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Speaking with the digital doctor: Q&A series with Robert Wachter

If we were asked to create a list of the most compelling healthcare IT books of 2015, Robert Wachter’s The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Computer Age would be in the running for the number one position. His book offers a plain-spoken, and utterly convincing argument that healthcare IT is in its infancy, and without  guidance and proper balance of patience, common sense and compassion, it will grow into a member of our society who harms, rather than helps, others.

I plan to conduct three interviews with Dr. Wachter. Below is the record of our first conversation. Our follow-up interviews will be posted in the coming weeks. 

(Editor’s note: To hear audio excerpts of this interview, click on the media player buttons that run throughout this article.)

Free: Let’s start our conversation by discussing your experiences investigating how vendors impact the use of healthcare IT.      

Wachter: I had a chance to spend a fair amount of time with vendors, and they’re smart people. I think we’re pinning a lot of our disappointment on them. Some of that, I think, is correct. Some of them have not done as good of a job as they should. Some of that is not their fault. When, for example, I looked at why the physician’s note has become such a disaster as a bloated piece of mostly unhelpful check boxes and confusion, I came to recognize that we’ve asked the vendors to solve ten different problems in the same space. Problems that they didn’t create. Again, for example, the note has to serve about ten different masters and vendors can only do so much with their limited exposure to the field. I do have some sympathy for their predicament.

 That said, I’ll say that probably the most instructive day I had in my research for the book was the day I spent at Boeing and talked to the folks that designed their cockpits. The sense that I got from those computer engineers was that they really, deeply understood the idea of user-centered design. You can say, “Yeah. We do that! Of course, we bring in users to be sure that we got it right,” but when I spoke to the Boeing engineers, there was this reverence for the experience of the pilots. This deep appreciation of the history of pilots, and of flying airplanes. They said to me things like, “How could we not bring the pilots in and make sure that we got it right? And every time we do, we realize we didn’t quite get it right, and we only realized that after we watch them for hundreds and hundreds of hours, interacting with our technology. And before we send this plane out into the real world, we wouldn’t dream of doing it before we watched them for thousands of hours.” I say, “Why do you do that?” They said, “Well, part of it is that we know that they’re going to teach us things we weren’t smart enough to figure out. Part of it is that we understand that the lessons that they have learned, people gave their lives to learn those lessons. People died to learn those lessons.” There was a sense of reverence for the traditions of pilots. I never heard anything that remotely resembled that from an IT vendor.

Part of these differences stems from the fact that the traditions of the medical and aviation fields are different. Part of the difference is that Boeing and Airbus build their entire ecosystem. That would be like if Epic and Cerner ran the hospitals. They don’t. It’s much more difficult for vendors in healthcare to bring in the end-users and actually see, not just what the interface looks like, but how it is actually going to be used in real life, and in an Intensive Care Unit (ICU) at 3:00 am with sick patients and alerts going off every two seconds. What’s that going to feel like?

That consideration for the user is the most important thing that the vendor community must make as they conduct their work. They must get out into the field, and see how their tools are really working in real-life situations. If they do that, they will build better, more effective tools. Part of the backlash you’re hearing from clinical users of tools is that they have the sense that the vendors have not done that, and that sense is largely correct.

Free: Some would argue that you are putting too much of the responsibility of the effectiveness of healthcare It on the vendors. How would you respond to that claim?

Wachter: I am a believer in the notion that every system gets the results that it’s designed to get.

When you look at the world of the vendors, for companies like Epic and Cerner, the big guys, they’ve been here for 20, 30, or 40 years, toiling away before there was a market. Twenty-five years after the first electronic medical records (EMRs), only 5 or 10 percent of hospitals or doctor’s office had an EMR. It was unbelievably slow adoption.

We know from the history of technology in other fields that you need an iterative process as you build your system. It should be understood that everything you create is as good as you can make it at that moment, both because of the technology and how you’re thinking about it changes over time and these changes impact how smart you get. Things get better because of the user feedback and user push back that occurs during the iterative process. You try it again and again. Eventually, on version 73, it kind of works.

This is such an interesting moment in healthcare because, after a lot of hurry up and wait for a generation, all of a sudden because of the Health Information Technology for Economic and Clinical Health Act’s (HITECH’s) incentive, we went digital pretty quickly. You didn’t hear doctors moaning about their computers five years ago because they didn’t have computers. Now everybody does, and everybody says, “Wow, this is not what I expected,” and “This is not very good.”

Could they have made it better? Should they have made it better? Yes and yes. But we are where we are and, going forward, we have to figure out a process where the feedback that the end users are giving is not dismissed as being the feedback of dinosaurs or people who are out of touch.

The vednors – Epic, Cerner, Athena – need to get out there. See how your tools are really working in the wild with doctors and nurses trying to do important work. You do that and, in time, we will see wonderful developments in improving patient care and lowering costs. If not, we are in for more of the same, or worse. 

An answer is: it’s not working as well as it needs to, and they need to take that feedback and iterate and make it better, and I think part of that is not dismissing the clinicians as technical obstacles, but understanding that although we’re not perfect, we are out there doing the work and the tools have to work for us. That philosophy really felt to me like a core, it wasn’t BS, it wasn’t a Hallmark card when the Boeing folks said it to me. It felt like it was a core way that they think about their work.  I don’t think it is the core way that vendors think about their work and I think if we are going to make this better, then they have to change. 
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