While health information technology is too often viewed through rose-colored lenses as the cure for all that ails the healthcare industry, it has intended and unintended consequences, according to Robert Wachter, M.D., a professor in the Department of Medicine at the University of California, San Francisco.
Wachter, who first coined the term hospitalist and is generally considered the father of the hospitalist field, spoke to Health Data Management about his new bookThe Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Agewhich comes out today in hardcover. Though for years medicine stubbornly resisted computerization, with the passage of the HITECH Act and after more than $30 billion in EHR incentives paid to providers by the federal government, Wachter asserts that healthcare has finally gone digital. Yet, once clinicians started using computers to actually deliver care, he says they started to realize that something was deeply wrong.
For his book, Wachter interviewed nearly 100 people ranging from CEOs at major IT companies to all of the federal IT czars over the last 10 years to frontline doctors and patients using new IT tools. He was in part motivated to write his book after reading a 2012 book by Eric Topol, M.D., chief academic officer of Scripps Health, entitled The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Healthcare. Topols book looks at the future state of technology and where we may ultimately be if all of this works out, Wachter argues, but in his own day-to-day life as a clinician and healthcare administrator he observes thats not what I was seeing.
HDM: What negative aspects of health IT were you seeing?
Wachter: I was seeing information technology and electronic health records being installed andalthough there were certainly wonderful things about themI saw unanticipated consequences. I saw disgruntled doctors and disgruntled patients. I saw them preventing certain kinds of medical errors, but causing new other errors. As I spoke to my colleagues and patients, I came to believe that nobody had really articulated what was going on now. So, my book really is a reflection of what the current state of medicine is at this watershed moment as we transition from an analog way of doing work to a digital way of doing work. The subtitle of my book was very purposefully chosen. Ive seen lots of hype. Ive seen some harm. And, I also have hope. But, were not there yet.
HDM: If we start with the harm done, is there a particular example you can provide?
Wachter: I have an excerpt of my book running on a website this week that details a case where we gave a 39-fold overdose of a routine antibiotic to a kid at my hospital. And, the way we did that was basically a simple screen error where the doctor didnt realize that she was prescribing in milligrams of drug per kilogram of weight. What was fascinating about it was that alerts were fired to warn the doctorand ultimately then to warn the pharmacistthat this was an error, but they were ignored by everyone. You might ask: how could they be so careless? Well, it turns out we get hundreds of thousands of alerts. If you add in the intensive care unit computer monitors, we actually get millions of alerts a month. And, so, of course normal people begin to tune out.
I was beginning to see cases of medical mistakes caused by the computers. Just go into doctors offices today and youll find doctors no longer making eye contact with their patients. As often as not, youll see the doctor looking down at the computer rather than up at the patient. I also saw changes in the way clinicians relate to each other. You see doctors and nurses who used to communicate verbally now sitting in their own electronic silos doing their work. And, if you go to the medical service that I run at my hospital, you see nurses there but you no longer see doctors because doctors see the patients and then leave the clinical unit to go off into this tribal space where they spend their day doing their computer work.
All of these things probably could have been anticipated, but I can tell you that none of them were. In some respects, I think we got spoiled by our iPhones. We believed that you just put the computers in, turn them on, and they make stuff better. But, computerization in healthcare is an extraordinarily complex social phenomenon and requires for us to really think hard about how we create an error-free environment, how we make sure that clinicians keep their brains engaged while they become increasingly dependent on the technology, and how we take advantage of this incredibly rich data while not kidding ourselves that this is Amazon and were buying books. Were taking care of fragile human beings. These are all very difficult questions and I just dont think weve addressed them in a particularly robust way.
Im a practicing doctor. I study patient safety for a living. Ive been waiting for computers for 15 years, hoping they would be saviors, and now we have them and clearly they are double-edged swords.
HDM: In terms of the hype, where do you feel the technology has been overblown in its marketing and is coming up short?
Wachter: In general, there are very few people that are using electronic health records today that believe that they are modern, well-developed tools that are as slick and functional as the tools that were all used to using in the rest of our lives. The companies that are building these tools had been toiling in obscurity for decades and then what happened was that six years ago the federal government made available $30 billion in incentive payments for us to implement themand so we did. We bought the best tools that were out there. Theyre just not very good. They have that Version 1.0 feel and feel sort of like your first browser or word processor, which makes sense because were 10 to 15 years behind in healthcare technology.
At the same time, when it comes to wearable sensors, you have people touting the concept of the digitized patient and that well all be running around with sensors measuring our steps, moods, and sweat. Again, it sounds cool but I have to say Ive tried Fitbit and Jawbone a couple of timesI wear them for a month or two and then I get bored and take them off. I dont see the value of knowing my heart rate second to second. I take care of incredibly sick patients in the intensive care unit and I dont need to know their heart rate second to second, let alone a perfectly well person. Theres absolutely no utility, no usefulness for that data. And, yet, these things are being marketed as cure-alls. I think right now theyre kind of exciting for people who have a little too much time and money on their hands. But, at this moment, I think it is more snake oil than real benefit.
There are people out there talking about how computers will ultimately replace doctors. I think there probably will for certain things that we do and they probably should. But, there are other parts of what physicians do, such as diagnoses of complicated patients which are incredibly challenging cognitive acts, that should probably not. Its a very different act than an algorithmic approach of does this patient need a vaccination or whats the right medicine for this patients blood pressure?
I dont disagree with the concept of democratizing data in healthcare and having engaged patients who have access to data independent of the physician as high priest. I think that is good for some patients, but not all. What I worry about is that for the most part its not ready for prime time. Secondly, there are some patients that dont want or cant do that. And, third, theres no easy way for a patient to figure out whether they are right or theyre wrong. Think about the average patient who has a set of symptoms and all of a sudden they are trying to diagnose it themselves using their iPhone. I dont know how you look at that situation and you dont worry about it.
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