An Exclusive Q&A with Robert Wachter, Author of Digital Doctor (Part 1 of 2)

It should be of no surprise that Robert Wachter, M.D. wrote a book on technology in healthcare. The professor and associate chair of the Department of Medicine at the University of California at San Francisco (UCSF) is surrounded by technology. 

He lives next to Silicon Valley. His wife writes about technology for The New York Times. UCSF, where he has been for years, is one of the preeminent healthcare organizations in America when it comes to implementing innovative technology. 

Yet, it wasn't until technology failed that he came up with the idea to write a book on...yes, technology in healthcare. The computer error led to a significant, near deadly overdose administered to a young patient in UCSF's Children's Hospital. "I'm sitting there at the meeting explaining what happened and I'm thinking, 'Wow.' It's not so much the computer systems are clunky, they are, but we've turned our brains off. I came home and told my wife, 'I think I have to write this,'" says Dr. Wachter. 

Healthcare Informatics Senior Editor Gabriel Perna recently got a chance to speak with Wachter on the book, how it came together, some of its most important chapters, the future of healthcare technology, and the message he hopes people get out of it. Below are excerpts from part one in a two-part series.

It was brewing over a few years. The genesis is my work for the last 20 years has been as someone who is an active clinician, an administer in healthcare, and I write and think about issues in healthcare that feel important to me. My issues tend to be the day-to-day work of doctors and patients. A lot of that in the last 10-15 years has been in patient safety. If you've been working in patient safety you've been waiting for computers to come and save us. I think the combination of my general interest in the way things work or don’t work in healthcare, my interest in patient safety, and layered on top, probably living in San Francisco and being surrounded by Silicon Valley, I was very hopeful they’d solve a huge number of our problems. 

And then computers entered my world. There was no question they were solving problems. but it was clear they were creating their own sets of problems. It was clear some of the changes were interesting and quite subtle. I talked about it in the book about radiologists, where I saw that this wasn't just digitizing the work, it was changing the nature of relationships, the geography of the hospital, and the power structure. Most people would ask what computers have to do with that, well they have everything to do with it. I began pitching stories (about technology in healthcare) to my wife. I was living vicariously through her. 

One day we committed that error that I go through in the book. I came home [after the meeting explaining the error] and told my wife, "I think I have to write this." Luckily for me she's a journalist, and she told me the only way to get this right is to approach it journalistically. You have to hear the stories. You have to educate yourself. Had she not told me that, I probably would have read a lot of stuff and tried to write a book and it would’ve stunk. The stories are what brought it to life. They allowed me to understand in a way that I never would have if I hadn’t gone in the field.

Everyone I asked said yes, some beyond what I would have expected. I happen to know Captain (Chelsey) Sullenberger who told me I should go spend a day at Boeing. So he wrote the head engineer at Boeing and told him I wanted to see how they think about cockpit automation. Next thing I know, I'm getting a day of VIP treatment at Boeing. Some of it was me, some of it was my contacts opening doors for me. I had amazing access. 

I think people didn’t see me as a journalist;they saw me as an insider trying to learn this better. People were pretty unplugged in telling me unvarnished truths. They trusted that I’d be fair, open and honest about it. I tried to be. I learned that from my wife. You have to figure how to be really honest and fair, but remember that you’re writing this in service of the reader. If you’re too careful about not making anyone unhappy or you're tip toeing around, you don't get this right. 

It took exactly one year. For the first six or seven months, I was still doing my day job but I had just gotten so psyched about this. I was doing as many interviews as I could from the Bay Area, doing nights and weekends. I was 25 percent done with the research and writing by June. Then I went on sabbatical from June to December. From June until October, I was writing and researching and interviewing 12 hours every day. My wife was my editor. It was hard but it went better and faster than I thought.

Some writers know their story arc and have plotted every page. I knew how I wanted to start and how I wanted to end it, I didn’t know where the arrow was going to be. I knew i wanted a day with Epic. It took me a while to get in the front door but I was able schedule a day there. I'm on an advisory board and one of the advisors is one of the founding board members of athenahealth...so I talked to Jonathan Bush. It was a lot of that. It was one thing leading to another, people telling me to talk to other people. By the end of August, I felt I had done enough interviews. You can always do one more because they're more fun than the writing. You have to have the discipline...to sit down and polish it off.

The day at Boeing was probably the most interesting because it was so different than anything I had ever seen. Their philosophy of user-centered design was so impressive to me. Plus, I got to fly a 777 simulator. There were so many that were great. There are people who have the ability to crystallize ideas and make sense of them. In the IT world, John Halamka is unbelievably interesting. Everything he says you want to write down and quote. Jonathan Bush has an amazing quirky personality. The day where I just happened to interview Abraham Verghese and Vinod Khosla right after each other, mainly because their offices were next to each other, was interesting. Just these seeing two brilliant minds, both 59, look at the same set of facts and come to such different conclusions. Abraham was fretting about the loss of humanity as we go technical, and Khosla was feeling this is terrific. I was a sponge. I was listening to all of it and trying to make sense of it. That's extraordinarily interesting and really hard. You have two smart people telling you things that come in total conflict with each other. There were so many interesting people such as speaking to the patient in Rockville, M.D. who’s dying of cancer but is getting comfort in an online community, where he is talking with patients with the same disease.

I felt like one of the pieces of disappointment with health IT are in the notes. The notes are bloated and unreadable. The doctors are spending their days inputting stuff into the note and can't pay attention to the patient. That has led to scribes and all of the other side effects. In telling that story, I couldn't see how I could without telling how the note came to be today. I came to believe that although we blame the computer for these problems with the note, it's not really the computer’s fault. The technology is an enabler for the input of data into the machine. It is the data being required of the frontline people that is really the problem. I wanted to understand how did the note get to be that way? It's become this Christmas tree on which we are hanging about 10 different ornaments and of course, it can't stand up anymore. When I went back and researched it, I shouldn't have been surprised but I was, the note began as a diary. It was a narrative of the patient's story. Over the course of the century, it grew more complex as we needed more information on the patient. At first, it was just the doctor. Then, all of a sudden, third party payment came into place,malpractice grew, and the note became this place where all people who were peering into exam room could get a window into the doctor and patient. The note became that vehicle. There was a book written 20-30 years ago, "Strangers at the Bedside," which explained how the billers needed to know what you did. The malpractice attorneys needed to know whether or not you did something. Quality measures. In a world with paper and pencil, you might want the doctor to write everything down but you couldn’t force it because there was no template. Once  you computerize though, you make the doctor record all these things that make these other people happy. The billing people, the quality measurement people, the malpractice people. From their perspective, it's asking the doctor to do "one more thing." But it's the sum total of 50 "one more things" and it's back breaking. You could not begin to describe why this was a problem until you got at what the note is all about and why it got to be that way. When people understand that, and you say you have a computer that makes, then they understand why it's a problem. It's become bloated. It's not the right way to tell that patient story.