Paging Dr. Watson: The Impact of Technology on Clinical Judgment

Last month, a provocatively-titled article in The Atlantic declared, “The Robot Will See You Now“. Starting with the story of IBM’s Watson going to medical school to learn to make diagnoses and treatment recommendations, it painted a future picture of medicine based on remote monitoring, clinical decision support, and above all, the cold, rigorous, seemingly-infallible power of Big Data.

“According to a growing number of observers, the next big thing to hit medical care will be new ways of accumulating, processing, and applying data.” Think: every primary care physician equipped with a Watson app to help them diagnose. Wearable sensors that track your blood pressure, heart readings, and numerous other indicators before you get to the doctor’s office. And as one venture capitalist predicts, computers and robots someday replacing 4 out of 5 physicians in the U.S.

Around the same time, I discovered a TED talk recorded in 2011 from Dr. Abraham Verghese, best-selling author and proponent of humanistic medicine, advocating for a very different kind of innovation:

“I’d like to introduce you to the most important innovation, I think, in medicine to come in the next 10 years,” Dr. Verghese declares, “and that is the power of the human hand.” Dr. Verghese goes on to describe the ritual of the physical exam–an age-old ritual of discovery and catharsis that has given way to something far less personal. He warns of a future “where the patient in the bed [becomes] an icon for the real patient who’s in the computer.”

“We seem to have forgotten — as though, with the explosion of knowledge, the whole human genome mapped out at our feet, we are lulled into inattention, forgetting that the ritual is cathartic to the physician, necessary for the patient — forgetting that the ritual has meaning and a singular message to convey to the patient.” -Dr. Abraham Verghese

So who’s right? Dr. Verghese’s message is simultaneously powerful and touching. But if we ascribe to his view, are we clinging to a romanticized notion of medicine at the cost of a less effective health care system? Are the two futures–one of “personalized” medicine and the other of medicine that is fundamentally personal–mutually incompatible? Or is there some middle ground we can aim for?

Déjà vu? The Unfulfilled Promise of EMRs

Turns out that somewhere 10,000 feet below the discussions of industry proponents and enamored health care executives, physicians have been debating a parallel of this question for quite some time. Not in response to the next robot-doctor, but to the replacement of good ol’ pen-and-paper notes with electronic medical records (EMRs).

According to a 2012 CDC report, the number of office-based physicians using EMRs has jumped from 18% in 2001 to 72% in 2012. EMRs were supposed to be the pill that saved us from an ailing, inefficient paper system. By digitizing all of our medical records, we could improve inter-provider communication, reduce errors, and finally solve the intractable problem of illegible physician handwriting. Indeed, much of the rapid adoption of EMRs in recent years has been driven by the Health Information Technology for Economic and Clinical Health (“HITECH”, har har) act of 2009, which provided incentives for physicians and hospitals to adopt EMRs. $27 billion of taxpayer money in incentives.

Unfortunately, a recent report by the RAND Corporation and subsequent reporting by the New York Times have highlighted some failures to achieve these promises. More and more people have begun seeing the whole thing as a scandal marred by industry influence, government complicity, and lack of evidence. Read a sample in this scathing account.

More directly relevant to our current discussion is the impact of EMRs on the end users (physicians) and the ultimate “beneficiaries” (patients). Driven like sharks to the frenzy of government money, EMR vendors rushed to spread their respective products, often without consulting the end user. As a result, physicians around the country began complaining about the burdens and limitations of EMRs, as Dr. Bob Watcher illustrates in a well-written post about the impact of EMRs on cognitive thinking:

“When I was on clinical service in July and read the notes written by our interns and residents, I often had no idea whether the patient was getting better or worse, whether our plan was or was not working, whether we need to rethink our whole approach or stay the course. In other words, I couldn’t figure out what was going on with the patient.” -Dr. Bob Wachter

The rigid, drop-down-menu style of EMRs may be impairing the ability of physicians to synthesize patient information. And that’s a scary thought.

