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Cliff Rutter

The Digital Doctor
The Digital Doctor by Robert Wachter explores the past, present, promises,
and pitfalls of health information technology. On the surface, it tells a story that is
both incredibly fulfilling and frustrating. Dr. Wachter chronicles the medical record
from the classical physicians in Greece to the bloated, undecipherable document it
has become today, and explores an idealistic view of what could be. Ultimately, The
Digital Doctor is a book that should be mandatory reading for new health
Part 1 presents the history of the medical record and describes how the
computerization of healthcare has impacted several facets of the medical world.
Most importantly, health IT has strained the doctor-patient relationship due to a
variety of factors. The record used to be a narrative of the patients course of health
or illness, but has been adulterated into a document to justify billing. This
phenomenon has shifted the focus from patient interactions to completing the note
as completely as possible. EMRs have enabled more thorough documentation, which
in turn has increased the billing efficiency. Two specific chapters that resonated
deeply with me were the iPatient and Radiology Rounds. Primarily, as a part-time
pharmacist, I have a deep understanding of the iPatient, often never seeing an
actual patient during a typical 8-hour shift. I rely heavily on the notes written by the
physicians to determine the actual events that have occurred and the patient
status. The iPatient is complicated by the snapshot of time that the note captures as
physicians often only write one note for the patient each day, regardless of the
days events. For example, the doctor may see a patient at 10 am and write his or
her note at 11 (often a copy and paste of yesterdays note), if the patient has a
significant event (such as a Code Blue or significant decompensation) the doctor
may not update the note or author an interim summary. In the case where no
update is penned, I am really unable to glean what occurred until the next day when
the note is written. The digitization of radiology records was felt during my rotations
during my 4th year of pharmacy school. I distinctly remember the exact conversation
when my ID team interrupted the radiologists to discuss the results of an imaging
study, in which we were told the official read was sufficient as Dr. Wachter
Part two of the Digital Doctor addresses the impending technological
revolution poised to significantly impact medicine. First is the discussion of IBMs
Watson supercomputer and the potential to diagnose patients with artificial
intelligence. Initially, there appears to be a conflict between two groups, one that
believes computers and AI will displace physicians completely and another that
believes that AI has no role in the medical field. However, like most things, the
solution likely lies somewhere in the middle. For example, studies have shown that
computers are noninferior to trained radiologists in reading imaging studies, but the
combination of AI and skilled human interaction was superior to both alone. In a
more basic form of machine learning, pharmacokinetic dosing algorithms that
changed based on the population of data being generated exist. This is important at
large centers that see especially ill patients as the vast majority of data is not
representative of these patients. This system would allow me to more accurately
anticipate drug levels in any given patient and limit the chances of low, or high,
drug levels. The final chapter of this section introduces a catchy idea, Big Data.
While I am a huge proponent of Big Data, or Data Science as Ive seen it coined

Cliff Rutter
more recently, there is a major pitfall Data are stupid. There is no amount of data
that suddenly transforms it into intelligent data. In order to be actionable, data
needs a guiding hand to analyze it and make the best use (whether that hand is
human or digital remains to be seen). For example, the self-quantification
movement is generating massive amounts of sensor data from steps taken per day
to heart rate variability to sleep quality measurements to serum electrolytes
inferred from the sweat of patients. This data is largely untapped as a research tool
but is primed to be analyzed.
Part three revolves around a major preventable medication error in the postEMR implementation era. The swiss cheese model of error is an apt description of
the calamity of horrors that occurred in this case. Some were systematic errors,
such as not implementing a hard stop on major overdoses, while others were user
error, such as the pharmacist verifying the second order. Overall, I feel like this story
exemplifies the problems of over engineering a process. For example, the
requirement to contact a physician to change the order for dosage forms greater
than 5% different than ordered instead of having pharmacy authority to change
introduces a step of potential error that could be avoided. I think I have
demonstrated during discussions that I have a love-hate relationship with EMR
alerts. On one hand, I find asinine alerts to be endlessly infuriating (such as drug
interactions resulting in hyperkalemia when a patient has a severely low potassium,
which a simple IF-THEN statement would fix). On the other hand, I find a lack of
major alerts to be an even worse issue. For example, when ordering medications
that need renal adjustment, an alert SHOULD be generated to insure an appropriate
dose is ordered. Ideally, the alert would provide the patients renal function
calculated in a variety of ways to best represent what the range of estimated values
are possible. In a final step (crazy, I know, asking a computer to do three things at
once!), a renal dosing recommendation could be provided. This alert while initially
daunting, would save time in the long run as all the information needed to make a
sound decision would be present in one alert. One argument I foresee is that people
preparing these alerts are largely programmers, not trained clinicians or
pharmacists. However, EMRs already link to large pharmacy data sources such as
Uptodate or Lexi-Comp (athenahealth even owns Epocrates not the most
reputable source but better than WebMD), so incorporating expert drug information
shouldnt be difficult. These sources even have specific sections for renal dosing of
medications, so the initial alert could scrape that section of the database and
incorporate the EXACT language a pharmacist would look for!
Part four introduces the connected patient idea, which is interesting, but I feel
ultimately that most patients are not interested or capable of using the EMR data as
currently developed. Part five explores the incentives and regulations surrounding
the mass uptake in EMRs in the US. It is important to recognize the economics of
EMR implementation do mirror a public good; however, the data generated and
stored in these systems are not public goods, for a variety of reasons that are
beyond the scope of this paper. One of the most interesting chapters in the entire
book is Chapter 24 Epic and athena, which explores the difference between two
players in the EMR market. Epic is the established entity in EMRs, and is often
perceived as the gold standard for EMRs. Prior to reading this chapter, I admit to a
certain amount of naivety to the business practices of Epic. For example, the
reluctance to work with hospitals with less than 250 beds in interesting, but makes
sense, as building an EMR is time consuming and expensive. One that is troubling is

Cliff Rutter
the rather closed culture that Epic seems to promote, such as limiting the API to few
vendors that are hand selected. This limits the interoperability and may ultimately
slow the sharing of data at a larger scale. In contrast, athenahealth is portrayed as
a small disrupting force in the EMR market. Due to the architecture that the system
is built on, athenahealth is easily shared and quite open to multiple vendors. While
this encourages sharing, I also feel that it may introduce a significant amount of
variation in EMR implementation among different sites. As of now, Epic will continue
to be the driving force for inpatient EMRs as the other offerings are significantly
more clunky and infuriating (SCM and MediTech!) or nonexistent (athenahealth).
Then final section introduces Dr. Wachters idealized future of healthcare, in
which, among other things, computers, physicians, and patients collaboratively
build the medical record to document the patients health (rather than construct an
elaborate invoice). While I agree that his version of the digital health system would
be amazing, he ignores one key aspect that is out of the scope of this paper cost
and who pays for this future.