The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age

Reading notes:

In healthcare, radiology is a successful sub-field that went digital without federal incentives, with a minimum of fuss and bother, and about a decade before the rest of healthcare did. Radiology’s experience over the past 15 years offers a crystal ball for the rest of the healthcare system. The speed with which computerization unleashed a series of forces that completely transformed an established field would be all too familiar to travel agents, journalists, and others who have been run over by the digital bulldozer, but it has shocked many healthcare observers, even astute ones. Will the computerization of the rest of medicine similarly upend the lives of other kinds of doctors, as well as their patients? The early returns are in, and the answer is yes.P66

When GE acquired the struggling vendor IDX, we all breathed a sigh of relief: surely the world’s greatest technology firm would not only salvage our system, but improve it. After all, the company brings good things to life.

But year after year, the system failed to deliver much beyond frozen screens and user-unfriendly, even dangerous interfaces. An interesting thing happens when you are a customer of a company like GE; I liken it to the way I feel about modern art. When I visit, but then am underwhelmed by, a highly touted exhibition of stark white canvases or stacks of empty seltzer bottles, I assume that the problem must be with me – I just don’t get it. So it was with our GE system: we assumed that if we were unsatisfied with the system, it must be us. Turns out it wasn’t. GE’s system is poorly rated by an independent rating agency and is stumbling badly in the hospital EHR business. (John Halamka, chief information officer at Boston’s Beth Israel Deaconess Medical Center, calls GE’s EHR offerings “Imagination at Work”) We ultimately decided to jettison the system in 2009.

Over the last several years, Epic has nearly cornered the market among large hospital systems, particularly academic medical centers. Virtually every large hospital that has switched from one system to another in recent memory has chosen Epic’s. It has become today’s healthcare version of what IBM was in the 1980s, when they saying went, “Nobody ever lost their job going with IBM.” Epic is the safe choice.

The first indication that an EHR Go Live was not tiddlywinks came in 2002, when Cedars-Sinai Medical Center in Los Angeles launched its brad-new system and the doctors nearly went on strike. For many in healthcare, the Cedars fiasco served notice that a Go Live was unlikely to be as easy as it had seemed during the vendor demo or -since Cedars had built its own system during early-morning discussions over bagels and coffe. Cedars’ experience was particularly scary because everyone knew that the hospital hadn’t done things on the cheap. But money can’t buy everything and in this case it failed to produce a usable system. Physicians grumbled about overabundant alerts, inflexible work flows and massive inefficiency. Soon after Go Live, the monthly meeting of the medical staff- usually a sleepy, clubby affair – was transformed into a near-riot, including threats to impeach the chief of staff. The medical center got the message and agreed to ditch the system within a month of going live. The cost, in 2002 dollars” 34 million. “The important lesson of the Cedars-Sinai case is that the electronic health record implementation is risky.

Abundant research has demonstrated that the term multitasking is a misnomer – performance degrades rapidly when people try to do several things simultaneously. Psychologist speak of the concept of “cognitive load” – the overall volume of things a mind is grappling with a given time. While there are some individual differences in the ways we manage cognitive load, one thing is clear: none of us does this as well as we think we do.

Gross and Tecco interviewed dozens of venture capitalists and entrepreneurs. Each brought them closer to understanding the obstacles to IT innovation in healthcare. They boiled the problem down to three main issues. The first was investor uncertainty: at the time, nobody knew whether the Affordable Care Act would pass and what its real impact on the healthcare marketplace would be. Until things settled out, healthcare’s longstanding market problems, particularly the lack of incentives for patients and clinicians to invest in tools that might improve quality or efficiency, would continue to cast a pall on IT investments large(EHRs) and small (wellness apps). (It should be noted that there were exceptions to this rule. The climate for certain healthcare technology investments – namely, those designed to be used by special-scanners, or those designed with lucrative self-pay markets in mind, such as lasers in plastic surgery – was and remain vibrant.

The second problem: most venture capitals firms, even those with an interest in healthcare, lacked personnel with the deep medical knowledge needed to evaluate new technologies or the problem they were designed to solve.

