The Best Health IT Book of 2015

The Digital Doctor by Robert Wachter, MD, is the book that will have the most long-lasting impact on health IT, and perhaps all of healthcare. Here are five takeaways.

Last winter, two health IT books dominated the discourse: Where Does It Hurt? An Entrepreneur's Guide to Fixing Health Care by athenahealth CEO and cofounder Jonathan Bush; and The Patient Will See You Now: The Future of Medicine is in Your Hands by Eric Topol, MD, cardiologist and chief academic officer of Scripps Health.

But the 2015 book that will have the most long-lasting impact on health IT, and perhaps all of healthcare, has to be The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age by Robert Wachter, MD, who directs the 60-physician division of hospital medicine at the University of California, San Francisco.

As evidenced by its frequent mention by attendees at HealthLeaders Media's own Population Health Exchange in June, The Digital Doctor is this year's required reading. About health IT, Wachter has said "We were bound to be disappointed." As we all return from summer vacation, I thought it would be timely to highlight my top five takeaways from Wachter's book.

1. When patient safety is at stake, it leads to powerful examinations of faulty EHR design. Wachter extensively interviewed more than 100 sources, including a few on the UCSF team who erroneously delivered a near-fatal overdose to a patient in 2013, due to what looks to me like design in Epic's EHR which could stand improvement (and since then has been modified). In fact, this overdose inspired Wachter to write the book.

To its credit, Epic permitted publication of the faulty EHR screens in question in Wachter's book. When I spoke recently with Epic president Carl Dvorak, he conceded that Epic customers are normally prohibited from publishing such screens in talks or publications, which he says does not materially differ from the policies of other EHR software publishers. In the case of Wachter's book, "We said, 'yeah, you can publish these screens, even though you're going to be disparaging, because we think it's an important message about safety, and we think there's something to be learned about that,' " Dvorak says.

2. Compliance officers and malpractice jitters are making infeasible the task of dividing EHR workload among team members, forcing already overworked physicians to work even harder. Wachter tells the story of a primary care physician, Christine Sinsky, MD of Dubuque, IA. At her clinic, compliance officers interpreted federal regulations such that nurses or clerks cannot sign a chart for later review by physicians; instead, the doctor must do everything.

When you pile those sorts of internal policies on top of well-known alert fatigue, usability, regulatory, and patient safety issues created by EHRs and other healthcare IT systems, it is no wonder that a recent survey showed physician dissatisfaction with EHRs is actually rising, not falling, in 2015.

3. The clinical quality measures collected as part of meaningful use and other compliance programs have a huge shortcoming, in that they fail to assess the quality of diagnoses. At length, Wachter discusses the advances and limitations of artificial intelligence to provide diagnoses by computer. Like him, I've been expecting this advance since I was young, but instead have wading through, as Wachter says, "the junkyard of failed computerized diagnostic programs built in the 1970s and 1980s." As a result, we live with a healthcare system where, according to one report, major diagnoses may be overlooked in nearly one in five patients.

Wachter does describe Isabel, a promising technology for augmenting physicians' ability to arrive at a diagnosis. But due to a lack of a business incentive or quality metrics, hospitals have no imperative to improve their diagnoses, whether or not technology can help, Wachter says. A cause for optimism, though, is a change in physician attitude that says there is no shame in doing a Google search, even in front of patients. After another generation, that will be profoundly true.

On a troubling note, Wachter notes (as do others) that anything that can assist in diagnoses or computer-assisted coding can also be used to increase the occurrence of "upcoding" which costs insurers and the public dearly in higher costs and premiums.

4. The iPhone, touted as an exceptionally "open" platform by many healthcare IT evangelists, actually derives much of its value from being quite closed. Wachter characterizes Apple's platform as "extraordinarily closed (or at least brutally prescriptive) about who and what plugs into its system." On the other hand, he says, "that's why your apps work so well. Epic is trying to do the same thing as it gradually opens up to third-party programs. That's what I want in my hospital, at least for the foreseeable future."

Perspective is everything. When Epic did not allow much application programming interface (API) access, then of course practically every other health IT platform looked open by comparison. EHR vendors, and customers such as UCSF and Wachter, realize they must strike a balance between control and freedom for developers to innovate, so that they do not get locked into a slowly changing base platform.

But opening up the electronic health record to outside apps is a double-edged sword. It raises all sorts of issues about the trust and reliability of what is being added to the record, either from external data sources or from patients. Don't expect the kind of rapid innovation explosion that occurred when Apple agreed to open up the iPhone. At least with the iPhone, there is essentially only one gatekeeper: Apple. With healthcare, expect overcaution from not only EHR vendors but from clinicians as well. Wachter alludes to the "hold harmless" clauses that technology vendors often hide behind. As long as a physician or a healthcare system is ultimately liable, innovation in healthcare IT will proceed at a relative snail's pace.

5. Although many physicians I speak with say that they can learn technology more easily than geeks can learn medicine, not everyone agrees. "It may be easier to teach a techie healthcare than to teach a doctor tech," says Nate Gross, cofounder of Rock Health, a healthcare IT startup incubator in San Francisco, interviewed by Wachter for his book.

No one is suggesting that tech types can actually practice medicine, but Wachter's book is a reminder that the many aspects of software design alone are simply beyond the training of physicians. Let doctors and nurses do what they are good at, and let software developers pay attention to precisely what it is that clinicians do, to arrive at intuitive EHRs and related systems.

Wachter will be one of the keynoters at the Health 2.0 Fall Conference, October 4-7 in Santa Clara, CA. I will also be there, moderating a panel on patient apps, with speakers James Madara, CEO of the American Medical Association, and Michael Tutty, PhD, AMA group vice president. I look forward to many good conversations there on the combination of technology and healthcare.