The Kübler-Ross Model of EHR Adoption

For over a hundred years the paper chart has been a trusted partner and best friend to many physicians and nurses. The paper chart was born the day a new patient walked into the office, a pristine, crisp and neatly color-coded folder, with just the right markings in carefully shaped calligraphy on its covers. As the years went by, the paper chart grew in size, acquired meaning and wisdom, and like most of us, became a bit tattered around the edges and heftier in the middle. It felt good to hold the elderly paper chart in your hands and its voluminous physical presence inspired confidence and trust. The paper chart is dead. In some places the paper chart’s pages are still turning slowly, but we all know its long, productive life has come to an end and someone should pull the plug and call it. Or do we?

In 1969 Elisabeth Kübler-Ross proposed a 5 stage model for typical grieving behavior. The various reactions from the clinical community to the apparent demise of the paper chart exhibit almost textbook adherence to the Kübler-Ross model, with each clinician advancing through the five stages of grief at his/her own pace*.

Denial – This is a joke. These people don’t understand medicine and this entire Obamacare thing will soon go away and we’ll return to normalcy. My practice is doing just fine on paper and my patients get all this fancy medical home care right here and always had. They actually get better care. Besides, I have patients to see and I am too busy to tinker with these fads that come and go every five years or so.

Anger – This is a cruel joke. This EHR thing is just a government ploy to punish doctors and enslave them. There’s nothing in this for me and you want me to pay for it?? We are all going to stop taking Medicare, Medicaid and all your government plans, which don’t even pay for my receptionist, see what you do then. Heck, why stop there? There will be no doctors left, period, because nobody is going to accept such humiliation and no bright students will choose medicine as a career. We can all do much better doing other things. I didn’t go through ten years of medical school and residency and pissed my entire youth away just so I can become your personal data entry clerk. You want data? Enter it yourself and feel free to treat yourself too. Go Google it, or go to an NP at the grocery store. Not to mention that these EHR contraptions are killing thousands of people every day because nurses are tending to EHRs instead of patients. Is that what you want? Suit yourself. I’m out.

Bargaining – This is not happening to me. This does not have to happen to me. I am a doctor. If I stop playing their game, they’ll have no way to touch me. I will only take cash, at least for a while, until this thing blows over. My patients love me and I will take better care of them than any computer can. They know that. They are willing to pay for a true doctor/patient relationship and my undivided attention. I have friends that switched to concierge practice and they’re doing great. I’ll practice good medicine, and in time everybody will come to their senses and see that this is the right way to care for people. They will see the errors of their way and everything will be back to normal. I just have to make it through the next couple of years.

Depression – What’s the point? Why did I have to sacrifice my entire life and work like a dog for these ungrateful people? There’s no respect any more. There is no gratitude. There’s no money in this either. I should have gone to law school and spent my time ripping everybody off like those shyster lawyers do every day. They want me to be a cog in their Toyota production line for people. I don’t know anything about computers. I can’t even type. Why should I? Doctors don’t type. There is no point. Can’t even give this practice away, let alone sell it; might as well just walk out right now. I have a little money. I don’t need to work. I’ll retire early. I’ll play golf all day. Maybe go into consulting for those thieving insurers. One thing’s for sure: no child of mine is ever going to medical school. It’s over.

Acceptance – This EHR is really primitive. Costs a fortune, but the hospital kicked in for most of it. They want to measure my performance; fine with me. I’m a good doctor and I take good care of my patients. I don’t like using the computer in the exam room. My nurse does though, but you should see her texting, and my receptionist says it’s better than the old system. I wish I could get the hospital labs, but they’re still faxing them over. They say it will get better. I don’t know. I have an iPhone and it has an app for medications, which is really nice. I have email and some patients use it. Not too many, but it’s nice too. I signed up for this new telehealth program starting in the fall. My father practiced for 40 years down in the valley. He wasn’t home much, but sometimes he took me along on house calls. Saw the first baby born when I was eight. I don’t think you can deliver a baby on telehealth, can you? Well maybe if there’s a midwife out there and you watch just in case… Never mind. I love practicing medicine. It’s hard right now, but I think I have another ten-fifteen years left in the tank, and if it gets much tougher, maybe I’ll just go work for the hospital. They already have my charts anyway.

But here’s the deal, folks: the chart is not really dead. It just underwent major reconstructive surgery. It has new legs and new organs and a new face, because, unlike people, they can do that for charts nowadays. Sure, it looks terrible right now, all stitched up and bruised and so very helpless, hooked up to wires and machines. It can’t do anything for itself. It moves slowly and sometimes just collapses under its own new weight. You will have to teach it how to use its new legs and train it to engage all those brand new bionic organs. It will take time and lots of physical therapy. It is a big commitment and there will be setbacks and more surgeries down the road. You could just walk out and leave it to its fate and to others to nurture it back to a useful life. Or you could take it home and tend to it, and every day be amazed at small miracles and watch it slowly get stronger, better and more beautiful, surpassing your wildest expectations, until it becomes the indispensable, trustworthy  and useful friend it always has been, with a brand new lease on life for you both.

