Dr Robert Wachter is Professor and Chair of the Department of Medicine at the University of California, San Francisco (UCSF). Dr Wachter coined the term ‘hospitalist’ in 1996 and is widely credited as founder and academic leader of the ‘hospitalist specialty’ – a specialty that focuses on the care of hospitalised patients. He is chair of the American Board of Internal Medicine and past president of the Society of Hospital Medicine. He begun his medical journey at the Perelman School of Medicine, University of Pennsylvania, and completed both his residency and chief residency in internal medicine at UCSF.
Dr Wachter is an international pioneer in healthcare safety and quality. He edits the US government’s website on patient safety and in 2004, Dr Wachter received the John M. Eisenberg Award, a top honour in this field. He has published more than 200 articles and 6 books on healthcare topics, including: ‘The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age’ and ‘Understanding Patient Safety’. His blog ‘Wachter’s World’ covers healthcare policy, healthcare quality and hospital safety.
Dr Wachter has served on the healthcare advisory boards of several companies, including Google. In 2016, Dr Wachter chaired the group advising the UK Department of Health and NHS England on the digitalisation of secondary care in the UK.
What advice do you have for clinicians in the UK who would like to bring about digital innovation in clinical settings?
Keep your eyes open – it is so easy to keep your head down and then go home and grumble about the things that didn’t work or could have been better. Identify the things that are not working, then make sure you have the skills and conjure up the bandwidth to make things better.
Bake some time into your schedule for a weekly or monthly meeting with colleagues, spent brainstorming on the pain points you are facing – the things that you grumble about. Think about what could be done differently, and whether there’s a way to reinvent the work, the workflow and/or who does what. Then, see if there is a digital tool that can help to enable this.
As it stands, we have it backwards – we import a digital tool, flick on the switch and expect it to fix us. It is so easy to be blinded by the magic of an app. If you start thinking about digital tools first, you will nearly always get it wrong. Healthcare is many orders of magnitude more complex than that. Focus on reimagining the way we do things, using post-it notes and brainstorming sessions first.
Bake some time into your schedule for a weekly or monthly meeting with colleagues, spent brainstorming on the pain points you are facing
How can you create a culture of innovation in a clinical setting?
It is the job of a leader to create a culture where everyone feels like their ideas are valued. This is one of the great leadership challenges. You need to encourage people to think about making things better and doing things differently. This requires an environment of team building and a sense of optimism.
Your innovation ‘batting average’ cannot be 100%– if it is, then you are not doing it right. Periodically you will try something new and screw it up. If so, then learn from it and try again. This “fail fast” mantra is the natural reflex in the entrepreneurial space, but feels unnatural in a healthcare setting.
Also, accept that innovations often migrate from elsewhere –syntheses of things that come from other industries. A lot of innovation is translational as opposed to pure invention.
Periodically you will try something new and screw it up. If so, then learn from it and try again
How do you assess the progress that has been made by the NHS in digital innovation and healthcare IT since your report in 2016?
There is definitely a sense of movement since the report, and I am extremely impressed by the degree to which my group’s recommendations have been taken up.
The NHS was lacking a cadre of clinicians trained in digital innovation, let alone placing them in national and trust level leadership positions. My committee identified that many NHS leaders in digital healthcare had never seen a patient.
So I was thrilled to see a National CCIO (Chief Clinical information Officer) appointed, and – just as importantly – the founding of the NHS Digital Academy, which has just graduated its first class. This is a robust training programme for clinicians to gain digital skills. It seeks to train a workforce – which previously did not exist – of clinicians with professional skills in IT and digital innovation. When you do not have these [dual-trained] clinicians you really hit a wall as you try to leverage your digital investments. You need people who can bridge the two different camps: IT and clinical.
The NHS has such extraordinary advantages in terms of central structures, scale, and universal coverage. The opportunity to be superb in digital is immense. There is no reason why the NHS should not be the most digitally innovative system in the world.
The opportunity to be superb in digital is immense. There is no reason why the NHS should not be the most digitally innovative system in the world
How do you think the US landscape for digital innovation differs from that of the UK?
