Dr. Robert Wachter, Author of the “The Digital Doctor”

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Mark Masselli: This is Conversation s on Healthcare , I am Mark Masselli .

Margaret Flinter: And I a m Margaret Flinter.

Mark Masselli: Well Margaret , could the broken SGR formula finally be on amend?

Margaret Flinter: It does look that way Mark and I think we may soon have the
illusive dark fixes they call it.

Mark Masselli: The reimbursement rates set by Congress back in 1997 plummet
every year forcing Congress to pass emergency spending bills to keep the rates at
market level. It’s been very disruptive force in many practices.

Margaret Flinter: Hard to believe, in this current political environment we are actually
seeing some sort of bipartisan consensus. That just seems to be what’s happening
now.

Mark Masselli: That certainly does , but this deal was worked out behind the scenes
and the President said he is ready to sign it. But I think we are seeing some real
momentum on this issue which should have been resolved a long time ago but will
take it now, and another bill signed recent ly, this one was in Colorado, where
Governor John Hickenlooper had approved a new extensive telemedicine bill. It
significantly expands the reach of tele health services.

Margaret Flinter: And that law now requires insurers to reimburse tele health
pro viders across the state.

Mark Masselli: The digital health movement is full of promises Margaret but it’s also
flogged with growing pains which could to lead to harm if not carefully managed.
That’s the premise of a book written by our guest today. Dr. Robert Wachter is
associate chairman of t he department of medicine at U. C. Sanction Francisco is one
of the world’s thought leaders on The Hospice Movement and the author of The
Digital Doctor , hope hype and harm at the dawn of medicine’s computer age.

Mark Masselli: Lor i Robertson , the Managi ng Editor of FactCheck.org . stops by, she
is always on the hunt for misstatements spoken about health policy in the public
domain but no matter what the topic, you can hear all of our shows by going to
www.chcradio.com .

Margaret Flinter: And as always if you have comments , email us at
[email protected] or find us on Facebook or Tw itter because we love to hear from
you.

Mark Masselli: But first here is our producer Marianne O’ Hare with this week’s
Headlines News .

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Marianne O’Hare: I a m Marianne O’Hare with these Healthcare Headlines . There is
a duck fix in the works but it won’t be finalized for weeks. The house has come to
bipartisan agreement on a 200 - Billion - Dollar Bill to fix The Medicare Reimbursement
Formula for clinicians trea ting Medicare patients. Not everyone is happy with the
agreement, which according to the summary scraps the current reimbursement
system and gradually increases reimbursements to clinicians over 5 years. The
House Package places more burden on seniors to shoulder the cost of their care
AARP another organizations representing seniors have registered displeasure with
the bill saying seniors bear too much of the brunt of the cause. President Obama
has indicated he will sign the bill. And now for the extend ed open enrollment, which
goes to the end of April by more than 16 million Americans have gained some kind of
health coverage under The Affordable Care Act in 2 years of open enrollment
millions had chosen for one reason or another to remain uninsured even though they
qualify for significant tax subsidies to offset the cost of purchasing insurance.
According to a survey by (inaudible 3:10 ) only 41% of those whose income was
between 151% and 200% have probably already signed up and someone who ha d
been more most adversely opposed to Obama Care is now perhaps one of its most
celeb rated customers. Presidential hopeful Ted Cruz had to go on The Healthcare
Plan. He has publicly land based it from its inception after losing his wife’s employer
coverage, she res igned her post at Goldman Sachs to work on her husband’s
Presidential Campaign. Another reason to get off your duff and get moving; a study
shows exercise actually changes the chemistry of tumors making them more
vulnerable to treatments. A study being d one between Mass General Memorial
(inaudible 3:48 ) looked at what happens when tumors become hypoxic essentially
chocked off by the network of vessels that initially go to feed that tumor, when
exercise was added blood flow increased to the tumors allowing drugs a better
access route to attack the cancer. I a m Marianne O’Hare with these Healthcare
Headlines .

