By MIKE MAGEE

In his book, “The Age of Diminished Expectations” (MIT Press/1994), Nobel Prize winner, Paul Krugman, famously wrote, “Productivity isn’t everything, but in the long run it is almost everything.”

A year earlier, psychologist Karl E. Weich from the University of Michigan penned the term “sensemaking” based on his belief that the human mind was in fact the engine of productivity, and functioned like a biological computer which “receives input, processes the information, and delivers an output.”

But comparing the human brain to a computer was not exactly a complement back then. For example, 1n 1994, Krugman’s MIT colleague, economist Erik Brynjolfsson coined the term “Productivity Paradox” stating “An important question that has been debated for almost a decade is whether computers contribute to productivity growth.”

Now three decades later, both Krugman (via MIT to Princeton to CCNY) and Brynjolfsson (via Harvard to MIT to Stanford Institute for Human-Centered AI) remain in the center of the generative AI debate, as they serve together as research associates at the National Bureau of Economic Research (NBER) and attempt to “make sense” of our most recent scientific and technologic breakthroughs.

Not surprisingly, Medical AI (mAI), has been front and center. In November, 2023, Brynjolfsson teamed up with fellow West Coaster, Robert M. Wachter, on a JAMA Opinion piece titled “Will Generative Artificial Intelligence Deliver on Its Promise in Health Care?”

Dr. Wachter, the Chair of Medicine at UC San Francisco, coined his own ground-breaking term in 1996 – “hospitalist.” Considered the father of the field, he has long had an interest in the interface between computers and institutions of health care. 

In his 2014 New York Times bestseller, “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age” he wrote, “We need to recognize that computers in healthcare don’t simply replace my doctor’s scrawl with Helvetica 12. Instead, they transform the work, the people who do it, and their relationships with each other and with patients.”

What Brynjolfsson and Wachter share in common is a sense of humility and realism when it comes to the history of systemic underperformance at the intersection of technology and health care.

They begin their 2023 JAMA commentary this way, “History has shown that general purpose technologies often fail to deliver their promised benefits for many years (‘the productivity paradox of information technology’). Health care has several attributes that make the successful deployment of new technologies even more difficult than in other industries; these have challenged prior efforts to implement AI and electronic health records.”

And yet, they are optimistic this time around.

Why? Primarily because of the speed and self-corrective capabilities of generative AI. As they conclude, “genAI is capable of delivering meaningful improvements in health care more rapidly than was the case with previous technologies.”

Still the “productivity paradox” is a steep hill to climb. Historically it is a byproduct of flaws in early version new technology, and status quo resistance embedded in “processes, structure, and culture” of corporate hierarchy. When it comes to preserving both power and profit, change is a threat.

As Brynjolfsson and Wachter put it diplomatically, “Humans, unfortunately, are generally unable to appreciate or implement the profound changes in organizational structure, leadership, workforce, and workflow needed to take full advantage of new technologies…overcoming the productivity paradox requires complementary innovations in the way work is performed, sometimes referred to as ‘reimagining the work.’”

How far and how fast could mAI push health care transformation in America? Three factors that favor rapid transformation this time around are improved readiness, ease of use, and opportunity for out-performance.

Readiness comes in the form of knowledge gained from the mistakes and corrective steps associated with EHR over the past two decades. A scaffolding infrastructure already exists, along with a level of adoption by physicians and nurses and patients, and the institutions where they congregate.

Ease of use is primarily a function of mAI being localized to software rather than requiring expensive, regulatory laden hardware devices. The new tools are “remarkably easy to use,” “require relatively little expertise,” and are “dispassionate and self-correcting” in near real-time when they err.

Opportunity to out-perform in a system that is remarkably inefficient, inequitable, often inaccessible and ineffective, has been obvious for some time. Minorities, women, infants, rural populations, the uninsured and under-insured, and the poor and disabled are all glaringly under-served.

Unlike the power elite of America’s Medical Industrial Complex, mAI is open-minded and not inherently resistant to change.

Multimodal, large language, self learning mAI is limited by only one thing – data. And we are literally the source of that data. Access to us – each of us and all of us – is what is missing.

What would you, as one of the 333 million U.S. citizens in the U.S., expect to offer in return for universal health insurance and reliable access to high quality basic health care services?

Would you be willing to provide full and complete de-identified access to all of your vital signs, lab results, diagnoses, external and internal images, treatment schedules, follow-up exams, clinical notes, and genomics?

Here’s what mAI might conclude in response to our collective data:

1. It is far less expensive to pay for universal coverage than pay for the emergent care of the uninsured.
2. Prior algorithms have been riddled with bias and inequity.
3. Unacceptable variance in outcomes, especially for women and infants, plague some geographic regions of the nation.
4. The manning table for non-clinical healthcare workers is unnecessarily large, and could easily be cut in half by simplifying and automating customer service interfaces and billing standards.
5. Direct to Consumer marketing of pharmaceuticals and medical devices is wasteful, confusing, and no longer necessary or beneficial.
6. Most health prevention and maintenance may now be personalized, community-based, and home-centered.
7. Abundant new discoveries, and their value to society, will largely be able to be validated as worthy of investment (or not) in real time.
8. Fraudulent and ineffective practices and therapies, and opaque profit sharing and kickbacks, are now able to be exposed and addressed.
9. Medical education will now be continuous and require increasingly curious and nimble leaders comfortable with machine learning techniques.
10. U.S. performance by multiple measures, against other developed nations, will be visible in real time to all.

The collective impact on the nation’s economy will be positive and measurable. As Paul Krugman wrote thirty years ago, “A country’s ability to improve its standard of living over time depends almost entirely on its ability to raise its output per worker.”

As it turns out, health data for health coverage makes “good sense” and would be a pretty good bargain for all Americans.

Mike Magee MD is a Medical Historian and regular contributor to THCB. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex (Grove/2020).

Bob Wachter has been about as influential an academic doctor as there’s been in recent years. He more or less invented the concept of the hospitalist, he’s been a leader in patient safety, and even dressed up and sang as Elton John at the conference he runs! (He’s also pissed off lots of doctors by being a recent one year chair of the newly controversial and perhaps scandalous ABIM). But for the last 2 years he’s been touring the good and the great of health care and IT to try to figure out what the recent introduction of EMRs at scale has meant and will mean. The resulting book The Digital Doctor is one of this year’s “must reads” and yes we will have Bob as the keynote at this Fall’s Health 2.0 Conference.

The immersion research he conducted was fantastic. Bob interviewed just about anyone you’ve ever heard of and a few you wish you hadn’t (more on that later). And in fact he’s been running interviews on THCB and elsewhere sharing some of the stuff that didn’t get in the book. But I’m still wrestling a little with what I think about the book itself. And I think it’s because I largely agree with him and his angst.

There is lots of wonderful stuff in this book. The change in the role of radiology post PACS, how patients are using open notes, whether Vinod Khosla agrees with Vinod Khosla about algorithms replacing doctors–all this and much more are here. But the book is largely about the introduction of the current generation of EMRs into the everyday practice of ordinary clinicians. There are by and large three camps of opinions about what’s happened.

One is that the EMR is a pox visited on physicians that costs a fortune, has worsened quality, heightened medical errors, blown up successful processes, and ruined the lives of doctors–unless they were given scribes. The second is that because of the “rush to judgement” caused by the HITECH Act and Meaningful Use, we put in EMRs that were based on 1990s client-server technology but they were the only ones mature enough for the job. Most of this camp thinks that they were way better than paper, will slowly improve, and that doctors and patients will find that these technologies will soon integrate with easy to use iPhone-like apps as their APIs open up–and that if we hadn’t mandated EMRs when the great recession gave us the chance, nothing would have happened. The third camp agrees that EMRs are better than paper but felt that the way HITECH was rolled out kept a bunch of dinosaurs in business, and is preventing the health IT equivalent of Salesforce displacing Siebel (or Slack displacing email).

Wachter interviews most of the former ONC Directors and he puts Blumenthal in the second camp and Brailer in the third. He also puts athenahealth’s Jonathan Bush in the third camp, whereas Epic’s Carl Dvorak & Judy Faulkner are (optimistic) members of the second camp.  I think Bob himself is straddling camps two and three. UX expert Ross Koppel and a few other “camp oners”  are interviewed about how EMR vendors know nothing and care less about the user experience, other than they try to prevent anyone from improving it using a variety of dubious legal blocks. But it’s the major story in the book, excerpted in Medium and featured in The New York Times op-ed Wachter wrote, which is squarely in camp one. It’s the harrowing five chapter recounting of how an adolescent at UCSF–Wachter’s own hospital–choked down 38 pills when he was supposed to get two and ended up in a coma. In short the Epic system was trying to handle pediatric and adult meds at the same time. The user interface was too confusing, and the alarms so frequent that physician, pharmacist and nurse all cancelled them out multiple times. Even the (relatively experienced) patient gamely assumed that it had to be right as it was in the system. In fact, Wachter went to Boeing to see how they treat alarms and found that they very rarely interrupt a pilot and when they do, it’s really serious. There’s a telling moment in The Digital Doctor when a nurse knows something is wrong in the ICU because she can’t hear an alarm.

There’s already a mini-meme online beating up Wachter and UCSF (and treating them as one) for poor implementation (see HISTalk here and here) but that doesn’t let Epic or really any of their competitors off the hook. The “camp three-ers” all decry the lack of UX testing and the “camp oners” claim conspiracy–particularly contracts that prevent screenshots or public criticism of technology. I know that at the HxRefactored developer & design conference Health 2.0 ran last year all the major EMR companies present claimed they were in the process of increasing their UX team by a factor of ten. And Wachter did have to get permission from Epic & UCSF to share the screenshots of the drug error (and in fact to publish about it at all).

Despite all this, and several other complaints–like the community clinic doc who can’t hand out her patient education materials that work but aren’t MU certified–Wachter doesn’t want to go back. You get the feeling that he wants to jump to camp three–let’s get it all in the cloud and get rid of the huge client server monoliths we’re putting in. But that would suggest that the EMR cloud was ready in 2008-9 which it probably wasn’t, at least not for complex academic centers–although with the Halamka-Bush alliance it might be soon. But I sense that overall Bob is a little tortured. He (like me) is a believer, but the current pain we have put doctors through is too hard to bear.

Like any tortured soul he flees at the end to Silicon Valley. To be precise he visits the two major centers of “new tech in health care” both within a stone’s throw of UCSF’s new multi-billion dollar Mission Bay campus. And in order to guarantee a lousy review from me, he gave Health 2.0 and me half a paragraph while lavishing 3 pages and a full color spread on Nate Gross at Rock Health. (Heaven knows how much ink Halle Tecco would have got had she been around that day, but for his next book I’ll make Indu Subaiya fly up from Los Angeles!) I did joke with Bob that my review would mostly be about Eric Topol’s new book instead…

All kidding/personal grudges aside, I think that the vision piece at the end (post Silicon Valley chapter) is the most troubling part of the book. As it seems disconnected from the rest and perhaps most unrealistic, given all the issues Wachter already raised. It’s just hard to connect the future we hope to see with the present, especially when the future may be the present, only longer.

But it’s a deeply informative book and it’s destined to be a classic. I just don’t quite know what to think about it, As the subtitle says, there is hope, there is harm and there is hype, and throughout the book it’s hard to tell one from the other. Which–and this is where I agree with Bob–is the truth in health IT as a whole.

