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

by Robert M. Wachter

The New York Times Science Bestseller from Robert Wachter, Modern Healthcare’s #1 Most Influential Physician-Executive in the US

While modern medicine produces miracles, it also delivers care that is too often unsafe, unreliable, unsatisfying, and impossibly expensive. For the past few decades, technology has been touted as the cure for all of healthcare’s ills.

But medicine stubbornly resisted computerization – until now. Over the past five years, thanks largely to billions of dollars in federal incentives, healthcare has finally gone digital.

Yet once clinicians started using computers to actually deliver care, it dawned on them that something was deeply wrong. Why were doctors no longer making eye contact with their patients? How could one of America’s leading hospitals give a teenager a 39-fold overdose of a common antibiotic, despite a state-of-the-art computerized prescribing system? How could a recruiting ad for physicians tout the absence of an electronic medical record as a major selling point?

Logically enough, we’ve pinned the problems on clunky software, flawed implementations, absurd regulations, and bad karma. It was all of those things, but it was also something far more complicated. And far more interesting . . .

Written with a rare combination of compelling stories and hard-hitting analysis by one of the nation’s most thoughtful physicians, The Digital Doctor examines healthcare at the dawn of its computer age. It tackles the hard questions, from how technology is changing care at the bedside to whether government intervention has been useful or destructive. And it does so with clarity, insight, humor, and compassion. Ultimately, it is a hopeful story.

"We need to recognize that computers in healthcare don’t simply replace my doctor’s scrawl with Helvetica 12," writes the author Dr. Robert Wachter. "Instead, they transform the work, the people who do it, and their relationships with each other and with patients. . . . Sure, we should have thought of this sooner. But it’s not too late to get it right."

This riveting book offers the prescription for getting it right, making it essential reading for everyone – patient and provider alike – who cares about our healthcare system.

Genres: Medicine, Health Care, Nonfiction, Science, Medical, Technology, Health

353 pages, Kindle Edition

First published April 7, 2015

Reviews

[Måns Magnusson · Rating 4 out of 5]

Pinpoints a lot of the problems with EHR (Electronic Health Record) systems. In Europe, we have even more problems trying to introduce American systems that don't fit our health care system.

Some highlights that I remember from the top of my head:

- Alarm fatigue: The system gives you so many alarms that you don't see the important ones. If a system or device does not make an alarm when something goes bad, the manufacturer is responsible. But there is no responsibility of having alarms go off without there being any problem. There is a story about a boy getting a 38x overdose of antibiotics because of a unit transformation and an alarm for the 38x overdose looking the same as a 1.05x overdose.

- User feedback is seen as harassment. Basically, there was no way for the technical support to modify and fix buggy user interfaces, etc. When someone repeatedly gave feedback about the system, he got a call from their boss telling him to stop the harassment.

- NDA's that are extremely aggressive about not discussing the EHR system with others, and not showing the system to anyone. My reflection is that this is what keeps the reputation of EHR vendors like EPIC and Cerner.

My reflections about EHR systems in Sweden right now:

I think the solution to the problems introduced by systems like Epic and Cerner is to make sure the hospital owns the software of its EHR system and can modify it, with inhouse developers. The systems needs to be developed together with the users. Also, I think hospitals should aim for minimalistic EHR systems. Do one thing, and do it well.

Forget the AI that tries to diagnose patients, etc, for now. It's not a very high priority. What we need are systems that are easy to use, and are not a hassle for the staff, which we know are best developed in an iterative process together with the end-users.

[Austin · Rating 3 out of 5]

This was an informative book, albeit one whose scope is much narrower than I originally thought. After all, 'digital' encompasses much more than just EHRs, which is the real focus of Digital Doctor. On the other hand, I didn't know just how large a role EHRs actually play: Turns out they are absolutely central to the functioning of modern medical facilities.

Many of the issues and opportunities Wachter explores apply equally well to other aspects of the digitization of healthcare, including the apps and medical devices that are my research focus. For instance, doctors should be folded much more closely into product design and development processes. There are huge rewards for entrepreneurs who take the time to satisfy the needs of all stakeholders in healthcare though this is not an easy or quick task.

My favorite quotes:

--"The growing prevalence of EHRs offers grist for the AI and big-data mills . . . "

--The Gartner Hype Cycle of technology: 1. Peak of inflated expectations, 2. trough of disillusionment, 3. slope of enlightenment, and 4. the plateau of productivity.

[Robert · Rating 4 out of 5]

Good mix of incidents and analyses of the impact of the increasing use of technology, especially of electronic health records, in medicine.

[Laura · Rating 5 out of 5]

Yes, this book is outdated now. Technology has progressed so much in ten years. But I found the subject material fascinating. How do you program an EHR like Epic so that both patients and doctors can be protected? And why are programmers not working with the people who are going to be using these programs?
I really liked the author's hopeful prediction that in the Future, technology will help free up doctor's time so they are spending less time on digital "paperwork" ,and hitting billing metrics, and more time actually listening to the patient. It is a pipe dream but hey, maybe it will be achievable one day.