The third obstacle stemmed from the youth of most IT entrepreneurs. Unless a 26-year-old computer engineer has a loved one with a serious medical illness or hails from a long line of physicians, the world of healthcare is utterly foreign, with a different language and a set of problems whose solution appear to be well beyond the horizon. “People like to build products that solve problems in their lives. Snapchat may do that, whereas a healthcare app doesn’t” Gross told me.

Three examples of Silicon Valley and healthcare hybrid:

  • Augmedix – doctors interact with their patients while wearing Google Glass with natural language processing helps create the note.
  • CellScope – replacement of doctor’s otoscope
  • Rock Health is a non-profit, funded through a combination of philanthropy from successful graduates and investors and fees for conferences and educational materials.
  • Lift Labs – Liftware helps patients who suffer from serious hand tremors.

Productivity Paradox

Organizations naturally create structures and cultures that support their usual way of doing things, and (for reasons from risk aversion to job preservation) resist radical new approaches. Yet this approach can be self-defeating. Studies of technology’s impact in other industries have clearly shown that thos organizations with the management processes and culture to take advantage of the new tools are the ones that thrive. In 1988, management guru Peter Drucker, he of “culture-eats-strategy-for-lunch” fame, presciently described how the then-fledgling field of information technology would allow organizations to flatten hierarchies and elevate the roles of “knowledge-workers.” In the future, Drucker wrote, “the typical business will be knowledge-based, an organization composed largely of specialists who direct and discipline their own performance through organized feedback from colleagues, customers, and headquarters.” It was the availability of information -“data endowed with the relevance and purpose” – that would catalyze the shift.

There is an underlying philosophy that we seem to lack in building health IT system. At every step of its design process, Boeing brings pilots into the simulators and checks to see whether the alerts (and everything else) work the way the designer intended. Under this philosophy of “user-centered” design, after the aviation engineers have completed their mock-ups and build a version of a new cockpit, they spend thousands of hours observing pilots in the environment, tweaking the technology until they have things just right. We do nothing like this in healthcare, partly because those who build the computer systems can’t easily test them in the diverse organizations in which they will be deployed (from rural clinics to large urban academic medical centers), and partly because the EHRs are trying to satisfy so many different audiences and demands. But no other mission should trump the mission of making healthcare safe. And the only way to achieve this goal is to make aviation-style integrated field testing a standard part of healthcare automation.

In the aviation industry, there is an abiding respect, even reverence, for the wisdom of the frontline workers. In a 2012 video discussing what healthcare can learn from aviation, Mike Sinnett, Boeing’s chief 787 project engineer, pointed to the difficulty of introducing new technology to midcareer pilots who have been accustomed to doing things a certain way for years and years. While pilots like new safety features, he said, ” We need to introduce them in a way that honors all their past training, but is also intuitive to them so it’s easy to use. All the technology in the world is not going to help you if it’s not intuitive and if the end user can’t use it.

I heard many references to this notion of honoring the pilots’ experience and traditions in my discussions with various folks at Boeing and with pilots themselves. It is clearly part of the DNA of commercial aviation. I never heard anything like it from a health IT vendor, many of whom see clinicians as expensive cogs to be replaced or technophobic obstacles to overcome. Physicians and nurses are far from perfect, but creating a high-functioning digital healthcare system is going to require far greater involvement of – and yes, reverence for – the members of these proud and noble professions.

Potential threats in healthcare IT

1. While computers can liberate patients and physicians, they also permit a level of control and micromanagement of clinical practices. While we want our doctors to follow well-established guidelines when they are appropriate, we don’t want government bureaucrats or insurance executives, rather than medical experts, exercising undue control over clinical practice. Such control was impossible in the pen-and-paper era. In the current digital age, this kind of oversight has become feasible, turning this question into an inevitable battleground, one that must be approached with great wisdom and care.

2. Quality. “hitting the target but missing the point” we must ramp up our support for the science of quality measurement, and then find ways to collect the data that don’t distract clinicians from the care of the patient.

3. As the machines get better, the tensions between them and the people who work with them will escalate. Perhaps the time will come when physicians are entirely removed from the healthcare picture. That will not be anytime soon. Until then, we will be in the business of creating collaborative work environments that blend people and technology.

4. There is no guarantee that the time freed up by our newfound technological efficiencies will be made available for the human touch.