I knew when I couldn’t find a parking spot that life would never be the same.

The day had finally arrived: September 14, 2010. As I left for work that morning, I told my wife not to expect me for dinner—maybe not even for breakfast the next morning. Who knew what the day would bring? I shut the car door behind me, took a deep breath, and headed for the back entrance of my family practice office.

It was “go-live” day for our electronic health records (EHR) system.

We had brainstormed, shadowed, prepared, trained, abstracted, schemed, argued, stressed, cried, worried, questioned, and rehearsed our way to this day. Now both anticipation and dread filled the air we inhaled with anxious sighs.

As the largest outpatient practice in our hospital system, we would be the last to take the plunge into the digital age. Not that we wanted to be. We had volunteered to be one of the first practices to go live. But with our 18 providers, the information technology department did not believe it could sail our ship too early. Now, years later, having watched all our sister practices settle in with the new system, having endured multiple launch delays for reasons we didn’t completely understand, having experienced what a 41-week pregnant woman must feel, our time finally had come.

IT CAN BE GOOD NOT TO BE FIRST

Turns out, though, that letting the other practices work out the bugs and make the mistakes ahead of us clearly was to our advantage. While we waited, our charts were abstracted. Our plans were laid. Our staff was trained. Our computers were installed. Our stomachs were ulcerated.

When September 14 came, we were ready. Well, as ready as any practice can be with an electronic Category 5 hurricane knocking at your door.

As I marched into the office that morning, I realized why I had to park nearly across town: the Great Invasion had occurred. I now was in occupied territory. A highly trained strike team, probably 30 strong, had descended on our office. It consisted of EHR support staff from the “mother ship,” the main hospital.

Stationed at every computer screen, these part-field generals, part-scouts, part-translators, part-grief counselors, part-punching bags stood ready. There was no turning back now.

We didn’t just add an EHR system to our family practice; the system created major change in every department and at every level unlike anything that had come before. Processes and approaches to patient care, phone calls, scheduling, lab results, interoffice communication—you name it—had to be retooled.

Posters with dazzlingly complex workflows were constructed with enough arrows and boxes to make any football coach smile. The weight of this metamorphosis had an interesting effect on our staff: older nurses retired in a steady stream in the months before our EHR launch, senior physicians contacted their financial planners to double-check their retirement dates, and those of us in the middle hoped our years playing Tetris would pay off OSHA Training.

FIRST APPOINTMENT NOT AS HOPED

My first appointment of the big day was with an elderly patient with diabetes. Confidently, I strolled into the exam room, eager to usher in the dawn of the digital age and use this powerful new tool to launch me into doctor utopia. But the home screen would not come up. I smiled at the patient and tried again. No go. Within the first 2 minutes, support staff stared at the screen with me as the patient sat quietly waiting. Not the start I had hoped for.

But then it happened. The moment I had dreamed of. The big payoff. A female patient in her mid-60s with 15 chronic conditions and 16 medications arrived for her annual refill visit.

It was the occasion I formerly dreaded each year like it was the anti-Christmas. My hand would cramp up just seeing her name on the schedule. Every year, I would labor through two sets of prescriptions (one for a local pharmacy, one for mail order) only to discover that I had written at least three scripts incorrectly.

Not this time. I made sure her medications had been abstracted into the system ahead of time. Now it was click, click, click, type, click, click, type, click, a few more clicks, and I was done. I almost cried.

Later in the day, my nurse commented, “You know, I don’t think I have talked to you much today.” She was right; she hadn’t. I guess we didn’t need to talk anymore.

Like a couple of teenagers, we were now communicating largely by beaming electronic messages to one another. (Is LOL an approved medical abbreviation?) If I wasn’t in an exam room, I was hiding out at an available computer finishing a note, responding to messages, or authorizing medication refills.

My time hanging out at the nurses’ station looking over charts and giving instructions to my nurse was gone. And so was my chance to ask about her weekend at the Chesapeake. Maybe the EHR system can remind me to beam a message to my nurse in a few weeks asking about her family reunion.

Before I knew it, the first day was over. All the patients had gone home, all the phone messages answered, all the lab tests attended to. I wouldn’t make it home in time for dinner, but at least the sun wasn’t rising anytime soon.