[Kaya]

A scary yet accurate picture of the current status of the electronic medical record.

[Steve Penner · Rating 5 out of 5]

This was a fascinating read. The book has been out six years and I'm sure the change in technology has been ongoing since its publication which may make things seem a bit outdated, but I certainly have observed much of what he describes. The use of Electronic Medical Forms, the access to medical records through patient portals, the lack of interoperability (you'll have to read the book to get the definition), the loss of eye contact with physicians, the use of scribes in office to visits to compensate for lack of eye contact, the retirement of physicians fed up with the digitalization process and more have been a part of my experience the past 6-8 years of cancer treatments. The book is very informative on how we arrived at this point in medicine and combines both skepticism and hope for the future. Perhaps the medical community will become safer and more efficient, retain the relationship of doctor and patient and be adaptive to the daily advance of technology. It's a longshot but the trajectory seems to be set.

[Jaume Sués Caula · Rating 2 out of 5]

The book has aged badly. Technological breakthroughs have far surpassed the author’s views on IT for health professionals.

[Henry Osterberg · Rating 3 out of 5]

Interesting read! Might have to drop out and retrain as a plumber, cos AI can’t take that job at least

[Eileen H · Rating 5 out of 5]

An informative read, and still relevant a decade later.

[Darren · Rating 5 out of 5]

Technology will transform the healthcare sector – this has been the promise for many years, yet in many cases it has been a costly, backward step.

In the world where everyone can be a home doctor thanks to Google, it can be easy to forget just how dependent hospitals and the medical world are on information technology. Yet it has not been plain sailing for healthcare professionals, who have been often slaves to a very expensive, inflexible machine.

This book looks at the great march of technology and how it has impacted on the healthcare sector. Written from a U.S.-perspective, this still provides a stunning, fascinating look at how technology is transforming (or hindering) one of the world’s most extensive, most advanced healthcare markets. Remember, technology and practices can be exported – so valuable lessons can be learned!

This is a very thought-provoking, considerate look at a massive system that certainly benefits (and suffers) from technology.

Is technology getting in the way of providing healthcare? Certainly in some situations yes is the clear answer. Many doctors are more focussed on their computer screens, entering vital and not-so-vital information to feed its thirst, forgetting sometimes the most basic elements of their profession - interacting with their patient. The technology can also mean that “simple human mistakes” can be overlooked and not questioned, such as a teenager being given a near 39-times overdose of a medicine due to a mix-up. Yet the computer said it was correct so….

Even if you do not have a specific interest in healthcare (other than being a patient) you can still get a lot out of this book as there is a great degree of commonality with project management, business development and information technology.

The author is quite critical about the thoughtless rush towards technology implementation, noting: “Medicine, our most intimately human profession, is being dehumanized by the entry of the computer into the exam room. While computers are preventing many medical errors, they are also causing new kinds of mistakes, some of them whoppers. Sensors and monitors are throwing off mountains of data, often leading to more confusion than clarity. Patients are now in the loop—many of them get to see their laboratory and pathology results before their physician does; some are even reading their doctor's notes—yet they remain woefully unprepared to handle their hard-fought empowerment.”

Some of the earlier moves to computerisation proved to be a hindrance rather than a help, so a nurse might need to consult 11 different information systems, featuring over 600 clicks and 200 screen transitions just to collate together necessary information. Many errors could occur in this wild interaction. A replacement system, noted the author, required just 25 clicks, it increased efficiency and accuracy and saved sometimes half-an-hour per patient record!

Some of the problems or errors reported in this book may have you smiling, even though they are of course very serious in themselves, such as the patient being documented as having the same blood pressure, taken from his foot, every day for a month - the problem was that the foot had been amputated at the start of that month.

One could talk about this book for a very long time. Even as someone who is not involved in the medical industry, this book presented an alarming and interesting look behind the scenes. One can only imagine how frustrating and annoying it might be if one was actually inside having to fight against the systems on a daily basis.

The Digital Doctor, written by Robert Wachter and published by McGraw-Hill Professional. ISBN 9780071849463, 320 pages. YYYYY

[Barbara (Bobby) Title · Rating 4 out of 5]

I am not in the medical field, nor am I involved with IT in any way, other than an interest in them. I have loved all of Abraham Verghese's books and when I heard BookTV's presentation of Wachter's book and Berghese's moderating Wachter's presentation, I knew I would find this book to my liking.

It certainly was as interesting as I expected it to be. But I was rather surprised with myself over my gut reactions: After I started reading the book on day one, I found myself lying in bed that night thinking what I'd read so far was the making of a wonderful Sci-Fi book. Images of lines of people waiting to be told they were worth saving were pointed to the left; those with more dire or dull problems were being pointed to the right. It hit me: Not Sci-Fi. Worse.

