Hastings Center Report

Several weeks ago, fifteen of my primary care-internist colleagues and I sat in a midtown skyscraper in a classroom fitted with a laptop computer for each of us. Coffee cups in hand, we embarked upon a two-hour class—the first installment of a ten-hour course—to learn to use a multispecialty electronic medical record (EMR).

The EMR our medical center has decided to launch is elegant, with lots of pop-ups, color-coding, and an amazing ability to collect and generate data. Our instructors pointed out that the new system was more than just a computer to write notes or order prescriptions. Our practice has had that capability for years.

No, this new system was different. It was a medical information superhighway. It connected you with colleagues throughout the medical center by means of a shared medical record. Between sips of coffee, we were told of the new system's capabilities: If you want to know about your patient's last visit to the urologist or send a pre-op clearance note to his cardiac surgeon, your colleague is but a click away. Order a drug that is incompatible with the patient's medication list, and the EMR will warn you away from your choice and steer you clear of a pharmacologic mismatch. Beyond its capability to promote safety, it also can facilitate outcomes research.

Although I was none too thrilled to trudge downtown for training, I must admit that typing up a mock patient visit on the computer was fun. Since it is not altogether different from ordering a book on Amazon or searching UpToDate for medical information, it was not entirely unfamiliar, but it was still [End Page 36] novel for a middle-aged doc whose career in medicine began before computers, much less the advent of information systems.

You see, I am part of that cusp boomer generation that came of age before the Internet. Although I am now wedded to a PDA at all hours of the day, night, and weekends, my worldview was shaped in an analog time right before the digital onslaught—now an almost premodern experience.

In high school, my chemistry class was the last to use the slide rule. We thought they were cool and a marker of scientific sophistication, at least until the first hand-held calculators displaced them. By our senior year, physics was made simpler by my little Casio computer, but I'll always be glad to have experienced the seventeenth century charm of a slide rule. It might have been centuries old, but it taught you to appreciate logarithms in a way the Casio did not.

In medical school, my class was the last to do pathology solely with glass slides and microscopes. The following year, an innovative pathology professor started to use primitive Apple computers to display some images. No longer were students wedded to one hundred prized slides that they lugged around in old wooden cases. The possibilities were limitless.

Because I am of a certain age, the age of informatics has been trailing me and will chase my generation forever. This is especially true when it comes to the galloping arrival of the EMR. When we were residents in the late 1980s, we would pride ourselves on how our charts read and looked. The chart was a place to tell a patient's story from our point of view. Although we had all been trained in the architecture of the medical note and the progression from Chief Complaint (CC) to History of Present Illness (HPI) on down to Assessment and Plan (A/P), each of us did it a bit differently. Each of us had our own voice. I recall marveling at the charting styles of my colleagues and professors: the long, obsessively complete note of the intern versus the almost aphoristic musings of the attending—the former chock full of unorganized information, and the latter synthetic in its encapsulation of the problem and plan of action. And in that transition, through our writings in the medical record, we all learned how to think as doctors.

The...