Notable Perspectives

#8 - Dr. Robert Wachter: Why we have to completely reimagine the work in healthcare

Episode Summary

“We deliver the appropriate, highest quality care maybe 50 or 60% of the time. Think about how long FedEx would be in business if they got you your package 50 or 60% of the time, and on the time that they promised. They'd be out of business by next Monday.” Dr. Robert Wachter, Professor and Chair of the Department of Medicine at the University of California, San Francisco (UCSF), explains the key to unlocking the productivity advantage of technology for healthcare, and much more.

Episode Notes

In this episode, Dr. Wachter sits down for an in-depth conversation with Dr. Muthu Alagappan, CMO at Notable. The two discuss the four stages of digital transformation in healthcare, why the healthcare industry will take longer to fully transform, what the megatrend of the next decade in healthcare will be, and more. 


Robert M. Wachter, MD is Professor and Chair of the Department of Medicine at the University of California, San Francisco (UCSF). In 2021-22, the Department was ranked the best internal medicine department in the nation by U.S. News & World Report. 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 medical specialty in the U.S. history. He is past president of the Society of Hospital Medicine and past chair of the American Board of Internal Medicine. He has written two books on safety and quality, including Understanding Patient Safety, the world’s top-selling safety primer (now in its 3rd edition). 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 2020-22, his tweets on Covid-19 were viewed over 400 million times by 250,000 followers and served as a trusted source of information on the clinical, public health, and policy issues surrounding the pandemic.


0:02:55: During his residency at UCSF, Dr. Wachter found physicians who weren’t studying genes/molecules but rather the system and how to make it work better.

0:03:29: Dr. Muthu Alagappan asks what sparked Dr. Wachter’s interest in digital transformation.

0:04:24: Dr. Wachter: “You can think of every walk of life, and digital arrived, and it transformed the way we did it, and created new expectations, and generally more satisfied consumers, although often a lot of unanticipated consequences. And I was kind of waiting for decades for our moment to arrive in healthcare. If you think about it, almost every other industry, maybe with the exception of education, went digital and was transformed, and I'd say mostly for the better.”

0:05:04: Dr. Wachter: “If you analyze medical mistakes you come to realize very quickly that many of them relate to information systems and structures that don’t work very well.”

0:05:53: Dr. Wachter: “In 2008, fewer than one in 10 American hospitals had an electronic health record. By 2017, fewer than one in 10 did not. So it was really over the past 10 to 15 years that medicine went from fundamentally an analog industry, to mostly a digital industry…”

0:07:21: Dr. Wachter talks about a 40-fold overdose of an antibiotic that was given at UCSF and the reason was that the digital systems recommended the dosage (because of human input errors), and the staff followed the recommendation vs. questioning it. 

0:07:41: Key quote from Dr. Wachter: “The fundamental flaw here was digital systems that, through a series of human glitches meeting the digital system, came up with an absurd dose. A 40-fold overdose would be like being on the highway and seeing a sign that said speed limit is 2,500 miles per hour, it's absurd. And yet everybody just turned their brains off and did it because the computer was telling them to do that, and they trusted the computer, and they've lost trust in their own instincts.”

0:09:15: Dr. Wachter’s conclusion from talking to dozens of people in the industry (and beyond) for his book? He’s optimistic about the future of healthcare.

0:09:45: Dr. Wachter says “It's going to take some time, and part of what it's going to take is to move from the monolithic system of your main digital thing is this big enterprise system called the Electronic Health Record that controls everything, to a much more nuanced, and a much more diverse set of digital tools…”

0:11:44: The four stages of digital transformation in healthcare, according to Dr. Wachter are 1) digitizing the data (that’s what the EHR did), 2) connecting different digital pieces (aka interoperability), 3) analyzing the data, making sense of it, and coming up with new insights/predictions around how to do things better, 4) take the insights and build new systems and new workflows and structures to make things better.

0:16:09: Dr. Muthu Alagappan asks why the healthcare trends from COVID (telehealth, virtual care, etc.) don’t seem to have ‘stuck’ now that we’ve come out the other side.

