Crowdsourcing My New Book on How Computerization is Changing the Practice of Medicine in Surprising Ways

I have been in blog-silence mode of late, for which I am sorry. Rumors that I’ve taken my Elton John act on the road are, I’m pleased to assure you, incorrect.

7 yr old's depiction of MD visit (Toll, JAMA 2012)

7 yr old’s depiction of MD visit (Toll, JAMA 2012)

Instead, I’ve been hard at work on my new book, tentatively titled “Disrupted: Hope, Hype and Harm at the Dawn of Medicine’s Digital Age.” I’m about one-third finished, and am on my way to Boston for a six-month sabbatical at the Harvard School of Public Health to keep working on it.

This is the most journalistic book I’ve ever attempted. I’ve already completed about 25 interviews for the book, and will do about 30 more by the time I’m done. And they have all been fascinating.

It seems a shame to leave so much great stuff on the cutting room floor. So for the next few months I’ll plan on posting some of the best, including interviews with Capt. Sully Sullenberger, Vinod Khosla, the head of Boeing’s flight deck engineering team Bob Myers, Abraham Verghese, Karen DeSalvo, and Gurpreet Dhaliwal.

Yet some of the best stories have come from chance encounters. At the Mayo Clinic, I met a physician who decided to leave his surgical training program for a career in informatics after a fateful internship night in which he found himself running four Code Blues simultaneously. He realized that medicine lacked the systems that we need to access information and communicate effectively. Another physician told me about trying to make sense of the clinical course of a wildly complex ICU patient. The notes in the EHR were such copied & pasted garbage that the only way he could tell what had changed from one day to the next was by printing out the notes and holding one sheet over the others against a window pane. And of course I’ve heard stories about scribes, Open Notes, Big Data, the death of radiology rounds, and much more.

I’m hoping you can help me. If you have an amazing story about how the computerization of medicine has transformed your life or your practice in any way, please do let me know, either by posting a comment (if you’d like to share it) or emailing me at bobw@medicine.ucsf.edu. These kinds of stories can help bring a subject to life.

To give you a sense of the range of topics I’ll be covering, as well as the book’s tone, I’ve pasted below a draft of the preface. If all goes well, “Disrupted” will be published in March, 2015. I’m doing my best to make it a fascinating and important book, and appreciate your help.

* * *

Draft Preface from “Disrupted: Hope, Hype and Harm at the Dawn of Medicine’s Digital Age” (posted with permission of McGraw-Hill)

If you’re a 24-year-old who does not plan on getting sick for the next couple of decades, this is probably not the book for you. By the time you need our healthcare system, it will be wired in ways we can’t imagine today. By then, computers will have transformed healthcare – as they already have retail, publishing, photography, and travel – leaving it better, safer, and maybe even cheaper. Most of the kinks, perhaps other than what our society will do with boatloads of unemployed dermatologists, radiologists, and hospital administrators, will have been ironed out. I hope to live to see this day myself. It’ll be, as my kids say, hecka cool.

But for the rest of us – both those who need our medical system today and those who currently work in it – the path to computerization will be strewn with landmines, large and small. The challenges are everywhere. Medicine, our most intimately human profession, is being dehumanized by the entry of the computer into the exam room. While computers are preventing many medical errors, they are also causing new kinds of mistakes, some of them whoppers. Sensors and monitors are throwing off mountains of data, often leading to more cacophony than clarity. Patients are now in the loop – many get to see their laboratory and pathology results before their doctor does; some are even reading their doctor’s notes – yet are woefully unprepared to handle their hard-fought empowerment.

In short, while someday the computerization of medicine will undoubtedly be that long-awaited “disruptive innovation,” today it’s often just plain disruptive: of the doctor-patient relationship, clinicians’ professional interactions and workflow, and the way we measure and try to improve things. I’d never heard the term “unanticipated consequences” in my professional world until a few years ago, and now we use it all the time, since we – yes, even the insiders – are constantly astonished by the speed with which things are changing and the unpredictability of the results.

