Matthew Holt

The Digital Doctor – The Review

Digital Doctor

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.

 

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sribeWilliam Palmer MDGregg Masters (@2healthguru)Tom GiannulliRon Recent comment authors
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sribe
Guest
sribe

You know, the issue of cloud vs client/server has ABSOLUTELY NOTHING to do with the quality of the products, nor the possibility of sharing data, nor anything else discussed. That was a complete non-sequitur.

@BobbyGvegas
Guest

“too much information out there for one human brain.
___

Larry Weed 101 — see “Medicine in Denial”

William Palmer MD
Guest
William Palmer MD

I think we are going to need the EHR and the EMR for Artificial Intelligence to work, but surprisingly not for what most of its proponents claim are its advantages today. We are going to need it to help in getting the correct diagnosis, especially in our next era of precision medicine and molecular pathology: too much information out there for one human brain.

@BobbyGvegas
Guest

Just finished reading. A fine book. Comprehensive, realistic, charitable, candid, Nicely written. Highly recommended.

Gregg Masters (@2healthguru)
Guest

Has a great chat with Dr. Bob Wachter via colleague Phil Marshall, MD:

http://www.blogtalkradio.com/healthtechmedia/2015/02/25/meet-robert-wachter-md

Tom Giannulli
Guest
Tom Giannulli

This is an important conversation to have within our industry, we need to face our challenges head on and solve these problems for the greater good. Given the fact that entrenched vendors are not going to be displaced any time soon, their willingness to make adjustments is critical and I hope this book helps the process.

Ron
Guest
Ron

Quite a nice review of a book that I must read! I have to say that I’m a little in all three of Mr. Holt’s camps: – HITECH was sold to Congress based on lies (the now disproven Rand report) and the environment of the time (new presidency, ACA battles, focus on stimulus, need for “success” of HITECH) led to some short-sighted and politically motivated decision-making and steamrolling of doubters (i.e. people raising concerns about safety, interoperability, usability, fitness of vendors, etc.) People quite senior in the administration – even the White House – knew of safety incidents involving “Certified”… Read more »

@BobbyGvegas
Guest

“People quite senior in the administration – even the White House – knew of safety incidents involving “Certified” EHRs and chose to downplay them in the name of “progress”
___

Document that. Name names. Cite/link actual statements.

Paul Slobodian
Guest

Granpappy Yokum is right….the key to optimizing innovation is this:

“everyone voluntarily and gladly used it.”

For EHR’s to progress at the optimal rate, all the mandates, incentives, subsidies, rewards and penalties….all administered by bureaucrats seeking to coerce implementation for their own ends (not the ends patients and doctors want)…..should be lifted. Then the focus of all investment would shift to creating systems that patients and doctors would clamor for.

Granpappy Yokum
Guest
Granpappy Yokum

“I do worry that docs are badmouthing (or worse) EHRs, creating poor public profile and opinion.” Agree. Docs should just do what they’re told and keep their mouths shut. Who told them they were allowed to have opinions? “before there was the iPad, there was the Newton; before there was ubiquitous wireless connectivity, we suffered the screeches of the dial-up modem” Terrible, terrible analogies. It was obvious that the Newton was a lemon and, like EMRs, nobody bought them. There was no government subsidy or requirement to use them, so they quickly disappeared. And, at the time, we thought dial-up… Read more »

Bob Wachter
Guest

Thanks, Steven. I agree with your point. Here’s how I addressed it in the book…. After talking about the new pressures for value, quality measurement, increasing regulatory burden, etc, I wrote: “Clinicians’ unhappiness with the current state of health IT needs to be viewed against the backdrop of these wrenching, but largely needed, changes. They are changes that will transform the doctor-patient relationship, profoundly alter the roles of physicians and other health professionals, and ultimately result in some, perhaps many, people losing their jobs, income, and prestige. Our electronic health records could be vastly better, no doubt, but we also… Read more »

Steven Findlay
Guest
Steven Findlay

Just downloaded it and look forward to a good read on this ever-fascinating issue. Thanks Bob for your hard work and contribution, and Matthew for your review. I’d welcome more comments/discussion of the consumer interface issue, and how portals linked to EHRs are and are not working. I do worry that docs are badmouthing (or worse) EHRs, creating poor public profile and opinion. I had dinner with friends recently (people in their 60s and 70s) where 1/2 hour discussion took place about how EHRs have screwed up doc’s world and the doc-patient relationship. Two of the attendees said their docs… Read more »

Bob Wachter
Guest

Matthew — thanks so much for this generous review. I agree with pretty much all of it (particularly the “must read” and “destined to be a classic” parts) 😉 Regarding the optimistic chapters near the end: well, you’ve captured my angst and ambivalence nicely. I do believe that HITECH was right and wise, in that it allowed healthcare to traverse a major tipping point. In 2008, 10% of doctors’ offices and hospitals had EHRs; today that figure is about 70%. We have finally, reluctantly, become a digital industry. I don’t think this would have happened without the $30 billion in… Read more »

@BobbyGvegas
Guest

“preventing the health IT equivalent of Salesforce displacing Siebel (or Slack displacing email).”
___

I had to use Salesforce while working in MU at my REC. What a total PoS. ONC made us use it, they owned the licenses. It was all about “tracking OUR every move,” not helping us get our work done. Sound familiar?

We ended up doing “double entry,” i.e., we set up a mirror system in Microsoft CRM (another clunky PoS) in order to capture and retain the “business intelligence” we gathered so that our data would survive for our further use the short-lived REC program.

Saurabh Jha
Guest
Saurabh Jha

I’m now determined to read Wachter’s book in the next ten days, along with a thousand other things pending. But there is one thing that strikes me about EMR, as someone who knows nothing about IT. That is the problem lies not with EMR but with formalization (i.e. a central systematic way of collecting knowledge, assessing value and obtaining approval). To be more specific, the problem lies not with bad formalization but with formalization in and of itself. It’s like the problem with peer review. Peer review certainly curbs the proliferation of BS in journals. But it also removes things… Read more »

@BobbyGvegas
Guest

To that point, see “Wikipedia vs Quackery – Standards vs Chaos” “Wikipedia, an online open-source encyclopedia, can boast 470 million visitors each month, making it one of the most popular websites on the internet. It is an incredibly useful resource – I think it’s fair to say it is the online reference of record. For that reason people care how topics important to them are represented in Wikipedia. Wikipedia, in fact, has become no less than a battleground over certain controversial topics. In essence people generally want Wikipedia to reflect their opinions on controversial topics, and if it doesn’t then… Read more »

Saurabh Jha
Guest
Saurabh Jha

Here is the problem – formalization certainly reduces quackery but then formalization becomes a quackery of sorts. I’ve seen this in peer review – where the reviewers comments are nonsensical monologues that express nothing.

I wonder if the ONC could have designed an I pad.

B
Guest
B

The Medium excerpt as referenced is a terrifying and sobering story. Should be at the very top of meeting agendas for every single healthcare entity across the country immediately.

@BobbyGvegas
Guest

I’m reading it at the moment (along with several others that are equally pressing). I will cite your review on my blog.

I’ve just experienced Epic from the PoV of an ER gurney and MedSurg floor bed. The user opinions were uniformly negative. Frustrated, resigned, wary of saying too much.

Q: “So, what do you think of Epic?”
A: “It’s a great tool — for tracking our every move.”

http://regionalextensioncenter.blogspot.com/2015/04/health-it-and-patient-safety-jcaho.html

Re “tracking our every move” — see some of my other reads: ” The Future of Violence,” “Data and Goliath,” and “Terms of Service,” to cite just three.