Healthcare leaders need to prepare for a new world of continuous change and unexpected consequences to intended actions, one in which information technology will be transformative both in anticipated and unanticipated ways: that was the message that Robert Wachter, M.D. delivered on Nov. 3 at the Sofitel Hotel Los Angeles at Beverly Hills, during the Health IT Summit in Beverly Hills, sponsored by the Institute for Health Technology Transformation (iHT2, a sister organization to Healthcare Informatics under the Vendome Group, LLC corporate umbrella).
In an afternoon keynote address whose title matched that of his book The Digital Doctor: Hope, Hype and Harm at the Dawn of the Computer Age, Dr. Wachter, a professor and interim chair of the Department of Medicine at the University of California, San Francisco (UCSF), told the assembled audience that “I have been waiting for technology to come into healthcare for more than 15 years, partly because of my involvement in patient safety. That was part of the reason I was interested in technology,” Wachter said. “The other was my iPhone. I think we had this sense that healthcare IT would be similarly easy and straightforward; and perhaps if Apple had done it, it might have been, but they didn’t, and it wasn’t. This has turned out to be extraordinarily complex, far more complicated than anybody had believed.”
Robert Wachter, M.D.
Wachter told his audience Tuesday afternoon that “I was thinking about those things until about 10 years ago at UCSF, when we gave a kid 39 antibiotic pills when the correct dose was one. And we were sitting in a meeting about this, and I little light bulb went off, and I said, I need to find out about this. So I went up to the head of risk management and I said, we have to do something about this. And she said, great, let’s have meetings about this. And I said, no, I need to write about it. And her hair went on fire, and I took a fire extinguisher and put it out. And then we had some meetings, and I approached the CEO, and he gave me permission to write about it publicly. And that was extraordinarily courageous of him and our institution.”
The first part of Wachter’s speech reflected some of the same background information he had shared with HCI’s Gabriel Perna in interviews published on May 8 and May 15. Of course, Wachter noted in his iHT2 keynote address and in his HCI interviews, he had been a practicing physician and a medical administrator for many years, but never a journalist. So it was fascinating for him to speak with healthcare leaders, and leaders from other industries like aerospace, and get a truly big-picture view of the changes rocking U.S. healthcare. Wachter said he was very gratified that the book made it onto the New York Times bestseller list, but he admitted that, like any author, he carefully watched how well the book was doing on Amazon’s ranking of book sales.
Meanwhile, Wachter told his iHT2 audience, “I’m going to take a wide-angle lens and make sure we’re all thinking about where this is all going,” as he showed a slide of a photo of a group of UCSF medical students. “They’re wonderful, smart, and haven’t been jaded yet,” he said of the med students, adding that, “I was trying to shake them up, so about a year ago, I said to them, ‘You folks are entering a profession totally different from the one I entered 35 years ago, because you are under unrelenting pressure to figure out how to deliver the highest-quality care at the highest level of satisfaction and at the lowest cost.’ And one student raised his hand and said, ‘What was it you were told you were supposed to do?’ And what’s odd is not that we’re under this pressure, but that it’s new. It’s odd that we were under no pressure to deliver the highest-quality care and the lowest cost, as in other industries. That’s new. And that’s called value.”
In fact, Wachter said, there are two major pressures facing clinicians and administrators in the U.S. healthcare system right now, and purchaser- and payer-driven efforts to compel a fundamental shift towards value-based care delivery and payment systems are one; the other is the pace of clinical practice and operational change being created by the digitization of healthcare in the U.S. “Healthcare has gone from an analog to a digital industry in just the past few years,” he said. “People say to me all the time, were you Luddites? We loved technology when you could stick it in a corner and bill for it”—meaning medical technology that is not information technology. “But in terms of information technology, our fundamental technology was pencil and paper.”