After day two's reading, I thought I had figured out the bottom line: The bottom line. Vendors, Companies, Businesses, Conglomerates. Any place the bottom line is the issue; the bottom line is the determiner of how we will go. And that was a very discouraging thought.

I finished the book this afternoon. I am still shaking my head. Don't the shakers and movers know there are millions of good but very dumb people in the world who faced with what the future as seen here will require of them, are lost? Dare I worry about hackers of the terrorist ilk who will be able to shut down a nationwide system in the future? And then I had to laugh to think that if I have another major attack of lichen sclerosis on my bottom side that to see a doctor I may have a choice of going to In-and-Out Burger as the site designated for people going to neighborhood "medical care sites" or producing a selfie of my bottom side and sending via Facebook to someone in China who just happens to be "on call" that day for medical problems that need to be seen to be appreciated? Do I jest?

Oh, I forgot to say this important fact. I needn't worry about all the worriable thing I read about in this book. I just turned 80 and I don't think the finale of this scary scenario will be played in my lifetime. But that book sure did make me think a lot. I'm passing it on to my son in Sonoma; I'll probably hear his reaction down here in SoCal without even needing a i-phone, which incidentally I am one of the dumb people who don't have i-anythings.

Aside from anything else, the book is a great piece of writing.

[Vernon Smith · Rating 5 out of 5]

An amazing book written by an amazing physician. I can easily see why he is currently referred to as the most influential doctor. Bob Wachter is a storyteller; able to weave an understandable tale around some very complex topics. He is self-depricating in his analysis of the current Health IT environment while clearly still possessing an immense depth in understanding of the topic. He concludes that while the current health IT offerings are poor, they are better than what we had before. He encourages the current vendors to continue development while acknowledging that they hold a virtual monopoly on their markets. I feel he is appealing to their greater good, almost as if they were fellow practitioners instead of the huge corporations that they are focused on market share and revenue. I am not so naive as to believe that anything other than government regulation or a serious disruptive competitor is going to affect the needed change. Unlike banks, gas stations, or grocery stores, the work force is not freely mobile, the transactions are not simple, one-time affairs, and the cost of entry is devastatingly steep. We have certainly seen this situation before; the telephone and airline industry come to mind. And just like that situation, I believe it will take government action, or someone with a large amounts of disposable income, to traverse the obstacles. I, for one, am still waiting for the fantastic future as predicted by Arthur C. Clarke.

[Harry Harman]

buying a book, making a restaurant reservation, finding a favorite song, or getting directions to the nearest Starbucks.

take our pulse, count our steps, and read our moods are pretty nifty, but they aren’t the change we need.

Dr. Will Mayo, cofounder of the Mayo Clinic, in 1915

When somebody, usually a nurse, walks into a hospital room and finds a patient in extremis (a Latin term physicians use that means “at the point of death”), she pushes an emergency button on the wall or calls an internal 911-like phone number. This pages the Code Blue team, usually made up of doctors, specially trained nurses, a pharmacist, and a respiratory therapist.

Just then, his Code Blue beeper went off again. he tried to manage the second patient by phone. Keeping these two plates spinning.

A busy hospital might see a single Code Blue in a day; seeing two is rare, and in 30 years of hospital practice, I’ve never seen three in an hour;

The survival rate for in-hospital codes is about one in six, and those who make it depend on a physician arriving within moments

the two Mayo brothers, Will and Charlie, in 1889

the volume of work was not pruned; it was simply compressed. “Now we were doing 120 hours’worth of work in 80 hours,”

“But I realized that most of mytime was spent moving information from one place to another, doing what we in computer science would call ‘simple transforms’”—like transforming the fact that a patient was on insulin, which lived on a medication list, into “diabetes mellitus” on a different page, the problem list. With Burton’s background as a computer expert, he knew that information technology could help with this kind of task

he had learned an important lesson: although his work was ostensibly about computers, cables, and controls, solving the technical puzzles wasn’t nearly as hard, or as important, as fixing the underlying business, cultural, and political problems. That’s what really determined how well the system worked.

breakdowns were those of the system: a system that placed too many residents where they weren’t needed and too few where they were; a system that missed the early signs of patient deterioration whose recognition might avert a Code Blue; a system that did not allow an overwhelmed young physician to summon help; a system that made it impossible for clinicians to access patients’ information or order treatments remotely. In Burton’s world, all these systems were nonexistent or had been slapped together. Yet not only were the technologies to support them available, they were already being used in other industries. “There are tens of thousands of people who can be surgeons,” his program director told him. “But there aren’t tens of thousands of people who can help solve these problems.”

The president turned to glare at his budget director, Josh Bolten, and said, “Josh, can we find $42 million in our $2.5 trillion budget?”

