The 5 Stages of EMR Acceptance (With Apologies to Kubler-Ross)


                 I can’t believe they are making me use this system!


                     THEY LAUGHINGLY CALL A SYSTEM!

‘Look if I agree too willingly and cheerfully use this system, can you ask for and fund these change orders, add these features, re-engineer this screen…..blah! blah!  Blah!, etc. ‘

I can’t beeeelieeeeeeve (sob, sob, sob, sob) theeeey (sob, sob, sob) are making meeeee (pouring tears from both eye tear wells) use this system!’ 

           I believe they are making me use this system.
                                         (Resigned Sigh) 
And just as in the original Kubler-Ross model, our only release from EMR agony is death……. an eventuality that I used to accept stoically as inevitable, but now positively look  forward to its release (as do my carpal-ly tunneled wrists!). 
Over the last months and the last several years as the deployment of EMR systems have proliferated even the most enthusiastic advocates of electronic documentation have difficulty pointing to any compelling advantages of the EMR systems other than enhanced legibility of charting and improved justification for higher billing. 


The costs are enormous for the front line clinician and his patient struggling to connect across the increasing gulf of random bytes and bits that contain the essence of the second oldest 1:1 relationship on the planet. 

It is perhaps the time of life to romanticize the old in preference for the new. But I don’t think I really suffer from that illness. However, the thing that attracted many of my colleagues, and certainly myself to medicine was the unparalleled opportunity to be autonomous in a respected profession. 

However, the profession has been under systematic assault from outside and within. Furthermore, for my own part, having spent the vast majority of my time as a physician within the US military I have become totally disenchanted (if I ever was enchanted with ) with medicine for profit.
As an undergraduate mathematics major with a heavy interest in and emphasis in computation theory during my undergraduate days, I was attracted to the field of medical informatics as a resident, just as I was attracted by the physics and mathematics that underlie most of cardiology.
However, when I learned in my informatics training that 80(+) % of medical costs were driven by physicians decisions, it became axiomatic to me that control of those decisions was a major hidden agenda item in the field. Furthermore, my non-physician informatics mentors, most prominently Reed Gardner failed to ever understand why I would want to look at my own radiological studies since I am not a radiologist, he considered this a waste of energy and effort, and never accepted my own assertion that since I brought the patient to the film, I could (and do) find things in the study either missed or overlooked by my fine radiological colleagues.
For me the allure of this field medical informatics was how to help myself and others make better decisions, not necessarily make standardized decisions. 
I am really un-humble, I am an exceptionally good clinician, but then that is all I have done for an average of 12-16 hours a day, every day for about 32 years (wow has it been that long) if I can’t figure out this dance after 80,000 (+) partners I am a slow study.  
To my eye the current quality initiatives are laughable in their simple mindedness. But the reality of statistical control theory, the soft and unpleasant underbelly of the theory is that the highs, i.e., the exceptional as well as the under performer are both squeezed/regressed to the mean. As some one never content to be within the mean, it makes me mean, and unpleasant at times to be forced towards the just barely acceptable. 
And that is how every good doctor is feeling right about now with the drive towards poorly designed encounter capture systems (I won’t dignify these monstrous pieces of software by calling them Electronic Medical Records), we are being driven to a pabulum state of consciousness just as our teachers have been driven to teaching the test, we are driven to documentation for billing, not for caring for the patient or for doing an exceptional job clinically. 
If I compare my professional dictations of yesterday, they were elegant, articulate, crafted with the care a good writer exerts over his/her craft;  But using the charge maximization systems now so prevalent, I can examine the chart with a magnifying glass and not find a recognizable part of my patient within the ‘sameness’ that characterize these infernal charting schemes.

Designed by engineers with the advisement of financial trolls who believe that a complete record is preferable over a patient’s story. For those of us who learned to enjoy the patient’s story and who are replenished and nourished and enchanted by these tales, there is are no real stories anymore. And the price of this de-emphasis on the unique patient in front of you, is higher medical costs, for the other 80% rule in medicine is 80% of the diagnoses are made by history and careful, intelligent, and active listening. The practice of narrative medicine is in my view, the best way to practice no matter what you practice, but the infernal button pushing, needed to be done to get paid, prevents the elucidation of the story at the center of the symptom and as such, results in good billing, but often times the wrong or incomplete answer.
Especially in my Emergency Department work, much less so in my cardiology practice, the time pressures result in conformity to a standardized and scripted response for the problem at hand since you don’t have the time to produce a hand-crafted thoughtful response to the problem at hand. This becomes disheartening to those of us in the profession who were raised to adhere to a standard in which you did your best for everyone, no matter what the odds or inconveniences or personal sacrifices. But this atmosphere/culture of expected exceptionality has been replaced by ‘is it enough to guarantee maximum return of billing.’
But at least for me it is the uniformity of the appearance of the products of medical work that is the output of electronic documentation systems that makes it seem like such a soul robbing endeavor. And I believe passionately that true clinical expertise is shown by what you choose to leave out, not put in the story or presentation of the patients case to colleagues.
Again, my goal here is not to be nostalgic for the old but rather to mirror for the fresh and unprejudiced minds in our mists, that the backlash at EMR technologies being seen among my colleagues does not necessarily represent push back from techno-Luddites but rather can be interpreted as a meaningful critique of the inadequacy of the current systems to support the healer and shaman that is the core personality component of every good doctor I have ever met, trained, or practiced with.
Existence of preventable medical errors is a feature of all types of practice, and as we well know, as detailed many times by Scott Silverstein (http://hcrenewal.blogspot.com) (also a negative nelly — but than I think in the field of medical informatics you have the choice of two diametrically opposed roles the negative nelly or the cheerleader)  that those who chant the mantra of patient safety seem perfectly content to minimize, ignore, or down play the new and more difficult to detect and prevent errors attendant to use of medical software systems. Classic example of EMR safety failings was the recent EPIC disaster (pun intended) related to the failure of diagnosis of the 1st case of Ebola virus infection in the US. (http://hcrenewal.blogspot.com/2014/10/did-electronic-medical-record-mediated.html). ( “Travel Information Wasn’t Communicated In Dallas Ebola Case Due To Electronic Health Record Flaw” (Huffington Post),


As many do not  know, the most costly software on the planet is Space Shuttle code which costs about $100,000 per line of code, and for which the code has meet the most rigorous software engineering tests, i.e., each line is proven by mathematical techniques to be complete, consistent, and free of unexpected/unpredicted program errors. Compare that level of software engineering excellence to software I have personally used where not only are there bug upon bug in the software, but the damn labels on buttons representing symptoms are misspelled. I consider it axiomatic, if the buttons are misspelled the code is flawed, but than you can’t judge a book by its cover, or can you? 


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