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Mark Masselli: W e are speaking today with Dr. Robert Wachter , Associate
Chairman of The Department of Medicine at The University of California San
Francisco. He is also Chief of Hospital Medicine and Medical Services at the UCSF
Medical Center. Dr. Wachter coined the phrase hospitalist. It is considered to be an
a cademic leader of The Hospice Movement. Dr. Wachter is a prolific writer on
Patient Safety and Healthcare Quality. He is the editor of several journals and he
has written several books including the latest The Digital Doctor Hope, Hype and
Harm in the da wn of medicine’s computer age. He earned his M.D. at UN. Dr.
Wachter welcome to Conversations on Healthcare.

Dr. Wachter: Thank you so much for having me.

Mark Masselli: You’re saying that we’re at the dawn of medicine’s computer age but
you cautione d that technology is neither the silver bullet nor the panacea that will fix
what’s ailing modern hea lthcare and you say despite being staffed with mostly well -
trained and committed doctors and nurses our system delivers evidence based care
only about half the time you love medicine and technology but you feel so strongly
about the potential harm of the emerging use of digital technology in healthcare and

why clinicians and patients alike should be concerned. Can you tell our listeners
more about that?

Dr . Wachter : For someone like me who studies patient safety, we have been waiting
for computers for over a decade to come in and solve all the problems with
healthcare and then when computers finally entered our world and it’s been
remarkably recently, I beg an noticing funny things and doctors and patients not
looking each other in the eye anymore and changes in workflow that were
surprisingly didn’t go down to radiology rooms anymore because we didn’t have to
and so I have been thinking kind of a lot about w hat went wrong and what these
changes were and then about 2 years ago at UCSF which is a fabulous place we
gave a kid a 39 fold overdose of a common antibiotic. At that moment, I came home
and I said I need to understand this better and then need to write about it and the
challenge of course is writing about it in a way that doesn’t dismiss the technology
but really looks at the moment that we are at an healthcare and ask why is it not
reaching its potential.

Margaret Flinter: Share with us how people co me together after a sentinel event like
that to say how do we make this technology work for us?

Dr. Wachter : When an error like that happens , in some way it’s easy to point your
finger at Cerner or whichever company built your technology and so like they need to
fix that, we came to realize that there were a series of policies that we created when
we implemented our computer systems that were perfectly well maintaining and
worked reasonable well most of the time but in this case it made the work more
comp licated than it needed to be. We also came to realize the system of alerts
which sounds like a great idea. This is one of the great promises of technology
when I am about to write for a medicine that a patient’s allergic to the thing is going
to pop up a nd show me, you know, the patient’s allergic to this, do this, but we find
that we have 100s of 1000s of alerts going off a month just within the computer order
entry system. Adding the alerts in the rest of the system, someone designing the
system says w ell what a great idea to alert the doctor or the nurse if there is an
overdose, if these two drugs might interact with each other but no one has flipped
the classroom and looked at it from the standpoint of what is it going to feel like to be
a doctor, a n urse, or a pharmacist in an environment where you are getting alerts
every 2 min ute s and the answer is you are going to ignore them and then there were
other issues that involve culture which is a young nurse sees an order for 39 pills
when the correct dos e is 1 and says to herself this is really weird but I know to get to
me it had to go through a doctor and a nurse and a pharmacist and a doctor and I
will check it my technology and so she barcodes it and by that stage with the
medication process the barco de’s job is to send the order and the barcode confirms
that that’s correct order. So we had work to do on trying to convince people that
when your speedy sense tells you that something seems really kind of buzzard trust
it don’t over trust the technology and don’t hesitate to pull the cord and say it’s time
to stop the assembly line, let’s ask a question here. So these are in some ways
predictable problems. But I think for many of us in healthcare they surprised us and
we are just beginning to address th em.

Mark Masselli: You have talked and written about The High - Tech Act. You have
some real concerns about The High - Tech Act. Was it too much money all at once?
Where did we go wrong?