 The story of Chesley “Sully” Sullenberger – the “Miracle on the Hudson” pilot – is a modern American legend. I’ve gotten to know Captain Sullenberger over the past several years, and he is a warm, caring, and thoughtful person who saw, in the aftermath of his feat, an opportunity to promote safety in many industries, including healthcare.

In my continuing series of interviews I conducted for my upcoming book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, here are excerpts of my interview with Sully, conducted at his house in San Francisco’s East Bay, on May 12, 2014.

Bob Wachter: How did people think about automation in the early days of aviation?

Sully Sullenberger:  When automation became possible in aviation, people thought, “We can eliminate human error by automating everything.” We’ve learned that automation does not eliminate errors. Rather, it changes the nature of the errors that are made, and it makes possible new kinds of errors. The paradox of cockpit automation is that it can lower the pilot’s workload in phases of flight when the workload is already low, and it can increase the workload when the workload is already high.

If you’re in the cruise portion of a long distance flight, it’s possible to have the airplane programmed to fly a specified vertical and horizontal path for many hours without much intervention at all. That relegates the pilots to the role of monitor, something that humans are not good at. Witness the TSA security agents, who are screening countless passengers looking for that one time in thousands where there’s a threat. Humans are much better doers than monitors.

The other problem with technology is, at least for now, it can only manage what has been foreseen and for which it’s been programmed. So one of the weaknesses of technology is that it has a hard time handling “black swan” events, like our flight.

BW: Why are computers so good in aviation and so mediocre in healthcare?

SS:  I think there are a number of reasons. First we have a long history of putting safety as one of our highest priorities. From the very beginning we’ve known that aviation is an inherently risky endeavor. And, in the media age, we all see the video of the huge orange fireball as the jet fuel explodes. That gives us a sense of urgency.

The second component is that we take a systems approach. We look at it from end to end. We look at connectedness, the interrelatedness of all the things that we do, of the systems and the airplane, the human system, the technology system, and the air traffic control system. So we have to be the absolute master of the machine and all the systems, of the passengers, of the environmental conditions… All simultaneously, all continuously.

And third, we have this formal lessons-learned process that does root-cause analysis, makes findings about fact, causes and contributing factors, and makes recommendations for improving the system in terms of the designs, the policies, procedures, training, human performance, and standards. It’s a self-correcting mechanism.

BW:  In the early days of aviation, was there an overarching philosophy about the relationship between the people and the machines?

SS:  Yes. That the pilot should absolutely be informed about everything going on in his or her aircraft, and ultimately able to affect the outcome, to change it, to control it.

BW:  So the pilot would be in charge?

SS:  Always be in charge.

I asked whether there was another camp in aviation – folks who believed that the technology could, and should, fly the plane.

SS: Airbus was, and still is, different than Boeing in their automation philosophy. Airbus tended to embrace letting the airplane do a lot of things, where Boeing’s philosophy was that the pilot is and should be in control of every part of the process. For example, Airbus would set hard limits in the digital flight control system laws, the fly-by-wire laws that would prohibit the pilot from exceeding certain limitations in how fast or slow the airplane could fly, how steeply it could bank, how many degrees you could tilt the angle of the wing from horizontal or raise the nose above horizontal. Whereas Boeing takes the approach that there are rare occasions where, to avoid colliding with another airplane or crashing into the ground, you need to pull harder than the flight control system might otherwise allow. I tend to favor having the pilot directly and completely in control of the airplane. The downside of that is that every pilot has to be trained well, be highly experienced, and have a deep understanding of airplanes and how they work.

BW:  But you had that experience because you had a whole career before all of this technology. How does a young person get that? And how do we prevent the erosion of skills as the technology gets better?

SS: As we use the technology more and more – and we’re encouraged to do so by our airlines because it’s so efficient – then we get the sense that it’s almost infallible. And, because we haven’t done much manual handling of the airplane, we lose confidence in our ability to manually control the airplane as well as the automation can. That sometimes makes some pilots reluctant to quickly and effectively intervene when they see things going wrong or when the automation isn’t doing what they expect.

BW:  Is the solution forcing them to fly manually more of the time?

SS:  Yes. We have to design our systems to require our engagement. We cannot design a system that’s so hands off that we are simply required to sit there and watch it for 14 hours. That’s simply not going to work.

Another piece of the problem is that our systems should offer more options than all or nothing. I’ve been proposing an a la carte menu, with increasing or decreasing levels of technology they can use. The only question we have to ask ourselves is what level of technology is most appropriate for this phase of flight. The answer is the one that keeps us engaged and aware and able to quickly and effectively intervene, and also keeps our workload neither too high nor too low.

We turned to January 15, 2009, the day Sully safely landed an Airbus A320 on the Hudson River, within a few minutes of a bird strike that disabled both the plane’s engines.

SS: What happened to us was a very rare event. And it happened late in my career, after I’d been an airline pilot for 29 years, a captain for 21 of those. In all that time, 42 years of flying, I had never experienced in flight the actual failure of even a single engine. That’s how reliable our propulsion technology is. And, in all that time I had never been in a situation in which I had doubted the outcome of a flight. I had never been challenged by a situation that I didn’t think I could handle.

BW:  Is there a strange part of one’s brain that says, “I hope that something like that would happen because I’ve been training for it my whole life”?

SS:  No.

BW:  Is that too crazy?

SS: No, it’s not, because it happens a bit in combat. I served in the Vietnam era but I was never in combat. I always wondered if I would have been up to the challenge. I think it’s just natural when you train for that to wonder: Would I be brave enough? Would I be resilient enough? Would I be a good enough leader? Would I be clever enough, strong enough to complete the mission and keep the people I was responsible for safe? I was prepared never to know the answer to that question. But I always wondered about it.

But in the airline world, it’s different. Our job is to make it calm and predictable. We make it look easy. We work so hard to plan and anticipate and have alternatives for every course of action.

And so on this flight, just 100 seconds after takeoff, I saw the birds about two seconds before we hit them. At that point we’re travelling at 316 feet per second, and there was not enough time or distance to maneuver a jet airplane away from them. It was like a Hitchcock film. I saw the birds fill the windscreen, I could hear the thumps and thuds as we struck them. And as the birds entered the center of both jet engines and began to damage them, I heard terrible noises I’d never heard before, severe vibrations and then within seconds, the burning smell came into the cabin.

We had a great advantage in that there was no ambiguity. I knew what the cause was and what that entailed, what that meant for us, and I knew it was going to be, after such a routine career, the challenge of a lifetime. Yet it was such a sudden shock, the startle factor was enormous. I could feel my blood pressure shoot up, my pulse spike, my perceptual field narrow. It was really distracting, and it was marginally debilitating. It absolutely interfered with my cognitive processing. It didn’t leave me with the ability to do the math on altitude and distance.

I had to do three things that, in retrospect, made the difference. First, I had to summon up from somewhere within me this professional calm that really isn’t calm at all. It meant having the discipline to compartmentalize and focus on the task at hand in spite of the stress.

Second, even though we had never trained for this, because I had such a well-defined paradigm in my mind about how to solve any aviation emergency, I was able to impose that paradigm on this situation and turn it into a problem that I could solve.

Finally, because of the extreme workload and time pressure I knew that there was not time for me to do everything I really needed to do. I chose to do the most important things, and try to do them very, very well. And I had the discipline to ignore everything else that I did not have time to do. Calming myself, setting clear priorities, managing the workload, load shedding… those were the key.

BW:  Did you do all that consciously, as in: “Here are all the things one might do, but here are the six that I’m going to do?” Or was it all instinct?

SS: I would say that I was able to quickly synthesize a lifetime of training and experience and intuitively understand that that was the approach I needed to take. It was partly a result of my military flight training, from being a fighter pilot. It was all very intuitive. Fly the airplane first. Make good choices. Pick the best place to land. That sort of process.

But I immediately did two very specific things that I remembered from the dual engine flameout checklist. I turned on the engine ignition so, if the engines could recover thrust, they would. And I started our aircraft’s auxiliary power unit, which is a small jet engine, a small turbine that has its own electrical generator. In a fly-by-wire airplane like the Airbus, it’s especially important to have an uninterrupted supply of electrical power because the plane does not have a mechanical, wires and pulleys connection between the flight control stick or wheel in the cockpit and the flight control surfaces on the wings and tail. Instead the pilot’s inputs are interpreted and mediated by flight control computers, which send electrical impulses to actuators that move the flight control surfaces of wings and tail. And that requires electric and hydraulic power.

Without that power, our systems and our information displays would have degraded. And the power also allowed us to keep intact all the flight envelope protection, which prevented us from getting too fast or too slow or banking too steeply.

As we’re heading toward the water, I’m the one controlling the airplane, but my first officer, Jeff Skiles, is monitoring the performance of the airplane and my performance. I didn’t have time to tell him how to help me. Right before landing he intuitively understood that he needed to help me judge our altitude. And so he stopped trying to use the checklist to regain thrust from what turned out to be irreparably damaged engines and he began to call out to me altitude and airspeed. You’re 200 feet, you’re 100… that kind of stuff. And if I had misjudged that height by even a fraction of a second – I might have raised the nose too early, got too slow, lost lift and then dropped it in hard. If I waited too long we would hit nose first way too fast with too great a rate of descent and that could be very bad.

And even though I was not at the minimum speed at which the Airbus flight control protections would have prevented me from raising the nose further no matter how hard I pulled, there was a little-known feature of the Airbus software – that no airline pilots, no airlines knew about, only a few Airbus engineers knew about – that prevented me from getting that last bit of maximum aerodynamic performance out of the wing. This was discovered very late in the investigation.

BW:  You didn’t perceive it?

SS:  Well, I’m not sure.

BW:  You had other things on your mind.

SS:  I wasn’t sure. But it turns out at the end I was not quite at the maximum angle the wing could be allowed to try to create lift. And yet even though I was pulling back, commanding full nose up on the side stick, the flight control computers prevented me from getting any more performance. That was something the investigators debated.

BW:  It’s interesting that you spoke about how you were glad you were in this automated envelope of protection. I might have guessed that you would have wanted at that moment to be completely off cruise control and have total control yourself?

SS:  Well, it’s not at all cruise control. The automation was not flying the defined path for me. But it put guardrails out there. So it kept me from making a gross error. It kept me from stalling the airplane.

BW:  So you were happy that it was there at that moment?

SS:  It was not something I consciously thought about but it was a good thing to have the airplane be fully operational. But it turned out that because of this little known aspect of the flight control system, we hit a little bit harder than we would have had we been able to get that last little bit of lift out of the wing right before we landed. The NTSB recommended that the airlines teach the pilots about this feature, because we didn’t know about it.

I asked Sully what lessons he drew about the relationship between people and machines from the Hudson landing?

SS:  I don’t think there’s any way that technology could have done what we did that day.  Absolutely no way.

BW:  You can’t envision a future in which the engineers have built in a “both engines fail” mode and the technology perceives it and starts doing X and Y?

SS:  I think that would be possible, but then that doesn’t take into account the whole divert decision. About where your flight path is going to intersect the earth’s surface in 208 seconds. And someone would have had to have anticipated this specific circumstance, this particular black swan event and programmed it to do that.