“I’m sure we can, sir,” replied Bolten.

most people get their care within 30 miles of their home or business

Some people believe that the answer is simply patience—that these things always get better with the passage of time.

Paul Batalden, a prominent expert in quality improvement, famously said, “Every system is perfectly designed to get the results it gets.”

You’ve probably played that parlor game in which you fantasize about what it would be like to have a drink with one of the great figures in history. Perhaps you’d choose Shakespeare, or Churchill, or Einstein. They all sound great to me. But as a doctor and a student of health policy, I would sooner choose Ignaz Semmelweis, the nineteenth-century Hungarian physician whose pioneering work on antisepsis led him to be committed to an asylum for heresy; Sir William Osler, who articulated many of the key principles of medical diagnosis and treatment; or Avedis Donabedian, whose insights transformed our understanding of healthcare quality. Or a man named Arnold “Bud” Relman.

Both physicians did, however, leave lengthy notes in Relman’s computer record, “full of repetitious boilerplate language and lab data, but lacking in coherent descriptions of my medical progress, or my complaints and state of mind,”

like a chef waiting until her restaurant has failed to determine what was wrong with the food.

In 1816, the 35-year-old Laennec tightly rolled up a sheaf of paper and listened to a young woman’s chest through it, thus creating a crude version of what would later become the stethoscope.

otoscope (ears) and the ophthalmoscope (eyes)

“modern therapeutic distancing,” as doctors’attention shifted from the words spoken by patients to the sounds produced by their organs. And thus began the transformation of the doctor-patient relationship.

across the street, or even across an ocean.

doctors needed to be sure that, if things went sideways clinically, their notes justified their actions.

a busy doctor might have 2,500 visits in a year

[Jim Gleason · Rating 5 out of 5]

book review by Steve Okonek:
Have you ever left a medical appointment thinking your doctor interacted more with her computer screen than you? Health care’s long immunity to computers had been remarkable when compared to other industries, until we entered the 21st Century. Now it too has fallen under the spell that digital technology improves the performance of everything it touches.
UCSF’s Chair of the Department of Medicine, Robert Wachter explores the good, bad and repugnant of we patients becoming Patients in his delightfully entertaining and informative “The Digital Doctor.”
It’s disconcerting reading about how medicine “en masse” teaches its doctors, nurses, and pharmacists to get in touch with their inner geek. Meanwhile, thousands of coders suddenly face that “Geez, wish I’d taken Anatomy” moment as they test software. The result “isn’t a technical project, but a social change project.”
System designers face a particularly onerous challenge, as the term “big data” hardly does justice to the amount of records that must be sorted through. He suggests, “There are two big data problems. First, the literature of medicine currently contains about 24 million records, and expands at the rate of 2,100 articles per day.” Second, the data contained within a complicated patient’s own health record can easily contain thousands of pages, both structured (such as lab results), and unstructured (such as physician narratives).”
Much of the hype stems from the promise that Electronic Health Records (EHR’s) would save lots of money. This belief was surprisingly bipartisan. In his 2004 State of the Union address, George W. Bush promised that every American would have a personal electronic health record by the end of the decade. His successor’s “Obama Care” effort utilizes digitization of health records massively for billing purposes. You’ll read how particular diagnostic codes can mean tremendous differences in Medicare payments, and how these peculiarities can be gamed.
The author muses, “In most industries, they bring in computers and immediately start laying off people. Only in health care do we bring in computers and then hire extra people to use them.”
A major gain of these EHR systems is the ability of the patient to see test results, (often before the physician), have encounter summaries, and of course, pay bills. But as yet unsolved dilemmas include interconnectivity between hospitals and complaints from privacy advocates. But should you fall sick and unconscious far away from home, an emergency room needs to know whom the heck you are. “Take Boston’s Longwood Medical Area, where several of the nation’s most prestigious teaching hospitals share a space of about ten city blocks. Exchange of information is critical, yet the joke goes around Longwood, ‘what’s the fastest way to get a patient record from Brigham to Beth Israel? Answer: A paper airplane.’ ”
Wachter introduces us to Epic Systems of Verona, Wisconsin, the 800-pound gorilla of EHR’s. Never heard of it? Virtually every large medical provider in the Bay Area – Stanford, UCSF, Davis, Kaiser, PAMF, as well as most of the top ten “Best US Hospitals” - as determined by various surveys have it at the heart of their information technology (IT) systems.
You’ll cringe while reading the drop-down menu details of how UCSF’s state-of-the-art computerized prescribing system ordered a 39- fold overdose of a common antibiotic (Septra) for a hospitalized teenager, nearly killing him. Even worse is how numerous hospital professionals didn’t catch this error.
To add insult to injury, healthcare IT vendors enjoy a contractual and legal structure that renders them virtually liability free, even if their proprietary products may be implicated in adverse events involving patients.
Wachter sees lots of potential in EHR’s, but believes there is a long way to go. Data entry is a source of heartburn for nearly all physicians, and he spends pages speculating whether diagnosis by computer can ever be as reliable as that of personal experience.
“Medicine is late to this digital carnival, but there are barkers everywhere telling us that this app will change everything,” Wachter concludes. “Starting now and lasting until forever, your health and health care will be determined to a remarkable, and somewhat disquieting degree, by how well the technology works”