Before we go any further, it’s important that you understand that I am all for the computerization of healthcare. I bought my first Mac in 1984, back when one inserted and ejected floppy disks so often (“Insert Excel Disk 2”) that the machine felt more like an infuriating toaster than a sparkling harbinger of a new era. Today, I can’t live without my MacBook Pro, iPad, iPhone, Facetime, Twitter, OpenTable, and Evernote. I even blog and tweet. In other words, I am a typical, electronically overendowed American.

And healthcare needs to be disrupted. Despite being staffed with (mostly) well trained and committed doctors and nurses, our system delivers evidence-based care about half the time, kills a jumbo jet’s worth of patients each day from medical mistakes, and is bankrupting the country. Patients and policymakers are no longer willing to tolerate the status quo, and they’re right.

For decades, healthcare’s immunity to computerization was remarkable; until recently, in many communities the local high school was more wired than the hospital. But over the past five years, tens of billions of dollars of federal incentive payments have raised the adoption rate of electronic health records from 10% to about 70% in both hospitals and doctors’ offices. When it comes to technology, we’ve been like a car stuck in a ditch whose spinning tires finally gain purchase: so accustomed to staying still that we were totally unprepared for lurching forward.

When I was a medical resident in the 1980s, my colleagues and I performed a daily ritual known as “checking the shoebox.” All of our patients’ blood test results came back on flimsy slips that were filed, roughly in alphabetical order, in a shoebox on a card table outside the laboratory. This system, like so many others in healthcare, was wildly error-prone. Moreover, all of the things you’d want your doctor to be able to do with laboratory results – trend them over time, communicate them to other doctors, patients or families, remind physicians to adjust doses of relevant medications – were pipe dreams. On our Maslow triangle of needs, just finding the right test result for the right patient was a sweet little triumph. We didn’t dare hope for more.

For those of us whose formative years were spent rummaging through shoeboxes, how could we not greet healthcare’s reluctant, subsidized entry into the computer age with unalloyed enthusiasm? Yet an amazing thing happened on the way to Clinical Nirvana. Once we clinicians started using computers to actually deliver care, it dawned on us that something was deeply wrong. Why were doctors and patients no longer making eye contact in the exam room? How did Kwashiorkor – the wasting, belly-bloating condition of children in famine-ravaged regions of Africa – start popping up as a common diagnosis in U.S. hospitals sporting marble lobbies and valet parking? How could one of America’s leading teaching hospitals (my own) give a teenager a 39-fold overdose of a common antibiotic, despite – check that, because of – a state-of-the-art computerized prescribing system? Logically, we pinned the problems on bug-ridden software, flawed implementations, muscle-bound regulations, and bad karma. It was all of those things, but it was also something far more complicated. And far more interesting.

As I struggled to answer these and other similar questions, I realized that I needed to write this book – first to explain all of this to myself, and then to others.

What I’ve come to understand is that computers and medicine are strange bedfellows. Not to diminish the miracles that are Amazon.com, Google Maps, or the cockpit of an Airbus, but computerizing the healthcare system turns out to be a problem of a wholly different magnitude. The simple narrative of our age – that computers improve every industry they touch – turns out to have been magical thinking when it comes to healthcare. In our sliver of the world, we’re learning, computers make some things better, some things worse, and they change everything.

Harvard psychiatrist and leadership guru Ronald Heifetz has described two types of problems: technical and adaptive. Technical problems can be solved with new tools, new practices, and conventional leadership. Baking a cake is a technical problem: follow the recipe and the results are likely to be fine. Heifetz contrasts technical problems with adaptive ones,

“…problems that require people themselves to change. In adaptive problems, the people are the problem and the people are the solution. And leadership then is about mobilizing and engaging the people with the problem rather than trying to anesthetize them so that you can just go off and solve it on your own.”

The wiring of healthcare is proving to be The Mother of All Adaptive Problems. Yet we mistakenly treated it as a technical one: simply buy the computer system, went the conventional wisdom, take off the shrink-wrap, and flip the switch. We were so oblivious to the need for adaptive change that we usually misdiagnosed the problem after failed installations, mangled workflows, and computer-generated mistakes; sometimes we even blamed the victims, both clinicians and patients. Of course our prescription was wrong – that’s what always happens when you start with the wrong diagnosis.

