With EHR Use, Computer Literacy Misses the Point

For most medical students, medical school gives them their first intimate look at the variety of ways in which the body can malfunction or be afflicted. At that point in their careers they have limited ability to think critically about what they are learning and they lack experience.

Consequently, it is not uncommon for student to detect in themselves, the signs and symptoms of the conditions they are studying.

The years in school, and later in residency, develop their skill in performing the tasks and procedures that make up much of patient care; experience and judgment continue to develop, albeit slowly. The best physicians continue to expand their knowledge and ability throughout their careers as they gain additional experience. At some point most physicians attain a state worthy of being called medical literacy, that is, they have the ability to assimilate and comprehend the body of medical knowledge and principles, to think critically about that knowledge and their patient’s problems, and to apply their conclusions to patients in the form of diagnoses and treatment plans.

It is medical literacy that enables physicians to absorb new scientific knowledge and grasp the implications and application of new medical modalities such as computed tomography and DNA microarrays as they emerge. Some new discoveries and technologies, however, are sufficiently unlike those things taught in medical school and additional literacies may be required before a physician is equipped to use them appropriately.

One such modality is the EHR. Hopes are high that this modality will be the "silver bullet" that will annihilate medical waste, abuse, bad outcomes, and high cost and thereby rescue the country from impending bankruptcy. Perhaps this is possible, but not with present-day EHRs and not with the prevailing level of knowledge about medical information science, the backbone of this modality.

Instead, we are assured that the systems are adequate and, if only the users were more "computer literate," the benefits would flow freely.

Furthermore, we are assured the upcoming crop of physicians are already "computer literate" so it won't be long before the dream is within reach. Evidence for this view is abundant, defining computer literacy as a "[level] of comfort when using technology. There is a significant generational gap between those who grew up using technology and those who have not." The suggested remedy is to identify "any deficiencies to computer literacy among staff and [correct] them…"

This definition of computer literacy is counterproductive; an example of the all too common phenomenon whereby words come to substitute for ideas that are far removed from the actual meaning, especially when the words engender feelings of confidence and safety. Used in this way "computer literacy" is not literacy but rather, skill or proficiency. It should be obvious that skill does not imply or require understanding or thought. Most drivers can't reason about the principles of chemistry and physics that affect their vehicle but driving skill can be achieved without that understanding.

Medicine, on the other hand, is all about information: its acquisition, storage, retrieval, and application. Using a computer to effectively apply information to patient care is not about knowing what button to click, it is about understanding how the computer can enhance, detract from, distort, obscure, and pervert information. It is about how to take and record a history and physical using a computer in a way that will maximize its value as information so that can be used to improve the patient's care. It is also about understanding programming, but that is a topic that requires separate treatment.

Computer proficiency can ease the strain experienced when using today's EHRs but is of little help to those who must select, evaluate, implement, or design one. Proficiency alone does not help the physician understand what happens to the information that is recorded (or should be recorded), how to get it out, and why and how the output can be misleading.

Medical schools, faced with numerous demands that subjects be included in the curriculum, are overconfident that medical students are already "computer literate." The failure to include medical information science and critical thinking in the curriculum is more a sign of ignorance than of sagacity. Until students acquire this core competency they will be just as adrift in the computer age as is the generation providing their education  - proficient midshipmen at best, but not possessing the literacy needed to be a captain or navigator.

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