Table 2.

Conceptualizing EHR Adoption as Personal Change Involving Loss

Stages of Grief (Kübler-Ross, 1969)	Representative Quotations Characterizing Stage of Grief in Change Process
	Physicians' Comments	Administrators' Comments
Denial Shock Feeling overwhelmed	“It's been probably one of the most unsettling things that I've seen for physicians throughout our entire system.” “…it was an overwhelming amount of information.”	“The docs were just overwhelmed. Not just the docs, but the clinical staff could easily be overwhelmed with that stuff.” “There was no gray; it was very black and white and that was shocking and upsetting at first.”
Anger Underlying pain	“It was a fairly painful process getting on top of it.” “By the time you've actually done all that, your patient encounter is half way over and then it is not even worth documenting in the patient room.”	“We're asking the clinical people to do more and more … so you end up having very highly paid, high thought process people doing data entry—bad idea. And that's painful for a lot of people.” “…anger on the part of physicians that they actually had to type and document and place orders and do histories and physicals themselves and meds.”
Bargaining Negotiation	“Everyone has mixed feelings. I mean there are a few that have all favorable but even those people acknowledge the issues and the problems that we have.” “And I went all the way to even less personal … why do they need that cover letter? It's obvious I saw the patient. Just give them the progress note. They can read the note.”	“…the ones that have already the little negative thoughts in their heads—that it's not going to work, I am not going to be as productive, I don't want to share my notes.” “We did lose physicians over this … There were doctors that left because they could not adapt … they did not know how to type.”
Depression Feeling empty	“The first 2 weeks, I could have quit medicine. It was really so destructive to my flow and my interaction with my patients.” “It was too much information … and then all of the sudden, the next day,… we were thrown in the clinics … which stressed me out for like 2 months!”	“We can't make them feel bad, they'll start crying. I had a provider cry on me once.” “…they just want to go back to doing work the way they used to do work.”
Acceptance Of changed reality New reality is permanent reality	“When you have somebody who is a very medically complex patient who sees a lot of different specialists, who has a lot of different outpatient visits and those clinics are within the EMR system and you can really use it to the best of its ability … You are able to have all of that at your fingertips and … so at its best, I think that it is a great system and it really … it changes the way that you manage people.” “…the ability to share information within our practice, very critical information that somebody knows something that somebody else needs to know, the ability to shift work to where it can be done better or more efficiently like off-site of to the right person. Definitely the ability to follow things we couldn't in the past because we can't do it on paper.”	“[They say] … while I used to have to take a stack of charts home to review them, now I can just dial in from home and do all of that stuff before I even come in.'” “Actually our biggest critic is … the staunchest advocate of the EMR.”