Don’t Blame the Technology–Blame How We Use It

Interestingly, buried down below in the comments (credit goes to Dr. Leslie Kernisan for picking up on this) is a gem of a response from one Dr. Lawrence Weed–the same man who Dr. Wachter lauds in the opening of his post. “Our difficulty with Dr. Wachter’s analysis,” writes Dr. Weed, “is that he assumes the primary vehicle for clinical synthesis to be physician judgment. In reality, synthesis should begin before the exercise of judgment.”

In other words, why should old-fashioned physician thinking be the only way of synthesizing clinical information into a diagnosis? And why can’t technology like Watson be used to synthesize disordered clinical data, medical literature, insurance claims, and other data sources into meaningful clinical information that the physician can then use to make more informed clinical decisions?

Dr. Weed goes on to highlight an additional shortcoming of the current discourse around whether EMRs are good or bad: “Effective synthesis is tool-driven and process-driven.” (Emphasis mine.) And our debate over whether EMRs–or Watson–are “good” or “bad” for medicine ultimately addresses only half of the picture. Can we develop guidelines to ensure that the physician uses technology to inform rather than dictate the diagnosis? Can we establish processes that require the physician to continually elicit patient input into the treatment process?

The answers to those questions might be the key to determining the ultimate impact of technology on clinical reasoning and the wider field of medicine.

How Will It Help the Patient?

An extremely timely article published a few weeks ago in JAMA found 190 cases of missed primary care diagnoses in one year across two large health systems. Almost 80% of the errors were traced to “breakdowns in the physician-patient encounter”, with 56% of errors related to the medical history and 47% related to the physical examination. In an accompanying commentary, Dr. Newman-Toker estimates the error rate at about 0.1% of all primary care visits, which when extrapolated across the U.S. means at least 500,000 missed diagnostic opportunities each year.

(Update: This just in: diagnostic errors are the leading cause of successful malpractice claims, with 40% of diagnosis-related claims resulting in death.)

Just last week, a new survey by The Economist Intelligence Unit rank-ordered the activities in which “the need for retaining a role for human imagination or intuition [is] most critical.” The number one result is telling:

Source: Economist Intelligence Unit, 2013, "Smart Systems, Smarter Doctors: Humans and machines in healthcare". http://ricoh.emailsrvc.net/track/dl/1394/Wave_2_Healthcare_final_WEB.pdf

Source: Economist Intelligence Unit, 2013, “Smart Systems, Smarter Doctors: Humans and machines in healthcare”. http://ricoh.emailsrvc.net/track/dl/1394/Wave_2_Healthcare_final_WEB.pdf

These data point to an increasing urgency for solutions to improve the accuracy of our diagnostic capabilities , while simultaneously highlighting the tensions of emerging technologies such as Watson and their potential impact on clinical judgment. There is no simple answer to whether new technology will be good or bad for medicine. Rather, as our experience with EMRs shows, unlocking the promised benefits of technology will depend on our ability to foresee and mitigate a number of pitfalls:

  • Will the end-user (physicians, nurses, and other care practitioners) be consulted in every step of the design process, so that the technology can be smoothly integrated into workflows instead of creating onerous burdens?
  • Will the technology be designed to actually save money rather than driving ordering of unnecessary tests and services, as this recent Senators’ report accuses EMRs of doing?
  • Will medical education continue to stress the importance of clinical judgment, even with the proliferation of new tools at our disposal? Or will physician and care practitioners become increasingly dependent on the judgment of Dr. Watson?

Given the limitations of relying solely on old-fashioned clinical judgment, we must not be afraid to embrace the promise of technology such as EMRs and Watson. But we should be vigilant against unintended consequences these technologies may have on cognitive processes and patient care–this means rigorous evaluations of the impact of new technology, something that has been conspicuously missing for EMRs. And as we continue to debate the benefits of new technology on the physician, we should all keep in mind some words of wisdom from former CMS Administrator Don Berwick: “How will it help the patient?