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[Kåre · Rating 5 out of 5]

Wachter fokuserer på EPJ, men har også noget om de fleste andre betydningsfulde nye sundhedsteknologiske opfindelser, interventioner. Han skriver godt og fremstår meget nuanceret og vidende. Bogen kan anbefales stærkt til alle, der arbejder med sundhed.
De første kapitler fokuserer på de forskellige måder, hvorpå lægers opmærksomhed er blevet vendt fra patienten mod data, maskiner, andet. Dette er generelt relevant, men er det især, fordi EPJ nu ofte opfattes og omtales som noget, der stjæler lægernes opmærksomhed fra det egentlige, som altså antages at være patienten. W nuancerer dette ved dels at pege på, at EPJ gør dette, dels peger på, at også andre teknologier har gjort noget lignende.
Kapitlet om Radiologi illustrerer et fag, som har været højt specialiseret og højt estimeret, og som med bedre teknologi/forandringer er blevet kørt over, således at radiologer nu kan erstattes af mennesker fra andre lande med mindre uddannelse, løn. Set fra lægers side, kan dette være en skrækhistorie. Set fra patienters side er det slet ikke oplagt en dårlig historie, selvom der naturligvis har været og er problematiske aspekter af denne udvikling. Kapitlet sætter scenen for det, som teknologien kan/vil gøre.
Flere kapitler fokuserer på bivirkninger ved EPJ.
Journaler bliver overfyldte og ulæselige, fordi man kan cut-and-paste. Dette lægger op til nye teknologi, som kan hjælpe med at sortere data. Der er vi dog ikke endnu, hvilket medfører, at lægerne er fanget i en situation, hvor de bliver ansvarlige for uendelige mængder af data, overfor patienter, som vil have individuel vejledning. Lægernes tilfredshed med job er således faldet. Men samtidig erklærer to tredjedel af læger i en undersøgelse, at patienterne har fået bedre kvalitet ud af det.
En informant forklarer situationen således:
”Lets say you´re a primary care doctor. The way certain EHR products are configuerede, every time your patient sees a specialist, or goes to the hospital, or gets a result on any test – even one you didn´t order – you get an e-mail, and they´re not necessarily prioritized in any way… The doctors are terrified of all this information coming in. Before EHRs, this information just wasen´t being transmitted. But now that everything´s connected and it´s unfiltered, you are now the weakest link in the information chain, and that´s a really uncomfortable place to be”
En skurk er alerts, som nu findes i så stort antal, at mange ikke ser dem. De bliver blinde for, hvornår de skal tage dem alvorligt. Samtidig tager alarmerne opmærksomhed, de bryder arbejdsrytmen.
Et kapitel undersøger spørgsmål om grænser for kunstig intelligens og samarbejde mellem mennesker og mellem mennesker og maskiner.
Et kapitel undersøger Epics dominas på markedet. Ws konklusion er, at der ikke på nuværende tidspunkt er noget seriøst alternativ til Epic. Men det betyder ikke, at man ikke også kan forsøge at etablere et alternativ. Det nuværende mest seriøse alternativ er baseret på apps, som kan kobles sammen til et helt epj. Dette er i modsætning til Epic, som giver et helt system, der dækker alt, men måske ikke gør det perfekt hele vejen rundt. W er faktisk for epic i praksis.
Herefter bruger W en case med en patient, som fik 39 gange for meget medicin til at illustrere ændringer og problemer med EPJ. Der er sammenligninger med fly-industrien, som angiveligt fungerer mere sikkert. Casen bruges til at gennemgå mange af de arbejdsprocesser, som findes og påvirkes af EPJ.
Den sidste del af bogen tager fat på forskellige hype-fænomener og sætter dem i kontekst. Det er sagligt og super gjort.

[Jonna Higgins-Freese · Rating 5 out of 5]

Interesting analysis of the role of ACA spending on IT (quoting former ONC Director Brailer saying that he would not have spent money on subsidies to digitize offices but on "standards, interoperability, a 'Geek Squad' to help with training and implementation, and creating a cloud-based 'medical Internet'" (18)

In 2008 only 17% of med offices had basic EHR! (12)
1. Expenses would be borne by independent physician practices (provide 60% of US patient care), but benefits would accrue to others, since the benefit of EHR is to make it easier for others to care for that patient.
2. Lack of interoperability standards (why Epic is so slow)

cornerstone of ACA was to shift from fee-for-service to value: "a new reimbursement model under which providers would be paid a fixed sum to care for groups of patients and held accountable for their performance on measures of quality, safety, and patient satisfaction" (15).

