Bob Wachter has been about as influential an academic doctor as there’s been in recent years. He more or less invented the concept of the hospitalist, he’s been a leader in patient safety, and even dressed up and sang as Elton John at the conference he runs! (He’s also pissed off lots of doctors by being a recent one year chair of the newly controversial and perhaps scandalous ABIM). But for the last 2 years he’s been touring the good and the great of health care and IT to try to figure out what the recent introduction of EMRs at scale has meant and will mean. The resulting book The Digital Doctor is one of this year’s “must reads” and yes we will have Bob as the keynote at this Fall’s Health 2.0 Conference.
The immersion research he conducted was fantastic. Bob interviewed just about anyone you’ve ever heard of and a few you wish you hadn’t (more on that later). And in fact he’s been running interviews on THCB and elsewhere sharing some of the stuff that didn’t get in the book. But I’m still wrestling a little with what I think about the book itself. And I think it’s because I largely agree with him and his angst.
There is lots of wonderful stuff in this book. The change in the role of radiology post PACS, how patients are using open notes, whether Vinod Khosla agrees with Vinod Khosla about algorithms replacing doctors–all this and much more are here. But the book is largely about the introduction of the current generation of EMRs into the everyday practice of ordinary clinicians. There are by and large three camps of opinions about what’s happened.
One is that the EMR is a pox visited on physicians that costs a fortune, has worsened quality, heightened medical errors, blown up successful processes, and ruined the lives of doctors–unless they were given scribes. The second is that because of the “rush to judgement” caused by the HITECH Act and Meaningful Use, we put in EMRs that were based on 1990s client-server technology but they were the only ones mature enough for the job. Most of this camp thinks that they were way better than paper, will slowly improve, and that doctors and patients will find that these technologies will soon integrate with easy to use iPhone-like apps as their APIs open up–and that if we hadn’t mandated EMRs when the great recession gave us the chance, nothing would have happened. The third camp agrees that EMRs are better than paper but felt that the way HITECH was rolled out kept a bunch of dinosaurs in business, and is preventing the health IT equivalent of Salesforce displacing Siebel (or Slack displacing email).
Wachter interviews most of the former ONC Directors and he puts Blumenthal in the second camp and Brailer in the third. He also puts athenahealth’s Jonathan Bush in the third camp, whereas Epic’s Carl Dvorak & Judy Faulkner are (optimistic) members of the second camp. I think Bob himself is straddling camps two and three. UX expert Ross Koppel and a few other “camp oners” are interviewed about how EMR vendors know nothing and care less about the user experience, other than they try to prevent anyone from improving it using a variety of dubious legal blocks. But it’s the major story in the book, excerpted in Medium and featured in The New York Times op-ed Wachter wrote, which is squarely in camp one. It’s the harrowing five chapter recounting of how an adolescent at UCSF–Wachter’s own hospital–choked down 38 pills when he was supposed to get two and ended up in a coma. In short the Epic system was trying to handle pediatric and adult meds at the same time. The user interface was too confusing, and the alarms so frequent that physician, pharmacist and nurse all cancelled them out multiple times. Even the (relatively experienced) patient gamely assumed that it had to be right as it was in the system. In fact, Wachter went to Boeing to see how they treat alarms and found that they very rarely interrupt a pilot and when they do, it’s really serious. There’s a telling moment in The Digital Doctor when a nurse knows something is wrong in the ICU because she can’t hear an alarm.
There’s already a mini-meme online beating up Wachter and UCSF (and treating them as one) for poor implementation (see HISTalk here and here) but that doesn’t let Epic or really any of their competitors off the hook. The “camp three-ers” all decry the lack of UX testing and the “camp oners” claim conspiracy–particularly contracts that prevent screenshots or public criticism of technology. I know that at the HxRefactored developer & design conference Health 2.0 ran last year all the major EMR companies present claimed they were in the process of increasing their UX team by a factor of ten. And Wachter did have to get permission from Epic & UCSF to share the screenshots of the drug error (and in fact to publish about it at all).
Despite all this, and several other complaints–like the community clinic doc who can’t hand out her patient education materials that work but aren’t MU certified–Wachter doesn’t want to go back. You get the feeling that he wants to jump to camp three–let’s get it all in the cloud and get rid of the huge client server monoliths we’re putting in. But that would suggest that the EMR cloud was ready in 2008-9 which it probably wasn’t, at least not for complex academic centers–although with the Halamka-Bush alliance it might be soon. But I sense that overall Bob is a little tortured. He (like me) is a believer, but the current pain we have put doctors through is too hard to bear.
Like any tortured soul he flees at the end to Silicon Valley. To be precise he visits the two major centers of “new tech in health care” both within a stone’s throw of UCSF’s new multi-billion dollar Mission Bay campus. And in order to guarantee a lousy review from me, he gave Health 2.0 and me half a paragraph while lavishing 3 pages and a full color spread on Nate Gross at Rock Health. (Heaven knows how much ink Halle Tecco would have got had she been around that day, but for his next book I’ll make Indu Subaiya fly up from Los Angeles!) I did joke with Bob that my review would mostly be about Eric Topol’s new book instead…
All kidding/personal grudges aside, I think that the vision piece at the end (post Silicon Valley chapter) is the most troubling part of the book. As it seems disconnected from the rest and perhaps most unrealistic, given all the issues Wachter already raised. It’s just hard to connect the future we hope to see with the present, especially when the future may be the present, only longer.
But it’s a deeply informative book and it’s destined to be a classic. I just don’t quite know what to think about it, As the subtitle says, there is hope, there is harm and there is hype, and throughout the book it’s hard to tell one from the other. Which–and this is where I agree with Bob–is the truth in health IT as a whole.