The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age

“Digital Doctor” provides the necessary context for those participating at the intersection of digital technology and medicine – “connected health.” This includes policy makers, regulators, hospitalists, physicians, nurses, technicians, Author Robert Wachter, Professor and Associate Chair of Medicine at the University of California at San Francisco Medical Center, while observing and participating in the digital healthcare revolution, had been thinking about writing this book for several years. He reached the conclusion that he had to write the book to makes sense of what was going on for himself and for others. He succeeded. This book will rank with Clayton Christensen’s “The Innovators Prescription” as one of the most important contemporary books on healthcare, particularly the digitization of medicine.Wachter points out that healthcare is on a path strewn with landmines. “Medicine, a intimately human profession, is being dehumanized by the entry of the computer into the exam room. Sensors and monitors are throwing off mountains of data, often leading to more confusion than clarity…Disruptive innovation in healthcare is disrupting the doctor-patient relationship, the clinicians professional interactions and workflow, and the way we measure and try to improve things.” Something is deeply wrong when doctors are no longer making eye contact.He goes on to outline two types of problems that need to be solved simultaneously – technical problems that can be solved with new tools, new practices, and conventional leadership; and adaptive problems where people are both the problem and the solution. “Healthcare has proven to be the mother of all adaptive problems” but we are now it as a technical problem, oblivious to the need for adaptive change. The result has been failed installations, mangled workflows, and computer-generated mistakes.Eight chapters are devoted to “The Overdose” which centers on 16-year-old Pablo Garcia who received 38.5 times the dose he was supposed to get at Wachter’s own institution, which is one of the most prestigious medical centers in the world. He guides us through this near-disaster by highlighting the error and the Swiss Cheese paradox, despite shrinking gaps in the system (the Swiss Cheese) and adding overlapping layers to eliminate errors, good competent people try to do the right thing but operate with misplaced trust in the computers and the system. What is needed is a “stop the line” culture in which every employee knows that he or she must speak up – not only when she sure that something is wrong, but when she’s not sure it’s right.In this section, he highlights the frightening problem of alerts sent by digitized equipment and devices. The result is “alarm fatigue,” which lead to clinicians and nurses ignoring alerts because there are so many false-positives every day. ICU bedside cardiac monitors send an average of 1 87 audible alerts for each patient. This translates to about 15,000 alarms across all ICU beds each day, and 2,507,822 unique alarms in one month in the UCSF ICU. Alarms and alerts are a clear and present danger for patients and clinicians.“Digital Doctor” covers the evolution of digital medicine, the harm it has caused, and its successes; government grants via the HITECH Act and Meaningful Use “which have locked in the incumbents and have locked out the young innovators”; the importance of the “Doctor’s note” and role of malpractice in diminishing its usefulness; the distinction between “information” and “knowledge” with clinicians becoming information-rich but knowledge-poor; “David and Goliath” which contrasts EPIC (Goliath) with Isabel (David) on the delivery of useful, actionable data to the clinician; the productivity paradox of digitization; and the “connected patient”.For the book, Wachter interviewed nearly 100 people from diverse backgrounds – frontline clinicians, world experts in artificial intelligence and big data, aviation engineers and pilots, federal policymakers, CEOs of major IT companies, entrepreneurs, patients and their families. “Each gave vastly different answers to many of today’s core questions.”The book closes with Wachter’s vision for health care information technology. He feels that today’s technical problems will be solved over the next decade. But the real “future will rest on whether the stakeholders – government officials, technology vendors and innovators, training leaders, and patients – work together and make wise choices. There will be far fewer hospitals. Patients will be able to receive most of the care in their homes or in new, less intensive community-based settings. Those hospitals that are left standing will be large, bristling with technology.The future will look more like an airline system with a hub and spoke distribution system with computerized decision-support, big data analytics, telemedicine, actionable intelligence, and the emergence of the case manager…There will be many clinic options in the community, mostly in the stores and pharmacies.” And we will have achieved an elusive goal where patients will have a much greater in the new health care system. Amen.

I'm a retired (disabled) 64 yo internist living in St Louis. I loved everything about medical practice except for the GDC (gosh darned computer). I lived through the nightmare of transitioning from paper to electronics. Hard and expensive enough by itself. Felt it intruded in the patient physician relationship. Shortly thereafter, Meaningful Abuse standards came into existence. Even more onerus. I can't say electronics are all bad The book is slightly dated, but the history is accurate and many issues mentioned in the book still exist.I was an owner/employee of an 80 doc group in St Louis. We needed a new EHR. We checked out vendors. The 2000# gorilla, Epic, woud not demo their product because we were "too small" (although we would have liked to use the same EHR as the local hospitals). We chose NextGen. Problem 1. Getting it up and running. Our group has to date asked for over 14,000 recommendations to the code writers to try to improve work flow. Problem 2 Our EHR couldn't talk to the hospitals' Epic systems. Problem 200. As pointed out in the book by a practioner trying to meet Meaningful Abuse standards, I also had a large library of patient handouts on numerous disease states. When confronted by computer stupidness requiring me to print out "their" version (often useless), I would do so to meet meaingful use standards. I would then trash the printed copy and give them my own version.Current issues for primary care docs. Information unavailability. Reports scanned into the chart often end up in places in which I would have never looked. Inability to seamlessly transfer my medical notes to anyone outside of my EHR system. (Interestingly, Barnes Hospital here uses a different version of NextGen, and our computers can't talk to one another). Docs "ignoring" their patients in the exam rooms while trying to click check boxes on the GDC (in retrospect, I should have employed a scribe, despite the perceived presence of a total stranger in the exam room.) I lament the loss of patient/doc "direct" contact (I was guilty of that, too). Spending most of one's time trying to please the computer's and government's masters DEFINITELY impaired my doc/patient relationship. I truly believe that actually getting the patient undressed and "laying on hands" (i.e. actually doing a clinical exam) is both helpful figuring things out medically, and emotionally helping patients trust us docs. And finally for now, I agree having access to the latest in computerized knowledge (I used UpToDate) helped me provide optimal healthcare to my patients.

Amazing book and a must read for everyone involved in digital developments in health and social care

I have been involved in talking about digital transformation in public services for five years or more - though never in a health setting. I've been frustrated at the pace of change (well, absence of pace) given the changes we've seen in every other sector. The Digital Doctor helped me understand better some of the barriers.Reading the book coincided with my first professional exposure of working alongside the UK's NHS and was a great primer for the art of the possible.

Very insightful and not just about the technological changes engulfing healthcare. Wachter rightfully recognises and analyses well the very significant human factors of being The Digital Doctor too. It's also an essential primer and evidence for anyone interested in the outcome of the 2016 NHS "Making IT work" review.

Excellent review of the current state of healthcare computing. Written by a clinician for clinicians. Removes the commercial hype from this topic and helps the reader to experience the issues with what is on offer from the major players in this field.

Fascinating review of the introduction of electronic patient records.