"Every system is perfectly designed to get the results it gets." Would need to change systems of recording patient info, ordering test sand meds, engaging patients in their own care, educating doctors and nurses, managing our tech within hospitals and clinics, designing and building computers for health care, paying for and regulating medical IT, instilling right amount of trust and skepticism re: technology. (19)

Editor of NEJM, Relman, wrote NYReview of Books essay about fighting a losing battle with EHR for his physicians' attention. "Neither physician seemed to be actualy in charge of my care, or spent much time at my bedside . . . [both left copious notes in EHR] full of boilerplate language and lab data, but lacking in coherent descriptions of my medical progress, or my complaints and state of mind" (25).

Abraham Verghese writes that "We're losing a ritual that I believe is transformative, transcendent, and at teh heart o fthe patient-physician relationship, the ritual of one individual coming to another and telling him things that she would not tell her preacher or rabbi; and tehn, incredibly, on top of that, disrobing and allowing touch. The ritual, he condluced, also signals to the patient that 'I will always be there; I will see you through this'" (27) (Culture Shock: Patient as Icon, Icon as Patient")

Health IT more complicated than others. Large health care system processes about 10M computerized transactions/day, twice # on NASDAQ. So high volume plus complexity of patient's medical history, various places of treatment, and preferences. Also who needs access to what: insurance some info, providers other (43)

SOAP note definition

American using ops coordinator to handle 10-12 flights/time, Southwest using 1 who coordinated among all team members to do conflict resolution and sense-making (57)

Christine Sinsky wrote about scribes, primary care physician in Dubuque who studies "joy in practice" among primary care physicians. http://www.nytimes.com/2014/01/14/hea...

Importance of shoulder-tapping, constant communication, as factor in missed Ebola diagnosis, even though info was in medical record. "if you encounter a nonnormal situation, there is a preexisting relationship. You don't have to devote as many resources to getting the team members on the same page" (78)

"The [EHR's] checkbox metnatity has even turned Larry WEed's beloeved Problem-Oriented Medical REcord -- in which the patients' issues are articulated, assessed, and addressed -- into a dessicated wasteland, devoid of thought or narrative arc. Part of the catch is that, while it is useful to enumerate problems one at a time, the real art of medical diagnosis comes in seeing the connections _between_ problems -- realizing that the patient's fever, heart murmur , and stroke, when woven together, add up to a diagnosis of bacterial endocarditis. Moreover, . . . we need to consider each case in its context: that the patient is scared, her mother died of cancer at an early age, she cant' afford her medications, and she has a teenager at home who's struggling with Asperger's." In 2012, author suggested a field for the uber-assessment: "In this field, please tell the many people who are coming to see your patient -- nurses, nutritionists, social workers, consultants, your attending -- what the hell is going on. What are the major issues you're trying to address and the questions you're struggling to answer? Describe the patient's trajectory -- is he or she getting better or worse? If worse (or not better), what are you doing to figure things out, and when might you rethink the diagnosis or your therapeutic approach and try something new? Please do not_ use this space to restate the narrow, one-problem-at-a-time-oriented approach you have so competently articulated in other parts of this record. We know that the patient has hypokalemia and that your plan is to replace the potassium. Use this section to be more synthetic, more novelistic, more imaginative, more expansive. Tell a story." (80)

Argues that technology is difficult in medicine b/c it's processual -- at one moment it seems the diagnosis is one thing, but when it doesn't respond to antibiotics it's something else. But that's still a decision tree (101).

Business case for diagnostic tools is hard to build b/c measuring whether diagnosis was correct is more problematic than measuring whether the correct medicine for asthma was given (107). Though we could change that through reimbursement policy.

Use of big data: "what we once thought of as lung cancer is actually a series of different cancers, each with a particular genetic signature, which may prove to be the key predictors of outcomes and guide to treatment" (119). Watson using "patients like you" algorithm.

"Much of the data in the EHRs continues to be collected for the purpose of creating a superior bill" (versus superior care) 121).

Example of antibiotic overdose due to UI problem & alert fatigue, "Epic alert Lucca received is a model of bad design. There are no graphical cues, no skull and crossbones, no medical equivalent of a cockpit stick shaker -- nothing that would tell a busy physician that this particular alert, unlike the dozens of others that punctuate her days, truly demanded her attention" (149. Talks about how aviation UI folks are appalled by number of alerts in medicine.

And problem of robot filling -- if a human had had to tear off 39 packs of abx, would have said something to pharmacist.

Computers can now show how much faith we should put in a particular suggestion, appropriately calibrated trust.

Open notes in fact decreased patient visits b/c they reviewed and suggested they not come in themselves.

