Electronic Heath Records: the Electronic Stages of Loss and Grief

The Kübler-Ross model of emotional stages experienced by those who experience grief provide a framework to understand the gamete of feelings experienced by physicians as they struggle with the changing paradigm of electronic health records. Kübler-Ross noted that the stages are not a complete list of all possible emotions, and can occur in any order. [i] At times, the emotions may occur simultaneously. Making it through a particular stage does not mitigate that you do not re-visit this stage.

I recently suffered the loss of a career-long companion. We used to sit together in the early evenings reviewing the day’s events, celebrating triumphs and lamenting failures. Our frequent meetings helped bring closure to occasions in which our imperfect science yielded to the inevitable; and we recorded for all to see.

My companion was the paper medical record.

Crisp manila and sparsely papered, represented a new encounter. Other times, thick, tattered, and volume 3….. ugh! Each chart was a patient’s medical journey and I was charged the duty of both captain and scribe in an untidy, but personal, hand. Some journal entries were comprised of nothing but a sketch of a complex vascular reconstruction, simple and intricate, the image remained vital to future decision making. Some recorded epic battles of bravery, seemingly wasted at the hands of time. Some fought disease; others, themselves. Many were altogether uninteresting. But in every case, there was texture.

With little fanfare, the paper chart was forced into a premature retirement by a newer and government-mandated technology, the electronic health record (EHR). The newfangled, electronic surrogate promoted evidence-based templates that promised optimized care through a process which electronically distilled thoughts and observations into a set of structured data points. These would power concepts of ‘interoperability’ and ‘standardization’ — things that neither I, nor my patients, understood or cared much about.

I idly watched nameless movers pack my coffee-stained biographies into boxes. Exiled to an undisclosed storage facility, they presented too great a risk to leave behind — a fire hazard, of sort — due to the remote possibility of self-ignition (and the real possibility of challenge to the new electronic status quo). As the charts exited, so too went doctor-patient interaction and freedom of expression. The holes were forming and a feeling began to churn in the pit of my stomach. I was living Ray Bradbury’s dystopian, Fahrenheit 451, except the charts were not being incinerated (at least to my knowledge!). The transformers had learned these lessons years ago — such a bold action would only call their actions into greater question.

Later that day I stood next to the barren metal racks and sadness washed over me. It’s the same feeling I get when I drive by a public swimming pool in the midst of winter. Rest in peace.

DENIAL

The change was introduced with extreme fanfare, which seemed to be based solely upon ‘change.’ I found it insulting. Prior to the conversion, digital signs were hung throughout the hospital which counted down each precious second until implementation. Seriously. To me it felt like a constant reminder that my vacation would be over in 3 days, ….2 hours …. and 12 minutes. The egoistic propaganda marked the transition from ‘people’ to ‘processes.’

‘Changes to workflow patterns’ were being promoted by an overly eager implementation team. In retrospect, I really did not really understand what that meant; but the typical pattern of grief soon emerged.

I denied that the change would significantly impact the doctor-patient interaction. I was happy with my current ‘workflow’ and spent my time naïvely hunting for some piece of computing hardware that would simply allow me to replace my paper chart with an electronic version. Although I found plenty of actors auditioning at the big box computer stores, most proved to be inadequate to meet my specialized needs. I turned to the internet, cost was not the issue, there was too much at stake. After a great deal of research, I settled on a 13 inch Sony Duo Tablet; it boasted an electronic stylus which produced point-click resolution similar to a pen and paper and an integrated keyboard, yet remained lightweight, durable. With the swipe of a finger I could rapidly flip from EHR template to art application and the dual core processors would allow me to simultaneously capture thoughts from both right and left brain.

I remember the first day that I proudly carried my new tablet into the exam room. I sat determinedly face to face with my patient while stealing cursory glances at the computer screen. It was harder than I had imagined. As the day passed, a dark realization slowly emerged. It was that day that I discovered that it was impossible to listen to the patient and simultaneously record data on a structured template. I initially told myself that I simply needed to develop a new skill set, and vainly attempted to perform dual roles of physician and data recorder. I found that my thought process became clouded and my mind’s ability to multitask was not existent. Try rubbing your belly and patting your head. You will find your brain rapidly switching between the two activities. I was simply switching between two tasks at a frequent pace. It would seem that our central processing units, while complex and powerful, are based upon a single core platform.

I tried to make it work. I tried hard. What became undeniable, however, was the mental fatigue which developed at my attempt to simultaneously satisfy both tasks. For those successful at simultaneously rubbing your belly and patting your head, try performing the tasks for 60 seconds. That is the discomfort that I was experiencing.

