Q&A: Robert Wachter on health IT's 'hope, hype and harm'
"The interviews really brought it to life; it was fun to do," says Robert Wachter, MD, describing the 90 or so people, from across the healthcare industry and beyond, he spoke with for his probing and sometimes provocative new book, The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Computer Age (McGraw-Hill), which looks at the consequences – intended and unintended – of the past five years of electronic health records.
Wachter – associate chair of the department of medicine at the University of California, San Francisco; practicing physician; patient safety guru; hospitalist pioneer and blogger – casts a wide net, exploring the sprawling and multi-faceted evolution taking place across this enormous industry these past few years through a series of well-reported and engagingly written vignettes.
He explores the EHR's effect on the physician note and patient experience at the point of care; the successes – and excesses – of HITECH and the meaningful use program; the battle for marketshare and mindshare of pugnacious vendors such as Epic and athenahealth; the impact of big data and supercomputers on doctors and the care they deliver; the changes in store thanks to increasingly engaged and empowered patients.
Crucially, Wachter explores IT's impact on quality and safety – focusing on a jaw-dropping case at his own hospital where a child was administered a 39-fold overdose of a common antibiotic thanks to an electronic miscommunication.
It all makes for a hugely compelling read, as Wachter weaves together a series of short stories that explore the "characters, the plot subtleties, and the triumphs and tragedies" (as John Halamka, MD, describes it in his book jacket blurb) of a momentous few years in which technology has been "pulling medicine apart with only a vague promise of putting it back together again," (as Atul Gawande, MD, puts it in his).
Wachter spoke to Healthcare IT News recently about his own experiences, his reporting and what he learned along the way.
Q: The subtitle of your book mentions the "hope, hype and harm" of health IT. Should we read anything into the order in which you list those words?
A: Not really, other than they sounded good in that order. But the three words themselves are crucial, and I thought carefully about them. What I wanted to make clear was that much of the discussion about health IT, much of the writing about health IT has sort of veered toward the hype side. And I think that's understandable. There are some vested interests that do have an interest in that. We're so used to IT in the rest of our lives exceeding our expectations and being almost jaw-dropping in terms of how good it is, I think the disconnect between the promise and what we're seeing in healthcare created they "hype" part.
The "harm" was a little tricky. Because there's no question that I think care is better and safer with computers than without them. But I do think we are seeing real instances of harm and I do spend a fair amount of time in the book going through one case (the antibiotics overdose at UCSF) that I think is emblematic and has surprised many of us who have worked in patient safety. We were waiting for years for computers to fix the problems of medical mistakes, and they're doing that to some extent, but they're also creating other new hazards.
The "hope" was very important. I didn't want people to think I was a luddite, or that the book would be a dismemberment of the health IT industry, or not reflect my deep feeling that we have to do this, we just have to do it better. As you can see in the book, I come out of it in a very hopeful place – much more so than I'd anticipated when I went into it. It became clear to me that we can get to a really wonderful place – and we probably will – but we're not there yet, and the path to getting there is what I was trying to explore.
Q: Talk about your own experiences with health IT.
A: I don't think I was all that atypical. Because I spend part of my time practicing, part of my time administering and part of my time writing, I saw it in different dimensions than a doctor or nurse might. I certainly saw the clinical impact, but then I would see the impact when I would go to the quality and safety committee and begin to hear about new kinds of errors.
Our first EHR was pretty clunky and there were the typical problems of new IT systems: It would freeze on you and it would go down periodically. It was blocking and tackling type of stuff. It was just not a very good piece of technology and that was obvious up front. Not to excuse it, because we needed it to work, but it was like your cell phone from 20 years ago, and we hoped it would get better.
The parts that really began to surprise me, and made me realize this was a more interesting and richer set of questions than I had recognized, were the changes in communication patterns. As I mention in the book, this idea of the end of radiology rounds. I mean, who would have guessed that? (The Digital Doctor features a chapter on radiology – which went digital years before the rest of healthcare – and explores some of the unintended consequences of that fundamental shift, including the fast disappearance of "collegial, educational, fascinating" collaborative review of X-rays, once PACS came into the picture.)
I went back and checked the literature to see if anybody, prior to radiology going from analog to digital, was anybody doing any hand-wringing about what this was going to do to the field, to the value of clinicians of going down and talking about their X-rays with radiologists? Almost nothing there. It was sort of a surprise to everyone. But quite clear that the minute radiology went digital, the rounds, which had been absolutely wonderful – the docs taking care of the patients would go down to the radiology department, look at the films and discuss the cases with the radiologists – they just evaporated, almost overnight.
I thought, well, that's interesting. I didn't guess that. And then I would walk up to the medical service, which I run, and look around: you almost saw tumbleweeds. I asked, where are all the doctors? And they were in this tribal computer room we'd created a couple floors away, hanging out with each other.
And it dawned on me that nobody thought that would happen, but it was, in retrospect, completely obvious it would happen. You're no longer tethered to the radiology department by a film or to a floor, to a ward, by a paper chart.
And that's really where I began thinking about these unanticipated, almost sociocultural impacts. And then when I watched Watson beat the Jeopardy! champions, I sat there and thought, "Oh my God, when is that coming to medicine?"
I'm very luck in that I had this outlet for questions, namely my wife, who writes for the New York Times. I kept turning to her and saying, "Here's an interesting story," and she'd turn around and write about, "Are we going to need smart doctors in the age of Watson?" And, "What's this thing with scribes, how did that happen?"
