Being a Physician in the World of Digital Healthcare (and will we - - PDF document

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Robert M. Wachter, MD

Professor and Interim Chairman, Dept. of Medicine Chief, Division of Hospital Medicine University of California, San Francisco

Being a Physician in the World of Digital Healthcare

(and will we need doctors?)

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Recapping a Few Points

Healthcare has finally, reluctantly, become a digital enterprise The transition has involved more pain, less gain than we expected We failed to appreciate that health IT is adaptive, not technical change My guess is that we’ll get there: the “Productivity Paradox”

“The Challenge That Will Dominate Your Career…”

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IT Adoption Skyrocketing: Now >70% in MD Offices & Hospitals

EHR Adoption in US Hospitals. Ashish Jha 2015 ~75%

Pressure to deliver high- value care The digitization of the U.S. healthcare system

The Big Picture: Two Transformational Trends

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When Things Will Really Get Interesting Health IT: The Mother of all Adaptive Problems

“… problems that require people themselves to change. In adaptive problems, the people are the problem and the people are the solution. And leadership then is about mobilizing and engaging the people with the problem rather than trying to anesthetize them so that you can just go off and solve it on your own.” – Ronald Heifetz, Kennedy School of Government

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“You can see the computer age everywhere but in the productivity statistics.”

• - Nobel Prize winning economist Robert Solow, 1986

The Two Keys for Unlocking the Productivity Paradox

Improvements in the technology Reimagining the work itself

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How Health IT Changes the Roles/Lives of Physicians

Physician unhappiness and burnout Measurement, feedback, and transparency in the digital/Big Data age Patient engagement and patient tools Can/will/should patients become their own doctors? “We have the capacity to transform health with

• ne thunderous click of a

mouse after another.”

US Secretary of Health & Human Services Michael Leavitt, in 2005

“ER physicians spent 44 percent of their time entering data into EMRs, clicking up to 4,000 times during a 10 hour shift.”

Becker’s Health IT magazine, 2013

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2014 Advertisement For AZ ER Job

Arizona General Hospital will be coming to The Grand Canyon State later this year!! Located in Laveen, Arizona, a suburb of Phoenix, Arizona General Hospital is a 40,000 square-foot boutique general hospital. Services offered include:

• Emergency Room
• Radiology Suite inc. CT, X-Ray, and Fluoroscopy
• Two State-Of-The-Art Operating Rooms
• Outpatient Surgery
• 16 Inpatient Rooms
• NO EMR

“The patient is still at the center, but more as an icon for another entity clothed in binary garments: the ‘iPatient.’… The iPatient’s blood counts and emanations are tracked and trended like a Dow Jones Index, and pop-up flags remind caregivers to feed or bleed. iPatients are ‘card-flipped’ in the bunker, while the real patients keep the beds warm and ensure that the folders bearing their names stay alive on the computer.”

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A 7-year-old Girl’s Depiction of her MD Visit

Toll E. The cost of technology. JAMA 2012

The Fastest Growing Job in Medicine…

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How Health IT Changes the Roles/Lives of Physicians

Physician unhappiness and burnout Measurement, feedback, and transparency in the digital/Big Data age Patient engagement and patient tools Can/will/should patients become their own doctors?

Health IT Facilitates Measurement in Many Ways

Granular clinical data allows better case-mix adjustment (for outcomes measurement) Process measures via checkboxes, etc. EHRs allow follow-up Natural Language Processing may allow analysis of non-structured data Other sources of info can be integrated (sensors, patient surveys, Yelp, Twitter)...

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Not a Large Leap from… To…

Patients like yours turned out to have strongyloides

Or…

Patients like yours did better on Ceftriaxone than Levo Patients like this did better when they went to a different hospital

Or… In the Tug of War Between Forces Promoting/Inhibiting Transparency…

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…Health IT Tilts the Balance Toward Transparency

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How Will Practice Deviations be Handled?

Recent guidelines suggest… Please call the CMO for approval What is your reason for deviation? Are you some kind of moron?

How Health IT Changes the Roles/Lives of Physicians

Physician unhappiness and burnout Measurement, feedback, and transparency in the digital/Big Data age Patient engagement and patient tools Can/will/should patients become their own doctors?

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In The Future…

Patients will increasingly have the information they need to make informed choices Increasing amounts of care will be self-care, aided by IT decision-support

– Using data from surveys, labs, sensors, genes, social media, and more – System will suggest appropriate behavior and nudge us toward it

Patient Access to Information

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Patient Access to Their Information

Patients have had a right to see their medical record for ~20 years

– Try getting it, though, in a paper hospital

Now, all that separates a patient from her medical record is a password

“OpenNotes”: Now available to ~5 million patients in U.S.

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How Health IT Changes the Roles/Lives of Physicians

Physician unhappiness and burnout Measurement, feedback, and transparency in the digital/Big Data age Patient engagement and patient tools Can/will/should patients become their own doctors?

The Patient In Charge: An Appealing Idea

“The patient becomes the chief operating

• fficer – a notable promotion from

nobody to senior management. The COO monitors all the operations of the body. He is fully in charge, including of the team in IT, getting all the relevant data accurately and rapidly analyzed and reported back to him…. The COO has periodic and ad hoc reporting to the chief executive officer, the doctor….”

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“Sick people have a primal need to be cared for; almost always, the sickest patients find that relinquishing the tough decisions to someone else brings huge relief. Healthy people may certainly enjoy monitoring their own physiology, but that activity can take up an awful lot of time. There are many wonderful things to do in this world other than keeping track of your own organs. Sometimes, it just makes sense to have someone do it for you.”

Abigail Zuber, New York Times, January 5, 2015

Pew Internet Health Survey, 2013

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My Son Benjy

Dad, I have diabetes and glaucoma

Striking the Right Balance

Patients, esp those with chronic diseases, need tools for self-monitoring and engagement Layers – of smart algorithms, coaches, “care traffic controllers,” and MDs – should help patients get best care at lowest cost

– Avoiding overload, and with seamless integration

Patients must have access to physicians and the medical care system when they need them, without unrealistic assumptions about what they can/should do themselves

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Franz Ingelfinger

Editor, New England Journal of Medicine, 1967-76

“I have subscribed for some time to the principle that the physician must be authoritarian and paternalistic to some degree, and my experience as a patient has substantiated that belief… I received from physician friends throughout the country a barrage of well-intentioned and contradictory advice. As a result, not only I but my wife, my son, and daughter-in-law (both doctors)… became increasingly confused and emotionally distraught. Finally, when the pangs of indecision had become nearly intolerable, one wise physician friend said, “What you really need is a doctor”…. When that excellent advice was followed, my family and I sensed immediate and immense relief.”

Ingelfinger F. “Arrogance” NEJM 1980