INTRODUCTION: The Stars Were Shining

Steve Osborn

One of the earliest recording stars was the great Italian tenor Enrico Caruso, who began his prolific recorded output in 1902 with a memorable version of the aria “E lucevan le stelle” (The stars were shining) from the opera Tosca. “Forever my dream of love has vanished,” sings Caruso in Italian, taking on the role of the condemned prisoner Mario Cavaradossi. “I die in desperation, and I have never before loved life so much!”

Caruso’s voice was captured for possible eternity by a spinning shellac disk called a record. The sound of the recording is scratchy and incomplete, but the voice is incredibly powerful, conveying all the torment in Cavaradossi’s mind as he awaits his execution. You can hear the recording for free on YouTube, or for a price in one of the many audio formats (vinyl disk, tape, CD, MP3) that evolved from the shellac record.

This issue of Marin Medicine addresses another type of record, one that began on paper but has now migrated to the computer and the cloud. Rather than capturing mere sound, this record attempts to encapsulate an entire human being, measuring the person’s physical characteristics, disease processes and life trajectory in the hopes of promoting the person’s health or curing what ails them.

The record, of course, is the medical chart, now rapidly evolving into the electronic medical record (EMR) or health record (EHR), depending on which acronym you prefer. As Dr. Carl Spitzer notes in his excellent overview of healthcare information technology, the electronic record allows doctors to capture vast quantities of clinical data, which can then be analyzed “to ferret out the treatments that are most effective, clinically and economically, and move away from those that are least effective.”

Capturing all that data won’t be easy. During their patient encounters, doctors are busy enough as it is, and many are leery of adding electronic records to the mix. “I can attest that current EHR systems are so poorly designed that most emergency physicians I know loathe using them,” writes Dr. Jason Ruben. In his view, the solution is to hire medical scribes who input the doctor’s comments into the electronic record during patient care. Doctors who use scribes, he notes, “get to take care of patients instead of having to sit in front of their computers.”

Dr. Brian Keeffe, a veteran user of smartphone technology, notes that electronic records are becoming more mobile, making desktop computers less necessary. Nonetheless, he cautions that “an obvious and major limitation of mobile devices is that they can distract from the doctor-patient relationship.” To minimize the distraction, he leaves his smartphone on silent when examining patients.

Other articles in this issue examine the practicalities of selecting an EMR/EHR vendor and communicating with colleagues via doctor-to-doctor smartphone apps. In addition, our “Practical Concerns” department investigates a related issue: How well are you protected from liability in case of a data breach? For some, “cyber liability coverage” may be the answer.

Technology of a different kind is highlighted in our “Local Frontiers” article by Dr. Deepak Lamba of the Buck Institute. He describes how his lab is developing stem cell-derived retinal cells that may someday be implanted in retinas to restore vision in patients with AMD and other degenerative disorders. The procedure is still years away, but the results to date have been impressive.

In our other departments, Dr. Georgianna Farren offers an update on Marin Community Clinics, including their recent implementation of electronic records in all their facilities. Dr. Lori Selleck reviews The Santa Rosa Reader, an anthology of writings about our northern neighbor’s esteemed family medicine residency. Finally, Dr. Jeffrey Harris brings us full circle by writing about the musical endeavors of several local physicians. Just like Caruso, many have made recordings of their efforts--but using digital technology rather than shellac.

Given the challenges of implementing electronic records and related technology, medicine still seems to be a long way from making an all-encompassing recording of a person’s health with the same ease as a studio engineer putting a microphone in front of a tenor and asking him to sing. At the moment, it’s hard to imagine an entire person fitting into a smartphone, available for replay or analysis at any time. By the same token, however, few people living before 1902 could have imagined that a tenor would sing “I die in desperation” onto a shellac disk and thereby live forever.

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Mr. Osborn edits Marin Medicine.

Email: sosborn@scma.org