Theoretically, maybe technology could do some of these things. But to handle the whole thing from start to finish required a lot of innovation, a lot of – it required us to take all the things that we had learned, adapt it, apply it in a new way to solve a problem we never anticipated and never trained for and get it right the first time. In 208 seconds.

BW: I can’t help but think that one of the riskiest things about technology is that it seems inconceivable that a young pilot today will have your skills and instincts, because they’ve grown up in such a different environment.

SS:  And that’s another great challenge – we have to find a way to pass on this institutional knowledge. And not just the what, but also the why. You see pilots of my generation, especially ones who have wanted to fly since we were five years old – we just couldn’t get enough. We couldn’t learn enough about the history of our profession, about historic accidents, about why we do what we do. Because almost every procedure we have, almost every rule in the Federal Aviation rulebook, almost every bit of knowledge we have is because someone, somewhere died. Often many people did. And so we have learned these important lessons at great cost, literally bought with blood. We dare not forget and have to relearn them.

Sully then discussed the 1989 landing of United Flight 232 in Sioux City, Iowa, after a catastrophic engine failure severed all of the DC-10’s hydraulic systems, rendering the plane’s flight controls completely inoperable. A pilot named Al Haynes and his crew miraculously conjured up a system of using differential thrust to control the plane sufficiently to save 185 of the 297 people on board.

SS: I remember having that radio communication back and forth with Patrick Harten, the air traffic controller. I said to Patrick, “I’m not sure we can make any runway. We may end up in the Hudson.” At that moment, I was thinking, that’s just like what Al Haynes said when the air traffic controller at Sioux City said –

BW:  Did Sioux City actually cross your mind at that moment?

SS:  Yeah, I thought about that flight, because at one point as they were approaching the Sioux City airport, the controllers want to give you the widest discretion they can to solve the problem any way you think is possible. And there were multiple runways of different directional orientations at Sioux City. The controller said to Haynes, “You’re clear to land on any runway.” At that point the control of the airplane was still so tenuous that Al said, almost laughing, “You want to be particular and make it a runway, huh?” And that thought – of Al’s comment – crossed my mind.

And so, yeah, we have to pass on this knowledge.

The policy known as Meaningful Use was designed to ensure that clinicians and hospitals actually used the computers they bought with the help of government subsidies. In the last few months, though, it has become clear that the policy is failing. Moreover, the federal office that administers it is losing leaders faster than American Idol is losing viewers.

Because I believe that Meaningful Use is now doing more harm than good, I see these events as positive developments. To understand why, we need to review the history of federal health IT policy, including the historical accident that gave birth to Meaningful Use.

I date the start of the modern era of health IT to January 20, 2004 when, in his State of the Union address, President George W. Bush made it a national goal to wire the U.S. healthcare system. A few months later, he created the Office of the National Coordinator for Health Information Technology (ONC), and gave it a budget of $42 million to get the ball rolling.

The first “health IT czar,” David Brailer, focused on convening stakeholders, banging the drum for computerization, and creating standards for health IT. The seemingly arcane matter of standards turns out to be crucial, since only through a common language and protocols could computer systems have any shot at sharing data with one another (“interoperability,” in IT-speak). This is not a new issue in the world of technology: a protocol known as TCP/IP was central to the success of the Internet. And standards are why your light bulbs and electrical plugs fit into their respective sockets when you bring them home from the hardware store.

Brailer did what he could with $42 million, but – when you think about trying to change the course of the $3 trillion dollar a year U.S. healthcare system – there was only so much he could do. Within five years, however, the ONC’s budget received an injection of new resources, and not a small one: from $42 million to $30 billion. The story of how that happened is an amazing blend of happenstance and opportunism.

In 2008, when Congress passed a $700 billion stimulus package to rescue the economy, it chose to spend the money on “shovel-ready” projects – those whose plans were on the drawing board. Tucked among the highway construction and railroad repair jobs that were funded was a project of a different sort: $30 billion to help the American healthcare system go digital.

Policymakers, concerned that doctors and hospitals might buy the computers with federal money and not use them, attached a very big string to the money: a set of criteria that IT vendors and those buying IT systems needed to meet to quality for the federal bucks. These criteria became known as Meaningful Use.

Let’s take a deep breath and review the state of the universe, circa 2009 – particularly in light of what we know today: that Meaningful Use has become the most controversial, even vilified, policy initiative in the health IT world, perhaps in all of health policy (okay, maybe second to Observation Status and the SGR). In 2009, very few people would have argued that it was a good idea to create a detailed set of government regulations dictating how doctors and hospitals should build and use their electronic health records. But that is precisely what MU has done. Some slopes are, in fact, slippery.

And yet, putting myself in the place of the 2009 decision-makers, I don’t see any villains, or even any particularly egregious blunders. It’s just that things have gone off the rails, which is why we now need to change course.

Okay, back to 2009. The first question: Was it a good idea to use federal money to promote health IT? My answer is yes. In 2008 only about 10 percent of hospitals and doctors’ offices had electronic health records. As long as Congress was spreading $700 billion of federal fertilizer around to stimulate the economy, why not use some of it to rectify this market failure? I think the health IT incentives were sound policy.

Second question: Did we need a set of standards to accompany these incentives? Here, too, my answer is yes. There had been earlier initiatives, mostly by private insurers, in which doctors were given “free” computers and simply put them on their shelves. That, of course, would have been scandalous when scaled up to federal size. So Meaningful Use, as a policy, made sense.

The third question reflects the common complaint that the federal incentives drove the purchase of “immature IT systems” – and that we should have waited until the systems were more mature. Here, too, I’m unpersuaded. A program with a longer timeline would likely not have met the shovel-ready requirement. Moreover, the vendors had been working on their EHRs for decades (Epic was founded in 1979); a couple of years’ delay wouldn’t have gotten the systems any closer to perfection. The only way that health IT was going to get better was to implement the best systems and improve them, guided by insights born of real-life experience.

So, given these facts on the ground in 2009, I believe the policy decisions were sensible. And for a while, everything went pretty well. Meaningful Use Stage 1, implemented in 2010-12, consisted of achievable standards designed to ensure that EHRs were being used effectively. But it was not so prescriptive as to stand in the way of the primary goal, namely, wiring healthcare. Adoption rates soared and MU ensured that the computers were being used.

With Meaningful Use Stage 2 (2012-present), things went sour. The standards became far more aggressive, veering far more deeply into the weeds of clinical practice. MU now dictated how doctors should give out handouts to their patients (they must be prompted by the computer). It held doctors and hospitals responsible for ensuring that patients viewed and transmitted their data to third parties (most patients had no idea how to do this). It forced EHRs to meet onerous disability access requirements. All of these are noble goals, but all are bells and whistles – the kinds of changes you make after you’ve nailed the basics of getting the darned machines to work safely and efficiently. I spent a morning in June watching Christine Sinsky, a primary care doctor in Dubuque, Iowa and an expert in practice redesign, struggle to survive the regulations. While the ONC’s goals were laudable, she said, meeting the MU requirements had become “like [solving] some riddle or puzzle. Life is hard enough. Why are we making it so much harder?”

This July, Karen DeSalvo, the director of ONC, told me that her office was looking to scale back the MU regulations. Jacob Reider, ONC’s deputy director, using a delicious euphemism, also conceded that the MU Stage 2 requirements were overly “enthusiastic.” While I appreciated the forthrightness of the ONC leaders, I wondered whether they would achieve their goal. After all, scaling back is not among the core competencies of government bureaucracies.

In the past month, both DeSalvo and Reider left ONC. DeSalvo is now the acting Assistant Secretary of Health, taking a leading role in the Ebola response (after announcing she was leaving ONC, the Department of Health and Human Services clarified that she’ll still be involved in its policy decisions, though will no longer have day-to-day management responsibility). Reider simply resigned. In the past six months, in fact, more than half of ONC’s senior personnel – its chief scientist, chief nursing officer, chief privacy officer, and director of consumer eHealth – have jumped ship.

Why? The last of the $30 billion will be spent by the end of this year. While it would appear that ONC will lose its power of the purse, it’s not that simple – the plan has been that, starting next year, rather than receiving a bonus for implementing an EHR that met MU standards, doctors and hospitals would begin seeing Medicare cuts if they didn’t meet them. But with Medicare already slashing payments through a variety of other mechanisms (value-based purchasing, no pay for errors, readmission penalties and the like), many people think that it won’t have the stomach to penalize hospitals and doctors for failing to meet the increasingly unpopular MU standards.

Unpopular is an understatement – the Meaningful Use program has clearly lost the hearts and minds of clinicians and CIOs. As of this month, only two percent of eligible physicians and about one in six hospitals have successfully attested to MU2 requirements. Even former supporters have taken to calling the program Meaningless Abuse. Not good.

In the face of all these challenges, ONC appears adrift, stripped of its resources as it tries to administer a failing program. It’s no surprise that its leaders are rushing the exits.

What should become of ONC and Meaningful Use? The key thing to remember is that MU was an accidental program – one that never would have happened had the economy not tanked in 2008. So rather than trying to salvage it by tinkering around its edges, it is time to rethink the whole shebang. In this, I agree with John Halamka, the Chief Information Officer at Beth Israel Deaconess Hospital and the chair of several HIT policy committees, who believes that ONC should “declare victory” and markedly pare back Meaningful Use.

Declaring victory would not be unreasonable. Against the primary goal of wiring the American healthcare system, ONC’s program worked – the number of hospitals and doctors’ offices with functioning EHRs skyrocketed from 10 percent in 2008 to approximately 70 percent today. The health IT market is far more vibrant than ever before. Even Silicon Valley – which has always given healthcare a cold shoulder – has now joined in the fun, with major health IT initiatives at Apple, Google, Salesforce, Microsoft, and in garages all over San Francisco.

Rather than continuing to push highly prescriptive standards that get in the way of innovation and consume most of the bandwidth of health IT vendors and delivery organizations, MU Stage 3 should focus on promoting interoperability, and little else. Last month, an expert panel presented ONC with a reasonable set of recommendations calling for standardized, publicly available application programming interfaces (APIs), the EHR version of standardized light sockets. This change would allow EHRs to communicate with each other and developers to write apps that could link to the large systems like those built by Epic and Cerner. Promoting this kind of interoperability would be a judicious role for a smaller, less muscle-bound ONC, and for MU Stage 3.

Ending the prescriptiveness of MU doesn’t mean abandoning the goal of using EHRs to improve healthcare. Now that the vast majority of U.S. hospitals have EHRs, the stage is set to promote the outcomes we care about through Medicare’s existing programs – without micromanaging the technology. When Medicare publicly reports adherence to evidence-based practices, hospitals with health IT systems will install decision support to meet those standards. When Medicare penalizes hospitals for excess readmissions, hospitals will create electronic links to primary care clinics and nursing homes. When Medicare ties patient satisfaction to hospital payments, healthcare system will offer their patients access to laboratory results, x-rays, and on-line scheduling, to say nothing of email and telemedicine access to clinicians. When ACOs live or die based on their efficient use of resources, they will implement computer systems that help them conserve resources. It is the outcomes we care about, and hospitals and doctors should be free to use whatever IT tools (or other non-IT strategies) to achieve those outcomes. That’s the best path forward.

By the end of this decade, I believe we will look back on the 2009-2014 era and see government intervention – particularly the $30 billion incentives and the early years of Meaningful Use – as having helped transform medicine, finally, into a digital industry. As our IT systems get better and our processes and culture adapt, this transformation will end up improving patient care and, eventually, saving money, notwithstanding our rocky start.

