In retrospect, we were bound to be disappointed. Our daily experience has taught us that all we need to do is turn on our iPhone, download an app, and off we go -- whether we're buying a book, making a restaurant reservation, finding a favorite song, or getting directions to the nearest Starbucks. It was only natural for us to believe that wiring the healthcare system would be similarly straightforward. Perhaps if Apple had done it, it would have been.
But healthcare's path to computerization has been strewn with land mines, large and small. 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 confusion than clarity. Patients are now in the loop -- many of them get to see their laboratory and pathology results before their physician does; some are even reading their doctor's notes -- yet they remain woefully unprepared to handle their hard-fought empowerment.
While someday the computerization of medicine will surely be that long-awaited "disruptive innovation," today it's often just plain disruptive: of the doctor-patient relationship, of clinicians' professional interactions and workflow, and of 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 astounded by the speed with which things are changing and the unpredictability of the results.
Before I go any further, it's important that you understand that I am all for the wiring of healthcare. I bought my first computer in 1984, back when one inserted and ejected floppy disks so often ("Insert MacWrite 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 only 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 not to.
For decades, healthcare's immunity to computerization was remarkable; until recently, in many communities the high school was more wired than the local hospital. But over the past 5 years, tens of billions of dollars of federal incentive payments have helped increase the adoption of electronic health records by hospitals and doctors' offices from about 10 percent to about 70 percent. When it comes to technology, we've been like a car stuck in a ditch whose spinning tires suddenly gain purchase, so accustomed to staying still that we were totally unprepared for that first lurch forward.
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When I was a medical resident in the 1980s, my colleagues and I performed a daily ritual that we called "checking the shoe box." All of our patients' blood test results came back on flimsy slips that were left, in rough alphabetical order, in a shoe box on a small card table outside the clinical laboratory. This system, like so many others in medicine, was wildly error-prone. Moreover, all the things you'd want your physician to be able to do with laboratory results -- trend them over time; communicate them to other doctors, patients, or families; be reminded to adjust doses of relevant medications -- were pipe dreams. On our Maslow's hierarchy of needs, just finding the right test result for the right patient was a small, sweet triumph. We didn't dare hope for more.
For those of us whose formative years were spent rummaging through shoe boxes, how could we help but greet healthcare's reluctant, subsidized entry into the computer age with unalloyed enthusiasm? Yet once we clinicians started using computers to actually deliver care, it dawned on us that something was deeply wrong. Why were doctors no longer making eye contact with their patients? How could one of America's leading hospitals (my own) give a teenager a 39-fold overdose of a common antibiotic, despite (scratch that -- because of) a state-of-the-art computerized prescribing system? How could a recruiting ad for physicians tout the absence of an electronic medical record as a major selling point? Logically, we pinned the problems on clunky 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 questions, I realized that I needed to write this book -- first to explain all this to myself, and then to others.
What I've come to understand is that computers and medicine are awkward companions. 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 the performance of 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, he explains, the people are both the problem and the solution. Leadership, he once said, requires mobilizing and engaging people around a problem "rather than trying to anesthetize them so you can go on and solve it on your own."
The wiring of healthcare has proven to be the Mother of All Adaptive Problems. Yet we've mistakenly treated it as a technical problem: 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 when we were faced with failed installations, mangled workflows, and computer-generated mistakes, we usually misdiagnosed the problem; 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.
Making this work matters. Talk of interoperability, federal incentives, bar coding, and machine learning can make it seem as if healthcare information technology is about, well, the technology. Of course it is. But from here on out, it is also about the way your baby is delivered; the way your cancer is treated; the way you are diagnosed with lupus or reassured that you aren't having a heart attack; the way, when it comes down to whether you will live or die, you decide (and tell the medical system) that you do or you don't want to be resuscitated. It is also about the way your insurance rates are calculated and the way you figure out whether your doctor is any good -- and whether you need to see a doctor at all. Starting now and lasting until forever, your health and healthcare will be determined, to a remarkable and somewhat disquieting degree, by how well the technology works.
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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've come to the wrong place. Part of the reason we're experiencing so much disappointment is that in the rest of our lives, information technology is so astonishing. I have no doubt that, even in medicine, our bungling 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 picked up this book looking for breathless hyperbole, you won't find that here, either. We are late to the digital carnival, but there are barkers everywhere telling us that this or 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. Lycra bike shorts that take our pulse, count our steps, and read our moods are pretty nifty, but they aren't the change we need.
What you'll find in these pages is an insider's unvarnished view of the early days of healthcare's transformation from analog to digital, with tales of modest wins as well as surprising obstacles. Notwithstanding the latter, 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 -- in fact, we must -- wire the world of medicine, 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 healthcare 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 one another and with patients. Sorting out all these issues will take deep thought and hard work on the part of clinicians, healthcare leaders, policymakers, technology vendors, and patients. Sure, we should have thought of this sooner. But it's not too late to get it right.
Robert Wachter, MD, is associate chairman of the department of medicine at the University of California San Francisco and author of several books. His newest, from which this excerpt is taken, is "The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age." Read MedPage Today's interview with Wachter.