*All first person utterances in this post are fictitious. Any resemblance to what anybody may have said or communicated to the author during times of great frustration is purely coincidental.

Margalit Gur-Arie was COO at GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing services for physicians. Prior to GenesysMD, Margalit was Director of Product Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large non-profit hospital organization. She shares her thoughts about HIT topics and issues at her blog, On Healthcare Technology.

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  1. “The only question I have is why we are all approaching and analyzing adoption of EHRs as a unique event. We have seen the same types of resistance and will probably see the same patterns of adoption as with every other significant medical technology change that personally involved physicians learning a new skill.”

    I’d extend that beyond health care to all change, in general. I’m sure a lot of people were perfectly happy with their horse and buggy, and wrote learned essays on how the internal combustion engine was nothing more than a satanic mill.
    There are many doctors, in fact, who do this now. I have personal knowledge of them.

    I can take you today to a surgeon who is using an EHR to produce every single note, which notes have no fluff, and he saves time from when he used to dictate. He does not use a scribe, and the notes are comprised of discrete data.

  2. There is some irony that the grief stages for cancer victims is borrowed for the illustration in this piece.
    That said, I will add STAGE 6: Epiphany. In this stage, one realizes being truly had by all of the profiteers and carpetbaggers who ply the politicians to get a piece of the healthcare spending pie.

    • I think for most people Epiphany is actually Stage 0. Maybe not so much about payments to politicians, but more about the constant barrage of solicitations from unscrupulous sellers of pure junk, trying to extract as much money as possible from physicians while the “iron is hot”.

  3. Really, before you base a whole essay on a 42 year-old psychological model of grief, you should probably check and see if there’s any empirical support for such a model, or whether it’s just (wrong) conventional wisdom.

    Because, had you actually looked at the research, you would’ve found very little empirical support for this model. I mean, it sounds good and all — “stages” just sounds like the right thing we go through — but the reality is that there’s virtually no data — in over 4 decades! — to support this theory.

    If you want the lowdown, I suggest Ruth Davis Konigsberg’s book called “The Truth About Grief.” It’s eye-opening and a must-read.

    • Dr. Grohol,
      I am not a medical professional and I did realize before I wrote this that there was controversy about this particular subject in medical circles. I saw other representations, more granular and fluid definitions and a study from Yale, I believe, that presented a different opinion. I did not see the book you are quoting.
      This is not meant as a clinical evaluation of those struggling with the loss of paper as a means of documentation. I think you would agree that whichever grief theory is now in vogue, it would hardly be applicable to this situation.
      However, strangely enough, most physicians struggling with this problem can be roughly divided into the 5 groups above. Not all of course and not to the same degree of accuracy, and many fit into more than one category.
      And then, of course, there is the growing number of doctors who don’t think this is a loss at all, but a rather significant gain.
      Just like, not all widows need six months…. more like 6 minutes would do 🙂

  4. @BobbyG,

    To me, they are one and the same. I’m 40 years old. I’ve had computers since I was 8 years old. I hardly hate them. Could I live without the Web, iTunes, and World of Warcraft? I think not.

    But the sad fact of the matter: EMRs are not ready for commercial use as yet. They are buggy, slow and unreliable. Their databases merge info from different patients together. They don’t talk to each other. They don’t keep track of chronic conditions and stuff that needs to get done. I’d love EMRs if they actually worked the way they are supposed to. They don’t.

    • Dr. Vickstrom,
      Obamacare (if we must) is a currently controversial piece of legislation, which is endorsing and promoting the use of EHRs. The HITECH act, also an Obama artifact, is providing an unprecedented push to the EHR concept. However, this is not in any way a departure from his predecessor’s strategy. President Bush instituted the ONCHIT and began the carrot & sticks games in the form of incentives for electronic prescribing.
      Personally, I don’t like these games. I find them somewhat demeaning to physicians and rather misplaced during a recession, since unlike the original ARRA/ HITECH intent, I don’t believe this initiative created a significant number of new jobs.

      I do agree with you that many EHRs are in a sorry condition and the current gold rush for incentives, coupled with practically nonexistent “certification” criteria for EHRs, has given birth to an astounding crop of junk software, labeled as incentives-producing-EHRs. I presume this was an unintended consequence.
      However, there are good products out there, not many and not perfect. Far from perfect actually. There are multi-billion dollars enterprises running these EHRs quite successfully. There are a handful of ambulatory EHRs that look very good and are getting better by leaps and bounds. No, none of them are as good as World of Warcraft, but then again, there is more to solid medical software than running around fancy forests.

      I think it is not realistic to assume that medicine would have remained a paper industry if government hadn’t intervened. The Kaisers and the VAs and the Mayos and practically all academic medical centers and assorted health systems everywhere have been deploying computerized records long before HITECH, and the same was true for large medical groups and to a lesser degree for medium size ones.
      It was happening. The government is just accelerating a natural and inevitable progression (perhaps a bit too much for my taste). I don’t think this can fail…..

  5. Actually, I’m not fighting it at all. I’m doing whatever I can to embrace it. Sometimes, the most cruel thing you can do to someone is give them just what they think they want. The longer waits for test information, lost information and increased fees are making patients think twice about Obamacare. My very wise administration chose this course, and they are reaping their just desserts. Full steam ahead to fail, Ms. Gur-Arie!

