Dr. Robert Wachter is a long-time patient safety advocate who has written extensively about the trends affecting quality and safety in health care. Wachter, associate chair of the University of California-San Francisco department of medicine, years ago coined the term “hospitalist” and predicted the rise of that profession.
In his new book, “The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Computer Age,” he turns his attention to technology in health care, and the risks and rewards as we digitize everything from medical records to office visits. We talked recently about his new book. This is an edited and condensed version of that conversation.
Q. As I read your book I couldn’t help thinking about the elderly. Many older people aren’t tech savvy. They’re intimidated by looking up information on computers, sending email to their doctors and the like. They’re also bigger health care users than many younger people. What needs to be done to help them get and stay engaged as technology advances?
A. It’s an important question. It’s not natural for them the way it is for the next generation and beyond. But most older people are at least using email and know how to surf the Web. Silicon Valley has woken up and realized this is a huge market. As consumer-oriented tech companies enter the health care field, I think they’re going to design tools and technology and ways of interfacing that make it seamless for the people who need to become engaged. This will allow older patients to at least do the basic stuff, like renewing their medications, the stuff that’s just incredibly annoying in the paper world.
Q. In your book, you talk about moving away from fee-for-service payments to doctors and hospitals and toward payments based on a population of people, adjusted for their baseline health. From a patient perspective, will that change how they pay for their care? At the most basic level, could that finally mean the end of incomprehensible “explanation of benefits” insurance forms, for example?
A. I wish I were more hopeful. Of all the nuts we have to crack, this is the one I’m least optimistic about.
If everybody is in an accountable care organization or the like, providers get a single payment when they treat someone. But as long as they’re still doing an adjustment for the relative sickness of the patients, the organization will need to account for all of the details. And I’m afraid the patient may also still see a confusing itemized bill, unless we can get to a point in which you’ve paid for the year and you’re done.
The movement away from piecemeal payments is hopeful, and so are the digitization of health care and the entry of Silicon Valley companies with a consumer sensibility. I guess the question is: Do all of those trends — when woven together — lead to something that’s more user friendly? When it comes to clinical care, I think the answer is yes. I see how we can get to a much happier place, with better care through digital medicine, in five to seven years. But the idea that you could get a simple, clear insurance bill that you pay with one click… that still feels like a moon shot to me. So maybe in 10 to 15 years.
Q. To what extent can technology really help people comparison shop for health care? To date, we’ve seen that it seems to work best for procedures like colonoscopies or MRIs, where the service performed is fairly comparable and relatively inexpensive. Could people really comparison shop for cancer treatment? Would we want them to?
A. Sure, why not? Some of this comes down to your fundamental belief in capitalism and the market. But we do have to pay some attention to fundamental differences between health care and other markets. For example, in health care, we can’t accept haves and have nots, while we readily accept this with other luxury goods. That said, I’m pretty convinced that if you create an environment where patients have the information they need to make those decisions, that the market will help them make good choices.
The area I worry about is the science. How do we really know that one doctor or hospital is better than another? Most aspects of quality measurement are not very advanced.
Another real challenge is fragmentation. If I get my colonoscopy at one place because it’s the best and cheapest but it’s in a different system than the one my primary care doctor is in, that’s a problem if the electronic records don’t talk to each other. As a patient, I’ve got to think about the advantage of receiving the cheapest procedure compared to the negative consequences of no one doctor having a complete view of my health.
Q. I want to touch on the Affordable Care Act. Do you think the health law requirement that people have health insurance positively affects their engagement in their own health care or the health care system?
A. I think everybody should have health insurance. The system works better and people have better health and health care with universal insurance. And the law was the most politically feasible way to make that happen, so I support it. When people have health insurance, it creates a connection to a system that is largely mediated through a primary care doctor. To have 40 to 50 million people floating outside the system – able to access the system only episodically and when they’re very ill – is crazy.
Has having insurance increased their engagement? Yes, but at a level that’s pretty wimpy. Now you can see a primary care doctor to manage your blood pressure in an office visit every six months, but is that the level of engagement we should aspire to? Nowhere near it. The hope is that by having everybody part of an organized health care system, now it’s in the interest of the system to have engaged patients – since that engagement should lead to fewer office visits, ER visits, and hospitalizations. But this is the sort of thing that takes years, if not decades, to develop.
Q. What about initiatives like OpenNotes that allow patients to read their doctors’ electronic notes about their care? How do they change the patient-doctor relationship?
A. OpenNotes illustrates the democratization of the health care system, which is going to challenge all of the system’s fundamental underpinnings. Digitization is an enabler. It’s changing the relationship between doctors and their patients from an extraordinarily paternalistic one to one that is more democratic. In the new world, a patient’s choice is no longer just, “Do I see doctor A or B?” but “Do I even need to see a doctor at all?” OpenNotes is part of this trend.
As wonderful as patient sharing access to their information is, along with new tools to self-manage and things like telemedicine that allow patients to receive care outside the traditional system, in a world of high copays you are going to see some patients making some very bad choices. In the old days, the sick patient had to go see a doctor. Now they can go to MinuteClinic. Or they can Google their symptoms. I wouldn’t want to turn back the clock, but it raises the question, “When is self-management a bad choice?”
As health care finally goes digital, some people believe that it’s no different than travel or banking. But no one is getting harmed by using TripAdvisor or Fidelity. I think you could argue that health care is fundamentally different.
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