I love paper, the feel of it, the sound it makes when you turn the page. I also love seeing patients in their homes, the experience of being in their worlds, the cultural diversity, the smell of a bubbling Haitian stew, the never-ending surprise of walking through that door. So you might think an innovation that would rob me of both of these things would leave me thinking about a career change. But the laptop computer is 7 pounds of irony. We have entered into a relationship with a soldered innovation that we can't live with and we can't live without. But it's getting better.

My productivity has been cut in half with the use of the laptop. I imagined that my employer, the VNA of Boston, would shudder at this fact. The laptop's labor-intensive format and the hours of data entry make it impossible for me, or my colleagues, to see the number of patients we once were able to see.

But the world of home care is a world like no other in medicine. It is one where the nurse generates the bill, and the laptop has enabled us to get this bill to the payer in record time. And as any good businessperson would know, this is a very good thing. Despite the fact that the introduction of the computer at the "Point of Care" in the VNA of Boston has cost over one million dollars, and will likely cost even more, it has saved the agency's financial life. PPS and paper did not mix well. It is entirely possible that the laptop has saved my job. Without it, my patient productivity would be zero. But I would have a lot of time to read. Now that's irony.

The introduction and implementation has come with no small measure of stress and dissatisfaction. Nurses in home care may present a different age demographic than nurses in hospitals. The average age of my coworkers is mid-forties. This disparity may have something to do with the fact that it undoubtedly takes more confidence and experience to navigate, in relative comfort and joy, from gunshot wounds to doilies, from steep stairs leading into dark basements to elevators rising into penthouses. And we are more familiar with Mickey Mouse than Mario Brothers. Hence, perhaps, our reluctance to shift from ink to electronics.

"This makes me want to eat bad things," said my nurse coworker Rhonda after 6 hours of struggling through one of her first days on the laptop. She's the one who snacks daily on fresh cut red and green peppers.

Joan wears two pairs of reading glasses as she sits next to me documenting her visits, one stacked on top of the other. Mike, who never wore glasses previously, now sports a pair the size of pie plates. And some kind of cyber-exhaustion has hit us as well. Incorporating the laptop into our back-to-back 12-hour shifts on the weekend, which is what my team does routinely, has produced a fatigue that is unique. If the brain produced lactic acid, we would all be toxic and cramping. "I was making the kids' beds on Monday," said Diane, as she pushed back from the glowing screen, "and I figured I'd just lie down for a few minutes. I woke up 5 hours later."

I have a more clinical concern that the computer will somehow serve as barrier between patient and clinician. It is a fear that so much attention will be paid to the electronics in the home that the patient will become secondary. I saw this once quite by accident when I was visiting an elderly friend of mine in another part of the country. I just happened to be there when a home care nurse came to do an admission. The clinician's attention was so focused on the laptop that he missed much of what my friend was saying. I vowed never to do that, but still worry that there is very serious potential to slip behind that electronic wall.

There are other shortcomings as well: the burdensome nature of the software, the small screen, the tiny font. In a word, it is often not very friendly. I also suspect that the program was not written by nurses but rather by lay technicians. My clue came when I noticed one of the options under Temperature. It was labeled "Auxiliary." A few weeks ago Mike, who sits two desks away from me, suddenly bristled out loud, "I hate when they call them 'Customers.'"

But it also must be said that there is tremendous potential and current benefit to the electronic changeover. Medication interactions are checked instantaneously. Physician orders flow smoothly and quickly. We will have the ability to print teaching tools, and I hear the possibility exists to access patient and clinician teaching video over the Internet. The days of illegible hand writing and lost charts are over. Certainly I feel overwhelmed. And I worry that the balance between humanity and technology has tipped in favor of the computerized tool. But nonetheless I imagine a day when this technology will be as friendly as the perfectly balanced pen.

Ray Kurzweil, in his new book, The Singularity Is Near: When Humans Transcend Biology, talks about the exponential growth in science and computers. He says there will be a time in the not-so-distant future when there will be "a merger between human intelligence and machine intelligence." And he says, "To contemplate stopping that, to think human beings are fine the way they are, is a misplaced fond remembrance of what human beings used to be."

After reading Kurzweil's words I gazed at my laptop and recalled a time in the past when it would have been considered high science fiction. Then I imagined Kurzweil's future and the same gray box looked suddenly cumbersome and antiquated. My musings on the future included a technology that would free nurses to spend more time with their patients and less time with their laptops. I was envisioning a time when home care nurses could walk through many more doors in one day, smell more bubbling stews, and become fatigued from climbing stairs, not straining their eyes.

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