In fact, Wachter said, one of the most surprising developments in the past several years has been the explosion in “consumer-facing” technologies (such as FitBits, etc.), coming out of the meaningful use process, in his view. In fact, he said, referring to the tens of billions of dollars in incentive payments to hospitals and eligible professionals under the HITECH (Health Information Technology for Economic and Clinical Health) Act, those billions “did an expected thing and an unexpected thing. The expected thing is the money that helped providers to buy electronic health record systems; and pretty much everyone is computerized. That was quite predictable. Here’s the part that I don’t think anybody quite predicted: it was that it created a market for consumer-facing IT.”
In fact, that path has been a complicated one, because an initial plunge by many non-healthcare corporations like Google and Microsoft in the 2005-2008 period led to a string of highly publicized failures. “After their first experiences,” Wachter said, “most of the big companies like Google and Microsoft said, this is too hard, this is too regulated, too crazy. So people said they’d build the next Snapchat or Instagram,” instead of delving more deeply into healthcare. “But that’s all changed now over the past four or five years,” he said, because the payouts from the HITECH program have helped to “sort of legitimize healthcare” in the minds of venture capitalists and other investors. “The Google app didn’t work because it was too hard to create contracts and each was a hassle. Now, companies are saying, the time is now, it’s the only segment of the economy that’s not wired, it’s 18 percent of the economy. But that was unexpected, and may turn out to be the biggest thing that came out of” the meaningful use process.
One of the key questions, Wachter said, referring to the difficult work laying the foundations of the Transcontinental Railroad in the 19th century, is this one: “Who lays the golden spike, so that there’s no difference in where the data comes from, whether a hospital EHR or a Fitbit? That’s when things really change.”
In fact, Wachter said, “We have no idea how this ends up, the digitization of the U.S. healthcare system. Ask my wife, who writes for The New York Times: digitization ended up upending the entire publishing industry. So for all of us in legacy organizations, the challenge is to do all this but make sure we don’t get upended by new companies or existing companies entering the space”—disruptive entrants such as CVS.
One example of all this, Wachter said, is how the digitization of diagnostic images has inadvertently led to the commoditization of radiologist services, as images can now be shipped off to India or anywhere, and radiologists are finding their previous economic and professional security threatened in ways that no one imagined when diagnostic images first went digital.
Wachter quoted Richard Baron, M.D., a primary care physician whom he knows personally, and who had implemented an EHR in his four-doctor office in 2005. Wachter said that Baron told him, “The staff came to work one day and nobody knew how to do their job.” In fact, Wachter said, “I think that’s a profound comment. We tend to think that when we digitize, we’re just digitizing processes, but in fact, you’ve transformed the core of your work. Rich said, we came to realize that we ran the office on post-it notes, and in fact, we didn’t know how to work without them.”
With regard to all the disruptive changes now buffeting providers, Wachter said, “In my book research, I did not find that there were bad people at Epic or Cerner or in the government or in hospitals, or anywhere. Everybody’s trying to do their best. But part of the problem is that we treated computerization in healthcare as technical change, meaning that you turn it on and follow a series of steps; and we thought healthcare IT would be like that, like turning on an app. But in fact, technology has posed adaptive problems: it’s been about people having to change because of technology implementation.”
So on the one hand, Wachter said, “It’s natural to think that you just put it in and it will work. But we all kind of whiffed on it. And now we’ve learned. And Erik Brynjolfsson in 1993 coined the concept of the ‘productivity paradox’ of information technology, across all industries. The idea was that there will be an inevitable delay in the productivity gains expected from computerization. And then somewhere between years five and 15, you see major gains in productivity. Brynjolfsson says there are two keys. First is that you see improvements in the technology. The second key is that people begin reimagining the work itself.” And that, Wachter said, is exactly what is beginning to happen in healthcare, as automation begins to afford possibilities for true process transformation in healthcare delivery.
Things will continue to be rocky and complicated for a while, Wachter concluded, but he said that healthcare leaders need to be prepared for the profound changes in re-visioning what healthcare delivery will be like, that will come soon enough. And with regard to technology, he said, “It’s a standard response to change: people don’t know what they want or need from a new system until they’re using it. Henry Ford said, if I’d asked people what they wanted” before he had invented the automobile assembly line process, “they would have said, faster horses.”