So today, even as we struggle with Meaningful Use, let’s praise the government for knowing when to intervene. Let’s hope that tomorrow, we can praise it for doing something far harder: knowing when to stop.

* * *

Note to THCB readers: Bob has spent the last eight months writing his book, “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age.” It is done (and the early feedback has been gratifying) and will be published by McGraw-Hill in the spring. (You can pre-order it now on Amazon if you’d like.)

I’m just back from the annual meeting of the Society of Hospital Medicine and, as usual, I was blown away. I’ve not seen a medical society meeting that is remotely like it.

As Win Whitcomb, who co-founded SHM, wrote to me, the meeting is “a mix of love, deep sense of purpose, community, mission, changing-the world, and just plain sizzle,” and I completely agree. I was also amazed by the size: having hosted the first hospitalist meeting in 1997, with about 100 people, seeing an audience of 3,600 fill a Las Vegas mega-ballroom was just plain awesome.

This enthusiasm did not equal smugness. Folks know that change is the order of the day, and with it will come upheaval and some unpleasantness. But the general attitude I sensed at the meeting was that change is likelier to be good for patients – and for the specialty – than bad. Whether this will ultimately be true is up in the air, but the mindset is awfully energizing to be around.

Here, in no particular order, is my take on a few of the issues that generated hallway buzz during the SHM meeting.

The Closing of Hospitals

While much is uncertain in the era of health reform, the number of hospitals is clearly going to shrink, perhaps by a lot. A healthcare system that tolerated the inefficiency of having two mediocre 125-bed hospitals in adjacent towns will no longer do so: one 200-bed hospital will be left standing when the dust settles.

If that.

The betting is that 10-20% of hospital bed capacity will be taken out of the system in the next few years. It could be even more, depending on the answers to several questions. Will electronic monitoring and telemedicine allow increasing numbers of sick patients to be cared for at home or in sub-acute settings?

Will payments for non-hospital care (home care, SNFs) be enough to expand their capacity to care for acutely ill patients?

Will ACOs, bundling, and other similar interventions truly flourish? Will a shift to population health and a new focus on wellness make a dent in the prevalence of chronic disease?

These are just some of the known unknowns.

What does this mean for hospitalists? Obviously, if you happen to work at a hospital that closes, you may be out of a job. But pick up a copy of the NEJM or the Journal of Hospital Medicine: there are still far more openings for hospitalists than there are people to fill them.

Although I’m expecting few if any unemployed hospitalists, there will be change: hospitalists will be working in fewer buildings, they’ll be working a bit harder, and the hospitals that do stay open will be more efficient.

Out of the ferment will come new opportunities for hospitalists. I’m on the board of IPC, the largest hospitalist company in the U.S. Several years ago, the company recognized that many patients who used to be in the hospital were now in sub-acute settings. Today, nearly one-third of IPC’s clinicians work in SNFs and long-term care facilities.

I suspect that some of the hospitalists displaced by hospital closures will find work in these kinds of settings – and these will not be your father’s SNFs. The level of patient acuity may be similar to that of hospitals a decade ago.

In addition to closures, we’ll see plenty of mergers and affiliation. I’m also on the board of Salem Hospital in Oregon, a terrific, mid-sized hospital that is – to a large degree – the only game in town for Salem, a mid-sized city with a population of about 160,000. The hospital is well run: we have had computerized order entry for a decade, have been running a robust physician leadership academy since 2009, and adopted Lean well before it became fashionable.

The hospital enjoys a healthy bottom line and significant reserves. Yet in the current environment, it was the judgment of the leadership and the board of directors that we could not go it alone. We announced last month that we are in talks with Oregon Health Sciences University (OHSU) to affiliate.

And at home, UCSF just merged our children’s hospital with Oakland’s. For those of us working in or running hospitalist programs, these new relationships are likely to mean significant change. In a three-hospital system with 100 hospitalists, I doubt there will be three different leaders and three independent programs.

Sorting out the relationships, the money, the schedules, and the culture will offer a new and complex challenge to those of us who have had the luxury of managing a single program in a single building.

Hospitalist Workload and Support

Last month in JAMA Internal Medicine, researchers at Christiana Health in Wilmington, Delaware correlated hospitalist workload with both quality and efficiency outcomes. Their findings were striking: when hospitalists ran censuses of more than 15 patients, for each additional patient, costs per case went up by $262.

These increases varied a bit depending on how full the hospital was, but no matter how full the building, the relationship held.

As I noted in an accompanying editorial, this study is important for several reasons. First, it illustrates a point that I’ve made since the early days of the field (but without much evidence to support it, until now): there must be a workload above which some of the advantages of the hospitalist model – on-site presence, constant availability – begin to erode. Just think, if you’re managing 20 patients and you spend 15 minutes seeing (and charting on) each patient, you won’t get to your last patient till well after noon.

And if a couple of patients get sick… well, the ballgame is over. I’ve frequently counseled hospitals that were considering supporting hospitalist programs that it might be in their financial interest (i.e., there might be an ROI) to do so if their dollars helped the physicians maintain a manageable census – independent of any advantages gained in recruiting, retention, and allowing hospitalists time to work on systems improvement.

The reason this is important is that, as hospital budgets tighten, hospital support payments to hospitalists will come under increased scrutiny. In primary care, the lack of evidence that bad things happen (other than physician burnout and patient unhappiness) when visits shorten to 14 minutes meant that there were no compelling counterarguments to briefer visits.

For hospitalists, the Christiana study creates such a counter argument.

Will this mean that hospitalist support payments will go unchallenged? Hell, no. IPC has grown to become the biggest player in the hospitalist staffing business in part because the majority of its programs do not receive significant hospital support (let me remind you again of my conflict here).

They do this by running programs efficiently, by billing effectively, and by employing a schedule that has people work more days per year than hospitalists do under the more common and very popular 7-days-on/7-days-off structure. Although IPC hospitalists have had a reputation of carrying large caseloads, I’ve seen the data and I know that their average census is, in fact, about 15.

The point here is that, just as hospitalists took over the world of hospital care because they demonstrated that they could provide high-quality care at a lower cost, the increasing financial pressures that hospitals are under will create, in turn, pressures on hospitalist programs to achieve quality, safety, patient satisfaction, and efficiency outcomes at the lowest possible cost to the hospital.

In this environment, every program needs to be looking at its caseload and outcomes to defend any support payments it gets. The Christiana study provides a strong argument that those support payments may be cost effective if they allow a hospitalist group to maintain market-appropriate salaries while keeping volumes manageable.

Also, the paper was important in that it is one of the first to look at the relationship between physician volume and outcomes, in any specialty. Such studies are familiar in nursing, and have led to major policy changes. In California, for example, nurse-to-patient ratios are mandated to be no more than 1:5 on med-surg floors, in part based on such studies.

But physicians have always had a Super Doc attitude: That they could see any number of patients and nothing bad happens. This defies the laws of both physics and physiology, and I hope the Christiana paper ushers in studies of other fields asking the question: what physician volume maximizes value.

There is another point about hospitalist organization that is worth paying attention to. The latest American Hospital Association data show that there are more than 40,000 hospitalists in the U.S. As the fastest growing specialty in modern medical history, it’s easy to think that the field has “won” and is safe from competitive threats. But with so much change afoot, such thinking is dangerous.

My friend David Meltzer of the University of Chicago is testing a model of comprehensive care – in which a select group of high risk, frequently admitted patients are cared for by a single physician in both the inpatient and outpatient setting. Sound familiar? It should: that’s the old system! Meltzer’s early results, presented at SHM and elsewhere, are promising.

Some people have asked me, given my advocacy for the hospitalist field, whether this bothers me. If it did, I’d be a hypocrite. The reason the hospitalist field thrived was that it demonstrated that it delivered better value than traditional models. But it is a completely plausible hypothesis that – for a subset of patients – the continuity of the old model might win out, particularly if these comprehensive docs are advantaged by the on-site presence of hospitalists (for nighttime coverage or if their patients crump acutely) and by the latter’s work improving the system of care.

So I applaud David and his colleagues for testing this model in the 5-10% of patients who might benefit from it. We must always stay open to the idea that there are better ways of doing things.

Leadership and Burnout

At the meeting, I was also struck by the degree to which hospitalists have emerged as leaders in systems of care, a point made nicely in a recent article in The Hospitalist. During the week, I saw plenty of hospital CMOs, CQOs, and even a few CEOs – such as Brian Harte, my former trainee who now leads one of the Cleveland Clinic’s major sites, and Pat Cawley, the former SHM president who runs the Medical University of South Carolina’s hospital.

On the national scene, it is no coincidence that Medicare’s top physician (Pat Conway) and the nominee for Surgeon General (Vivek Murthy) are both hospitalists. The field’s focus on improving value, systems of care, teamwork, and collaboration; its natural integration with hospitals; and its breadth (who else knows how things really work on medicine, in the ED, in the ICU, and on surgical services?) make us a training ground for leaders.

At UCSF, the medical center’s lead physicians for quality, patient experience, cost reduction, and IT are all hospitalists.

Interestingly, there is another thing driving the push toward hospitalist leaders, and that is less positive. Burnout from clinical work – which was remarkably low in the old days – is a growing threat.

A recent study found rates of burnout rivaling that seen in the angst-ridden field of primary care – not a benchmark we should be aspiring to.

Of course, some of this was inevitable, as the early novelty of the field began to fade. The buzz at SHM convinces me that it hasn’t entirely worn off (at least for the segment of the field that attends the meeting), but a 45-year old hospitalist doing 12 hour shifts of 7 days on, 7 days off is going to begin feeling it in his or her bones.

While the movement to leadership and administrative roles is fantastic, it should also make us ask whether the jobs we’ve created are truly sustainable.

Although the evidence of burnout is a concern, overall I continue to be wowed by the energy and enthusiasm of the hospitalists I meet. The field has – at least so far – managed to resist the temptation to become overly protective of turf, cynical, soulless, or humorless. Seeing the young people in the field is remarkably energizing.

* * *

An SHM postscript: for the past ten years, I’ve been asked to give the conference’s closing address. This is both a great privilege and a growing challenge – the latter since it’s awfully hard to remain fresh after a decade of talks. From time to time at family events, I rewrite the lyrics to a song and sing and accompanying myself on the piano.

I’m a decent piano player and an enthusiastic crooner, and, playing to a home crowd lubricated by bonhomie and prosecco, it usually goes pretty well. A friend heard me do such a song at my own wedding and suggested that I consider something similar at SHM. Well, one thing led to another – the meeting being in Vegas and all – and the next thing I knew, I was opening a FedEx box from Candy Apple Costumes (“Deluxe Rocket Man Costume,” $69.99), which consisted of glittering jacket, white pants, blonde wig, and star-shaped glasses.

I should have realized that this Elton John outfit was sized for a lanky teenager headed for a costume party, not a 56-year old man with a paunch. But after the costume arrived, it seemed too late to turn back.

Pre-meeting, I planted a few cryptic tweets about an “unforgettable finish,” but, with the help of the stellar SHM staff, I managed to keep my plan a secret. After my 40-minute closing address, I left the stage and did a frantic backstage makeover. SHM CEO Larry Wellikson introduced a special guest, “Dr. Elton John,” and there I was. The result is here. I’m pretty sure the standing ovation I received was for chutzpah rather than talent, but I’ll take it.

