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An Exclusive Interview with Robert Wachter, Author of Digital Doctor (Part 2 of 2)

May 15, 2015
by Gabriel Perna
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Robert Wachter, M.D.

Robert Wachter, M.D., author of Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age, recently spoke with Healthcare Informatics' Senior Editor Gabriel Perna at length about the book in a two-part interview series.

Wachter is a professor and the associate chair of the Department of Medicine at the University of California at San Francisco (UCSF).

Part one of the interview featured Wachter talking about how the book came to be, how he was able to get so many interviews, and some of the people he enjoyed talking with while writing it. In part two of this interview, Wachter addresses the meat of the book: the critical chapters on alert fatigue, Aetna vs. Epic, and healthcare IT policy. Below are excerpts from the interview.

The story that got me interested in reading the entire book was the tale of Pablo Garcia and his 38-fold overdose of a drug called Septra, thanks to issues with alert fatigue. Obviously, that happened in UCSF, what fascinated me was that your organization allowed you to write such an in-depth tale of a major screw up. How did you convince them to do that?

It never would have worked if I were younger, newer, and hadn’t been hanging around here for 20 years. Doing stuff that's pushed the envelope has mostly worked out. I've had series in medical literature and wrote a book on patient safety where we talk about medical mistakes and did them anonymously, paid attention to HIPAA protections, paid attention to the right people. The organization believes in me and believes when I choose to do this my motives are in the right place, and I'll do this fairly and carefully. UCSF believes that’s been a good thing for the organization, for our patients, for the people that work here. I come into it with a little bit of street cred, which helps.

When I heard about that case, I was sitting at the root cause analysis meeting, I was flabbergasted. I thought, "My God this is the perfect case to illustrate how our hope that computers would make plow through medical mistakes has been partly realized but has created a new classes of errors." I loved how the case fit in the dominant paradigm of patient safety, the Swiss cheese model. It's never one thing, it’s 10 things. It’s the technology plus the people, the human factors, the culture.

What was so beautiful about this was that the part we thought were fixes created new problems. "The computer can alert you," doesn't work when you get two million a month. Replacing a human with a robot is fine for medication distribution, but when it’s told to do something crazy, it doesn't object. You had a young nurse on an unfamiliar floor seeing an order that is in retrospect completely ludicrous, and she knows that, but she figures to get to her it had to go through a robust safety system. She checks with the barcode scanner, which signals that the order is correct. So that extinguishes her concerns over the bizarreness of the order. It was so beautiful in every dimension, I couldn't have made it up. So when we're at this meeting, the head of risk assessment, the lawyer whose job is to prevent us from getting sued, is sitting next to me and I said to her, "This case is perfect, I need to write about it." She quite appropriately said, "Oh my God really?"

She told me I'd need to anonymize it but she didn’t reject it out of hand. She told me to get permission from the CMO, who told me I needed permission from the CEO. I asked the CEO about it and he was mulling it over. He and I were at a meeting discussing the case and it became clear that the case was fabulous in spelling out the challenges in technology, the human/technology interface, the culture, all that. He looked up at me. I saw I had gotten an email from him and he said, "We have to publish this."

I think it’s a remarkable act of organizational bravery. There are many, many places in the country that would not have let me do it. Part of it was me because I had done this sort of thing before and it worked out. The fact the kid didn’t die, had he died I don't think I could have gotten permission. That was dumb luck. He could have easily died but it turned out this antibiotic is not the most dangerous one in the world. They all told me it would be great if I could get permission from the patient, which I did. There was a lot of bravery. The mother allowed me to interview her and her son. The most the brave people were the doctor, nurse, and pharmacists...they asked me to change their names...I could see them never wanting to talk about it again. They all said, if anyone could learn from this experience and decrease the chances of it happening again, then it's worth doing. I'm proud of them and proud of my organization for letting me doing this. Not a lot places would have.

What do you think Pablos tale tells you about health IT systems?