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Sometime in the last few months “it” happened. I am not sure when it occurred but, it did. I officially became a dinosaur. Yesterday, I was called an “Internet Immigrant.” An Internet immigrant, to distinguish the term from that of an Internet native, is a person for whom the Internet and all of its trappings have always been present. For this group of 20 to early 30 somethings, the Internet has been omnipresent. There is no need to claim discovery or invention of the Internet for them—it has always been. For me, typing is a skill learned in high school on a manual typewriter. The use of an electric typewriter was a thrill experienced only in college. For my colleagues who are younger than a certain age, typing is a skill in development before preschool. Despite years of work and millions of e-mails, I can rarely look up at the screen while typing. My only solace is that, unlike my children, I can spell, a skill they claim is obsolete.
Despite online subscriptions to all of my periodicals, I still keep a pile of those “to be read” in a corner of my office. My new associates have clean and clutter free desks, using discs and desktop files on their laptops filled with recently saved articles for reference. I cling to the paper versions for the initial read. I use e-mail at work but rarely at home, preferring to call my college-age children, much to their irritation, who would prefer that I send them messages through instant messenger or Facebook, so that they can multitask, communicating with their friends and mother simultaneously. A PowerPoint presentation is always a source of humor at my expense. Having few artistic skills, my high school-age daughters insert clip art and change color and font at will. Intuitively, they hit combinations of keys such as control Q or F6 for amazing results. I would never think of touching these buttons lest I delete the entire document and have to start again. I remain an outsider, just in sight but out of reach of the cutting edge. Secretly, I suspect that I am not alone.
I reveal this not so well-kept secret as my practice ekes its way toward a fully integrated electronic health record (EHR). EHRs are here and they are staying. As the demands for increased accountability and documentation drive payers into pay-for-performance, the electronic medical record (EMR) becomes essential. The billing office seeks as its holy grail an integrated system that captures encounter charges with administration codes, patient's insurance information with other demographics, and real-time drug expenditure costs. As oncologists, we seek safe evidence driven care for our patients preferably in an efficient manner. The EHR may accommodate all of our interests and goals in the future, but for now I remain skeptical.
There is real work to be done right now in the development of oncology specific EMRs. The EHR Lab in Chicago at the American Society of Clinical Oncology (ASCO) Annual Meeting was preceded by months of work from the Internet Technology Committee and an EHR workgroup that developed oncology-specific measures. The treatment planning and summary documents were instrumental in achieving a common set of expectations. By the time this article is in print, the 2007 EHR Symposium in Dallas, Texas, will have occurred. It is critical, as we move toward this EHR world, that practicing oncology professionals take a look at what they are doing and communicate to the vendors and the EHR Workgroup what needs remain unmet for integration of the EMR/EHR into their practice.
Still, I worry that I will be left behind, not able to foresee what it is that I really need from an EMR. I know that a seamless EMR will be better for my patients when I am not present in the office. The covering physician or nonphysician practitioner will have full access to the chart and supporting documents. Conversely, it will be great for me not to search for missing paper lab reports and dictation summaries from the hospital on the first visit back for a sick patient. Each EMR that I have seen to date has limitations. One may have chemotherapy ordering that is great but a flow sheet that is better suited for an accountant. An EMR where the provider types in the encounter specifics may never allow me to finish and go home.
Over the past few years, because of my personal interest in EMR and my volunteer positions with ASCO, I have learned more than most about EMRs. Health Insurance Portability and Accountability Act specifics, Certification Commission for Healthcare Information Technology (cCHIT) certifications, operability and interfaces, web-based versus server-based systems, Systematized Nomenclature of Medicine (SNOmed) language specifics, and voice recognition software packages are now part of my vocabulary, yet I remain an Internet immigrant, and the day we go paperless I will be a wreck. I will worry about missing a document, deleting a text box inadvertently, or losing a byte of vital information to cyberspace. Of course, this happens with paper charts, but they are my language, my culture. This uneasiness will fade with time and even now I remain committed to this process of integrating a full EMR into my practice even though it is unsettling. I can't help it; I am officially a dinosaur.