While this is a book about the challenges we’re facing at the dawn of healthcare’s digital age, if you’re looking for Dr. Luddite you came to the wrong place. Part of the reason we’re experiencing so much disappointment is that information technology in the rest of our lives is such magic. Even in medicine, I have no doubt that our awkward adolescence will ultimately mature into a productive adulthood. We just have to make it through this stage without too much carnage.

Of course, if you came looking for breathless digital hyperbole, you won’t find that here either. We are late to the digital carnival, but there are barkers everywhere telling us that this and that app will transform everything; that the answer to all of healthcare’s ills is being developed – even as we speak – by a soon-to-be billionaire twentysomething tinkering in a Cupertino garage. This narrative is seductive; some of it may even be real. But for now, despite some scattered rays of hope, the digital transformation of medicine remains more promise than reality. Having a few Millennials wearing Lycra bike shorts that can read their moods and count their steps is nifty, but it isn’t going to be the change that we need.

What you’ll find in these pages is an insider’s unvarnished view of the early days of the transformation of healthcare from analog to digital, with tales of modest wins, growing pains, and surprising bumps in the road, some the size of elephants. The answer to what ails healthcare is not going to be found in romanticizing how wonderful things were when your doctor was Marcus Welby. We can – we must – wire our world, but we need to do it with our eyes open, building on our successes, learning from our mistakes, and mitigating the harms that are emerging.

To do so effectively, we need to recognize that computers in medicine don’t simply replace my doctor’s scrawl with Helvetica 12. Instead, they transform the work, the people who do it, and their relationships with each other and with patients. Moving from “disruption” to “disruptive innovation” will take deep thought and hard work on the part of clinicians, healthcare leaders, policymakers, vendors, and patients. Sure, we should have thought of this sooner. But it’s not too late to get it right.

11 Responses to “Crowdsourcing My New Book on How Computerization is Changing the Practice of Medicine in Surprising Ways”

  1. Robert Ley June 16, 2014 at 4:20 pm #

    A terrific preface outlining a tough row to hoe. Your long-term perspective and human-centered approach should be a big plus. I can’t wait to read the final product. I hope you include the visionaries Atul Gawande, Clayton Christensen and Arnold Relman in your interviews.
    Good luck and happy sabbatical!

    • Bob Wachter June 16, 2014 at 4:45 pm #

      Thanks, Robert — all three are on my list of folks I want to interview. You’ve captured part of the reason I chose Boston for my sabbatical: I think the two best places to be around deep thinkers on this topic are Boston and San Francisco, and I happen to live in the latter.

      That said, I realize that not all answers will be found in the rarified air of cities like these, so I’ll be visiting docs’ offices in places like Dubuque, Iowa, and also trying to learn from other industries. In fact, my trip to Boeing in Seattle two weeks ago was one of the most interesting experiences I’ve ever had. (Note to Boeing: sorry I crashed your 777. At least it was in a simulator.)

      • Robert Ley June 16, 2014 at 4:52 pm #

        From ‘way behind in computers’ in the hospital to ‘way ahead in computers’ at Boeing must be a fascinating, and sobering, comparison. I’m jealous.
        Are you sure it wasn’t the batteries and not your flying?

        • Bob Wachter June 16, 2014 at 4:54 pm #

          777, not 787. (They tell me the batteries are fixed, BTW.)

          And believe me, it was my flying. Their IT design is magnificent, but you still need to know how to fly the thing.

  2. John Gosbee June 16, 2014 at 4:50 pm #

    Bob

    Cool idea for book.

    By the time I left VA center for patient safety, many of us were devoting time to understanding and trying to fix computer related (caused) adverse events. And, I worked and interacted with informatics folks since my first job writing specs for NASA’s first space hospital in late 80s.

