In discussion with: the 'digital doctor'

To complement our new report, Delivering the benefits of digital health care, we’re running a blog series exploring how digital information technologies can help to transform health services. The series is a mix of interviews and thought pieces from a range of perspectives including frontline staff, digital practitioners, researchers and others.

To kick off the series, we interview Robert Wachter, author of The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age, about his experience introducing digital health technologies in the US and breaking through the ‘productivity paradox’.

Why do you think the process of adopting technology into medicine has been so difficult?

I’ve studied the technological innovation and adaptations in other industries and it’s clear that our issues in health care are not unique. In medicine, we always tend to think that this is the first time the world has ever heard of these problems. This idea of the ‘productivity paradox’ – the lag between the adoption of technology and the realisation of productivity gains – is a well-known phenomenon. Technology enters industries and often those industries don’t quite know what to do with it. Perhaps they haven’t screwed it up quite as badly as we have in medicine, but technology never reaches its full potential at the very beginning.

There are a few reasons for that. One is the typical process of disruptive innovation: there are a lot of stakeholders that have an interest in the old way of working. And so the politics of changing things in a radical way are very complex.

But mostly, humans are generally just not very good at envisioning fundamental changes in the way they work. We tend to think incrementally. As a quote often attributed to Henry Ford goes, “If I’d asked people what they wanted, they would have said ‘faster horses’.”

Are there aspects of the health care profession that have made it more challenging?

A unique aspect of computer adoption in health care is that it didn't occur organically. In many other industries, what you saw was a very natural technology adoption curve, where you had early adopters and then laggards and then, eventually, everybody got there.

But, in health care, people were so resistant to ubiquitous technology – electronic health records, particularly – that it took a long time for it to happen. And then, when it did, at least in the US, it happened very quickly. So we went from essentially nothing to nearly everybody having electronic health records in three to five years.

The result of this is that nobody’s had the time to do the adaptation phase. In other industries, by the time the rank and file and the laggards adopt a technology, the early adopters have had it for 10 years and they’ve already traversed the curve, working out the bugs and developing a model that was replicable. That’s what we’ve been missing in health care.

How do we find our way out of the so-called ‘productivity paradox’?

Erik Brynjolfsson at MIT, who coined that phrase, said that the history of technology teaches us that, as it enters industries, people think it is going to be immediately transformative. In the business world, they think it’s going to revolutionise the industry, whether that be manufacturing, publishing or something else.

You need two keys to resolve the paradox. One of them is the technology, which of course needs to get better. But the second is that the work needs to be reimagined. You can’t just recreate your analogue processes with technology, without rethinking them. You need a new generation of leaders who are not wedded to a certain way of thinking, who are willing to challenge existing ways of working that are just no longer fit for purpose. Hospitals are now in a business where they are not going to be able to survive unless they demonstrably produce a high-quality, safe ’product‘ at the lowest cost. It’s not a theory any more: it feels very real. As people begin to reorganise, they are forced to consider how technology can help them to do that. That business case to improve performance is a very important adjunct to this.

Ultimately, work must be transformed, both by generational change within existing organisations but, very importantly, by technology serving as a fulcrum, an enabler, for new entrants into the market that had no access to the health care world before. And that’s everything from technology companies – whether it’s Google or Apple or start-ups – to patients and their advocates, now enabled and empowered by technology to transform a market that they previously had to be completely passive in.

Eventually, it has much more to do with the choices, the policy and the paradigms shifting, than it has to do with the actual interfaces and the software.

The tone at the end of your book is ultimately one of optimism for technology in health care. Do you still feel that way?

Believe me, when I started writing, I wasn’t doing it from a mindset of optimism! Ultimately, the reason I started writing the book in the first place was because I was disappointed. I had seen how remarkable IT could be in other aspects of my life, and how transformative it was in other industries. Yet I wasn’t seeing any of that in our own work.

That was what catalysed me to start writing the book, but I did go in with an open mind for the future. And the more I spoke to people, the more they cemented my feeling of disappointment with where we were. But they also solidified a feeling of hope. I could see the early forces, the early innovations and attitudes that will ultimately help us mature digital health care into something that really works.

It’s going to take a while, and we have to make some better decisions first. But, after a while, we will get there.

The views presented in this blog are those of the authors and do not necessarily represent the views of the Nuffield Trust or our partners.

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