0:18:42: Dr. Wachter says we don’t know the answer. Key quote: “I think there is something about the doctor-patient relationship, that some combination of doctors and patients value as an in-person enterprise in a way that they don't seem to value in terms of a relationship with a travel agent, a bank teller…”

0:19:33: Dr. Wachter continues: “So there are a lot of subtle forces, some of which are cultural and historical, some of which relate or are in some way sociological that you and I were trained to lay our hands on and feel that that relationship is very meaningful.”

0:21:09: Dr. Muthu Alagappan asks about the productivity paradox and how Dr. Wachter defines it in healthcare.

0:23:50: Dr. Wachter explains the paradox, saying “The paradox being you do not see productivity gains [from new technology] the way you expected and the way you hyped. The wonderful news about the productivity paradox and the one that makes me a digital optimist is in essentially every case that I can think of, the paradox ultimately resolves itself.”

0:24:09: Dr. Wachter: “It resolves itself, and sometimes it takes five years, sometimes 10 years. And I expect in healthcare it'll be more in the 10-20 year timeframe. Because the regulatory environment is harder. The stakes are higher. You know, I live in Silicon Valley, fail fast sounds good if you're building a restaurant app, pretty bad if you kill somebody. And so there are a lot of reasons why healthcare will be slower.”

0:26:01: The key to unlocking the productivity advantage of technology? It’s reimagining the work. Dr. Wachter says, “But no one seems to be creative enough to understand what their world with technology will look like until they actually are living with the technology. So they typically do not re-think the way they do the work or the workflow, or the way they staff themselves in advance. They have to live with the technology for a few years…”

0:28:32: Dr. Wachter on why the change is so slow in healthcare: “This takes 10 or 20 years, because you've got to then build the culture, the people, the structures, the incentives to truly re-imagine the work and an industry like healthcare that generally is relatively fat and happy, there are very few unemployed doctors and nurses.” 

0:29:35: Dr. Wachter discusses that historically healthcare’s solution to any problem has been to hire people to handle it. Billing, scheduling, call centers, etc. Now, for the first time in his 40-year history in healthcare, that’s just not possible. 

0:30:33: Dr. Wachter: “ there's actually a limit on the number of people you can find, so that's a forcing function that may create a meaningful difference that even if you have enough money, you may not be able to find the bodies, which really is a very powerful argument for automation.”

0:30:48: Dr. Muthu Alagappan asks about reimagining the workforce.

0:34:14: Dr. Wachter: “I think the competitive forces are going to make us ask some very hard questions about the way we're organizing work…”

0:35:52: Dr. Wachter on the future of work in healthcare. “We've gotta think in a very new way about who's doing the work and how they could do their work better and safer and less expensively if they had technology in a form that was really useful and usable. And that to me is one of the most exciting phases that we're at in healthcare.”

0:37:24: Dr. Wachter on what ails healthcare today. “You look at the amount of time that people are spending trying to figure out what your insurance will or won't pay for, so that they can send the appropriate build to the appropriate person. Or you look at the struggle that someone has to try to get an appointment to figure out who the right doctor is and get an appointment in my system or yours. It's just terrible, it's wasteful, and in almost every other industry, people wouldn't tolerate it.”

0:37:55: Comparing healthcare to other industries. Dr. Wachter says, “We deliver the appropriate highest quality care, maybe 50 or 60% of the time. Think about how long FedEx would be in business if they got you your package 50 or 60% of the time, and on the time that they promised. They'd be out of business by next Monday.”

0:39:53: Muthu asks about technological innovation and the balance that will come from the legacy EHR vendors vs. newer companies that sit around the EHR.

0:43:40: Dr. Wachter: “I would bet on the third-party vendors, obviously not all of them, a lot of them won't do well, and a lot of them will go out of business. But the ones that do well, I think have an advantage in solving some of these complex, specific use case problems.”

0:44:13: Dr. Muthu Alagappan asks 'what is the big technology trend on the horizon for healthcare?'

0:46:17: Dr. Wachter says, “It's no longer, going to be elective, you're going need to use AI and AI-based tools to take the data, get smarter about it, and to some extent replace human FTEs with systems that can automate certain processes. I think that feels to me like the megatrend...”

0:48:19: END

Relevant links

Dr. Wachter on Twitter

Dr. Alagappan on LinkedIn and Twitter

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