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If your initial reaction isn't positive, hang in there. You're not alone.

Fam Pract Manag. 2012;19(5):40

Dr. Ward is a research assistant and scribe for the Department of Family and Community Medicine at Eastern Virginia Medical School and an incoming intern for the Portsmouth Family Medicine Residency in Portsmouth, Va. She would like to thank Dr. Christine Matson, Dr. Robert Ringler, Dr. Richard Bikowski, Dr. Bruce Britton, Cheryl Hassell, and all the physicians she worked with as a scribe. This article is modeled after the "Five Stages of Grief," introduced by Elisabeth Kubler-Ross in her 1969 book On Death and Dying. Author disclosure: no relevant financial affiliations disclosed.

I found myself with a spare year between medical school and residency, and I spent it as a scribe, learning how to navigate my residency clinic's electronic health record (EHR) and helping family physicians transition to its routine use. At its best, the EHR seamlessly integrates clinical notes, patient records, imaging, and lab reports into one searchable system and produces clinical summaries of the office visit, which help patients stay informed about their health and remember what they discussed with their doctor. At its worst, the EHR becomes a confusing, time consuming, and demanding third person in the exam room.

I observed that physicians had several distinct reactions to working with the EHR:

1. Denial. One way to cope with the presence of the EHR is to avoid using it or work around it as much as possible. Some physicians continued to use paper notes and would have them scanned into the EHR. This gave them the convenience and familiarity of handwritten notes, but with none of the advantages of the EHR, such as legibility or the ability to gather “meaningful use” data.

2. Anger. Often, those who reacted with anger to the EHR had computers that were too slow or would freeze just as they moved their cursor arrow above the “print” icon. Sometimes the printer would sit idly, despite several requests for it to produce a document, and then six hours later it would spit out the required form four times. With these physicians, it wasn't uncommon for notes and clinical summaries to disappear without a trace, or for the mouse to be slammed down several times on the desk in a desperate attempt to get the computer to respond.

3. Bargaining. Some physicians struck a compromise between the old system and the new. They would write their notes by hand in the consultation room and then type an electronic note after clinic. This was time consuming and laborious, but at least they were using the system.

4. Depression. Despite having good computer skills, some physicians despaired at ever being able to use the EHR in a meaningful way. Even a few of our best typists and early adopters of technology viewed the EHR as an insurmountable hurdle. To them, the new system was too complex and confusing – and too imperfect – to be used in clinical practice.

5. Acceptance. Some physicians were eager to integrate the EHR system into their practice and saw the value it could eventually bring to patient care. They still had problems and needed help, of course, but they were keen to master the required skill set.

No physician displayed a single reaction to the EHR. In fact, physicians often displayed several reactions all in the course of a single clinic session. However, as clinicians, our brains are wired to solve problems, and working together we found a variety of solutions. Less skilled typists used a dictation system, speaking their notes into the microphone as the computer transcribed them into electronic form. Some physicians opted to create portions of the note before the visit and then would add to it during the visit, minimizing their time spent facing the computer screen instead of the patient. Deep breathing exercises worked when dealing with uncooperative printers. We developed a few fictional “test” patients in the EHR so that physicians could practice navigating the system outside of an actual patient visit. We upgraded hardware as needed. And staff who were more comfortable using the computer provided assistance to others.

Our EHR is not yet perfect; it needs to be adapted in a few areas to suit our clinical practice, and we need to integrate it better into our workflow. However, I'm convinced that soon we will wonder how we ever got along without it.


The opinions expressed here do not necessarily represent those of FPM or our publisher, the American Academy of Family Physicians. We encourage you to share your views. Send comments to, or add your comments below.

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