Q&A on Medicine’s New Horizons with Dr. Robert Wachter

Dr. Robert Wachter is a familiar name among patient safety advocates. He is credited with coining the term “hospitalist” for doctors who focus on the care of hospitalized patients, and his latest book, “The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Computer Age” concerns the risks and rewards of health care increasingly dependent on this technology.

Following are excerpts from an interview Wachter did recently with KaiserHealthNews.org. on trends in health-care safety.

Q. Many older people aren’t tech savvy. They’re also bigger health-care users than many younger people. What needs to be done to help them get and stay engaged as technology advances?

A. It’s not natural for them the way it is for the next generation and beyond. But most older people are at least using email and know how to surf the Web. … As consumer-oriented tech companies enter the health-care field, I think they’re going to design tools and technology and ways of interfacing that make it seamless for the people who need to become engaged. This will allow older patients to at least do the basic stuff, like renewing their medications, the stuff that’s just incredibly annoying in the paper world.

Q. In your book, you talk about moving away from fee-for-service payments to doctors and hospitals and toward payments based on a population of people, adjusted for their baseline health. From a patient perspective, will that change how they pay for their care? Could that finally mean the end of incomprehensible “explanation of benefits” insurance forms, for example?

A. Of all the nuts we have to crack, this is the one I’m least optimistic about.

If everybody is in an accountable care organization [doctors, hospitals, laboratories, etc., that coordinate care for higher quality and who are paid according to the quality standards they reach] … providers get a single payment when they treat someone. But as long as they’re still doing an adjustment for the relative sickness of the patients, the organization will need to account for all of the details. And I’m afraid the patient may also still see a confusing itemized bill, unless we can get to a point in which you’ve paid for the year and you’re done.

The movement away from piecemeal payments is hopeful, and so are the digitization of health care and the entry of Silicon Valley companies with a consumer sensibility. I guess the question is: Do all of those trends – when woven together – lead to something that’s more user friendly? When it comes to clinical care, I think the answer is yes. I see how we can get to a much happier place, with better care through digital medicine, in five to seven years. But the idea that you could get a simple, clear insurance bill that you pay with one click … maybe in 10 to 15 years.

Q. To what extent can technology really help people comparison shop for health care? This seems to work best for procedures like colonoscopies or MRIs, where the service performed is fairly comparable and relatively inexpensive. Could people really comparison shop for cancer treatment? Would we want them to?

A. Sure, why not? Some of this comes down to your fundamental belief in capitalism and the market. But we do have to pay some attention to fundamental differences between health-care and other markets. For example, in health care, we can’t accept haves and have nots, while we readily accept this with other luxury goods. … I’m pretty convinced that if you create an environment where patients have the information they need to make those decisions, that the market will help them make good choices.

The area I worry about is the science. How do we really know that one doctor or hospital is better than another? Most aspects of quality measurement are not very advanced.

Another real challenge is fragmentation. If I get my colonoscopy at one place because it’s the best and cheapest but it’s in a different system than the one my primary care doctor is in, that’s a problem if the electronic records don’t talk to each other. As a patient, I’ve got to think about the advantage of receiving the cheapest procedure compared to the negative consequences of no one doctor having a complete view of my health.

Q. Do you think the Affordable Care Act requirement that people have health insurance positively affects their engagement in their own health care or the health-care system?

A. I think everybody should have health insurance. The system works better and people have better health and health care with universal insurance. And the law was the most politically feasible way to make that happen, … When people have health insurance, it creates a connection to a system that is largely mediated through a primary care doctor. To have 40 to 50 million people floating outside the system – able to access the system only episodically and when they’re very ill – is crazy.

Has having insurance increased their engagement? Yes, but at a level that’s pretty wimpy. Now you can see a primary care doctor to manage your blood pressure in an office visit every six months, but is that the level of engagement we should aspire to? Nowhere near it. The hope is that by having everybody part of an organized health-care system, now it’s in the interest of the system to have engaged patients – since that engagement should lead to fewer office visits, ER visits, and hospitalizations. But this is the sort of thing that takes years, if not decades, to develop.

Q. What about initiatives like OpenNotes that allow patients to read their doctors’ electronic notes about their care? How do they change the patient-doctor relationship?

A. OpenNotes illustrates the democratization of the health-care system, which is going to challenge all of the system’s fundamental underpinnings. Digitization is an enabler. It’s changing the relationship between doctors and their patients from an extraordinarily paternalistic one to one that is more democratic. In the new world, a patient’s choice is no longer just, “Do I see doctor A or B?” but “Do I even need to see a doctor at all?” OpenNotes is part of this trend.

As wonderful as patient sharing access to their information is, along with new tools to self-manage and things like telemedicine that allow patients to receive care outside the traditional system, in a world of high copays you are going to see some patients making some very bad choices. In the old days, the sick patient had to go see a doctor. Now they can go to MinuteClinic. Or they can Google their symptoms. I wouldn’t want to turn back the clock, but it raises the question, “When is self-management a bad choice?”

As health care finally goes digital, some people believe that it’s no different than travel or banking. But no one is getting harmed by using TripAdvisor or Fidelity. I think you could argue that health care is fundamentally different.

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