Robert Wachter, MD, professor of medicine at UCSF, is widely regarded as a leading figure in the patient safety and quality movements. He edits the federal government’s two leading safety websites, and the second edition of his book, “Understanding Patient Safety,” was recently published by McGraw-Hill. In addition, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine and is the former chair of the American Board of Internal Medicine.  His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.

A few weeks ago, a middle-aged man decided to tweet about his mother’s illness from her bedside. The tweets went viral and became the subject of a national conversation. The man, of course, was NPR anchorman Scott Simon, and his reflections about his mother’s illness and ultimate death are poignant, insightful, and well worth your time.

Those same days, and unaware of Simon’s real-time reports, I also found myself caring for my hospitalized mother, and I made the same decision – to tweet from the bedside. (As with Simon’s mom, mine didn’t quite understand what Twitter is, but trusted her son that this was a good thing to do.) Being with my mother during a four-day inpatient stay offered a window into how things actually work at my own hospital, where I’ve practiced for three decades, and into the worlds of hospital care and patient safety, my professional passions. In this blog, I’ll take advantage of the absence of a 140-character limit to explore some of the lessons I learned.

First a little background. My mother is a delightful 77-year-old woman who lives with my 83-year-old father in Boca Raton, Florida. She has been generally healthy through her life. Two years ago, a lung nodule being followed on serial CT scans was diagnosed as cancer, and she underwent a right lower lobectomy, which left her mildly short of breath but with a reasonably good prognosis. In her left lower lung is another small nodule; it too is now is being followed with serial scans. While that remaining nodule may yet prove cancerous, it does not light up on PET scan nor has it grown in a year. So we’re continuing to track it, with crossed fingers.

Unfortunately, after a challenging recovery from her lung surgery, about a year ago Mom developed a small bowel obstruction (SBO). For those of you who aren’t clinical, this is one of life’s most painful events: the bowel, blocked, begins to swell as its contents back up, eventually leading to intractable nausea and vomiting, and excruciating pain. Bowel obstruction is rare in a “virgin” abdomen – the vast majority of cases result from scar tissue (“adhesions”) that formed after prior surgery. In my mother’s case, of course, we worried that the SBO was a result of metastatic lung cancer, but the investigation showed only scar tissue, probably from a hysterectomy done decades earlier.

The treatment for bowel obstruction is to place the bowel at rest (“NPO”) and to suction out the contents of the stomach through a nasogastric (NG) tube, which decompresses the GI tract and decreases the pain and distension. And then you wait. Many SBOs will open up on their own, but those that don’t after a reasonable waiting period (4 to 7 days, generally) require surgery. Mom’s first obstruction didn’t open up, and a mercifully uncomplicated laparoscopic procedure successfully cut the fibrous band that was kinking the bowel (“lysing the adhesion”), relieving the obstruction.

Unfortunately, she had two more cases of SBO in the next year; these resolved after 3 to 5 days of bowel rest without surgery. We hoped we had seen the end of it, but we hadn’t: on a visit last month to the Bay Area to see my sister and me, my mother developed another SBO, a few hours before getting on the plane to Florida. Her pain began slowly, but within an hour she was in agony, retching, sweating and literally shaking. (By the way, nothing prepares adult children to see their parents in this much distress; it seems so very wrong, the world turned on its head. One of Scott Simon’s tweets captured my feelings: “I wish I could lift my mother’s pain & fears from her bones into mine.”) I took her to UCSF Medical Center’s emergency department. The next day, I sent my father – who is becoming a bit frail and whose presence by the bedside of his wife of 59 years was likely only to make everyone more anxious – back to Florida.

I’ve “eaten at my own restaurant” many times before: my two sons were born there, I’ve had surgery there, and I’ve accompanied family and friends to a dozen or so ED visits over the years. But being there with Mom somehow felt different: first of all, it was my mother; second of all, her hospitalization was likely to last several days (culminating in either resolution of the SBO or surgery), with brief periods of excitement punctuating long periods of waiting. This offered me the chance to soak in the processes and the culture. Here are six lessons I drew from my observations:

Chokepoints: One of the key principles in “Lean thinking” is to identify steps in a care process that don’t add value. Within a few minutes in the ED, I found a doozy. There was little question that Mom was having another bowel obstruction and, just as clearly, was going to end up with an abdominal CT scan. The scan has become trivially easy to do: there’s a scanner in the ED, and the test now takes about 10 minutes to complete. Blood tests were drawn and some results, such as the CBC, returned quickly. A few minutes after the blood was sent to the lab, the radiology tech arrived to obtain a chest x-ray and KUB (two different x-rays). Why did she need these, I wondered, when she’s going to get a CT scan in a few minutes?

It turns out that even a “stat” creatinine takes an hour or so to return, and radiology, understandably, won’t do a CT scan with contrast in the absence of a recent test of kidney function. Given the small chance that Mom was suffering from some other abdominal catastrophe like a perforation, the ED docs felt that an hour’s wait for the CT was too long. And so came the stat KUB/CXR – at a cost of several hundred, perhaps even one thousand, dollars – all because the creatinine was not more promptly available. It made me wonder: has anybody done the accounting to figure out the cost of a more rapid creatinine assay, factoring in the savings (in dollars, motion, and radiation) from obviating the need for the other, inferior, studies? And how many other chokepoints like this are scattered around our system?

Introductions and Rounding: On our medical service at UCSF, we’ve worked hard at improving the way we introduce ourselves, and my experience with Mom made me glad of this. We now have a white board by each bedside, on which all of the players (attendings, residents, students, nurses) are supposed to write their names, although adherence is less than perfect. Moreover, all our physicians now hand patients “face cards” with our pictures, names, titles, education, and a description of our role.

On Mom’s surgical floor, while the nurses and patient care assistants (PCAs) were excellent at introducing themselves and writing their names on the whiteboard, the doctors were not. Some didn’t introduce themselves at all; most did, but their roles were unclear. There were no face cards, and no physician names on the whiteboard. While the physicians in the ED did a good job introducing themselves, once we made it to the surgical ward, it was more than six hours before we had any idea who her primary doctor or team were. Later, when they came in to see her, they left behind no written traces.

We need to standardize, and then modernize, this effort. Sure, let’s start with cards and whiteboards. But how about this for an ideal futurist scenario: when doctors or nurses enter a room, our badge automatically triggers our picture, bio, and position description to pop up on the patient’s television screen or tablet computer, all recorded so that they can be shared with family members and looked up later.

Which brings me to rounding practices. On UCSF’s pediatrics inpatient service, teams now prospectively plan their morning rounds and – are you sitting down – produce a schedule that tells patients and families when the team will be by to see them. This schedule allows the nurse to be there, as well as some of the relevant subspecialists. We’re currently trying to figure out if we can pull this off on our much bigger and more geographically scattered medical service. I will push for us to do so, particularly after my experience with my mother.

I knew the surgeons would be there at some point between 6:30am and 9am, but had no way of pinning down the time beyond that. (Think about how you feel when Comcast says that the cable guy will be there between 1pm and 5pm.) I also knew that once the surgical team members left the floor, I would have no further access to them for the rest of the day. Most mornings, I came in by 6:30 and waited. One morning, I got there five minutes late, but luckily caught them before they left the ward. And one morning, I missed them and, as Murphy would have it, that was the occasion for the worst error of the hospitalization.

(Far) Too Much Information: On the morning I missed the surgeons on rounds, I had given myself a treat, stopping at Starbucks on the way in to the hospital. While sipping my mocha, I received a frantic call from my dad in Florida. “One of the doctors was just in to see your mom, and told her she has lung cancer,” he said, his voice shaking. I’m on my way in, I told him.

You can guess what happened. A harried July intern was running from room to room seeing patients, her mind probably distracted by the thoughts of everything she needed to get done that day. She saw the official reading of the abdominal CT scan from the prior day. On it, Mom’s left lung nodule was seen and called “suspicious for malignancy.” (Her prior films are in Florida; the UCSF radiologists had nothing to compare this to.) Rather than calling me about the finding (yes, everyone knew who I was [though I remain unconvinced that VIP status necessarily improves one’s outcomes] and my cellphone number was on the whiteboard), the intern came into Mom’s room, woke her from her morphine-aided sleep, and told her that the x-ray showed probable lung cancer. My mother wasn’t sure if she had dreamed this. Unfortunately, she hadn’t.

I was livid, but now have the distance to draw some general lessons from this error:

• The word “cancer” remains emotionally nuclear; it should not be tossed around lightly.
• Don’t give weighty, complex, and highly charged information to narcotized elderly people – or anyone for that matter – who are just waking up without having their family there.
• The intern should have made a little effort to inquire about prior films.
• We really need interoperable health records, which would have allowed our radiologists to access Mom’s Florida scans.
• Even when you’re rushing through your checklist, please use a little common sense.

The Nurses: I’ll not be the first person to observe that it is the nurses, not the doctors, who really determine the overall experience of a hospitalization. Our nurses, on 13 Long at UCSF Medical Center, were exceptional. The nurses and the Patient Care Assistants (PCAs) were competent and caring, and they had their acts together. In the old days, our nurses wore varying types of clothes, the roles of nurses and PCAs were vague, and basic processes like medication administration and shift change were done haphazardly. Today, UCSF nurses are dressed professionally, in uniforms that make clear their roles; their handoffs are robust (“I’m signing off in 30 minutes; this is Anna, who will be taking over for me”); it’s clear what the nurses do and what the PCAs do (there is a special place in heaven for the PCAs, by the way); and the presence of bar coding and computers in the rooms makes things feel far safer and has standardized previously chaotic processes. (All of these elements are captured by our achievement of “Magnet Status.”) One nurse tried an IV twice, couldn’t get it, and calmly said, “I wasn’t successful; I’ll get my colleague who will get it done.” (She did.) And everybody cleaned his or her hands, every time. It was very impressive.

Part of the reason that the experience with the nurses is so important is that it either does – or doesn’t – give you as a family member trust that things will be okay when you’re not there. When Mom was hospitalized in Florida last year, my father hired a private nurse to be with her one night; on another, I asked to sleep at her bedside, and was given a cot so disgusting that it would have been rejected by every youth hostel I stayed in during college. At UCSF Medical Center, I left at 10pm each night with complete confidence that things would be okay overnight.

Yet there are nursing-related processes that can be improved. Two bits of technology remain the bane of patients’ lives in the hospital: the nurse call button and the IV pump alarm. In 2013, in a hospital in San Francisco, can we really not come up with a system where the call button triggers a video feed to allow a nurse to see and speak to the patient, allowing for effective triage? And the IV pump beeps incessantly: kinked line, empty IV bag, incoming tweet, who the hell knows. Isn’t there some new technology to improve this situation?

(Speaking of new technology, the NG tube also seems ripe for innovation. Rigid and uncomfortable; it gives poignancy to the old schoolyard insult, “up your nose with a rubber hose.” Can’t we do better?)

