Health Policy$ense

The Elusive Digital Doctor

A Conversation with Robert Wachter

Along with being Interim Chair of the Department of Medicine at the University of California and ranked by Modern Healthcare as the most influential physician-executive in the U.S., Robert Wachter, MD, is the author of 250 articles and 6 books, the latest of which has become a New York Times Best Seller. Entitled The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine's Computer Age, the book is being hailed across the country as the most compelling one yet written on its subject.

Also see video excerpt of Dr. Wachter's presentation at LDI here.

The Digital Doctor, which was the subject of Dr. Wachter’s recent talk at the University of Pennsylvania's Leonard Davis Institute of Health Economics (LDI), explores a dramatic, real-world case in which a child received a 38-fold overdose of a common antibiotic. Wachter uses that example to illustrate some of the unforeseen consequences of health IT and how it is influencing all aspects of health care. We spoke with him about the accomplishments and unexpected consequences of health IT, the process of writing the book, and new ideas that might deserve more attention from health care leaders and policymakers.  

Imran Cronk: How did your views on the pitfalls and promises of health IT change or evolve during the research, interviewing and writing process for this book?

Robert Wachter: My passion for writing this book was drawn from my own experience, which was terrifically disappointing. That came from a lot of angles: my own experience clinically, my   work in patient safety, and from seeing the way IT seamlessly fixed all the other problems in my life. I thought, “Health care is dysfunctional and clunky. I need to understand what has happened.” In the research, I came to believe that the dysfunction was almost predictable and even a natural outgrowth of the complexity of the problem, as well as the different and only partly integrated activities of diverse stakeholders.

As I got toward the end of the book, though, I had this epiphany. It dawned on me that this is all going to work out. You can feel like that with children if they’re screwing up. “Does today’s problem in first grade mean my kid’s going to be a heroin addict on the street?” [Laughs] Then you see these glimmers of “oh, that’s a success” and “that’s a success.” I can actually see how, as the kid matures, he’s eventually going to become a normal and valuable human being.

We’re definitely not there yet. Part of the goal of writing the book was to be honest and make clear why we’re not there and what the problems are – without sugarcoating them and getting stuck in the hype. It was like “OK, I get it, here’s what everybody needs to do. Here’s what the path looks like.” Then it really became a question of “How long is this going to take? Is that 30 years or is that 10? It’s certainly not two.” It became clear to me that to get to that place requires better choices and deeper understanding by a lot of different parties. I ended up in a much more optimistic place than I was when I started.

IC: What was the actual process of writing the book like?

RW: It was an interesting process. One of my trepidations when I decided to write it was that I’m not an informaticist. I know it to some extent as a clinician and administrator and in the work I do with patient safety, but my fear was that I would get into these very deep weeds and my lack of a deep understanding of the technical aspects of informatics were going to thwart my ability to understand and then tell the story.

It turned out to be a profound advantage, because I think you can get lost in the techno aspects. I came to understand that the fundamental problems here are not technical. Certainly, you need to work out the technical pieces, but these are fundamental business and organizational problems, as well as psychological, clinical, ethical, and financial. These are all areas I’m comfortable with, so in some ways it made me the perfect observer for all this.

I came in agnostic. What I was not agnostic about was my disappointment. It was clear [health IT] was not working out the way everybody had promised. Then the story sort of told itself. I sat down with my head just spinning with all of these insights from all of my interviews and my own thinking about it, and it kind of flowed in a way that was very exciting. It was an incredibly fun and, in some ways, magical experience. It all came together and little light bulbs went off, both in terms of my own understanding and in terms of making the writing work for the reader.

IC: How did you conduct the research and interviews for the book?

RW: I interviewed about 100 people and I was careful to be as broad as I could, to get people from a lot of different perspectives. Themes just emerge — you have a list of questions, but the interview just takes you where it takes you. There’s a richness that comes from not feeling like you have to get the answer tomorrow, but that the answer will emerge organically. You start with a big block of clay and you’re chipping away at it, and eventually you’ll have a statue. That’s the way it felt. The interviews are so much fun, if you like to learn and you’re open to it. At some point you have to stop and say “I have to write” which is hard.

I was on sabbatical. It took about a year — the first four months was in San Francisco while doing my day job, so it was really busy and hard to find the time to get things moving and start the interviews. I was in Boston for six months, which was not only to be on sabbatical and be in an incredibly rich environment with a lot of smart people around, but also to be stationed on the east coast. I came down to Philly and Washington and made some trips to various places — Epic headquarters, IBM headquarters, and spent a couple of days driving across the country with a primary care doctor to Dubuque, Iowa.

Being in Boston in particular, there were so many smart people around. Having a day where I would interview John Halamka first thing, Ashish Jha in the late morning, and Atul Gawande in the afternoon, and MIT artificial intelligence experts, and so on. There are a lot of smart people thinking about this from a lot of different angles around there. That was a tremendous luxury.

