Q&A: Big Data is a doctor's responsibility

Robert Wachter, MDRobert Wachter, MD

Robert Wachter, MD, has plenty to say about Big Data and the asssociated realities of quality, safety and, perhaps most important, physician responsibility. 

Being provocative and innovative is what Wachter – widely read at his blog, Wachter's World, and followed on Twitter (@Bob_Wachter) – is good at.

Associate Chair of the Department of Medicine at University California San Francisco, Wachter is pioneer of the hospitalist field (he coined the term), a medical speciality that focuses on primary care in inpatient settings. He's a past-president of the Society of Hospital Medicine, and has helped the specialty become the fastest-growing in healthcare.

Wachter is also author of a forthcoming book, due out in 2015, titled, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age. In it, he explores the consequences, both hoped for and unintended, of the great health IT revolution.

On Thursday, Nov. 20, at the Healthcare IT News Big Data & Healthcare Analytics Forum, Wachter will deliver a talk titled, "The Value Agenda: Why Quality, Safety, and Patient Satisfaction are No Longer Elective." In it, he'll discuss how physicians must make smart use of data and analytics – not just to heal their own patients, but also to help improve the prognosis of the healthcare industry itself.

We spoke to Wachter recently from Boston, where he's taking a sabbatical from UCSF to finish up his book.

Q: Tell us a bit about yourself, and about how you helped create the hospitalist specialty.

A: I'm a general internist and an academic physician. My career can best be explained as "What happens when a political science major becomes an academic physician." I got very interested in how the system works, or doesn't.

In the mid-90s I was given a new job: to run the inpatient medical service at UCSF Medical Center, a big academic hospital. I had a very smart boss, and he said, "The service looks like it's organized when I was a resident here 20 years ago. That can't be right. Come up with some new model."

I started sniffing around to see who was doing innovative things in inpatient care. And I started to hear tales of different ways of doing it. The overarching theme was, moving from the old model of your primary care doctor taking care of you in the hospital to a new model where a separate doctor did that. You can argue there are a lot of reasons why that might be a bad idea, in terms of discontinuity. But it struck me as probably being a good idea.

And being in keeping with what happened with the rest of medicine – if you think about it in the old days there were no separate intensive care unit doctors, no separate emergency room doctors. You expected your own doctor to go there and take care of you. And then over time people said, "That doesn't work. These places are really complicated. We need someone who's there all the time. Who lives there. Who understands the system well."

And so I organized a model of doing that in my own hospital and wrote an article in the New England Journal of Medicine that coined the term hospitalist. I started getting calls from hospitals all over the country saying, "This is exactly what we need. Come out here and tell us how to do it."

More interestingly, I began getting calls from doctors who said, "I've been doing this for five years here in Springfield, Mass., or Gainesville, Fla., and I thought I was the only one in the country. I thought it was local and idiosyncratic or had to do with the nuances of payment or physician structure and preferences.

That's when I realized something interesting and organic was going on. And to make a long story shorter, that was 1996 and we're now almost 20 years into it. It's the fastest growing specialty in the history of medicine. Over 40,000 doctors now, a thriving professional society, all the attributes of a specialty: textbooks, meeting, board certification.

The evidence, by and large, supports the premise I had in the beginning. Concerns remain, though, which is why I got interested in technology. We do need to figure out now how to move information effectively from one doctor to another doctor, from one setting to another setting. But we have to do that all over the place in medicine.

By and large, I think it works better: The idea of having your own primary care doctor take care of you in the hospital sounds romantic and sounds terrific. When Marcus Welby did it, it was great.

But it just doesn't work. Patients are too sick in the hospital. They really need someone to be there, and primary care doctors are too busy in the office juggling the balls they're juggling. I think this is a better mousetrap.

Q: It's clearly an idea that's found a need. That's got to be gratifying.

A: At the Society of Hospital Medicine meeting, I get chosen each year to give the closing address: speaking to 2,500 or 3,000 people who really want to do the right thing. My group at UCSF is now 60 physicians. They're amazing people and they do great things every day.

I'd say the most gratifying thing was a very lucky break. As the field began to grow, we came of age at precisely the same time as the healthcare industry was being pushed to transform itself in ways that were very different than what I grew up with. We were being pressured quite vigorously to figure out how to provide high-quality, safe, satisfying care at a cost that won't bankrupt the country.

A lot of other physician groups said, "Leave us alone, we're too busy." For our field, since we're a brand new field, and a generalist field, we don't have a procedure, per se. We said terrific, that's exactly correct. That's exactly what we need to be doing.

So we jumped in with both feet to this idea of value improvement, the idea of making the system we work in work better.

