Q&A: Dr. Robert M. Wachter, Professor, and Chair of the Department of Medicine at the University of California, San Francisco (UCSF)

RamaOnHealthcare July 2, 2023

Poised for Digital Transformation in Healthcare

Today, RamaOnHealthcare talks with Robert M. Wachter, M.D. Dr. Wachter is the author of 300 articles and 6 books. He coined the term “hospitalist” in 1996 and is often considered the “father” of the hospitalist field, the fastest-growing specialty in the history of modern medicine. He has long been an international thought leader in hospital medicine, patient safety, health technology, and most recently, Covid.

Dr. Robert M. Wachter, Professor, and Chair of the Department of Medicine at the University of California, San Francisco (UCSF)

RamaOnHealthcare (ROH): What would you say to those considering healthcare leadership today?

Dr. Robert Wachter (RW): Today’s healthcare leadership roles are not for the faint of heart. Leadership in healthcare has always been about the intersection between clinical medicine and science with economics, policy, sociology, and politics.

But layered on top of this baseline complexity, in today’s world political partisanship and the megaphone of social media add to the challenge, particularly since healthcare is a battleground for some of the most contentious issues in our society – misinformation, inequities, abortion, gun violence, opiates, and more.

Of course, the traditional business challenges remain and are also getting knottier, with more financial pressure from patients, payers, businesses, government, marketplace consolidation, labor shortages, and the early stages of digital disruption. As the saying goes, “May you live in interesting times.”

Before potential leaders go running for the exits, there are few jobs that are more interesting and more gratifying than healthcare leadership roles. I hope that skilled and passionate leaders continue to gravitate toward taking roles in healthcare.

ROH: What are the priorities regarding medical staff education today and how do we accomplish those?

RW: A generation ago, all we expected of the members of our medical staff was that they had strong skills in clinical medicine and stayed up to date with the latest advances in their field. But that has changed – the skillset of your medical staff required for success has burgeoned in the past several years.

I recall an eye-opening incident I had a few years ago. I was speaking to a group of UCSF medical students, and I decided to shake them up a bit by telling them about the pressures they would feel during their careers. My voice was dripping with gravitas. I said, “You’re now entering a career entirely different than the one I entered 40 years ago. You’ll be under unremitting pressure to deliver the highest quality, safest, most satisfying, accessible, equitable healthcare at the lowest possible cost.” One of the students raised his hand and said, “And what exactly were you trying to do?” And of course, he was right. We should have always been accountable for healthcare value, but we just weren’t.

The students, clearly, had integrated leadership in systems improvement into their understanding of what a high-quality physician looks like. For a seasoned MD, this transition is not so easy. But medical staffs now need to educate their members on how to achieve excellence in areas ranging from patient safety to quality to value. And in recent years, we’ve added the issues of equity and diversity, public health, misinformation and scientific communication, as well as population health and social determinants of healthcare. And now, of course, we add issues around technology, including, but not limited to, artificial intelligence.

Luckily, we now know how to teach in these content areas, and we are beginning to figure out how to measure performance in them. The greatest challenge is that physicians are busy and it’s difficult to get access to their brains when the requirements of day-to-day clinical practice have exploded. The tradeoff here is that if we can implement new tools – whether teams or technologies – that free up physician time, some of the time can be repurposed for medical education, even as most of the time is used to allow the physician to spend more time with their patients.

ROH: What is the most significant change or requirement across healthcare today?

RW: To me, the most profound issue for healthcare today is digital transformation. Virtually every other industry has been utterly transformed by technology. In most cases, after some initial stumbles, digital transformation leads to products and services that are better, more convenient, and less expensive – whether we’re talking about buying a book or hailing a “cab”. Healthcare’s digital transformation has not yet occurred, but the last 10 to 15 years have laid the foundation for it. The main component of the foundation was the implementation of the electronic health record (EHR), which has become near-universal since the HITECH Act was implemented in 2010. Prior to that time, approximately one in 10 American hospitals and doctor’s offices had EHRs. Today, fewer than one in 10 does not have an EHR. Healthcare has finally morphed from analog to digital.

But digitizing the record, we’ve learned, is not the same as transforming the work. Not only did the implementation of EHRs fail to lead to digital nirvana, but it also created new burdens, particularly those related to documentation and the electronic inbox. Yet, as painful as the last decade has been, I believe we’re now poised for transformation, since virtually all healthcare data – not only patient data traditionally in the EHR but also, for many patients, data from wearables; as well as the entire medical literature – are now online and ripe for the application of tools to improve documentation, communication, and both clinical and operational decision support.

In Ernest Hemingway’s The Sun Also Rises, one of the characters describes how a man goes bankrupt. “Two ways,” says the character. “Gradually, then suddenly.” I think healthcare has come to its Hemingway Moment. Why now? Because most healthcare data are now digital and stored in the cloud, and advances in AI, data analytics, and visualization offer new capabilities to gain insights from that data. Also, tens of billions of dollars are being invested in companies to take advantage of this potential. This leaves us poised to transform everything from creating a physician’s note to developing a differential diagnosis, from how we read x-rays to how we diagnose skin lesions, from creating an understandable hospital bill to integrating genomics into clinical medicine. So, yes, I think the issue of our time in healthcare will be digital transformation, which will be a net positive for patients and clinicians. But if the last decade is any judge, it will also be peppered with unanticipated consequences.