In his book, Fast Thinking and Slow Thinking, Nobel laureate psychologist Daniel Kahneman describes the rapid switching as not intrinsically pleasurable. “You can do several things at once, but only if they are easy and undemanding.” [ii] I soon found myself leaving my tablet outside at the nursing station. I told myself that I needed to let the computer battery charge. I lied. Truth be told, I found it a luxury to be able to simply sit and listen and focus upon the patient and their current ailment. I was a better doctor.

PAIN & ANGER

It did not take long before I decided to do away with my tablet computer. It was an imposter, and I refused to compromise care. Unfortunately, it came at a steep price. I was forced to take an evening job as a data entry clerk, logging the day’s events into the electronic database. My world had changed in ways that I could not have predicted.

Completing my records in a timely manner soon became a source of anxiety. A glass of wine at the end of the day dulled the pain, but only temporarily. It was dangerous territory. I soon found myself waking at 4 AM worrying that I was falling increasingly behind. Would I qualify for meaningful use?

Yard work was my former escape. Most any Saturday, I would lose myself in the imposed seasonal callings: fertilize, trim, rake, ….repeat. I worked alongside musty marsh breezes with the heron as my work companion. Those revitalizing days became almost non-existent. On one such day, my neighbor came running across his lawn to greet me. His words hit me hard, “Boy I am glad to see you! I have not seen you in such a long time that I was afraid that you had gotten sick, or had gotten divorced and moved out.”

I smiled and shook my head, “Not yet.”

I stopped reading too. And writing.

As the masking effects of denial wore thin, the pain of reality re-emerged in the form of anger. I directed curt emails at tech support and hospital administrators. Neither inanimate computer hardware, nor fragile family members and patients were immune. I am sorry for those moments.

BARGAINING

Like many other physicians, anger was soon supplanted by pragmatism. I was tired of being angry and I began to talk of quitting medicine altogether. When the self — negotiations began in earnest, I began to compromise, “I’ll practice for a few more years, while I downsize my needs.” I sold my beloved ’54 Chevy pickup truck and we put our beach cottage up for sale. I would be better down the road, without that load.

Regrettably, we have lost a number of excellent physicians at this stage. They simply refused to concede to the mandates imposed by an imperfect electronic system. With the rudder of experience suddenly gone, the medical ship was off course.

DEPRESSION

Although I considered alternative opportunities, I found my time severely limited by the very object that I was trying to escape. It seemed that the harder I struggled, the tighter the noose became. My bargaining came to an end when I was forced to acknowledge the reality of my obligations. My children, the banks and my patients depended upon me to continue to work. Quitting did not seem to be a feasible option.

I felt trapped and I began to purposefully isolate myself. I quit our hospital’s Board of Directors, stopped attending faculty meetings, began to skip lunch and stopped exercising. I told myself I was too busy, but the problem ran deeper.

Encouragement from others only made matter worse, as they tried to empathize. Rather than accepting their good intentions, I often drove people further away by arguing that they could never know the depths of despair that I was experiencing. I was constantly exhausted, and had little interest in social interactions.

Soon after, the physical symptoms followed. I developed an insatiable appetite for air — constantly gasping and hyper-inflating my lungs in attempt to satisfy a newly developed dyspnea. I became convinced that there must be something organic — maybe lymphoma — or other?

I did not really care.

ACCEPTANCE

I was well beyond my tipping point. I could continue to complain and wallow in self-pity, victimized by a process I did not understand, or I could effect change. Reaching this stage of mourning is a gift not afforded to everyone. It is not necessarily a mark of bravery to resist the inevitable and to deny ourselves the opportunity to make our peace. This is not a period of happiness but is marked by withdrawal and calm. I began to ask the hard questions: What went wrong? How can I change the system? As I explored these questions, I began to accept the reality, and with this, I began to heal.

Discontent is the first necessity of progress .”

Thomas Edison

Acceptance breeds hope. Over the last two years, I have spent significant time and effort in helping to reshape that which what is broken. I am cautiously optimistic that in the very near future new physician-oriented tools will emerge which reduce physician and patient frustration, the promise fulfilled.

In part 2, Designing the Ideal Electronic Health Record, we break down the components of an Electronic Health Record. We’ll explore what works well, what needs to be fixed, and what is on the horizon.

Christopher L Wixon, MD is a vascular surgeon who is passionate about developing physician-oriented electronic record systems. He has co-authored a platform for cardiovascular services ( http://www.mtuitive.com) and has developed a unique search engine for ICD-10 and CPT which use a hierarchical algorithm (http://www.codecatcher.co)

[i] Kubler-Ross ref

[ii] Kahneman, Fast and Sow Thinking

Written by

Chris Wixon, MD

President and Managing Partner, Savannah Vascular Institute

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