Technology tends to disappoint early in its history because people expect it to work perfectly immediately without adapting their workflow around it.
As technology has entered the medical field, it has reduced some errors but introduced problems of its own, according to Robert Wachter, MD, a professor at the University of California San Francisco School of Medicine and the author of "The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age."
Dr. Wachter, who teaches and practices internal medicine at the UCSF Medical Center, is a self-proclaimed lover of technology but understands why others in the medical industry don't get along with EHRs and other digital tools. After observing many of the problems physicians face with technology and seeing little writing about it, he decided to travel the country to interview providers about their experiences and eventually compiled it into a book explaining the story of technology in healthcare.
His conclusion is that there is always a lag in technology, and the medical industry has already passed a tipping point — adoption rates are at an all-time high, and the only thing left is for physicians to like the technology they are using. That may be years away, but it is coming, he said.
Note: Answers have been edited for length and clarity.
Question: Why do you think some areas of the healthcare industry have been so slow to adopt technology and others have been more open to it?
Robert Wachter: I think the fact that we needed $30 billion of federal incentives to transform the healthcare industry is an amazing story in and of itself. Healthcare did transform from an analog industry to a digital industry in the last four or five years. Radiology did do it before the rest of the industry. In the '80s and '90s, you were typically getting a chest X-ray, and printing each one cost about $4. Starting in the '90s, the most prevalent ones were CAT scans and MRIs, which were printing out between 50 and 200 images. At that time, the cost of digital storage was plummeting, and radiology transformed overnight. It did go digital on its own, but it was also sort of a canary in a coal mine. In some ways, that's sort of been the history of technology in other industries as well. You are actually transforming the nature of the work, and if you're going to get it right, you need to think pretty deeply about the process.
Q: Why do you think there has been such strong opposition to digitizing?
RW: What happens typically is that as the computer comes of age, the care that physicians are delivering is being scrutinized closely. Quite predictably, the hospital wants to maximize its billing and performance, and it doesn't really want physicians to write a narrative. It wants physicians to check boxes so they can do the best they can in pay-for-performance. There's a huge tension there between what physicians are trained to do — understand the patient's story — and these imperatives to try to maximize performance in all sorts of other ways. That's where the rubber meets the road. You have the physician trying to satisfy his or her professional training with their requirements to check all sorts of boxes, and you end up with sort of a mess.
Q: In your book, you describe an interaction with IBM's Watson engine, which famously out-performed humans on Jeopardy. Is there any future for physicians being replaced by computers as diagnosis providers?
RW: In some places, the physician's note is the articulation of our findings from a patient. From what might be 200 facts that physicians glean, we then have to see the diagnostic engine. Of those 200 facts, the computer has no way of telling which one is the most important. Physicians can do that. It's not to say the computer can't ever crack it, but the people who say we're almost there with computers aren't really aware of the obstacles.
Q: How will technology in the clinical setting contribute to patient engagement?
RW: I think technology does, in every industry, democratize information. Patients have had the legal right to look at their charts since 1996. In the age of Google, doctors are no longer the source of exclusive medical information. Patients have the ability to interact with their medical system in new ways. We're still figuring it out, but there's a lot of that coming down the line. Online communities are very exciting as well. Patients with cancer are talking to patients with the other same cancers online. There's also a fair amount of information that patients get from their physicians now that they could do themselves. I think that's all for the good. The way I worry, though, is that there is a fair amount of work physicians do that's not like that. It will be difficult for patients to know how to draw that line, particularly in a world of higher co-pays where they have an incentive not to interact with the healthcare system.
Q: There is some fear that providing patients with all their health information can lead to confusion. What do you think patient portals can do to help patients understand their information?
RW: People have been worried about it forever, saying patients aren't going to be able to interpret their information, and now 5 million people have access to their physician's notes [through the OpenNotes project]. People worry that it's going to drive patients crazy, and the research doesn't seem to show that there are massive problems, but it is often delivered to them in a way that is not patient-friendly. As an expert, I spent 10 to 20 years training to look through spreadsheets for numbers. To show the same view to a patient is crazy. The door has opened, patients are going to have access, and now you're going to see products come out there that is going to make the information more useful to patients.
The reason that hasn't happened very well so far is that the portals are developed by the existing IT companies. These companies, they're not in the business of producing consumer-friendly websites. Maybe they'll figure it out, but it seems to be much more likely that the kind of displays and analysis that will be most helpful will be more likely developed by consumer-facing companies. It's sort of like the Transcontinental Railroad, where you have two sets of railroads being built, but they have to connect.
Q: Hospitals often have to face the issue of cost when investing in technology. Is there a digital divide between large and small hospitals in terms of IT investment?
RW: I think that's a huge problem. [For example,] Epic has done very well among big and well-to-do hospitals with several hundred million dollar budgets to install that system. Where does that leave small hospitals and small practices? I hope that there's a vibrant environment of other companies to fill that niche. We need a market where both of those can survive, and we need a market where they can all link together.
I think the digital divide is having an interesting effect: It's promoting consolidation. There are lot of forces out there promoting consolidation of healthcare organizations and healthcare systems becoming much more systemic. I think IT is another enabler of that. If you are a small hospital, the cost of buying your EHR and keeping it up is a daunting thing. If we become part of this big system and use their system, that will save some costs.
Q: Where do you think the tipping point will be where the medical industry starts to become more comfortable with the introduction of technology?
RW: I think that what's happened over the last five years is that because of the incentives, you now have adoption rates in hospitals of over 70 percent. That adoption rate was 10 percent in 2008. You don't go backward. No one has pulled out. People have switched, but nobody goes back to pen and paper. There's an enthusiasm gap, for sure. When people are going to look at their technology and think of it as fondly as they do of their iPhone, I think that's 10 years away. The history of technological history is that it disappoints early on. Part of the reason is that people put systems in and then don't change the rest of their work. That's natural. It usually takes 10, 15 or 20 years for technology to reach its full potential. Technology gets better, but most importantly, people re-imagine the work. Sometimes, that takes people retiring, sometimes takes changing training programs, new technologies. It's an incredibly interesting sociopolitical and technological phenomenon.
The kicking and screaming right now is just a stage we have to go through. Healthcare IT is not reaching its potential yet and the standards of producing products are not as good as they should be, but I think it's a natural step. Ultimately, this will be good. I have no doubt that we'll get there, but how fast we get there depends on the choices that we make.