IC: How did it feel to complete the book?

RW: I remember the day at the end of October where I kind of set down my pen and my word processor, and turned to my wife who was helping me edit it, and I said, “Honey, I think it’s done.” I’m now thinking about this topic for a year since then, and I have read through it in various ways over the year. I don’t think I'd change a word. It really felt like, at the end, it was the place I’d wanted to be and said what I’d wanted to say. That was a very good feeling. It would have been quite crummy to feel like I rushed it.

IC: Health IT is changing so rapidly. What developments in the months since The Digital Doctor was published give you concern and/or reason for optimism?

RW: One reason for optimism is that the pressure for interoperability has grown substantially. Interoperability is really not a technical problem — it’s a political problem. If you are a vendor or a purchaser of IT, and even from the standpoint of most hospitals and health systems, you’ll say that you want to connect to everybody, it’s God’s work, and it’s the right thing to do.

But that’s not what determines whether you’ll do it. It’s hard work, it’s politically challenging work. The economics of it are not obviously beneficial to either party. So you’re only doing it if you’re made to. It could be that the legal or regulatory environment changes, or the business environment changes so that there’s an economic advantage to doing it, or you’re shamed into doing it — there are all sorts of mechanisms to get organizations and people to do stuff they don’t naturally want to do. Pressures for interoperability were growing when I wrote the book, but things have escalated markedly. That’s very good. I think it’s a crucial next stage to figure out how to get all these machines to talk to each other, and I think that will happen within the next several years, in part because important players like Congress, like journalists, even to some extent health systems, have determined that it’s got to be so and it’s time to make it happen. That’s a positive trend.

One trend that was emerging when I wrote the book was the entry of Silicon Valley into the world of health IT. It was conspicuously absent for a long time, since it made more sense to build the next Snapchat than to build the next health IT app. One of the unanticipated virtues of HITECH — $30 billion to try and make EHRs ubiquitous — was that it legitimized health care as a digital market for Silicon Valley and software companies. So we are beginning to see some cool things coming out of digital innovation shops, and the combination of the pressure on interoperability — which is linked to the pressure to create open platforms and abilities for third party IT tools to link into existing EHRs — those twin pressures create the opportunity for hugely exciting and truly disruptive innovations. Everybody talks about “this thing is Uber for health care” and “this thing is Airbnb for health care” — who knows? But none of that can happen until the innovator community gets excited, students in business schools get excited, computer science majors get excited and see health care as a viable market where you can make a profit and, by the way, do some good. That’s clearly what we want to have happen. That was only partly true when I was writing it, and it’s become more true recently.

I think the privacy and security breaches have become greater, not only in health IT but also in other fields. That’s the scary part of this — in some ways, it’s the dark side of something great. We’re going to have all these systems linked together, and you’ll be able to see patients’ records anywhere, and have big data with patient records, not just in your one building but in very large health care systems. That’s all very exciting, but if you’re a hacker in China or North Korea, it’s also exciting for you. We have not figured that one out, so that’s the scary part of the good part of having data aggregated. Those are the trends I spoke about in the book, but if anything they have grown since then.

IC: Along those lines, what developments or ideas haven’t we seen yet that you think should be a larger part of the health IT conversation?

RW: The health technology conversation can’t just be about technology. I’ll read where people will talk about, “We have this new sensor or monitors that tracks a patient’s heart rate every minute, and it’ll send it to their primary care doctor who will use it to manage his or her patients more effectively.” It’s like, what planet is that? It’s not one I’m familiar with. These sort of silly conversations about data being good for data’s sake and how wonderful it’s going to be if this happens or that happens, without even the slightest clue about the health care ecosystem. Really, patients and families are going to be able to use that to manage themselves this way? Really, a primary care doctor’s going to be getting data feeds on 2,000 patients and do something useful with that? How’s that going to work?

I think we’re beginning to get more sophisticated and mature conversations about the role of technology as an enabler. The purpose here is not, “Does technology do something spiffy?” but how does it actually work to improve health and health care? That’s inevitably going to take new business models, new staffing models, new specialties and workforce evolution. That’s what we got so wrong in the beginning. We just had this idea that you just produce a piece of technology, stick it out there, and it’s all good. There are a thousand examples of how crazy that is.

I think the alerts were the most interesting and scary example of that — “Wow, how great is it going to be in a computerized environment, when the doctor is about to do something wrong, or there is some information that the doctor should have, we’ll fire an alert!” Well, that sounds great. And then you say, “Oh, the doctors are getting millions of alerts. They’re normal human beings. They will ignore them just to get their work done.” Nobody really talked about that, but of course three minutes into using these tools you say, “Why didn’t we think about that?”

We have a set of complex problems to solve, and the solutions may be new technologies, but until you ask the question of “How is this actually working in real life with real people?" you will never get to the answer. I think that’s where we have to go.