Dr. Wachter: The High - Tech Act has actually an amazing back story in 2004
President Bush announced in the State Union Address a set a goal of computerizing
healthcare system and healthcare there are differences that made it such that
healthcare was not going digital on its own but the initial budget to do that was 42
mil lion dollars, so that’s to try to transform the 3 - trillion dollar healthcare economy
that’s like trying to change the direction of the battle ship by sticking your feet in the
ocean and kicking hard. It’s not possible. And then what happened in 2008 was the
economy imploded and they were coming up the 700 billion dollar stimulus package
to revive the economy and some smart health policy leaders adhere that at one
chance they will, it will ask for about 5 minutes and then go away forever and that
was High - Tech so that was the 30 billion dollars of Federal incentives that got us to
go digital. And I am actually not critical of those decisions more of High - Tech I thi nk
the idea of a federal incentive program to try to push a sliver line hit a tipping point
where doctors and hospitals would go from analog to digital I think was smart, it was
happening on its own but unbelievably slowly and I think it has worked so we a re up
to 70% EHR adoption in hospitals and doctors office as we were 10% 6 years ago.
Where I get critical of the Government here is when High - Tech was passed they
quite sensibly said, we better have another set of policies that ensure that people
just do n’t accept The Federal Money and stick the thing on the shelf and so we are
going to create another set of policies that’s called meaningful use. So basically if
you were going to give you federal money you need to demonstrate that you are
using the compu ter in a meaningful way that’s not silly because the risk was real but
what happened with that was that Federal Government got very deeply into the
weeds of essentially prescribing what your computer system should and shouldn’t
do. A lot of that is not ok ay and I think we are in the weeds now. You know, there is
a model of The Feds getting it right and the model is internet where in the early days
the internet was invented by you know, Federal Researchers with Federal dollars
and then they realized very q uickly that it’s time for us to pull out and it’s worked
spectacularly well. The market forces through the ACA and other mechanisms that
are driving healthcare systems to me are good enough that if you have a computer
system, you will tweak it in the way as you need to, to meet those ultimate goals.

Margaret Flinter: Well let’s stay in those weeds for a few minutes, it is a fascinating
area and we’ve had the pleasure of talking over the years with David Brailer and Dr.
Blumenthal, Dr. (inaudible 11:25 ) m eaningful use was the first phase of that. A
tremendous boon to practices who were trying to shoulder to the cost of
implementing Electronic Health Records really helped to get people out of those
paper charts and on to an Electronic Health Record, you kn ow, the second and third
phases are really about trying to use the electronic health record to drive a change in
the model of care. It doesn’t seem to me it’s likely that your average independent
small practice can meaningful use two or three and wonder i f you would like to
comment on that and start the gains and losses when we do that?

Dr. Wachter: I think there is a general bias in Federal policy making, the healthcare
should run more like a business in the set of incentives that allow the creation of a
Google or an Apple or another high - functioning company, and not to be in existence

in the healthcare and if they were in existence they would drive toward larger and
more systematic kind of organizations with better use of data. I am probably a little
b it biased because I live in San Francisco and where Kaiser permanently such a
dominant system and I think it works pretty well. I mean I think that the model of a
true system of the doctors and nurses and hospitals and they are all being part of the
syste m getting a dollar and distributing it as they see fit to deliver the best outcomes
at lowest cost. I think that makes more sense as an organizational principal. I guess
my hope is that with new IT tools and with an increasing focus on the matrix that we
care about that there will be a way to create sort of the best experience or patients in
the context of the benefits that larger system can bring. Increasingly, people will get
some of their healthcare or maybe lot of their health from their home or thei r
workplace enabled by new technology tools or tele medicine but it all has to sit
together in this pretty complicated jigsaw puzzle and I think it’s more likely that we
will succeed in achieving the goals that people are glued together in larger system.

Mark Masselli: We are speaking today with Dr. Wachter, Associate Chairman of The
Department of Medicine at The University of California San Francisco. Dr. Wachter
coined the phrase Hospitalist and is the author of The Digital Doctor, Hope, Hype
and Harm at The Dawn of Medicine’s Computer Age. You know, you make a case
for the emerging healthcare system that’s not only based on man versus machine
but rather on 2 elements working together in tandem . Tell our listeners more about
where the medical professi on might be heading in our newly wired world ?