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(My List of) 2013 Health Care Trends to Watch

Welcome to 2013! Apologies for the long hiatus since last October; I got hit with crunch time at work, then the flu, and then went on a week-long road trip to the south.

Being super nerdy at the CDC.

Being super nerdy at the CDC.

However, with the project finished, the flu defeated, and myself filled with more fatty fried foods than I’d care to think about, I thought it would be appropriate to kick off 2013 with an overview of the biggest health care trends to watch for in the upcoming year. I know, every health news outlet is doing it–but for those who don’t subscribe to Modern Healthcare and Kaiser Health News, here is what I hope to be a pithy, reader-friendly list. Enjoy!

  1. The impending (?) roll out of health insurance exchanges. Mandated by the Affordable Care Act, state-wide exchanges are slated to begin enrollment this October. What is a health insurance exchange? Imagine Amazon.com, except for health plans, where individuals without health insurance (or whose companies drop their health insurance because the penalties aren’t high enough) can go to buy their own insurance. Want a living example? Visit the Massachusetts Health Connector site, which has been up and running since 2006. The Department of Health and Human Services conditionally approved 8 more states last Thursday, bringing the total to 19 plus DC. Key questions include how many employers will actually leave their employees to the exchanges (one survey suggests, none); how insurers will react to capture this new market segment; and perhaps most importantly, whether the fed can actually roll out well-functioning exchanges in the 25+ states that have opted for federal exchanges by the October deadline.
  2. More posturing and debate about Medicaid expansion. The ACA had initially required all states to expand eligibility of Medicaid to all adults under 65 at or below 133% of the federal poverty line (with the fed covering 90-100% of the cost). Thanks to a surprise Supreme Court ruling, that expansion is now optional. Check out this cool map I’m shameless posting from my company showing where the states stand on the expansion decision. More news stories come out every day, with Idaho’s governor rejecting expansion this Monday, New Mexico accepting expansion today, and Florida’s governor brandishing exorbitant costs of expansion–even when his own experts tell him the numbers are wrong.
  3. Possible Medicare overhauls? The fiscal cliff fiasco and the last-minute deal in Congress didn’t save us from disaster–it just created Fiscal Cliff 2.0 in February and March, during which automatic 2% spending cuts are scheduled to hit again unless Congress can strike another deal. The fact that we’ve already played the tax-increase card has some analysts predicting the end of Medicare and other entitlements, which will have to be cut to escape our deficit crisis. Not so, say others, who think that Medicare and Social Security are still too sacred to be touched. In any case, Pres. Obama has expressed a willingness to consider changes to Medicare to address its unsustainable cost to the government, and may even try to use it to find common ground with conservatives.
  4. Continued transition to “value-based payment”. For those unfamiliar with health care jargon, that basically means shifting from a world in which providers are paid for volume of services to one in which they are paid for based on the quality of care they provide (you think we’d have figured that out sooner, go figure). Much of this shift is being accelerated by various ACA programs. CMS kicked off its Value-Based Payment program last October (here’s a great overview by Kaiser Health News), which is already rewarding and penalizing hospitals (apparently those here in DC are doing the worst), and beginning this October will be adding patient mortality to the mix of incentive measures. CMS is also accelerating its Accountable Care Organization program, in which groups of providers can band together into systems that can be awarded savings for providing cost-effective, high-quality care. Starting with only 32 “pioneer” ACOs in December 2011, recent research indicates 328 ACOs as of November 2012, with CMS expected to announce the 2013 participants soon just announcing 106 new ACOs today (updated Jan. 10).
  5. …And due to the surging interest in ACOs and population health management, hospitals are responding with continued consolidation, building of physician networks, and partnering with post-acute and other providers. Scale is once again the name of the game. Expect a slew of anti-trust cases to follow.
  6. Finally, often under-reported by the mainstream media, expect further developments in health IT. Continuing growth of electronic health records, app-enabled consumer tech, and cybersecurity breaches, oh my! Take a look at some of the biggest trends here.