    A few germs of some ideas or sections

    1) for our human factors book in 2005, we excerpted a cool Forward from a 1975 (yes, 1975) book on human factors in healthcare (Pickett and Triggs, Heath). A physician who knew human factors, Maurice Rappaport, recounted his trials in using the very first hospital computer system in San Jose. When I get home I will send whole article. Coincidentally, Pickett and Triggs were at hsph when they edited this book.

    2) mike Astion from univ Washington wrote about lab report pagination nightmare. Printer drivers/formatting at receiving end caused results column to be chopped off. Leaving reference standard column. Since HIV ref std is “positive”, it was read to patient as positive. Since ambulatory mishaps are overlooked or not apparent, I am betting this kind of stuff is bigger than hospital stuff.

  3. Kathi Sigona June 16, 2014 at 6:12 pm #

    I have subscribed to your blog for several years and look forward to reading when each entry is rolled out. I do hope you mention the Health eHeart Study and the impact it has had on the study of the heart. I am not in medicine but in education and I am a patient. Being part of the study has facilitated my care and has presented a more rounded picture of my health to my local doctors as well as to Dr. Olgin at UCSF. During my career, I focused on data and analyzed it to better my students’ growth, provide valuable info to my teachers and parent community and improve my school’s climate. Without that data, we were just full of good ideas. So why not have the same benefit in healthcare by using the technology available to track data about me, the patient.

  4. Bill June 16, 2014 at 11:13 pm #

    I’m not a healthcare professional nor am I a patient with a story to tell. I’m just interested in the industry that sooner or later will determine my quality of life (I’m 68).

    However, I’m an old “manufacturing guy” who has been down a similar road when, in the mid-1980s we tracked the elusive “factory of the future.” Consequently I fully support your inclination to look at this as an adaptive problem to be addressed. If you get a chance to interview some “systems integrators” from 30 years ago you will hear similar stories and, hopefully, hear stories of “hype, hope, and reality” that may be of use.

  5. James Legan June 17, 2014 at 1:52 am #

    Dr Watcher,
    My 13 year old inadvertently revolutionized my practice about 6 months ago. I reluctantly took the electronic plunge in 2011, for fear of being driven out of private practice due to the impending penalties for not participating in Meaningful Use.
    I was able to make a critical decision early on, choosing the appropriate EHR for my needs.
    While reading EKG’s at home on a newly gifted Christmas Chromebook, my 13 year old suggested I read on our large screen TV mirroring the Chromebook by way of HDMI cable.
    I soon traveled to Costco and got a large screen TV mounted on the wall of an exam room and began projecting the patient’s chart with the Chromebook onto the TV. This set up has literally opened up a whole new dimension to my practice and the dissemination of data and modification of the chart is done in real time WITH the patient. Paradoxically, instead of data overload, as I feared, it has had an extremely therapeutic/cathartic effect on my patients.
    I am quite excited about this solution and 6 months of experience has verified in my mind what a fantastic, affordable, simple approach this has been.
    I do have a YouTube video (my first) and recently started a Twitter site to help get the message out.
    I am hoping to share my story other physicians grunting it out in the trenches, that indeed, there are affordable tools that can be implemented to keep us doing what we love.

  6. Forked tongue July 21, 2014 at 11:41 pm #

    From the Boston Globe:

    “Computerization in health care was a market failure,” said Dr. Robert Wachter, a physician and medical school professor at the University of California, San Francisco. “The idea that you would need a federal incentive program to get United Airlines to computerize or Walmart to computerize is laughable.”

    Tell us of the adverse events. Let’s be honest.

  7. Bonnie kaiser September 10, 2014 at 11:31 am #

    Excited about your new project and want to read your book when published.

    I know it will be a success. You are quite a remarkable person. Best always Bonnie

Trackbacks/Pingbacks

  1. Crowdsourcing Medicine in the Digital Age, with Bob Wachter, MD | Ted Eytan, MD - July 23, 2014

    […] Hope, Hype and Harm at the Dawn of Medicine’s Digital Age.” – see: Crowdsourcing My New Book on How Computerization is Changing the Practice of Medicine in Surprising … for […]

Leave a Reply