Dr. Wachter: ( I naudible 13:58 ) a year and half ago that I needed to write about this
but I am not a techie person at heart and so my wife is a journalist who writes for The
New York Times and she suggested to me that the only way I was going to get this
right was to do it journalistic ally and that meant I interviewed about 90 people
including all the offices of national coordinator directors decided and went to see
primary care doctor doing their work (inaudible 14:20 ) so when I asked them where
does this all end up if we get it right? The vision that almost everybody had was
about the same and it was actually quite nice and you know, the patients are getting
digitally enabled care in their homes, in their work places, we are using big data.
Technology brings us closer to patients and brings patients closer to each other. So
I profiled one of these peer to peer sights called smart patients where patients get a
diagnosed with cancer and they go on the web and they talk to other patients with
the same cancer and they learn tremendous am ount from that. Care will be better
and more patient - centric and less expensive. It’s sort of man versus machine I think
is in some ways an artificial argument that when you get it right, it’s not, these two
were not in competition, these two weave toget her in new and wonderful ways and I
think that it takes 10 or 15 years for the technology to settle into a new industry and
make things really measurably better, we are at the stage in healthcare where I think
we broadened the technology and we didn’t re - i magined the work or why it shouldn’t
look like Facebook or twitter where there is sort of a stream of information that
everybody contributes to including the patient. I don’t think we have thought deeply
enough about what are our goals and how does techno logy help us reach those
goals.

Margaret Flinter: I think may be given your leadership in the area of developing the
role of the hospitalist and not giving an opportunity to comment on that as well
because certainly for a generation those really physicia ns who were disrupted by this

in primary care and in community medicine, spent years and decades in many cases
with the hospital it’s kind of their daily social mailer before they went back to the
relative isolation of their practices and the hospitalist m ovement as it developed for
all the very good reasons it developed really was a big dislocation what’s the jury
verdict on the gain and the loss around the almost complete transition not to The
Hospice Movement around the country?

Dr. Wachter: I have a s trong belief and I think the evidence supports that the
organization of care with a separate hospital doctor achieves more gains and losses.
The old notion of your doctor and your regular doctor taking care of you in the
hospital was attracted and all sor t of ways but in the era of patients who were in the
hospital being really sick the pace being incredibly fast I think you need a doctor
there all the daylong and my model to this when I am quite determined kind of began
thinking about this, in the old, ol d days there were no critical doctors and people
realized that you need a physician a general physician who is essentially a specialist
in the place and ultimately now the hospital has become as complicated place where
the stakes are that high you can have a patient being managed by someone who
has a different job, 10 hours of the day. I think the data say that on an average
quality and safety are at least neutral if not better. Well I think these really get
exciting is the maturation of the hospitals fie ld because what we did was position the
field as being a new kind of doctor. A doctor who would not only take care of the
individual patients but also has been a steward of the system and pay a lot of
attention to this other sick patient meaning the healt hcare system. And as I look at
my group at UCSF, we are the unquestioned leaders in the organization in improving
the system and have almost remarkable number of leadership roles at UCSF. It’s
not a coincidence I believe that the surgeon general is now a hospitalist and the top
physician at Medicare is now a hospitalist. To young field, but I think we have bread
a disproportionate number of leaders, in these areas because we have a deep belief
that we did need a different kind of physician who paid atten tion to improving the
system as well as individual patient care. But it means we have to pay a lot of
attention to how do we move information back and forth but in a good system,
people actually speak to or e - mail each other to make sure there is a person al
connection. When I look at a high - functioning mult i - specialty group, when I look at
Keizer Permanente or (inaudible 18:23 ) or Palo Alto Medical Clinic, I think what they
have done is they have created environment in the ambulatory setting where
physicians get much of that joy and benefit and collegiality so I think it’s in some
ways another argument against the one or two person practice. I think we nee d
larger organizational units for one reason to kind of re - imagine the environment in
which the physicians will get that kind of professional benefits.

Mark Masselli: We have been speaking today with Dr. Wachter, Associate Chairman
of The Department of M edicine at The University of California San Francisco. Chief
of hospital medicine and medical services at UCSF medical center and author of The
Digital Doctor, Hope, Hype and Harm at The Dawn of Medicine’s Computer Age, you
can learn more about his work b y going to the - hopitalist.org, Dr. Wachter thank you
so much for joining us on conversations on healthcare.

Dr. Wachter: It’s been a great pleasure.

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Mark Masselli: At Conversation s on Healthcare , we want our audience to be truly
known when it comes to the facts about healthcare reform and policy . Lori
Robertson is an award winning journalist and manag ing editor of FactCheck.org , a
nonpartisan, nonprofit consumer advocate for voters that aim to reduce the level of
deception in US politics. Lor i, what have you got for us this week?

