In an interview with MedPage Today, Robert Wachter, MD, associate chairman of the Department of Medicine at the University of California San Francisco, reflects on the nimbleness of companies in Silicon Valley and the sense of disappointment with the state of technology in healthcare.
Robert Wachter, MD, works an hour north of Silicon Valley. Being surrounded by an "incredibly dynamic, vibrant IT ecosystem" contributed to a sense of disconnect for the associate chairman of medicine at the University of California San Francisco.
Wachter couldn't help but compare the nimbleness of companies to the sense of disappointment with the state of technology in healthcare, he told MedPage Today.
He doesn't mince words. "In retrospect, we were bound to be disappointed," reads the first line of his latest book, "The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age," when he compares the daily experience of consumer technology to healthcare's less straightforward path to computerization.
But in addition to pointing out technology's problems, Wachter offers hope: a vision of what healthcare could look like "if we play our cards right" -- if stakeholders "work together and make wise choices."
MedPage Today talked to Wachter about the most encouraging and frightening aspects of technology in healthcare and who can provide guidance in navigating the changing digital landscape.
MedPage Today: In healthcare, what is technology very good at doing?
Wachter: I have no doubt that having technology is better than not having technology. I have no doubt that my hospital is safer now than it was before we went digital. The people who are arguing that we should pull out the computers -- I think that's crazy.
What are the main advantages? Creating a way that multiple people, separated in time and geography, can look at legible information has been extraordinarily valuable. I can read my residents' or a specialist's notes from home, look at an x-ray on the floor rather than going to radiology, show patients their x-rays in the hospital room. The combination of legibility and the fact that you're not tethered in a single place to read the medical record has been a huge advance.
I think also -- this is a little bit in the earlier phase -- that computerization is contributing to the democratization of healthcare. You're beginning to see patients take advantage of online resources to learn about their diseases, to communicate with their physicians, and to communicate with each other. I think that's largely for the good.
MPT: Are there areas that we've been promised that technology will deliver but then didn't live up to the hype?
Wachter: Well, that's what much of my book is about. Most of my reason for wanting to look at this was that the hype was far outstripping the reality.
I'd say electronic health records are an example more of promise than hype. I don't remember a huge amount of hype about how electronic health records would transform everything, but there was a general feeling that they would make care safer and cheaper. That certainly was the promise the federal government was counting on when it put $30 billion behind EHR [electronic health record] adoption in 2009. But I don't think people were saying that they're going to be magical.
I'd say the area that feels pretty "hype-y" right now is big data, which has huge promise, but has had limited results in healthcare, at least so far. In particular, the Quantified Self idea -- patients walking around with sensors and figuring out their steps and their heart rate and all that -- I think that's mostly hype for now. I've worn a FitBit a couple of times for about 2 months, and then I got bored with it. And counting steps is actually useful data.
What possible use will a patient have for minute-to minute monitoring of blood pressure or heart rate or some of the other physiological variables? I have no idea. I'm a physician and I have no use for that kind of detail, at least not yet. But I think they're being hyped by companies and others who have an interest in their sales.
Artificial intelligence in medicine has also been over-hyped. I get it -- how could you have watched Watson defeat the "Jeopardy!" champions and not believe that computers would ultimately take over for doctors? It turns out to be -- lucky for us physicians -- harder than it looks. But that hasn't toned down the hype.
A related area, genetics, will likely ultimately be tranformative, perhaps even miraculous. But today, with a few exceptions, mostly in oncology, it hasn't been all that helpful in managing the day-to-day issues that come up for doctors and patients.
A lot of this hype was natural, and expected. Just think about technology in the rest of our lives, where it is so slick, and so magical. And there are lots of companies that have an interest in promoting their products. I think it's up to all of us to see through the hype and get to what's real and what we need to do to make it better.
MPT: You spend chapters in the book talking about what healthcare will look like in the future, what the ideal situation is. For you, what are some of the most encouraging parts?
Wachter: One of my discoveries in writing the book is that part of the hope comes not so much from better technology but from re-imagining the work. The first one that comes to mind is re-imagining the doctor-patient visit, so that clinicians can simply have conversations with patients and focus on their stories. In the future, I believe that the computer will capture that conversation and put it into whatever form it needs, through natural language processing and technology, rather than having the doctor sit there having to fill in 20 fields and check a dozen boxes.