It really did not dawn on me that I was going to write about this, partly because I'm not a technology person at my core – although I certainly use it and like it – and it wasn't until the day where I attended the meeting where we discussed this unbelievable medical error where we gave a kid a 39-fold overdose – at a hospital where there are a lot of really good and smart people, and some of the best technology that a lot of money can buy.
There was a moment where I was just flabbergasted. And then the next moment I came home and said, "I really need to write a book about this." It just evolved gradually. And I think I am quite fortunate in that I do still practice medicine, I do still have administrative roles, locally, and some national positions where I get to see this from a number of different levels.
And what I get the sense of is this story of the elephant. People were looking at this particular story and seeing different parts of it, but nobody was seeing the big picture. And everybody was sort of surprised and a little shocked that it wasn't going better. It's a contribution I thought I could make: deeply immerse myself and really see the whole elephant – describe it in a way that might be helpful for people looking at it from other angles.
Q: So how did you decide how to lay the book out? You let the anecdotes tell the story, but how did you decide who to talk to, where to go?
A: I sort of started at the beginning. And the breadcrumbs led me to various places. The things I knew I wanted to do in the very beginning were to do something about the note, and why documentation had become so problematic. I knew I wanted to do something on communication patterns. I knew I wanted to do something on artificial intelligence. I knew I wanted to do something on this one particular error because that's my sweet spot, patient safety. And I knew I wanted to do something about big data, mostly because I kept hearing about it and I didn't know much about it and I thought it sounded cool. I wanted to know if it was real, or all hype.
Those were some of the general directions I wanted to go in. I also knew that the reason this was such an interesting story now, and not so much 10 years ago, was that we are in this remarkable period after 15-20 years of talking about computerization, where it has finally happened in the past five years – largely because of HITECH and $30 billion of federal fertilizer. I knew I needed to explore those policy dimensions at some level: has that federal intervention worked, or not worked?
So those are five or six threads, and with each of them I sort of started at the beginning. For the fed angle, (former National Coordinator for Health IT David Brailer, MD) is a good friend and I called and asked what were you thinking at the time and how did it work? I came into this with the bias that it was a really good idea; that healthcare was a market failure and we needed government intervention to make it work and getting us computerized. Sure, I'd heard a little bit of moaning about "meaningless abuse" but I thought it was sort of people who were anti-government. This was our first interview, and David said to me, "It's turned into the Frankenstein that I'd most feared."
The big data, the tension between the humanism and the data approach, Abraham Verghese is a good friend, and I'd been reading the stuff Vinod Khosla has been writing about computers taking over for doctors. That seemed like a logical pairing and it just so happened I got interviews with them both on the same day.
There were other parts that were complete serendipity. I was visiting the Mayo Clinic and told a friend of mine there who is a hospitalist and informatics expert, Jeanne Huddleston, I told her I was writing this book and she said, oh before you leave you need to speak to this guy, he's one of our informatics gurus, he started life as a surgeon but left the life of surgery after one night there were four code blues on his watch. I paged him as I was leaving for the airport and I kept the cab waiting for an extra 15 minutes as he was describing this to me.
Captain (Chesley) Sullenberger told me that if I was really interested in this I should think about going up to Boeing to see what they think about computers in the cockpit, and cockpit design. I never would have thought of that on my own, and I'm not sure I could have gotten access. But one email from Sully and I'm sitting in a 777 simulator.
Q: What were some other things you learned?
A: I had to learn something that was a hard lesson – one I learned from my wife, which is that if you're too careful, you can't do this justice. You're doing this for the reader. You're not doing this for your relationships with these people. And I've heard people come back to me and say, "Y'know, you were tough on (former National Coordinator Farzad) Mostashari, you were tough on (Vinod) Khosla." And I get that, I probably sort of was. But that's where the story took me. In some ways it's like being a physician: your'e getting a set of facts and in some ways beginning to create a hypothesis about what the diagnosis is.
(Mostashari's tenure as ONC chief is praised for its "zeal and motives" in the book, but comes under some criticism for raising the bar too far on Stage 2 meaningful use, with many of the mandates -- such as the view/download/transmit rule -- depending on a "clinical ecosystem and healthcare culture that did not yet exist," as Wachter writes.)
I kept talking to people, whether it's primary care docs or CIOs, and they keep saying, meaningful use it's a step too far, and it's too prescriptive, it's too far in the weeds and it's driving us crazy. I had a hypothesis about how that could happen: How someone is Washington with the power and the budget, who was passionate about making this go in a certain direction – particularly someone who might not deeply understand what it's like to practice medicine – could do that.
Mostashari was nice enough to let me interview him, and he told me about how he became "Farzad Unplugged" (aggresively pushing for more and faster IT adoption). And as he describes his own philosophy, it fell into place, and I could understand how he could kind of do as he did. What I was hearing back from my interviewees was that while they understood it, and were appreciative of the philosophy at some level, what was really happening in day-to-day practice, had more negative than positive.
Q: In closing, were their any surprises you encountered along the way that maybe changed your initial way of thinking about all this?
A: Certainly, Chapter 27, about the future state (of health IT), was a much more optimistic chapter than I would have anticipated writing. That was a reflection of speaking to 90 different people who had wildly different views on some of the key questions of the day. But I always at the end said where does this end up if we play our cards right? And no matter how different their approach was to all sorts of questions, their answer to that question almost always converged in the same pretty hopeful, pretty wonderful place. And I came to recognize that that place was within our reach, and we probably would reach it. The real question is whether we get there in five years, or 25. The choices we make will determine that.