At the University of California, San Francisco (UCSF), where I practice, we have 20-25 clinicians who have advanced training in Informatics, and they have significant, compensated roles dedicated to implementing digital innovations.
In an equivalent UK Trust [in 2016], there was only one clinician focused on digital innovation, and often just for one or two days a week. This struck me as a huge gap that needed to be bridged between the clinical and IT workforces. The NHS needs more individuals that have skills that span across both worlds, and can understand the points of view of technologists and clinicians.
In the US, clinicians have a greater predilection to improve things. The spirit of trying something new [amongst clinicians] in the US is greater – there is a better sense that “if we make a good case the money will flow.”
The US has a more pluralistic model with more autonomy within each health system. So there is more risk-taking, more entrepreneurialism and often better clinician leadership.
However, the picture isn’t entirely rosy. The US spends twice what the UK spends but does not achieve better overall care outcomes. The UK guarantees a good level of care to all in an inpatient and outpatient setting. This universal access is a tremendous virtue that we do not share in the US. I felt that the best care in the US is better than in the UK, but our worst care is worse – particularly since many of our patients have no access to any care at all, other than through the emergency department. Our market-driven system allows for more polar outcomes. This is problematic in healthcare.
Our market-driven system allows for more polar outcomes. This is problematic in healthcare
Changing tack slightly as I know you have spent some time guiding the healthcare strategies of Big Tech firms in the Valley, such as Google. What role do you think Big Tech will play in healthcare, and have they learnt from their previous mistakes?
They have tremendous potential. It is a very exciting era as all the tech companies are jumping back in [to healthcare] in a major way.
This is not the first time they have tried their hand at healthcare. In fact, 10 years ago they all tried and failed miserably. But their efforts are very different today. They now know this is a twenty-year play, and that they can’t make a difference in healthcare unless they deeply appreciate how a doctor thinks. So they have hired a lot of doctors and other clinicians.
However, they do not yet fully understand the regulatory environment, the doctor-patient relationship, and the full array of politics and ethical issues. If they do try to enter healthcare without the requisite clinical partnerships they will blow it, as they do not understand well enough how the care delivery process works. They have to partner with healthcare organisations and clinicians if they want to succeed in a major way. I think they have learnt their lesson and will get it right this time.
Being that you oversee a large clinical team in the heart of Silicon Valley, how do you mitigate against people defecting to external opportunities, and what lessons could the NHS learn from this given our own current workforce crisis?
I have had several faculty members leave to become Chief Medical Officers at startups and to Google [amongst other tech firms]. A moderate amount of recruitment of our faculty by outside firms is healthy and exciting – it leads to some connections with tech companies that we could not get otherwise. And these connections often create resources to support our research.
In trying to retain our faculty, there is no way we can match the rate of pay of Silicon Valley companies. If they want the experience of working in the tech world or want to double their salary, there is nothing we can do. So, at UCSF we try to create an environment that is unique, and offers opportunities such as mentoring and training medical students. We give clinicians some freedom to develop innovations without a need to develop a product that has to be monetised [unlike for-profit firms]. They can develop ideas for the sake of discovery, and do so without the burden of making a profit from the innovation.
Even though being in Silicon Valley creates some retention issues, many faculty are attracted to working at UCSF because of the opportunity to partner with these companies.
Finally, as the 2020 US elections draw close what changes would you like to see in the US healthcare system?
In general, a bigger push towards value-based payments. But, we have come to realise that value and quality are hard to measure. It is clear, though, that fee-for-service is not the right way to organise high-quality, safe and efficient healthcare.
In terms of digital innovation, the biggest need is interoperability – the ubiquitous connectivity of all the systems to each other. We need to make it substantially easier for a hospital to bring in a 3rd party tool and link it up to their core enterprise system without spending thousands of dollars of fees to Epic, for example. It is extraordinary that a relatively small company can hold up the connectivity of digital systems. We need a policy solution to this issue.
In terms of digital innovation, the biggest need is interoperability