Jargon: Boy, this one is tough. I’ve got a pretty good jargon detector, but after watching the docs speak to Mom for a few days, I realized that half of what I say is probably unintelligible to my patients. One of the surgeons, who I regard as a fabulous communicator, came in one day to talk about Mom’s surgical options. “We can go in there and try to lyse the adhesions, but this only will work if we can find a focal lesion,” he said. Not the worst I’ve heard, but listening through my mother’s ears, I realized that she did not understand anything after, ‘We can go in there…” On our rounds, perhaps we should appoint one team member to be our official jargon-detector, offering the speaker feedback in an effort to sensitive all of us to this pernicious problem. (Sure, the patient-centered view would have us empower patients to speak up if they don’t understand something, but I think few patients will. Certainly not my mom – unfailingly polite, she just shook her head in agreement, despite understanding very little).

Managing Uncertainty: Because of my VIP status, we had a lot of doctors weighing in on the best treatment. The answers to some questions were clear, including the desirability of waiting for spontaneous resolution rather than doing urgent surgery. Thankfully, on Day Three her bowel opened up and she began to eat. (By the way, the only wonderful thing about NG tubes is that taking them out is one of life’s great pleasures; think ski boots and multiply by 100.) But whether she should go for elective surgery, given the near-certainty of future recurrence, and whether and how to modify her diet, were areas of great ambiguity.

On each of these, I liked the fact that the physicians laid out the plusses and minuses of the various actions. What was difficult – even for me – was how to deal with conflicting recommendations. Many folks emphasize the importance of a strict low-fiber diet, and yet one surgeon made clear that it probably doesn’t make any difference. (Mom chose to stick with the diet; mainly because doing something feels better than doing nothing). And we decided against elective laparotomy to “clean out the abdomen,” a big operation with no guarantee of success. This was the consensus judgment of several physicians, although there were a number of variations on the theme that could have led to some confusion.

All of this made me more convinced than ever of the need for a quarterback, one physician to synthesize all of the conflicting advice and present a unified recommendation to the patient and family. It’s what a good hospitalist does. In my mother’s case, this role was assumed by the lead surgeon, who also supplied me with some of the key literature, which was extremely helpful.

Unlike Scott Simon’s mom, my mother’s hospitalization had a happy ending, at least for now. Overall, I was very pleased with the quality of care she received at UCSF Medical Center and would recommend it to other patients without the slightest hesitation. The nurses and doctors we met are bright, committed, friendly, and collaborative, and the systems we’ve put in place over the past decade – IT, handoff processes, whiteboards, and more – are making a difference.

That said, like all great organizations, every encounter provides an opportunity for improvement. I hope we can use my mom’s experiences – and those of other patients and families – to do a little better for the next patient.

Robert Wachter, MD, professor of medicine at UCSF, is widely regarded as a leading figure in the patient safety and quality movements. He edits the federal government’s two leading safety websites, and the second edition of his book, “Understanding Patient Safety,” was recently published by McGraw-Hill. In addition, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine and is the former chair of the American Board of Internal Medicine.  His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.

There are tens of thousands of policies in Medicare’s policy manual, which makes for stiff competition for the “Most Maddening” award. But my vote goes to the policy around “observation status,” which is crazy-making for patients, administrators, and physicians.

“Obs status” began life as Medicare’s way of characterizing those patients who needed a little more time after their ED stay to sort out whether they truly needed admission. In many hospitals, “obs units” sprung up to care for such patients – a few beds in a room adjacent to the ED where the patients could get another nebulizer treatment or bag of saline to see if they might be able to go home. Giving the hospital a full DRG payment for an inpatient admission seemed wrong, and yet these patients really weren’t outpatients either. The Center for Medicare & Medicaid Services’ (CMS’s) original definition of obs status spoke to the specific needs of these just-a-few-more-hours patients: a “well-defined set of specific, clinically appropriate services,” usually lasting less than 24 hours. Only in “rare and exceptional cases,” they continued, should it last more than 48 hours.

A recent article in JAMA Internal Medicine, written by a team from the University of Wisconsin, vividly illustrates how far the policy has veered from its sensible origins. Chronicling all admissions over an 18-month period, Ann Sheehy and colleagues found that observation status was anything but rare, well defined, or brief. Fully one in ten hospital stays were characterized as observation. The mean length of these stays was 33 hours; 17 percent of them were for more than 48 hours. And “well defined?” Not with 1,141 distinct observation codes.

To underscore just how arbitrary the rules regarding observation are, an investigation by the Inspector General of the U.S. Department of Health and Human Services released today found that “obs patients” and “inpatients” were clinically indistinguishable. Their major difference: which hospital they happened to be admitted to.

The potion that turned this particular policy into a monster was the Recovery Audit Contractor (“RAC”) audits, whose existence was authorized by the 2003 Medicare Prescription Drug Act. RAC auditors can target a hospital, pull a hundred or so charts, and, if they find improper billing, collect a bounty for every dollar they save CMS. With the determination of obs status so amorphous, hospital administrators have adopted a “better safe than sorry” stance, generally deciding that cases that are anywhere near a close call should be called obs. (Just this week, Beth Israel Deaconess Medical Center in Boston forked over $5.3 million to Medicare to settle charges related to admissions that auditors believed were really obs.) The result of all this angsty wheel-spinning: the number of obs cases in the U.S. went up by 50 percent between 2006 and 2011, with a more-than-400 percent (!) increase in Medicare patients staying more than 48 hours under observation.

If this mess were only about the question of money for Medicare, hospitals, and auditors, it would be plenty maddening but not miasmal. Unfortunately, patients and their families are unwitting victims, collateral damage.

Picture this: your mother is sitting in a hospital bed, with a band on her wrist, an IV in her arm, nasal prongs in her nose, and EKG squiggles skipping across a telemetry monitor. Luckily, she does reasonably well and is discharged to a skilled nursing facility after a three-day stay. OK, your family thinks, at least we know that Medicare will pay for the SNF since she’s crossed CMS’s magic three-day threshold to trigger SNF coverage.

Only later do you learn that her hospital stay doesn’t count, because she was on obs the whole time. Or you get a co-pay bill for several thousand dollars because, while inpatient medications are covered under Medicare, “outpatient” medications are not. While she sat in her hospital bed, you see, she was really an outpatient.

In my editorial accompanying the Wisconsin paper, I cite the case of a 78-year-old woman who received a $16,000 bill for an uncovered nursing home stay following a four-day observation stay in the hospital. “I thought it was surely a mistake,” she said. “Nobody ever said I wasn’t admitted.”

In a brochure that could have been written by Franz Kafka, Medicare tries to explain the unexplainable. “REMEMBER,” it says, the capital letters designed to make you fully alert for the nonsense that follows, “Even if you stay overnight in a regular hospital bed, you might be an outpatient.” Huh?

I hope you’ll take a look at both the Wisconsin paper and my editorial. In this blog, I’d like to extend the discussion to the fix, which didn’t seem like a bad idea to me when I first penned the editorial, but which I’m coming to learn might – hard as it is to believe – make things worse.

On April 16, 2013, CMS proposed a new rule that would, using a time-based criterion, clarify which patients should be on observation. Patients who stay for less than two midnights (“one Medicare day”) will be assumed to be obs; those staying longer than two midnights would be inpatients. Medicare apparently believes that turning all these two-day or more stays from obs into inpatient admissions will cost the agency money, since they have proposed a 0.2% cut in hospital reimbursement to compensate for these projected increased costs.

Yet CMS has not released any financial models that might help predict what the impact of this change is likely to be. And, whatever Medicare’s projections may be, many hospital administrators believe that the new policy will cost them huge amounts of money. How can this be? While hospitals will now receive a full DRG payment for some longer-stay patients who previously would have been observation (a win), these administrators believe that their losses – particularly on short-stay surgical patients who will now be observation, despite high resource use – will far outstrip the gains. I’ve seen some preliminary data that supports their fear.

Moreover, there is a widespread panic that, rather than soothing the RAC auditors, the new policy will be fresh meat for them. After all, with the two-midnight rule, it’s likely that RAC auditors will be suspicious (potentially with some justification) that hospitals will keep some patients an extra midnight. You might call it an inverse Cinderella effect, as patients are not sent home before midnight in order to capture an inpatient reimbursement and spare the patient the costs associated with an observation stay. So the unproductive and maddening cat-and-mouse game will continue, albeit within slightly less arbitrary boundaries.

A watchdog organization, the Center for Medicare Advocacy, recently highlighted this concern. Theynoted that the new policy calls for an inpatient admission when…

the patient is expected to be in the hospital for at least two midnights. The physician “expectation [of a two-midnight stay]. . . should be based on such complex medical factors as patient history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event.” These factors “must be documented in the medical record in order to be granted consideration.” In other words, the physician certification that he or she expects the patient will need to stay for more than two midnights is not enough: [RAC auditors] can scour the medical record and if they don’t see evidence, they can deem it an improper hospitalization.

Richard Rohr, a seasoned hospitalist leader who is now a consultant, echoed this fear, adding in a note to me:

The basic problem with observation stays is the disconnect between functional status and medical necessity. Many elderly patients who are not able to care for themselves and need more help than a family can perform come to the hospital because it is the social service agency that is open at night and on weekends and does not turn anyone away. These patients often do not have medical needs as defined [by Medicare]. Having stepped away from clinical hospital medicine to focus on medical necessity work, I talk regularly with hospitalists and other physicians, who struggle with the distinction between functional needs and medical needs in caring for patients.

A rather dense (and, at times, impenetrable) editorial in this week’s New England Journal of Medicine also questions whether the proposed policy is an advance. The authors don’t think so. They recommend that patient co-pays be capped, that the costs of medications the patient is already on at home be covered, and that obs days count toward the 3-day requirement for SNF eligibility.

While these are reasonable recommendations, they don’t go far enough to stem the madness. Rather, the line of the old song comes to mind: “Let’s call the whole thing off.” It’s time to restore obs to its original meaning. Medicare should develop a new payment code for those patients who need several, perhaps up to 24, hours of very specific therapy, in a physical observation unit, to determine whether they need admission: nebulizers, fluids, maybe a unit or two of blood. For everyone else admitted to a regular bed on a hospital ward, they are (and it seems silly to have to say this) admitted to the hospital, and the reimbursement system should reflect this. Utilization Review can look to see if there was medical or social justification for admission – if not, the day or days can be denied. Isn’t that simpler?

While the policy around obs is important and frustrating, there are larger issues at play. As I wrote in my editorial, Medicare is in the process of transforming itself from a “dumb payer” into an active shaper of the medical marketplace, through policies such as public reporting, “no pay for errors,” and value-based purchasing. On balance, that’s a good thing. But when Battleship CMS turns, it sends out giant wakes, some of which are unanticipated, even by the organization itself. Policies like the one related to obs status risk capsizing a lot of boats.

Whether the problems with the new observation policy will represent unintended consequences, a lackluster analysis, or a purposeful cost-cutting strategy will doubtless be in the eyes of the beholder. But whatever the motivation, it will be crucial for interested parties (AHA, SHM, and others) to thoroughly vet the proposed changes and push back hard on CMS if they truly are wanting. It’s a sad reality that CMS may well be in the process of turning a vague but maddening policy into one that is less vague but equally problematic.

Robert Wachter, MD, professor of medicine at UCSF, is widely regarded as a leading figure in the patient safety and quality movements. He edits the federal government’s two leading safety websites, and the second edition of his book, “Understanding Patient Safety,” was recently published by McGraw-Hill. In addition, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine and is the former chair of the American Board of Internal Medicine.  His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.

Yesterday was my last day as chair of the ABIM, and the end of my eight-year tenure on the Board. In this blog – a bookend to the one I wrote at the start of the year, which went near-viral – I’ll describe some of our accomplishments this year and a few of the challenges that I leave my talented successors to grapple with.