ROH: Define digital healthcare leadership. How might this impact or integrate into the role of all physicians?

RW: In the same way that we no longer talk about the “electronic chart” (we just call it the “chart”) nor about the “digital x-ray” (we just refer to “the image”), I don’t think we’ll be talking about “digital health leadership” in the future. As digital becomes ubiquitous, it will just be “healthcare leadership.”

Healthcare leaders will need to be experts in digitization, but that doesn’t mean that they’ll need to know how to write or interpret computer code. Rather, it means that they understand the role of digital in whatever the organization does, including what is sometimes called “reimagining the work.” One of the lessons of the past 20 years is that achieving the benefits of digitization not only requires the implementation of robust digital tools and technologies, but also that people take a good look at their workflow and work processes and staffing and ask: Is there a better way of doing this work?

During their initial years of digitization, every industry tends to simply replicate its analog processes using digital tools. That is why the physician’s note in an EHR looks like a digital piece of paper stored under a digital tab – no one had the imagination to conceive of a new way of recording the physician’s observations that take advantage of modern communication paradigms, such as in a Facebook Wall, a Twitter Feed, or Google Docs.

Reimagining the work often requires a generational change in which new workers and leaders are unburdened by the experience of having worked in a paper environment – leaving them poised to ask the key question: “Why do we do it this way?” Digital healthcare leadership is the art of creating a culture and structure in which the organization is constantly thinking about how to work better and more safely and less expensively, taking advantage of digital capabilities.

ROH: What do you foresee for the role of tools such as ChatGPT?

RW: Like any new technology, ChatGPT and related Large Language Models (LLMs) will go through their hype cycle – and they’re certainly at peak hype right now! But GPT is different from previous IT innovations in that hundreds of millions of people have already tried it and have mostly been wowed by it. I have GPT-4 front-and-center in my computer browser and on my iPhone, and it – not Google – is now frequently my go-to resource when I’m trying to answer a question. Particularly since GPT is so intuitive and conversational and hundreds of millions of people have tried it, it will be relatively easy to convince non-digitally savvy individuals that the tool might have value.

The question will be how to take that value and translate it into tools that address important healthcare use cases. I’m guessing that the first use cases will be in improving back-office functions – things that currently take huge numbers of staff and are full of friction, like scheduling appointments or sending out bills, or communicating with patients before or after procedures. Implementing AI in these areas will be made easier by the significant labor shortages in many healthcare systems. These shortages mean that the tools won’t lead to large numbers of layoffs, which makes the politics less contentious.

On the direct care side, the lowest hanging fruit is in physician documentation and solving the problem of the EHR inbox. Many physicians now spend several hours each evening, both documenting that day’s visits and answering EHR inbox queries from patients. It’s not hard to see how LLMs could help solve these problems if effectively integrated into tools and workflows. I think we’ll see many new companies enter this space.

Once tools like digital scribes are in place, it’s a relatively short leap to layer in clinical decision support, such as suggesting differential diagnoses, based on GPTs “reading” of the clinical note it has just created. I’m excited about all of this, though I’m worried about the usual things – bias, so-called AI “hallucinations” (when GPT just makes stuff up), and lack of explainability. But my greatest worry is automation complacency. We know from driverless cars and from digital airplane cockpits that it’s a normal human response to stop checking very carefully when the computer is right the vast majority of the time. Training and prompting clinicians to stay alert and to provide a meaningful double-check when the computer is highly reliable (though imperfect) is one of the great challenges of educating people in an AI-rich environment.

ROH: How do you integrate the impact of transformation across the industry and into the curriculum?

RW: Many clinicians are already familiar with these digital tools and are using them in their day-to-day work. But they’re using them offline, which is concerning. If they’re putting patient information into GPT-4 on their phone, this of course creates significant privacy and compliance risk. So, it’s important for healthcare organizations to quickly vet these tools and, if they pass muster, build them into the secure workplace environment, since there will be no way to prevent many of our clinicians from using them in their work.

Otherwise, I would focus less on teaching trainees and practicing clinicians about the technologies themselves and more on the issue of being a leader in an increasingly digital environment. They are skills in areas like change management, health economics, health equity, and systems thinking – areas that will be highly influenced by technology. Some clinicians will want their career to focus on the technology, and these individuals will benefit from specific training in informatics. But for rank-and-file trainees and practicing clinicians, I’m more interested in being sure that they understand how to be leaders in systems that are increasingly implementing digital technologies to improve healthcare value than I am in teaching the intricacies of the math underneath the hood of GPT-4.

About Dr. Wachter: He is past president of the Society of Hospital Medicine, past chair of the American Board of Internal Medicine, and an elected member of the National Academy of Medicine. His 2015 book, The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Computer Age, was a New York Times science bestseller. In 2020-23, Wachter’s tweets on Covid-19 were viewed more than 500 million times by 275,000 followers and served as a trusted source of information on the clinical, public health, and policy issues surrounding the pandemic.

More regarding Dr. Wachter can be found at: @bob_wachter (Twitter)
https://profiles.ucsf.edu/robert.wachter
https://www.leighbureau.com/speakers/rwachter