With each patient encounter that first day, my EHR skills steadily improved. And I knew that the next day I would inch a little closer to mastering the system. As I headed out of the office, I was not impressed as much with the power of technology as I was with the human capacity to adapt and learn. And yet it felt as if something had died on go-live day. With each new computer-enhanced patient encounter, a strange sense of loss developed in me. I wonder whether the older doctors in the practice felt it more acutely.

PATIENTS HAVE WELCOMED CHANGES

Despite the occasional conspiracy theorist worried that information about his hemorrhoids will end up on Facebook, patients have welcomed the changes at our practice. They seem impressed with how quickly we can retrieve medical information and how easily we can transmit prescriptions to the pharmacy.

Yet I get the impression that patients wonder what took us so long to catch up with the rest of the business world. And despite the “wow” factor the practice has gained, I still find it awkward having a computer in the exam room. The black, flat-screened terminal seems out of place, like something accidentally beamed into the exam room by a wayward time traveler. And its use has made me feel like a medical student again, bumbling through an office visit.

To save time, I have attempted to document the subjective component of my note during the patient interview. My typing skills are adequate at best, and some of the sentences I’ve typed have looked like Klingon. (Who would have thought home row was so important?) I wonder, too, whether patients can decipher my blank looks as I make eye contact while they talk but my brain struggles to remember where Q is on the keyboard.

TRANSITION WILL BE GRADUAL

Our full transition from paper to digital will be gradual. Although every action now transpires in the language of Electronica, at the time of this writing we still lug paper charts to each visit and plan to do so for 6 months.

Once the object of my disdain (and the cause of my back pain), I now cling to those paper charts like a kid hugging her favorite stuffed animal during a thunderstorm. They’re comfortable, safe, and familiar. Frequently, I find myself still leafing through the paper chart instead of checking the computer screen for the same information. I’m afraid old habits won’t die easily.

Family medicine sure has changed. With every practice iteration, with every attempt to classify and codify what we do, with every introduction of new technology, I fear we move further away from the roots of our profession.

Gone are the days of quick, hand-scribbled chart notes detailing a visit. Now documenting and billing for a patient encounter can take more time than the visit itself. Soon, gone will be the mountains of multicolored paper charts—filled with frustratingly illegible notes at times yet marked up in ways as unique as the individuals they describe. Now every patient is identified with words in the same font in the same location on the same screen.

Thanks to the advent of the International Classification of Diseases system and now EHRs, gone, too, is more of the organic, fleshy character of our profession. Medicine is more robotic now, more pre-fabbed and algorithmic. The problem is, neither I nor my patients are any less human today than we were last week.

I often tell my patients that medicine has no rules, and yet we attempt to join medicine with technology, which is governed by defined codes and commands. The marriage of the two can be awkward at best. Hence, no five-digit codes exist that can accurately portray: “Patient worried that Lyme disease is causing excessive ear wax” or “Physician has no clue what’s going on with this woman.”

I knew there would be no turning back from this season of “progress,” and in a few months I won’t want to. But somehow it felt like my profession lost its last bit of innocence that day.

BENEFITS STARTING TO SHOW

Despite the hiccups and hesitations, however, I am starting to see benefits EHR provides.

Maybe I will be able to get back to actually caring for the woman with 15 problems and 16 medications rather than feel overwhelmed by paperwork whenever she comes in. Maybe I will be able to provide more prompt, coordinated care for my patients, as in the case of the woman who cancelled her colonoscopy due to a misunderstanding with the gastrointestinal medicine specialist. I was able to read his office note (his practice uses the same EHR system) and send him a message to which he responded within an hour to help resolve the issue. That’s the way it should be.

Maybe the system will save me from countless medical errors. And maybe the EHR will drive me to hold on tighter to the one remaining hallmark of this profession: my relationships with my patients.

Around the office, doctors joke that medicine will continue to evolve until we come in one morning and find ourselves replaced by robots. I hope that go-live day is scheduled after my retirement.

This article was originally posted at http://www.modernmedicine.com/modernmedicine/article/articleDetail.jsp?id=714240&sk=&date=&pageID=3