  6. Great piece. The only question I have is why we are all approaching and analyzing adoption of EHRs as a unique event. We have seen the same types of resistance and will probably see the same patterns of adoption as with every other significant medical technology change that personally involved physicians learning a new skill. The general surgeon who spent 3 hours doing his/her first laparoscopic cholecystectomy was at least as vexed as the general surgeon spending his first day in the office with a new EHR. In both cases the learning curves are significant and the user didn’t really have any issues with the old technology in the first place. Initially, Internists reluctantly adopted the fiberoptic sigmoidoscope because it was expensive and required a skillset they didn’t possess. To them , the rigid sigmoidoscope worked just fine (at least from the doctor’s end). Maybe we should spend a little time looking at barriers to adoption of new technologies in medicine to draw some insight and expectations about EHR adoption.

    • Rich Leff asks, “Why we are all approaching and analyzing adoption of EHRs as a unique event ?”

      Because, unlike other technologically driven changes, they are transformational — a radical change — in the way they will allow us to organize and think about health care delivery. Furthermore, wisely used, EHRs are a tool to take on medicine’s vested interests of big pharma and its co-opted FDA, and perhaps keep them honest. “How did Vioxx debacle happen?” Here is the FDA memo that was released on the same day Merck withdrew Vioxx worldwide.

      • But they aren’t transformational from the user’s standpoint. I have chosen, installed, customized and implemented 2 EHR systems in a practice that is now 42 specialists. Although the EHR changed how we looked at our practice in many ways and was transformational, adoption by the user does not depend on that. It is a doctor by doctor process and the user looks at the differences in personal practices, not how it changes the system. That is a lesson I learned painfully from experience. Although doctors are very interested in the politics of healthcare reform and this could increase resistance to EHR adoption, they are most interested in how benefit associated with adopting this new technology will overcome their personal pain of adoption.

    • New techniques ultimately were better for the patient and the doctor. Not so with EHR. The patient will lose privacy and the doctor will lose productivity.

      • I agree with your concerns. From experience, the drop in productivity is temporary but painful. In the long run, productivity is increased to a minor degree. That isn’t the major benefit of the EHR, clearly. Privacy is an important issue and I can’t address that from my experience because our system was a single practice with a closed system so we could protect privacy. We were able to keep random people in our system from looking at charts that did not “belong” to them and to monitor who looked in charts as well. With a national interconnecting system, you have significant risk to privacy.

        • In all honesty, I have to point out that even in a small seemingly closed system, privacy is still an issue.
          First, many vendors reserve a right to connect to your local server and extract analytics or even just plain data. Sometimes, you are not even aware that they do that unless you read the contract with a magnifying glass and a dictionary in hand.
          Second, if you e-Prescribe (not fax), lots of your data and your patients’ data is going out to foreign systems over which you have no control. Some of this stuff is available anyway from claim data, but some is not.

  7. Grief is the reaction when a situation can no longer be altered. However, the morrass of healthcare deform can and will be changed, leading to jihad more than acceptance.

    • You may be able to repeal health care reform laws and you may have the questionable pleasure of seeing ACOs fail and costs rise as usual. We may even be unfortunate, or foolish, enough to witness this entire sector blow up, but computerization of medical records is indeed inevitable under all scenarios. External circumstances may slow it down a bit, or speed it up a little, but there is no way that medicine will end up being a paper island in an increasingly technology based global society.
      This can no longer be altered. Even by jihad (I hear they use facebook for that too now).

      • No one wants to stay with paper. Likewise, no one wants the central committee at the Center for Misery Services to micromanage medicine either.

        As long as EHR is not a script, then it is a tool.

        The user usually determines the character of his tools. That is why there are Mayo scissors and Metzenbaum scissors and all diffferent styles of tools: For individual preferences.

        EHR will not lower costs, because it will not improve productivity. It does not change patient behavior. It does not improve the legal environment. It does not improve quality of care. It does make really voluminous files of fluff.

        • I have a question for you: Why do you think Mayo and Geissinger and and Kaiser and the VA and others have spent all this money on these things if they are really so bad? Can’t be billing because VA and Kaiser don’t work that way, so what is it?

          • Total detachment from reality.

            Even VA and Kaiser have to control costs and follow resource utilization. Nothing like a computer to give managers grist.

            No one can acuse the VA of being a paragon of comprehensive care, available at all times for their patients who suddenly get sick. A computer can give them even speedier access to information allowing them to decline to accept a transfer of their patient from me.

  8. Great analogy.
    Combine this with Vince Kuraitis’s take on the PHR and you can see the inevitability of the EMR/PHR. That is not to say that most doctors are still in the denial stage… (or may have moved on to anger… hello to MD as HELL hiding behind an apt pseudonym). It will take a while for the old docs to die off and be replaced by people more comfortable with computers. Unfortunately, I think that many older docs are so ossified in their thinking that they will not be able to adapt and will stay stuck in the bargaining or depression stage until they retire.

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