
more time to do what they used to do on paper. Even after
having the system in place for a while, the docs are still
spending more time doing record-keeping than before – and that

6. time is time that they used to have to care for patients! Also,
when they put in a system somewhere in Pittsburgh, the EMR
system was actually associated with an increase in the number
of medical errors! Dr. Johnson: I have followed that research,
Jody, but I think there’s a bigger picture to consider here. While
it’s true that EMR systems do require the physicians to spend
more time entering data and so forth, there’s also evidence that
with an EMR it is actually the right people who are entering the
data – not some non-clinical person trying to decipher a
physician’s notes about what was done, or trying to figure out if
a visit was long or short. Also, evidence is beginning to build
that when EMR systems are coupled with decision support logic
such as order gets with CPOE systems, this type of systems can
actually save time. Instead of going through multiple screens to
find all the meds and tests that need to be ordered, the physician
can just click on the asthma order set, for instance, and review
the options there. Dr. Smith: But what about patient-centered
care? Who says that every patient is alike? For heaven’s sake,
what if your patient needs something different? How long does
it take to find that when everything is based on a standardized
order set? And how about the resident physicians? Maybe they
will stop thinking about making patient-specific clinical
judgments and just click the standard order set for everyone!
Have you really thought this through? Dr. Johnson: I know there
are issues, Jody, but I truly believe the future of medicine is in
electronic records. I’m guessing you’ve been following what’s
going on at the national level, and there are policy-type folks
involved making a strong push toward expansion of EMRs into
outpatient settings as well. Policymakers are concerned that
hospitals and physicians have been too slow to adopt these
systems, which they believe will improve both patient safety
and the quality of care delivered, and they are beginning to
propose incentive systems to encourage adoption. As I just
mentioned to Amanda Chapman, the director of medical records,
I don’t think this is a question of “whether” any more – it’s just
a question of “when.” Saint Vincent is a terrific system that

7. should be at the forefront of medical and technological
advances, not waiting to see what everyone else does. 5 Dr.
Smith: I’ll bet Ms. Chapman was thrilled with the prospect of
losing control of her medical records area. I understand your
desire to help Saint Vincent, but I don’t think you’ve been here
long enough to appreciate how great we already are. Our docs
are content with paper, we have a functional and responsive
medical records department, and I’m not sure I sense any
burning need to be the “most digitized” or anything. This isn’t
Boston, after all. A lot of us chose to practice here because we
could what we do best – provide excellent clinical care –
without the distraction of a push to be number one in the world
or something like that. I’m just not sure you can make a major
like putting in an EMR and keep everyone happy like they’ve
been for so long here. Dr. Johnson: I realize I haven’t been here
at Saint Vincent very long, but I’ve been working very hard to
get a sense of this place before I propose and major changes. I
also realize that introducing and EMR system to a place that is
completely paper-based is no easy task. At this point, I know
there is still considerable work to be done to better understand
both Saint Vincent and the opportunities and risks associated
with implementing an EMR. However, I strongly believe the
future of medicine will require the electronic capabilities
associated with an EMR system, and I am not willing to “watch
and wait” much longer. I’d like to make an EMR system
implementation a major goal for the coming year, we will form
a task force which will be charged with the selection and
implementation of an EMR system. Dr. Smith: I think this is
crazy. I agree Mr. Ash. We should wait and see what happens at
other hospitals and health systems and learn from their
mistakes. There is no reason to stick our necks out on the
“cutting edge” of EMR system implementation. And by the way,
I’m not alone in my beliefs. Lots of other physicians agree.
What we do here works just fine, and the people who work here
are happy doing things the way they are done now. Dr. Johnson:
Thanks so much for sharing your thoughts. Dr. Johnson left

8. Smith’s office with his mind reeling. Was Saint Vincent truly
content with paper-based records and letting other hospitals
pass them by with electronic capabilities? Regardless, Dr.
Johnson knew he was right about the future. He knew Saint
Vincent needed to get on the EMR bandwagon, and the sooner
the better. However, he now knew the implementation challenge
was even greater than he had anticipated. Not only were the
member of the medical records department threatened, but
apparently physicians weren’t all that interested in changing
their practice pattern either. His only allies appeared to be
among Ms. Rice’s IS team.
Considering the Resistance
Dr. Johnson recognized that in addition to uncovering some
attitudes toward EMRs, he had learned quite a bit about Saint
Vincent’s organizational culture during these exploratory
conversations about EMR adoption. It appeared the predominant
culture was comfortable clinging to the status quo, and that few
individuals were open to considering the possibility of change.
He had felt resistance from Ms. Chapman and Dr. Smith, and
knew that resistance to 6 change was a major hurdle he would
have to overcome if there was any hope that an EMR
implementation process could succeed. Yet Dr. Johnson sensed
that this resistance was not merely resistance to change, but
resistance to change that would result in a loss of control for the
individuals involved. As he reflected upon his conversations
with Ms. Chapman and Dr. Smith, he thought about some of the
unspoken messages they had sent. Ms. Chapman and her group
felt threatened by the loss of control they would have over the
medical records process. With electronic systems in place, they
would no longer have a major role to play in health systems

9. operations, and their jobs might even be at stake. Dr. Smith’s
comments suggested that the physicians were uninterested in
changing their practice patterns because they would lose some
of the control as well. The introduction of standardized order
sets and other decision support tools could truly change the way
physicians practice medicine thus leading to less discretion for
individual providers with respect to viable treatment options. As
both Dr. Smith and Dr. Johnson knew, with electronic medical
records, there would be a searchable digital trail, which could
be used to monitor those providers’ practice patterns. While Dr.
Smith mentioned her fear that newer physicians would to rely
too much on decision support systems and stop thinking for
themselves, there was also an unspoken fear that if a physician
did not do what the order set had defined as the “right things,”
they might face problems.
Learning More
Dr. Johnson knew of several IT implementation failures that had
occurred over the past several years, with the most notorious at
Cedars Sinai in Los Angeles. There the hospital had rolled out a
CPOE system across both the inpatient and outpatient settings
and the process was deemed an utter failure. Physicians revolted
and the hospital had to retreat, going back to paperbased
processes while they decided what to do. On the other hand, he
had also heard anecdotal stories about implementation
successes, such as an incremental implementation that had been
taking place at Children’s Hospital in Columbus, Ohio. While
the Children’s physicians were all hospital-employed and thus
had little ability to “just say no,” as the physicians at Cedars
had, the process at Children’s had been carefully planned and
seemed to be proceeding according to schedule – without
alienating the entire provider population. Dr. Johnson had to
plan his next steps carefully. He knew doctors valued evidence,
and he had to build a good case for moving forward with an
EMR implementation, and he had to build a good case for

10. moving forward with and EMR implementation. He suspected
there might be value in learning more about implementation
successes and failures, but he also guessed there was other
information out there he was not aware of. Dr. Johnson decided
to recruit Ms. Rice’s summer resident to help him expand his
search for evidence and help build the case for EMR adoption.