Lori Robertson: President Obama recently said that the Affordable Care Act is
reduc ing the overall cost of healthcare including putting “1800 dollars in people’s
pocket ” but the President’s 1800 - dollar figure is n’t a reduction in insurance premium
but rather it’s the difference between the cost of the average employers sponsor plan
in 2014 and what the average premium would have been if based on average rate
increases from 2000 through 2010. The calculations were do ne by White House
Economic Advisors but even they say The Affordable Care Act isn’t responsible for
the full 1800 - dollar difference. Employer sponsored premiums have been growing at
low rates for the past few years and The White House council of economic advisors
looked at what premium growth would have been since 2010 it’s the growth rate
have been as high as they were in the decade before. That calculation showed the
average family premium for employer sponsored plans would be 1800 dollars more
than it actually is. But does the ACA get credit for that as Obama said it should, it
could be responsible for some of the slower growth but experts largely attribute it to
the sluggish economy. The Council of Economic Advisors said “a significant fraction
of th e slowdown in healthcare inflation could be linked to the ACA but it didn’t say
how much. Also the 1800 - dollar difference is the total premium amount that would
have been paid by both employers and employees so not all of the 1800 dollars
would amount to money in people’s pocket. And that’s my FactCheck for this week; I
am Lori Robertson , Managing Editor of F act C heck.org.

Margaret Flinter: FactCheck.org is committed to factual accuracy from the country’s
major political players and is a project of the Annenberg Public Policy Center at the
University of Pennsylvania. If you have a fact that you would like checked, email us
at chcradio.com , we will have FactCheck.org ’s Lori Robertson check it out for you
here on Conversations on Healthcare .
[Music] Mar k Masselli : Each week Conversations highlights a bright idea about how to make
well ness a part of our communities and everyday lives. Pregnancy is normally an
exciting time for most women but according to the research an estimated 10% of prenatal women e xperience some kind of depression during their pregnancy and many are reluctant to treat their depression with medication for fear of harming the fetus.
Margaret Flinter: In fact a higher percentage are experiencing lower - grade
depressive symptoms so the y might not meet a full criteria for major depressive episode but they are having significant symptoms that are getting in the way of a feeling good and perhaps even getting in the way of engaging and the kind of healthy behaviors that are going to support a healthy pregnancy and left untreated
those mild - to - moderate symptoms can progress and can lead to a more serious
depre ssion .

Mark Masselli: Dr. Cynthia Battle is a psychologist at Brown University with a
practice at women’s and the infant’s hospital in province. She and her colleagues
decided to test a cohered of pregnant women to see if a targeted prenatal Yoga
Class which combines exercise with mindfulness techniques might have a positive
impact on women dealing with prenatal depr ession.

Dr. Cynthia Battle: We worked with these experts to really come up with a program
that was similar to what you might find in the community of prenatal yoga that would
include physical postures, meditation exerc ises and we enrolled 34 women who
were pregnant who had clinical levels of depression on average over the 10 - week
program that came to about 6 classes, and we measured their change in depressive
symptoms over that period of time.

Mark Masselli: Not only were women able to manage their depressive incidents,
they also bonded with other pregnant women during the program and found
additional support from their group.

Dr. Cynthia Battle: So we found that women on average were reporting both on their
self rep ort questionnaires and in the observer - rated interviews that we did that they
were reporting much less.

Mark Masselli: A larger study with controlled groups is being planned with the
assistance of The National Institute of Mental Health.

Dr. Cynthia Bat tle: Women who are depressed during pregnancy unfortunately do
often have some less ideal birth outcome. So one thing we are interested in seeing
is when we provide Prenatal Yoga Program can it improve mood and then can we
even seen some positive effects in terms of the birth outcome.

Mark Masselli: A guided Non - Medical Yoga Exercise Program designed to assist
pregnant women through depression symptoms, helping them successfully navigate
those symptoms without medication ensuring a safer pregnancy and a healthier
outcome for mother and baby, now that’s a bright idea.

(Music)

Margaret Flinter: This is Conversations on Healthcare , I a m Margaret Flinter .

Mark Masselli: And I am Mark Masselli . Peace and health.

Conversations on Healthcare , broadcast from the campus of WESU at Wesleyan
University, streaming live at www.wesufm.org and brought to you by the Community
Health Center.