This idea of the "productivity paradox" was a key revelation for me. History tells us that, in many industries, they brought in the technology, said it's going to transform everything, and it took 10, sometimes 15 years to do so. It's not that technology has to get that much better, although it does get better. But it really is a case of everyone getting comfortable working in a digital environment and then re-imagining the work.
For us, it will be: what should training look like in this environment? What should the doctor-nurse relationship look like? What does the doctor-patient relationship look like? How do you use big data in a way that's productive? For the patient being managed from home -- through sensors and telemedicine -- how do you ensure that they're getting the care they need?
MPT: Your book also talks about potential and actual harms. What are some of your greatest fears when you think about how healthcare is going increasingly digital?
Wachter: It's very clear that computers fix a lot of patient safety problems, but they create new ones. That shouldn't be that surprising. That's the history of patient safety.
The alert and alarm fatigue is the biggest one, I think. We must be much more creative and thoughtful about that. We have pushed millions of alarms out to people with absolutely no cognizance of human factors and what happens to humans when they get bombarded with alerts.
What struck me when I spent a day at Boeing was that technologically mature industries design around these issues. Before they put in an alert, they watch and see what happens when the pilots use it. When you look at how Google and Apple do their work, they're constantly tweaking the technology and seeing what happens when they do. We need to start thinking this way in healthcare tech design.
I have other concerns, too. In an environment in which patients are going to have access to their own medical data, new sites will emerge that allow patients to make diagnoses and help figure out what the treatment is. All of us are now used to self-managing our travel and our finances, which creates a huge impetus for people to try to manage all their medical problems themselves. Much of that is healthy, but some of it is pretty scary, because people may make some pretty bad decisions. Or be given a level of responsibility that they either are not capable of or truly don't want to have.
That's not to say that we should go back to old-style paternalism. For the most part, more patient-centered care and more patient involvement is a good thing. But it's a double-edged sword and we have to calibrate it right. If you have a $100 copay to see the doctor, then you've got a pretty strong incentive to try to manage this problem yourself. And some of the time, that's going to be the wrong call
MPT: You've mentioned Boeing and Apple and Google in terms of who we can look to for guidance about how best to use the technology. Is there anyone else that you can think of that we can look for guidance? Doctors? Patients? Politicians?
Wachter: Not politicians, I'm afraid. I think that my model for the government's role in technology comes from the Internet. It was really scientists from the Department of Defense who invented the Internet. But soon after it was invented, the government, which could have regulated the hell out of it, pulled back massively. They had the instinct -- a correct one, in my view -- that government is not going to be good at managing a technology that's got to be nimble and adaptive and can't be swayed by the politics of the moment.
I think the government's decision to invest $30 billion, under the HITECH Act, to fund healthcare IT was a good call. But the time has come for the government to pull back from its present posture. Unfortunately, giving up power is not generally a core competency of any government known to man. So I think it's tricky.
I don't want to tar the IT companies. I spent several days with people at IBM, at Athena, at Epic. These are really smart, good people, who are generally trying to do the right thing. But they have certain business models. Particularly in the case of Epic, building a relatively closed system has worked for them up until now. But I doubt it's the right model for the future. They're going to need either some political or market pressure to open up. Because ultimately the winning model can't be a closed one.
Silicon Valley has traditionally kept far away from healthcare, feeling like it's way too regulated, the payoff is too far in the future, and you're better off building the next Facebook or Snapchat. But now, because healthcare has finally gone digital, they realize that this is really the last big sector of the economy that still has rudimentary IT tools. So they're now jumping into this in a very big way. I think we are going to see a lot of really exciting innovations from start-ups and companies that have built consumer-facing IT up until now.
The challenge there is that these companies are going to be pretty good at the patient-facing part of this. Because they're used to that. But it still leaves the enterprise part of the equation, your hospital or clinic EHR, stuck in the old model.
Will we see the kind of innovation that we need from the existing health IT companies, or will these companies be supplanted by new models? I think that's an open, and crucial, question.
Read an excerpt from The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age.
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