The Doctor’s Advocate | Fourth Quarter 2016
From the Chairman
Perspectives on the Future of Medicine
In just the past few years, the healthcare system has undergone a remarkable transformation from a paper-based system to a digital one. On top of that, healthcare organizations and physicians are under intense pressure to improve value—measured as safety, access, efficiency, cost, and patient experience.
Robert M. Wachter, MD, professor and chair of the Department of Medicine at the University of California, San Francisco, and bestselling author of The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, discussed this unprecedented change in the healthcare environment—and how it will affect both doctors and patients—during his keynote speech at our 2016 Executive Advisory Board. In the following conversation with Dr. Wachter, I asked him to share his thoughts on the challenges and opportunities ahead.
—Richard E. Anderson, MD, FACP
Dr. Wachter: In the future, our healthcare system will be primarily digital, and there will be a far more fluid flow of information than there is today. The patient’s information will be available to the patient, to the family, and to the clinicians, whether the patient is at home or in a clinic or being seen in a hospital. Patients will have the information that they need to manage themselves. And clinicians will have the information they need. And so will the system—in fact, ours will truly become a learning healthcare system, one that makes itself iteratively better as it takes advantage of the experience of prior patients. Up until now, most of the investments have been in enterprise systems like EHRs in hospitals. I think the next big wave in healthcare investment is in consumer-facing technologies that allow patients to monitor their own health.
Startups in big cities have attempted to bring back house calls, although there is concern that this will not scale for large populations of patients, particularly in rural areas. Telemedicine has also exploded in use and popularity, although reimbursement and liability issues have not been resolved. How do you see these alternate avenues of care evolving in the future?
Dr. Wachter: If we can resolve these issues about telemedicine, I see patients getting most of their care from home, managing their chronic conditions like diabetes, high blood pressure, and heart failure through information provided by the computer through a series of smart algorithms. And when they need to see clinicians, it will be largely through televisits. The idea that a patient would have to take off a day from work and drive to a hospital or to a doctor’s office, park, and then see a doctor for a 20-minute visit—people will look back at that and say, “You did that 15 years ago?” I think this vision is quite inspiring. I think that when we get to that place, we will be providing care that’s better and safer and cheaper and more patient centric than what we do today.
Dr. Wachter: First of all, just in terms of the national marketplace, there will be far fewer hospitals and those that exist will be fairly large, will be bristling with technology, and will really be one big ICU. The notion of a separate ICU will go away. Patients will have single rooms. When I walk into the patient’s room, the patient will see on their screen who I am, along with my background and bio.
The nature of consultation will also change. Right now, when I see a patient in the hospital, if the patient needs the help of a cardiologist or a nephrologist, I’ll call them for a consult and they may come and see the patient later in the day, and then they’ll leave a note for me and I’ll read it and go back and see the patient. In the future, I’ll go in and see the patient and if I need a nephrology consult, I’ll pull him or her up on the screen in the patient’s room and we’ll have a three-way conversation. That ability to integrate our care and talk to one another facilitated by technology will make things much better and more efficient than they are today.
The idea of patient engagement—encouraging patients to be actively involved in their healthcare—has become a common discussion in medicine. This concept, including ideas such as giving patients open access to doctors’ notes, nudges patients to be involved, but it also means that patients will be expected to live up to a different level of responsibility for their health. How do you see the patient role in future years?
Dr. Wachter: The role of the patient in their own healthcare is going to be utterly transformed. Patients have been passive in the healthcare system up to now. Technology democratizes everything, and it will elevate the role of the patient by giving them new tools and access to information. The doctor will no longer be the only expert in the room. We'll see patients who are able to partner with their doctors in ways that they're not able to today—through computer tools, smart algorithms, and linkage to online communities where they meet other patients with similar problems.
But we have to be careful because patients also may try to take care of themselves and be their own doctors. We have to figure out how to get this right—how to allow technology to permit our patients to manage themselves better on their own or with the assistance of the healthcare system, but also to recognize there are times where patients really need to see a doctor or someone that's part of the healthcare system.
While EHRs have brought many positives, they have also created new risks and frustrations for doctors and patients. The Doctors Company did a study of our closed malpractice claims in which EHRs were a contributing factor, finding that 64 percent of these claims were caused by system factors like lack of alerts or clinical decision support and 42 percent of claims were caused by user factors like inputting incorrect information. What are your thoughts on current EHR issues?
Dr. Wachter: EHRs are really important because we can’t possibly take care of patients using paper and pencil and fax machines. But today’s versions of EHRs are not very good, because they were built to serve too many masters. If they were built simply to help the doctor take care of his or her patients, they would look one way. But they weren’t. They were also built to make billing more efficient. They were built for malpractice prevention, to meet regulatory requirements, and for quality measurement. And the problem is that when you build a digital system for 10 different masters, you come up with something that isn’t very good for any of those goals.
We’ll have to do three main things to make the EHR the vehicle that we want it to be. First is promoting for more use of user-centered design. The second is dealing with too many alerts—alert fatigue is overwhelming and dangerous, and we simply have to figure out how to prevent it. And the third is interoperability, to ensure that patient medical records can be shared easily between doctors, hospitals, and other healthcare providers at any time.
Technology has brought great things to healthcare, but it always brings unanticipated consequences. It’s dangerous to believe that technology will solve all problems—we must instead view it as just another tool to help us improve how we care for patients.
We have partnered with Dr. Wachter to provide unique tools to help doctors stay current with digital trends in medicine. Visit www.thedoctors.com/digitalmedicine to access innovative digital medicine resources, including 12 short videos featuring Dr. Wachter.
More About Dr. Wachter
Dr. Wachter has published 250 articles and six books in the fields of quality, safety, and health policy. Dr. Wachter coined the term “hospitalist” in a 1996 New England Journal of Medicine article and is past president of the Society of Hospital Medicine. He is generally considered the academic leader of the hospitalist movement, the fastest-growing specialty in the history of modern medicine.
The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.
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