I had two very tangible tasks to accomplish during my chairmanship. First, after a decade-long tenure as CEO and President of ABIM, Chris Cassel announced her intention to step down. (Chris is now CEO of the National Quality Forum, which is increasingly crucial in a world looking for robust measures of quality, safety, and value.) After an extensive search, we selected Richard Baron to become ABIM’s new CEO, and Rich began earlier this month. Rich is one of the most impressive people I’ve met in healthcare, and a perfect choice to lead ABIM into the future. As someone who practiced general internal medicine for nearly three decades in a mid-sized Philadelphia office, he is a “doctor’s doctor.”

He is intimately familiar with the work of the Board, having served on the boards of both ABIM and the ABIM Foundation for over a decade (including a year as ABIM chair). He also has extensive policy experience, most recently as director for Seamless Care Models for the Center for Medicare & Medicaid Innovation (CMMI), where he was responsible for putting meat on the bones of concepts like the “Medical Home” and “Accountable Care Organization.” Rich is wickedly smart, a superb communicator, and a great listener with impeccable values and an unerring ethical compass. He’ll be splendid.

The second area may be a bit more Inside Baseball, but will ultimately be just as important. A couple of years ago, we began a process to redesign the ABIM’s governance. Our 28-person board was both too large and had too much on its plate for effective decision making. In work that was superbly led by then-chair Catherine Lucey, assisted by a crack committee, staff and governance expert Jamie Orlikoff, we decided to transform our governance structure. As of tomorrow, the ABIM board shrinks to 15 members – chosen for their experiences and competencies rather than because they represent a given medical subspecialty – and a new group, the ABIM Council, is formed.

ABIM’s work is now divided: the new board is charged with developing and carrying out our overarching strategy and holds fiduciary responsibility; the Council is responsible for the core work of the organization: the certification and MOC processes. This separation (accompanied by appropriate cross-links) is designed to give both groups the time and support they need to focus on their very large agendas.

My thanks to Catherine, Jamie, the staff, and the Governance Task Force (particularly Governance Committee chair Pat Conolly and inaugural Council chair Lee Berkowitz) for breathing life into this structure, and to the entire board for a thoughtful deliberation and a very bold decision.

There were several other initiatives we started under my watch but which I’ll hand off to our able new chair, David Johnson, the Board, Council, and staff. We created a committee called Assessment 2020, led by Harlan Krumholz, whose job is to rethink how we assess physicians in the future. Here are merely some of the issues we’re grappling with:

• In a world in which virtually every doctor is documenting his or her care in an electronic medical record system, how do we take advantage of these data, as seamlessly as possible, to assess the quality of care?

• As more of our assessments are drawn from data created during care delivery, how do we ensure that we’re also measuring things that are harder to assess than care processes or even outcomes, such as diagnostic acumen and empathy?

• Since we know that the quality of care delivered by individual doctors is profoundly influenced by their practice setting, how do we measure context and take it into account in our certification process?

• In a world of ubiquitous and instantaneous access to online information, does a purely closed-book test make sense?

• How do we integrate modern simulation techniques into our assessments?

• How can we assure that individual physicians have the skills they’ll need to contribute most effectively to a rapidly changing healthcare landscape?

While our methods must remain consistent with modern thinking and technology, we can’t abandon scientifically valid tools and assessments for the latest fads. The Assessment 2020 committee is an eclectic and accomplished group that includes experts from healthcare, education, simulation, and a variety of other domains. I look forward to seeing what we come up with (I’ll continue on as a committee member).

This year we also sharpened our focus on two other challenging and hugely important issues: harmonization and transparency. We know that many physicians complain of being crushed by the burden of being measured by a variety of payers, healthcare systems, quality coalitions, as well as the Boards. We have worked hard to integrate MOC with these efforts – our goal is to allow (if the diplomate wishes) the same activities to “count” for Medicare and other insurers’ quality incentive or public reporting programs, Joint Commission practice assessments, state Maintenance of Licensure programs, Meaningful Use incentives, and more.

We’ve made some headway on this, but it remains a work in progress – these are some very big cats to herd. We’ve also worked hard to keep our costs down. They are among the lowest of boards that make up the American Board of Medical Specialties(the umbrella organization for the major certifying boards). I am confident that future boards will remain committed to this path.

Moreover, we recognize that many physicians are now participating in robust QI programs within their own healthcare institutions. We have created a pathway by which such organizations can oversee their physicians’ quality work – so a group of doctors in a given hospital working on a diabetes or heart failure improvement project can all receive MOC credit, offered by their own institution, for this work.

In our harmonization efforts, we have been encouraged by the response of others (particularly Medicare, under CMO Patrick Conway’s superb leadership), who appreciate that physicians themselves (this is, after all, what the Boards are – groups of physicians creating standards for their own specialties) will do a better job than payers or regulators. This too is a work in progress, but we have made real advances.

In addition, a personal passion of mine was to push the Board to become more transparent. I mean this in both senses of the word. First, how we do our business and make our decisions should be accessible to everyone who wants to know. We’ve taken strong steps in this direction, with even more to come next year.

Even more importantly, I believe that the Board should, ultimately, make more information available to patients and other interested parties than simply whether physicians are, or are not, board certified. But what type of information? Should it be levels of performance (for example, expert vs. competent), areas of specialization within a specialty (for example, an endocrinologist who has a particular expertise in thyroidology), or something else? We’ve begun a process to think through these very hard questions, with a lot of input, over the next few years. Of course, this issue is highly intertwined with our Assessment 2020 work.

Our efforts to modernize our certification programs and consider issues of transparency will be facilitated by more frequent touch points with our diplomates. All of the boards under the ABMS have been asked to transition to a more continuous process in which physicians participate in MOC more frequently than every ten years. In focus groups that we conducted in planning our MOC transformation, many physicians begged us to “just tell me what I need to do.” Our soon-to-be launched web portal will fill this need. This is an extraordinarily complex undertaking: a senior physician might be “grandfathered” in internal medicine, but have certain requirements for, say, her subspecialty of cardiology, and others for her sub-sub specialty of electrophysiology. The new web portal will represent a real advance.

It would be wildly unusual for an accreditor or standard setter to be universally loved, and ABIM is no exception. We sit at a delicate interface. Patients and patient representatives often ask us to domore: provide them more information about physicians to help them make choices and weed out “bad apples.” Yet many physicians – including a particularly vocal group of readers of this blog – clearly want us to do less. After my tenure on the Board, I remain convinced of the value of professional self-regulation and assessment, and utterly unpersuaded by the argument that MOC should just go away, that every physician can be counted on to keep up with advances in their field on their own, and that patients don’t deserve to know whether their physicians have met a set of scientifically-valid standards set by experts in their own specialty.

But can the process be improved? Sure. I’ve done my best to help ABIM, which is filled with talented and highly committed staff and board members, to do just that. As we do, it will be important to look unblinkingly at where our programs fall short, but also to base such efforts on real data, not some of the misinformation I’ve seen flying around the web. For example, between 1997 and 2012, the pass rate on the MOC exam has been 87% for first time takers, with an ultimate pass rate of 96%, not the far-lower rate being suggested in some posts (though rates on individual exam administrations do vary).

Between 1990 and 2001, more than 72,000 physicians received time-limited certificates from ABIM; 92% of them enrolled in MOC at the appropriate time, and 84% completed the process successfully. Finally, we ask physicians to assess their experience with the testing component of certification and MOC. Eighty-three percent of physicians who participated in certification were satisfied with the experience, as were 78% engaged in MOC (3% and 5% were unsatisfied, respectively; the rest were neutral). Seventy-nine percent of those who participated in MOC would recommend it to a colleague.

As important as physicians’ attitudes are those of patients. In a 2003 Gallup survey, 90% of patients felt it was important or very important that physicians be reevaluated every few years; 87% thought it was important or very important that doctors periodically pass a written test. More than half stated that they would find another doctor if their own physician’s board certification lapsed. Patients want and deserve a fair and robust certification and MOC process.

I look forward to seeing what the future holds, and wish my colleagues the best of luck in pursuing this crucial agenda. I’ll continue as a Trustee of the ABIM Foundation, whose main focus over the past few years has been the highly influential Choosing Wisely® campaign.

And, of course, I’ll continue to maintain my certification, proudly.

Robert Wachter, MD, professor of medicine at UCSF, is widely regarded as a leading figure in the patient safety and quality movements. He edits the federal government’s two leading safety websites, and the second edition of his book, “Understanding Patient Safety,” was recently published by McGraw-Hill. In addition, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine and is outgoing chair of the American Board of Internal Medicine.  His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.

I sometimes explain to medical students that they are entering a profession being transformed, like coal to diamonds, under the pressure of a new mandate. “The world is going to push us, relentlessly and without mercy, to deliver the highest quality, safest, most satisfying care at the lowest cost,” I’ll say gravely, trying to get their attention.

“What exactly were you trying to do before?” some have asked, in that wonderful way that smart students blend naiveté with blinding insight.

It is pretty amazing that healthcare has been insulated from the business pressures that everybody from Yahoo! to my father’s garment business have experienced since the days of Adam Smith. We experienced a bit of this pressure in the mid-1990s, when pundits declared healthcare inflation “unsustainable” (sound familiar?) and we invented managed care to slay it. We know how that story ended – the public and professional backlash against HMOs defanged the managed care tiger to the point that it could barely produce a “meow.” The backlash was followed by a 15-year run during which efforts to slash healthcare costs have been remarkably meager.

That run has ended.

Luckily, while we’ve been let off the hook on cost-reduction, we’ve not been given a free pass on improvement. Beginning with the Institute of Medicine reports on safety (2000) and quality (2001), we have been under growing pressure to improve the numerator of the value equation: patient safety, quality of care, and patient satisfaction. Particularly for those of us who work in hospitals, we now feel this pressure from many angles: from accreditors (more vigorous and unannounced Joint Commission inspections, residency duty hour limits), transparency (Medicare’s Hospital Compare), comparative measurement (HealthGrades, Leapfrog, Consumer Reports and many other hospital rankings), and, most recently, payment policies (no pay for “never events,” penalties for readmissions, value-based purchasing, and “Meaningful Use” standards for IT).

These initiatives have created an increasingly robust business case to improve. Hospitals everywhere have responded with new resources, committees, ways of analyzing data, educational programs, computer systems, and more.

In my own Division of Hospital Medicine at UCSF, we have powerwalked this walk. Faculty members from my division now lead our division’s QI committee, our department’s QI efforts, our medical center’s QI/safety and patient satisfaction programs, and our hospital’s IT implementation.

While our commitment to improvement has been inspiring, about three years ago I started worrying about the balance of our value improvement activities. At one of our weekly lunches, I asked about 30 of my faculty a series of questions.

“How many of you are involved in a project designed to improve quality?” I asked. Virtually everyone raised his or her hand.

“Great, how about patient safety projects?” About half raised their hands. “Fabulous.”

“Projects whose primary goal is to improve the patient experience?” About a third.

“OK. How about projects whose primary goal is to reduce the cost of care or decrease waste?” One or two people sheepishly raised their hands.

“Wrong!” I barked, nearly banging my shoe on the table. “If we’re serious about improvement – and we need to be – then we should be attacking the denominator of the value equation with as much passion as we are the numerator.” The next day, we launched our efforts to rebalance our portfolio.