Zeiger and Frydman and SmartPatients and patient-centered communities.

[Chris Weatherburn · Rating 5 out of 5]

The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age by Robert M. Wachter

Good account of modern day health care and the requirements for digital to be implemented. Provides balanced arguments of the risks and benefits of digital implementation. Summarises some (mainly US) history including Barack Obama and President Bush pledges to fix this. Touches on large issues in the field of clinical informatics such as interoperability and the rise of some companies such as EPIC. Suggests that EPIC became so large as they offered a solution to many issues (prescribing, laboratories, billing, medical and nursing documentation) that actually works and was adopted by several large hospitals. If you are in a different hospital or clinic and also have EPIC you can get this information, if you have a different system then you can’t.

I like the bit about how computers have got in the way of the doctor-patient relationship, so much so that in some hospitals if you attended having lost a limb people would not believe you until you have had a CT scan reported and an orthopaedic opinion (this is his joke).

Contains a lot of information about the struggles of implementing an electronic open health care record. The challenges of patients obtaining useful access to their records (not just booking appointments). Ends with a slightly scary tale of the future predicting remote monitoring of patients, with large screens that can zoom in on patients to even see their pupils dilate, these are remotely monitored by artificial intelligence, machines can do most of the work (such as cannulation) and physicians are overseeing this. If you're interested in an overview of health Informatics would highly recommend this book.

[Jonathan · Rating 5 out of 5]

The book is heavily focused on the rocky road america has taken in EHR (Electronic Health Record) implementation. The only surprising part of Watcher being an MD is the fact he is an excellent and poetic writer & journalist. Watcher takes you through an EHR implementation first hand at large health institutions & small clinics. He dives into health care policy driving EHR implementation & affecting it today. He takes a good look at HITECH, HIPAA, Meaningful use, and the ups&downs of delivering value based health care to patients. He also dedicates a whole chapter to the private sector of EHR providers - specifically AthenaHealth & Epic.

Most compelling is the personal and heart-wrenching stories he tells. Wachter also looks to other industries (auto manufacturing & commercial airlines) as basis for how to model the healthcare IT system of the future.

I have read other reviews about the book which complain about the heavy emphasis on EHRs - but if you read between the lines what Watcher never says explicitly is an inter-operable EHR will be the first step to a functioning “doctor’s visit” of the future.

One of the last chapters explains Watcher’s prediction of what the future of Healthcare in america may look like - it is so important to understand all the issues addresses with inter-operability, alert fatigue, population health management, and the loss of the “human” relationship in a doctor’s visit to get to how a true digital healthcare system may operate in the future

Highly reccomend to anyone interested in healthcare IT, policy, value based outcomes - or just reading the chapters on “the patient” for a fantastic story that will have you on the edge of your seat wondering the outcome of Pablo’s 39X overdose

[Pallav Sharda · Rating 4 out of 5]

Most of the books that focus on innerworkings of American healthcare system hover around history, politics and whats-wrong-today perspectives. They are boring, esp. for outsiders.

This book is entertaining. It reads more like a TV sitcom - describing characters, incidents. So it's different enough in that perspective alone to warrant a read.

The history and issues are explained (as usual) - so that may be repetitive for some. Interesting add-on flavor is the frequent dives into the culture in medicine. Bob has a flair to do it in an engaging way, since he has a certain command over language and expressions.

If you are looking for health IT product features and capability insights, or get an overview of the vendor space, market trends in health IT, this is not the book for you.

PS: The narrator is not very effective. Does an average job. Sounds robotic throughout. Not a big drawback though.

[D.C. Lozar · Rating 5 out of 5]

As a Family Practice Physician deeply concerned about the interposition of technology between my profession and the patients I care for, I found Robert Wachter's, "The Digital Doctor," highly informative and thought-provoking. We stand on the cusp of a new age in medicine, one that is both exciting and dangerous. Mr. Wachter did a fantastic job of showing both sides of this growing debate in a way that allowed the reader to develop their own bias and provided supporting evidence for each argument he discussed. This book is superbly written, engaging, and, if you buy the audio version, narrated. If you've noticed that your doctor spends more time data entry than they do listening to you, the book begins to explain why. As a fellow author, D.C. Lozar, I know how hard it is to keep an audience informed, engaged, and actively thinking and would happily recommend this book to anyone willing to learn something new while being entertained. Well done.

[Dr. Ashori · Rating 3 out of 5]

I enjoyed listening to the book and the author clearly did a lot of research. But as a physician my main concern is the patient and my ability to do my job effectively. The author discussed EHRs in depth but it read more like an advertisement for Athena and Epic. Now, a decade after he wrote the book, we aren't any closer delivering the ideal care to patients using such technology.

Technology hasn't penetrated healthcare well. The places it has had good penetration is more on the administration side and less on the care delivery. I am hopeful that this will change but I don't believe that the predictions or hope the author has for technology in healthcare pans out.

