Robert Wachter, M.D., chair of the Department of Medicine at the University of California, San Francisco, is considered the “father” of the hospitalist field and a leader in the patient safety field. He’s written six books, including “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age,” which took a detailed look at the role of technology in health care. (We covered his 2015 talk to AHCJ-New York chapter members in this article).
Wachter was a keynote speaker at the recent Society to Improve Diagnosis in Medicine Conference in New Orleans – where he talked about medicine’s digital transformation and the upsides and the downsides that accompany progress. He sat with me for a brief interview prior to his presentation.
Q: How far have we come since you first started researching and writing your book?
A: I think we’ve come a little bit further. I think we can see a clearer path to real substantive improvements. One of the things that’s been interesting is that the fact that the entire health care system became digitally enabled and promoted a huge investment in digital health care by venture capital companies and by every digital giant in the world.
We’ve seen in the last two years some major initiatives from Amazon, Apple, Google, Microsoft and IBM. Those aren’t paying off yet, but it seems unlikely that they won’t. These companies aren’t stupid. They see a huge swath of the economy that’s going digital and they see the opportunity to improve quality or decrease waste or improve productivity. Whether it’s the digital giants, whether it’s startups funded by venture capital, I think we’re beginning to see evidence of improvements on a path for real transformation over the next five years or so.
In good delivery systems that have had their computer systems for a handful years, you get past that early shock phase, that early squeamish computer phase, and you begin to say, how do we think about a new way of doing this “thing?” How do we take advantage of this technology, recognizing the new way doesn’t come with instructions when you open the box from [EHR developer] Epic? Nor is Epic or Cerner enabled to do it but they allow you to rethink the way you do certain tasks. I’m beginning to see enough of that in my organization that it’s demonstrating, I think, what the future will look like.
Q: Are the patients embracing this shift? What does digital take away – or add to – the doctor-patient relationship?
A: It can and should do both; one hopes it adds more than it takes away. Right now, I think it takes away more than it adds. Our problem is that we turned on these computers, we really didn’t think about the impact of technology entering the exam room, we said to the doctor in the middle of trying to do this really complicated thing, with a lot of uncertainty, talking to a human being, who’s got a bunch of different issues, and synthesizing them, now you also have to be the chief documentation officer. Now that we have a computer we can make you fill in a whole bunch of boxes – you won’t be able to close your encounter unless the things are filled out, and for all of that hard work, you essentially get nothing back from the computer.
We have to do a bunch of things. We have to decrease the documentation burden; we have to create new electronic tools that handle some of the documentation so that doctors don’t have to sit there and type; and also change the ratio so you’re not just inputting stuff but the computer actually delivers meaningful decision support. I don’t think we’re far away from that. I think people have recognized that it’s a horrible situation – the doctor looking at the computer rather of the patient. You see a number of startups and you see Microsoft and Google and others, now trying to figure out what a digital scribe would look like. It’s probably not two years away, but no more than five, when the doctor and patient will actually have a conversation and they’ll be some Alexa-like thing in the corner that will essentially feed the chart. That should make it substantially better.
Q: Do you see any differences between younger and older patients accepting the changeover to digital record keeping?
A: I think younger people are more accepting of the notion that the people they interact with are going to be more distracted; you go out to dinner and everyone is on their devices. I think everyone’s annoyed by it; everyone wants the full attention of the other person when you’re talking about something that you’re concerned or anxious about. That can be fixed by technology. Technology caused the problem but it can also fix the problem.
In terms of the balance of the doctor-patient relationship, the technology is enabling patients to have access to medical care in far different ways. The fact that my patients can take a picture of a skin lesion and send it to a dermatologist, or schedule an appointment online or have a tele-visit or … at our place 20 percent of consultations are electronic consultations, without the patient going to see the specialist. Those are massive advantages for patients.
My theory is we got this really wrong by not understanding the complexity of converting this wildly complicated industry from one way of doing work to another. In retrospect, the fact that it’s been so infuriating should have been predictable. And it was almost a necessary, although unpleasant, stage that we had to get through to get to a better place. Some of what you’re hearing is the sounds of progress.
Increasing rates of physician burnout and doctors complaining about their computers is what it looks like to create pressure on technology companies and on Medicare to change the billing rules, to build better user interfaces, to build a digital scribe. I don’t think there would have been a business case for this five or 10 years ago. It’s only after it’s been out there for a while that you then create the platform to make things better.
Q: Why was the idea of pushback from doctors and patients basically ignored when this massive shift in documentation, communication, and relationships was occurring?
A: In a different world you could say we should’ve anticipated all of this and fixed it before we implemented the computers. But none of us are really smart enough to rethink the entire work and workflow around the technology until we have the technology in front of us and play with it and complain about it and kick it a few times.
Maybe Henry Ford had that imagination; maybe Steve Jobs had that imagination. The rest of us mortals don’t know anything more than taking the technology and inserting it into an old system, and lo and behold, it not only doesn’t make things better, there are times it actually makes things worse. For example, when we built the doctor’s notes in the computer it was just an electronic version of a paper note. It was unwieldy and hard to use. We made the note worse by taking the technology and trying to do something before we actually had the tech to do it. You weren’t creative enough to do something truly novel so you did the old thing, without thinking through the implications of what that might look like.
I’m a believer that in a different world we could have bypassed this adolescent phase. But I don’t think so. It’s a necessary growing pain. The hardest thing to do we did – going from a paper-based to a digital-based industry in the last 10 years. That’s a pretty heavy lift and that’s pretty exciting.
Q: Do we run the risk of patients bypassing doctors and over-relying on digital solutions because their apps or smartwatch or a webpage gives them one part of a possible solution?
A: There’s risk and non-risk. There are plenty of times where patients have to take a half day off from work to see a doctor that an intelligent system could diagnose correctly. There are also times that patients do that and the computer says to them you’re OK and they’re not. One of the things that digital does in every industry is democratize it and this offers patients access to information that allows them to self-manage things that they used to depend on a credentialed professional to do.
We do our travel, and taxes and finances ourselves and most people would say that’s a good thing; until you screw something up and realize you probably should have seen a professional. In medicine, the stakes are higher, there are more things you probably should see a professional for. To me, this is part of the excitement. It’s easy to imagine a system where for a number of things the patients need to do they do themselves, aided by technology. The question is how do they then interact with that medical system in a way that may not be that 15-minute office visit? You may need another layer that monitors data from your watch or app and answer some questions.
Q: How can journalists tell these stories better?
[note: Wachter is married to journalist Katie Hafner]
A: Be really skeptical of hype. Now that there’s a lot of money in this you’re seeing the entry of traditional digital companies and a lot of startups. They’ll sell you a bill of goods and they’ll sell others a bill of goods and they may be well meaning; they’ve got to try and create a business or those initiatives will flame out. The questions aren’t so much about whether the technology is working but what are the deeper implications of this? What’s the workflow? What happens when the patient gets really anxious about this? Who does the information go to?
It’s technical vs. adaptive change. It’s easy to cover the technical change – here’s the new bell and whistle – and does it do the thing they say it’s going to do accurately. It’s a little harder to cover adaptive change, which is how does this actually fit into the lives of patients and the health systems and health organizations and doctors and nurses? I think those are going to be the more interesting stories.