And what's unbelievably gratifying now is to see leaders in hospitals all over the country emerge from this field. The top physician at Medicare is a hospitalist. The surgeon general nominee is a hospitalist. They are really emerging as national and local leaders. Many CMIOs are hospitalists.

That's not surprising to me. It's born of the field's driving and founding philosophy, which is we are here not just to take care of the individual patients but to take care of this other really sick patient which is the healthcare system.

Each one deserves a lot of attention, and each one is hard, and each one requires special training. The same rigor you put into being a really good doctor – to diagnose people and know how to treat them – we also need to get trained to diagnose the system, when it's screwed up, and make it work better. I'd say that's the most gratifying thing of all, seeing that all come together.

Q: It's clear why a hospital C-suite would pay close attention to analytics and business and clinical intelligence -- they want to reduce readmissions, avoid penalties, increase patient satisfaction scores and improve their bottom lines. Why should physicians, with so many sick patients and so much else on their plates, care about big data?

A: A quick story: I was speaking to the medical students at my school about a year ago. I said to them, you people are entering this field where you're going to be under intense pressure your entire career — that was very different than what I was under — to deliver high-quality, safe, satisfying care at the lowest possible cost.

I was trying to shake them up. One of them raised his hand, and he said, "What exactly were you people trying to do?"

I wake up in the morning and say, as my defining mantra, that the system has every right to say to us as a profession, "You are here to serve us." You think you've been doing it your whole career, but that's not the game here.

The game here is to deliver incredibly terrific, evidence based safe care — and to do it at a cost that's survivable. I think physicians believed for a long time that we're not part of that. That we sort of operated above, or independent of those imperatives that somehow our ethical duty was to focus like a laser on what the patient needed, and damn the costs.

I think we're waking up now and realizing that that's not right. In a no-money, no-mission way. As in: If it's damn the costs, we're going to go out of business and not be able to do the things we need to do.

And it's right for our individual patients as well. When we are profligate in our spending we don't take advantage of the data we have to figure out the best way to treat patients, the best way to prevent bad things from happening, the cheapest way — we often use mealy-mouthed words but the correct word is cheap — the cheapest way to safely and effectively take care of a patient. Should that be in the hospital, should that be at home, should that be in a clinic?

When we're not doing that, I think we're not following our hippocratic oath.

Now, does every doctor need to be an expert on analytics and big data? I don't think so. In the same way that not every doctor needs to be an expert in surgery or radiology.

We all need to know how to use it, we all need to know what to make of it, we all need to be good consumers of it. That's a new set of competencies that's extraordinarily important. And bring the doctors and the systems they work in closer together. Good systems that survive and thrive in the future are going to be ones where that way of thinking — that the C-suite thinks this way, but I'm a doctor and I think this other way, and somehow I'm on a little higher horse, a little bit more morally pure.

That's all going to go away, We're all going to think the same way. The job here is to produce the best care at the lowest cost. And there's a set of structures and culture and data and analytics that allows us to do that. A good doctor will say, "Terrific. I need to be a part of that, I need at the very least to understand how to do that."

And some of us need to be experts in that, because if it's just non-clinicians that do that they won't be asking the right questions, and they won't be able to communicate as effectively with their brethren as some people who are physicians.

It's quite parallel to the emergence of CMIOs. I spent the other day at Epic. You could argue, Do IT vendors need to have physicians and nurses on staff? You could argue Why, this is all about technology, this is all about code. But they've all come to realize, not really!

You need to understand the workflow, you need to understand how these people think. And you're going to have to have other people who cross over between these two worlds. I think the same is true with analytics and data.

Q: Talk a bit about your equation for determining "value" in healthcare: quality plus safety plus patient satisfaction, divided by cost.

A: It's not rocket science. Every industry in a capitalist economy is driven toward producing the best product at the lowest cost. The code word for that is value.

What's funky about medicine, as that medical student asked me, is that we have really not been. There are multiple reasons. One is that the insurance system insulates everyone, to a large extent, from cost. The costs get hidden and moved around in funny ways that make them not obvious.

This morning I had to run out and get my large mocha, because otherwise I would not be functioning at 9 a.m. I have to decide whether it is worth $3.65 to give to Starbucks every morning for this cup of coffee. And I do that based on my consideration of value: quality, satisfaction, whatever pleasure it gives me, divided by the cost. I decide whether it's worth it. That cost comes completely out of my pocket, and if I decide one day that it's not worth it, and the $1.80 I can get from Dunkin' Donuts down the street is good enough, and I'm gonna save that money and do it another way, that's what I'll do.

We have an abiding belief in America, and I think it's been largely borne out, that that sort of pressure — producing the best thing, however you define the best.

This article originally appeared on Medical Practice Insider sister site Healthcare IT News