At the New York eHealth Collaborative's (NYeC) Digital Health Conference, Robert "Bob" Wachter, M.D., reflected on healthcare's digital journey while outlining the critical factors for industry success going forward.
Wachter, professor and chair of the department of medicine at the University of California, San Francisco, author of "The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine's Computer Age," and notable expert in health IT circles, told a packed audience at the New World Stages venue in New York City's theater district that the two major trends currently occurring in healthcare are the pressure to deliver high quality care at a low cost while also becoming digitized. "What's odd isn't that we're being pressurized to deliver high value care at low costs, but [rather] that this is new," said Wachter. "This is a mega trend and is independent of which administration is in the White House. This is a bipartisan issue."
On the second trend of healthcare becoming digital, Wachter noted that only in the past five years has healthcare has gone from paper to digital. "It's not hyperbolic to say we have gone from having the primary information backbone of this enormous industry—with 18 percent of the GDP and $3.2 trillion dollars spent per year—being the clipboard and fax machine to now spending $30 billion [as part of the Health Information Technology for Economic and Clinical Health Act] to digitize healthcare. This was truly an amazing investment, spending $30 billion to transform a $3.2 trillion industry," Wachter said. "My hospital spent close to a billion dollars on its Epic EHR [electronic health record], of which we got some $20 million [in aid] from the government. This has all happened in a very short period of time."
Now, healthcare is right in the middle of these two transformational trends. Today, Wachter said he is paying attention to the value pressure most, but 10 years from now the trend will undoubtedly be more about the digitization of the healthcare system. "Every singly industry that has gone from analog to digital did not look anything like it did when it started its journey. We are only three to five years into the big picture, and we haven't really seen anything yet," he said.
Over the last few years, while the adoption of health IT has been rapid and widespread across the U.S., there have been pain points that were not originally anticipated by stakeholders and policy makers, Wachter said. At the core of these struggles is the inability to understand how computerization would change workflow, he said. Wachter noted an anecdote of this occurring to a small internal medicine practice in Philadelphia that was at the forefront of technology change, buying an EHR for its office in 2004. "There is an inability to understand how computerization would utterly change the work," Wachter said, attesting that the practice's employees didn't know how to do their jobs on day one of the EHR go-live.
To this end, Wachter noted how the average doctor now spends 50 percent of his or her time doing computer work while the average ER doctor averages 4,000 clicks during his or her shift. "When you go to the hospital floors that patients are on, they are now devoid of doctors. In the old days doctors had to be there to do their charts. But now, the minute we are done seeing our patients, we go to our 'tribal' rooms to our colleagues and computers. This has been another unanticipated consequence of digitization," he said.
Further expressing his point, Wachter showed an image of a 7-year-old patient who drew a depiction of a recent visit with her pediatrician. The picture portrayed the girl, her mother, and the doctor—except the doctor was on a computer with his back turned to the patient. "Scribes have become the fastest growing profession in medicine," Wachter said, speaking to physicians' desire to have more face-to-face time with patients rather than being data entry clerks. "EHRs are at the top of the list for physician burnout, and this is something no one predicted or planned for," Wachter said.
As such, when talking about the "digital squeeze" on doctors, Wachter said that clunky technology systems and pain points with documentation are only part of the issue, despite that being the common narrative. But what really captures their angst is the lack of control and autonomy that existed not too long ago; and along with that, a shot to their egos, Wachter opined. "It was just 15 years ago when physicians had total autonomy over their practice, were widely respected and were paid well. Patients and payers were not questioning them," he said. "But computers are enablers of corporate control, so now someone above them is making decisions that affects what they are doing. Patients also have access to medicine they never had before, so this is threatening doctors' unique expertise. Just like you go on Yelp to read restaurant reviews, people are going online for medical [advice]." But Wachter does urge caution to the hype surrounding a complete democratization of healthcare. "Access and convenience is great, and telemedicine is great, but the idea of 'I am my own doctor' is both thrilling and scary. You can't replace years of studying and practicing medicine with a Google search," he said.
Despite these issues, Wachter believes that the people who want to go back to paper "are psychotic." He said, "There is no question in my mind that digital is safer and that we provide higher quality care than we would if we were on paper. The literature supports that, but we need to get though the painful stages in the best way possible," he said. He noted that health IT went through a technical change—assuming that it would be a straightforward process, similar to what an iPhone offers—but in reality, health IT needed to be an adaptive change. "We got it completely wrong. We didn't understand that plunking computers into healthcare environments and saying 'do your work' is not the right idea. People are the problem, and they are also the solution," he said.
Moving forward, Wachter said that the sector is progressing along a four-stage path of health IT, currently in the middle of the first two foundational steps: digitizing the system, which has mostly been done in the past decade; and connecting the parts together. "The $30 billion investment did not achieve [interoperability]," he said. There are different levels of "connecting the parts", Wachter continued: enterprise system to enterprise system, third-party apps to enterprise systems, and patient-facing systems to enterprise systems, and to one another. As such, interoperability has become a main priority now, he said.
The third stage of health IT is gaining meaningful insights from the data, and here, Wachter said that predictive models do exist but only in immature forms so far. And the fourth stage, he said, is converting these insights into action that improves value. "We are almost done with the first stage, we are just starting with the second, we are scratching the surface with the third, and we are not doing anything with the fourth stage," Wachter said.
But it won't be long before things really start to get interesting, Wachter predicted, noting that the $30 billion federal health IT investment largely led to the building of one set of "tracks," which was EHRs for doctors and hospitals, drawing a comparison to the first Transcontinental Railroad. The second part of that investment was that it woke up the Silicon Valley consumer-facing side of the world, getting IBM, Google and others interested in healthcare, he said. "They were not interested in this industry before because there was nothing they could do," Wachter said. "I was on Google's advisory board for healthcare in 2007, and it was at that time they formed Google Health and invested lots of money into wanting to build its EHR, but they then aborted the plan two years later. They said healthcare was too hard for them at the time. There wasn't any digital data for them to do 'Google-y' things with. But now they are back into the game. Every Silicon Valley company has jumped back into healthcare," he said.
Wachter concluded by explaining how the productivity paradox—referring to the slowdown in productivity growth in the U.S. In the 1970s and 1980s despite major development in IT—has applied to healthcare these past few years. Wachter quoted American economist Robert Solow who said, "You could see the computer age everywhere but in the productivity statistics." But Wachter said that the paradox always gets better, and that on average it takes 10 years for real productivity to be quantified, though healthcare likely will take longer due to to its unique complexity.
Indeed, there are two keys to unlocking the paradox, according to Wachter: technology getting better, and more importantly, having people reimagine the work itself. "It's why you need young people around you. When we digitized healthcare, we created digital versions of the exact same thing we were doing before. But then a young person comes in and brings up how Twitter or Facebook integrates different combinations of videos and [the like], and it makes you realize that you need to take the essence of what you're trying to do and add digital tools to do that," he said. "That's when the productivity paradox gets figured out. This is the biggest thing we have to do. In the end, the highest value care will win, but we have to connect the digital pieces to each other."
