Robert M. Wachter, MD, began his recent presentation for the Healthcare Risk Advisors (HRA) virtual lecture series by admitting what he jokingly called “the dumbest thing I’ve ever said to a mentee” , many years ago: âWhat will you do? after setting up our electronic health record? To date, we have all seen that the deployment of the electronic health record (EHR) has not gone as planned. If we have read Dr. Wachter’s book The Digital Doctor: Hope, Hype, and Prejudice at the Dawn of the Computer Age of Medicine, we can even understand why the deployment went so badly. Fortunately, Dr Wachter believes that it is now, finally, “the time for optimism” in the digitization of health care. Our success on the digital road will depend on what he describes as âreimagining the workâ.
The four stages of digitization
Studying the digitization process in other industries, Dr. Robert Wachter, professor and chair of the Department of Medicine at the University of California at San Francisco (UCSF) and a member of the board of governors of The Doctors Company, identified four digitization steps. for health care:
1. Digitization of the recording.: This is the stage we are completing now, rather later than we would have liked.
2. Interoperability: Connect (a) primary care providers to hospitals, as well as hospitals to hospitals, then (b) the entire digital ecosystem (i.e. third party applications, patient systems and business systems).
3. By gleaning meaningful information from the data.
4. Convert information into actions that improve value, whether measured in terms of safety, cost, access or equity.
We have already started step two, but to reach steps three and four we need a radical change in the way we think about digital data: less like something to collect, more like something to act with and on which to act. Dr Wachter says organization leaders need to wake up thinking, “We have all this data lying around, let’s do something with it.”
The IT productivity paradox
Baseball statisticians can predict with amazing accuracy whether a certain player can hit a curved ball thrown by a left-handed pitcher in the rain just after a full moon. Meanwhile, Dr. Wachter wryly observes that our inpatient sepsis alerts, considered a triumph among clinical decision-making tools, are wrong about a quarter of the time.
Today medicine is caught in the âcomputer productivity paradox,â a term coined by economist and technology expert Erik Brynjolfsson, PhD, of Stanford. In other industries, the benefits of converting from paper to digital systems only began to be felt after two, five, or even 10 years. Healthcare, which by nature is highly regulated and cannot afford to play the entrepreneurial game of ‘go fast and fail’, can take 10 to 20 years from the start of the EHR conversion to see. these benefits accumulate.
What needs to happen before digitization begins to bear fruit? Industries reap the rewards of digitization when technology improves, yes that is a given. But the central challenge is to “reimagine the work”.
Take the example of a doctor’s note: those who created electronic notes imagined scanning a piece of paper in a filing cabinet. But if we were to design the electronic note from scratch today, Dr. Wachter points out, it would be more like a feed on Facebook or Twitter. It would include video and audio components. And, like Wikipedia or Google Docs, it would be more collaborative, with room for comments from nurses, social workers, and others.
Part of the reason for the IT productivity paradox is that humans have a hard time thinking of entirely new ways of doing things. We need healthcare workers and administrators to start asking, ‘Why are we doing this? X in this way? Why don’t we do it this other way? To help us see new possibilities.
A digitization success story
Robert Rushakoff, MD, a diabetologist, is the backbone of UCSF’s inpatient blood glucose management service. Each morning, Dr. Rushakoff uses a personalized dashboard to review data from patients hospitalized at UCSF Medical Center who meet certain criteria. For about half of these patients, Dr. Rushakoff alerts the healthcare team that they need to make an adjustment. His name is now a verb: clinicians say to themselves: “I have received Rushakoffed”.
Dr. Wachter says this system reduced hyperglycemia and hypoglycemia by about 40 percent each.1 Examining Dr Rushakoff’s dashboard of data on about 20 high-risk hospitalized patients with diabetes takes him about an hour each morning, the time it took him to complete an endocrinology consultation. That is to say, this dashboard allows Dr. Rushakoff to improve the health of the population in hospitals, facilitated by digitization.
The creation of the dashboard required 10 to 15 hours of programming. Programming is not what was difficult, says Dr. Wachter. It was hard thinking. It’s reinventing work.
Divide to rule better: how to structure technical teams for success
Dr. Wachter suggests that organizations organize their technology workforce into two teams with two profoundly different functions:
- Team 1 could be called the âtraditionalâ digital arm of the organization. Its members solve today’s problems of clinical and business care, maintaining the day-to-day functions of the organization as they currently exist. They tend to focus on the EHR as the cornerstone of their work.
- Team Two is the digital solutions store. Its members are responsible for anticipating âbig thorny issuesâ for which there is no tool on the shelf.
Dr Wachter explains that the technological strength of UCSF is organized in this way and that there is no way Team One ever had the bandwidth to deliver the Doctor’s One-Stop Blood Glucose Management Service Dashboard. Rushakoff – after all, they’ve got their hands full troubleshooting everyday EHR use and interoperability issues. Their current multi-year project is called âUCSF Digital Patient Experienceâ.
Keep Calm and carry on
As we enter the second step in the search for full interoperability, Dr. Wachter offers the encouraging idea that we are finally, truly, entering the post-EHR era, an era in which we will take advantage of new tools and modes. thought to improve the value of health care. Maybe now we will finally learn the answer to that question from years ago: What will we do after implementing our electronic health record?
To hear Dr. Wachter describe the digital revolution as only he can, go to his recording. presentation.
David L. Feldman, MD, MBA, FACS, Chief Medical Officer, The Doctors Company and TDC Group; Senior Vice President, Healthcare Risk Advisors
1. Rushakoff RJ, Sullivan MM, Windham MacMaster H, et al. Association between a virtual blood glucose management service and blood glucose control in hospitalized adult patients: an observational study. Ann Intern Med. 2017; 166 (9): 621-627. doi: 10.7326 / M16-1413