Physicians need more time with patients and easier access to patient records. We need more information at our fingertips and need to know when the information is biased towards financial profits or clinical science.

[Erlend · Rating 2 out of 5]

Unfortunately I was disappointed by the book. It takes 100 pages to go through the invention of patient records and how previous radiology rounds functioned etc. until todays systems, which seems far more exhaustive than necessary in a book trying to address the new computational technology in medicine. It further elaborates extensively in one major mistake in which a patient was harmed due to human and technological errors, before it discusses some upsides and downsides of technology and AI in medicine and a political discussion about the American health care. Working in a modern Scandinavian health care system where the digitalization of medicine seems to be years ahead what is presented in the book, it gives very limited new insight.

[Laura]

I feel compelled to point out that the free excerpt of this book covers not only the most interesting part, but also has a satisfying epilogue to the case study that is not included in the printed book.

hhhh. I read the excerpt online and found it so compelling, I bought the book off the back of it. And there are some great takeaways, such as alarm fatigue, but overall I found it American-centric and a little dull. And a little technophobic. Pre-emptively defensive, perhaps. Some of it is e.g. trying to prove that doctors cannot be replaced by machines but is anyone trying to do that this decade? maybe less-shitty-forms is an achievable goal? whatever.

[Satrughan Kumar Singh · Rating 4 out of 5]

TL;DR Summary : "When it comes to healthcare, writing code is the easiest piece of the puzzle"

Lengthier Version:
As a software engineer reading it, in an age where anyone who can write afew decent lines of code is considered a rockstar, this book humbled me.

It showed me enough to get me to understand that the most challenging problems of our time wont be solved just by dumping technologies at it, but by supporting it with proper policies and processes.

It showed me that although the ability to write code is fantastic, it is pointless in the hands of an engineer who is not in touch with people he builds for.

[Daniel Chen · Rating 5 out of 5]

Engrossing narrative that describes the past, present, and future of digital medicine and how we can take the lessons learnt from the implementation of EHRs and apply them to other telemedicine technologies. Wachter spends a good chunk of the book describing the history of EHRs and the pitfalls it has gone through. Albeit far from perfect, the technology gives insight to the future of how technology intertwines with physician-patient interactions.

Wachter also highlights the different problems impeding innovation, and until those complications can be resolved, we'll continue to see the current problems in our healthcare system.

[Barbara · Rating 4 out of 5]

I spent a big portion of my working life writing computer software and performing computer-adjacent occupations. I never wrote any medical records code. I'm interested in the growing use of EHR (electronic health records). Thus far, the software is apparently somewhere between difficult to use and downright harmful. It doesn't seem to me that doctors should be spending their time wrestling with poorly designed software. Doctors should be doctoring, not engaged in activities of data entry or tasks required for medical billing.

This book is hopeful that future medical care and future EHR can evolve to better suit both patients and physicians.

[Matthew Vandermeulen · Rating 5 out of 5]

The electronic medical record is an oxymoron, as it is wonderful and terrible at the same time. This book brings to light where the electronic medical record has fallen short and why. But the author also interviews people from different fields to try and understand how it can improve in the future to make a powerful tool.

I definitely recommend this book to anyone in the medical field as a must read. It’ll help you understand the creation, and reasoning behind what you use every day. I also think this book will be useful to anyone who wants to understand why the medical field is operating the way it does - not always efficient and not always with human connection.

[Rachel · Rating 4 out of 5]

Excellent presentation of the benefits and the dangers of modern Health IT. I appreciated the numerous examples given throughout the book to support thoughts or opinions. The plethora of interviews and differing opinions gave the book an overall unbiased look at current Health IT as well as the future of it. I appreciated the author's attempt at instilling the idea of medicine as being human. Although robots and digitization may help with safety and quality, medicine still requires a large part of the human element; something I wholly agree with.

[Justin · Rating 4 out of 5]

Thorough and interesting explanation for the layperson who wants to understand the role tech plays in the modern the health industry and how it got to be (especially in the US) so wacky. Spoiler: the road to hell is paved with ideas that sounded good at the time.

This is not one of those books where the author harps on and on trying to convince you of the same one or two ideas. It's complicated stuff, without simple solutions, and the author does a great job of explaining how it works, what's broken, what solutions have failed and why, and how we might make it better.

[Bryan · Rating 5 out of 5]

This book was both fascinating and too close to reality. In reading it, the scenarios had a very true and personal ring to them. People often complain that health care providers (physicians, nurses, etc) spend too much time in front of a computer. This is both colleagues and patients/family members saying this, and it’s true. But it’s a double-edged sword. If you aren’t dotting your I’s and crossing your T’s, you haven’t done your job and there’s no reimbursement. But if you are, you’re not spending time with your patient. Food for thought.