We’ve been at this value improvement business for a couple of years now, and there are some lessons regarding how to structure a program that I’d like to share with you. I suspect that if you’re not deeply engaged in this work yet, you will be, and soon.

The first question we faced was this: where should the various components of value improvement “live” in our org chart? We faced this at the divisional level, but this question is relevant to departments, to medical centers, and to healthcare organizations. Is cost reduction work its own thing or is it a branch of the existing QI workflow?

As I described in my closing address at last week’s Society of Hospital Medicine annual meeting, there are some fundamental differences between quality and cost work. First, the latter requires the acquisition of some new skills, including methodologies such as Lean (more on this later). Moreover, to do cost reduction well, you need to know something about accounting and payment policies, or make sure there is someone on your committee who does.

Perhaps more importantly, cost reduction work requires that you pay attention to diplomacy. One can spend a lifetime improving quality and safety and not make anyone too upset. But the minute you begin to tackle “unnecessary” procedures or “wasteful” practices, you are attacking someone’s livelihood and budget, and you have to be prepared for pushback. When our division decided to take on unnecessary CT scans, it was only a few minutes before the chair of radiology gave me a ring, inquiring about what we were doing and how he could help. Key stakeholders need to be identified before you get too far into their space, either bringing them into the tent or figuring out ways to manage their objections.

Despite these differences, if you already have a strong quality/safety/improvement infrastructure (as we did), I strongly recommend that you roll your cost reduction work into it. Many of the core skills (literature and best practice reviews, change management, IT, data analysis) are the same, and building a new infrastructure would be, ironically, wasteful. Perhaps the largest threat to rolling the cost work into the existing quality/safety/patient experience work is the chance that the former will be under-resourced – significant new work being covered under the old budget. But the alternative, I believe, is worse.

Our division created a “High Value Care Committee” – a multidisciplinary group co-chaired by an extraordinary young faculty member, Chris Moriates, and our fabulous division administrator, Maria Novelero. In its first year, Chris, Maria, and the energetic committee members have tackled a half-dozen targets, areas in which our practice was costly and added little value: using nebulized bronchodilators when metered-dose inhalers would do, ordering far too many ionized calcium laboratory studies (at $100 a pop), leaving patients on proton-pump inhibitors for far too long (or putting them on inappropriately in the first place), excessive and near-reflexive use of telemetry beds. Some of our choices were informed by the lists produced by the ABIM Foundation’s “Choosing Wisely” campaign, while others were chosen by the committee after brainstorming and literature review. As Chris described at the recent SHM meeting, the results to date are impressive, including a nearly 50 percent reduction in the use of nebs. More importantly, these projects have gotten the attention of our trainees (who increasingly find cost awareness “cool”) and the other services in our medical center. I will be surprised if other major departments, and the medical center itself, don’t launch equivalent committees within a couple of years.

The High Value Care Committee’s work “lives” under the umbrella of our QI director, Michelle Mourad, and we treat it as one of the components of our quality work, along with safety and patient satisfaction. (The nomenclature is a source of perpetual confusion. I think of value as being the integration of quality, safety, patient experience, and cost. Yet the oversight committee is often called a “quality” committee, and the cost/efficiency group is often called a “value” committee. As we did, these choices should be made pragmatically, and based on local culture and preferences.) As hoped, keeping the work connected has created many synergies (such as shared personnel, data, and infrastructure), and a high level of physician engagement. As this work goes medical center-wide, I will lobby to stick with the same philosophy: not to wall off cost-reduction in a corner of the organization (such as under Finance, which would disenfranchise the clinicians) but to make it a critical component of our value improvement activities.

Another part of the jigsaw puzzle – one I didn’t anticipate – comes in the form of Lean. Many healthcare leaders, most prominently Virginia Mason’s Gary Kaplan, have embraced Lean with near-religious fervor, to great effect. At UCSF, under the leadership of Adrienne Green, a hospitalist and the medical center’s Associate CMO, we’re just beginning to use it to attack complex processes. One of our first Lean projects involves mapping out all of the wasteful steps in our discharge process. As you know, Lean’s philosophy begins with this kind of mapping, followed by identification of non-value-added steps to be purged. While I worry that Lean is being a bit overhyped, it is a powerful tool to address complex, multifaceted, multidisciplinary processes. I’m quite sure that every healthcare organization will need to adopt it, or some similar methodology, to help organize its cost and waste reduction activities in the next few years.

So this is another part of the puzzle that needs to be solved: some efficiency activities will resemble the ones that Chris and Maria are working on: attacking discrete targets like overused nebulizers, CT scans, or laboratory tests. The steps here are relatively straightforward: choose the target (via literature review, inclusion in Choosing Wisely, or faculty consensus), analyze the consequences of overuse (including cost but also patient harm and wasted clinician/patient time), build a campaign around curtailing its use (including education, audit and feedback, computerized decision support, administrative or other barriers to use, and perhaps incentives), anticipate and address pockets of resistance, analyze the outcomes, disseminate them (if the program worked; retool if it didn’t), and implement a strategy to maintain the gains.

This process works well when you’re trying to get the docs to order fewer hematocrits, but is all but irrelevant when you’re trying to improve the registration process. For the latter, a Lean-type effort will be necessary. Whether the same committee manages both of these kinds of programs is going to be determined by local circumstances, including the interests and skills of the leaders. For our division, Chris and Maria’s committee is currently driving the target-specific work, while Adrienne and the medical center are managing the Lean projects. My hope is that we will ultimately integrate the two types of work under a single structure, though the Lean projects, particularly the big ones, involve so many departments and disciplines that they are likely to require co-management at a higher level of the organization.

Yes, culture does trump strategy, and a great org chart will not guarantee a great program. But a bad one can nearly guarantee failure. As we move aggressively into value improvement, making sure this work is organized and resourced correctly will markedly increase the odds of success.

And succeed it must. Given the estimate that 30 percent of healthcare expenditures produce no benefit for our patients, we are, quite literally, Too Big to Fail.

Robert Wachter, MD, professor of medicine at UCSF, is widely regarded as a leading figure in the patient safety and quality movements. He edits the federal government’s two leading safety websites, and the second edition of his book, “Understanding Patient Safety,” was recently published by McGraw-Hill. In addition, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine and is chair of the American Board of Internal Medicine.  His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.

Everybody hates curbside consults – the informal, “Hey, Joe, how would you treat asymptomatic pyuria in my 80-year-old nursing home patient?”-type questions that dominate those Doctor’s Lounge conversations that aren’t about sports, Wall Street, or ObamaCare. Consultants hate being asked clinical questions out of context; they know that they may give incorrect advice if the underlying facts and assumptions aren’t right (the old garbage in, garbage out phenomenon). They also don’t enjoy giving away their time and intellectual capital for free. Risk managers hate curbside consults because they sometimes figure into the pathogenesis of a lawsuit, such as when a hospitalist or ER doctor acts after receiving (non-documented) curbside guidance and things go sideways.

There is some evidence to support this antipathy. A recent study published in the Journal of Hospital Medicine examined 47 curbside consultations by hospitalists, in which formal consults by different hospitalists (unaware of the details of the curbside encounter) were performed soon thereafter. Conducted by a team of researchers from the University of Colorado, the study found that the information given to the curbside consultant was incomplete or inaccurate roughly half the time, and that management advice offered via the two forms of consultation differed 60 percent of the time. (In those cases in which the consultant was given inaccurate or incomplete information, the advice differed more than 90 percent of the time!) This is not the first warning about the dangers of such consults (see also here and here), and it won’t be the last.

I recall several cases at my own institution in which curbside consults contributed to mistakes with tragic consequences. In a memorable one from nearly a decade ago, a cardiology fellow was curbsided to look at an ECG in a young patient with non-cardiac symptoms. The primary team attributed her symptoms to a pulmonary illness and asked the specialist whether the patient’s potentially alarming ECG findings could be seen in that syndrome. His “yes” answer – which may have been correct in theory – led the team to stick with its original diagnosis, an error that contributed to the patient’s death. There seems little question that had the cardiologist actually seen the patient, reviewed the history in detail, and looked at the electrocardiogram in that context, his recommendation would have been different, and the outcome might have been as well.

Cases like this, and studies like the JHM paper, inevitably cause some to lobby to ban curbside consults, and I’ve heard of a few organizations and subspecialty services that have done just that. While such a move seems logical on the surface, my own belief is that it would be an extremely dangerous thing to do.

Imagine a law firm or a business in which none of the partners were comfortable asking for the advice of a colleague without a formal, written request. Let’s also imagine that the advice could only be given after the colleague had reviewed the case file for half an hour and spoken to the client himself. This would be a disaster – collegial, informal exchange of information and ideas is what lubricates the gears of every effective organization; it’s what a “learning organization” looks like. Stripped of this lubrication, the machinery freezes up; before you know it you have a hidebound, bureaucratic monstrosity. One of the key lessons of the past decade is that healthcare organizations are so-called “complex adaptive systems,” in which formulaic approaches tend to fail. In such organizations, it’s crucial to nurture the informal connections that allow for the diffusion of wisdom: from senior leaders to front-line managers, from teachers to students, and yes, from specialists to generalists.

What would actually happen if we did ban curbside consultations? Picture a resident caring for a patient with a tough case of C. difficile colitis. The resident spies an overworked, underfed GI or ID fellow looking harried. The resident would realize that if he asked the fellow the question, “Cynthia, I got this guy with recurrent C. diff. What’s the best treatment?” the response would be: “Are you asking me for a formal consult?”(Accompanied by a Please-God-No facial expression and toe tapping that would put Savion Glover to shame). Faced with that scenario, it’s likely that the resident wouldn’t ask the question of the specialist, instead choosing to wing it with the help of UpToDate or perhaps another resident’s advice. In other words, while we know that curbside consults can be dangerous, what we don’t know is how much useful information is transmitted via such consultations, and whether the advantage of better formal consults would trump the loss of shared wisdom through this fractal information market. I suspect it would not.

As with so many complex issues in medicine, the right answer will require a nuanced approach. For complex clinical questions whose answers truly hinge on the consultant having a deep understanding of the patient’s history, physical examination and clinical situation, a full-bore consultation is appropriate and should be required. I’m guessing that that description covers the minority of day-to-day clinical situations. To deal with the others, we need to get creative. Rather than banning curbside consults, we should develop new “consult-lite” models: ones in which the consultant feels comfortable opining without being obligated to see the patient and the complete dataset. For example, a pulmonologist might be comfortable rendering a recommendation after hearing a thumbnail history and seeing a chest CT; a dermatologist might need little more than a photo of a rash; a neurologist might be able to observe a hospitalist examining a patient through a video link and make a recommendation with confidence. (These recommendations and the information on which they were based should be briefly documented in the medical record.) Of course, there is a chance that their judgments might have changed had they spent 30 minutes talking to and examining the patient (and some will undoubtedly complain about the further dehumanization of medicine), so we need to weigh these concerns against the efficiency of this consult-lite approach.

To make all of this feasible, it will be important to take the matter of professional fee billing off the table. One hopes that the movement toward a value-not-volume payment system will give healthcare organizations the freedom to organize themselves in ways that promote appropriate types of consultation and information exchange. In places like Kaiser Permanente, which offer us a head start on envisioning the future, they try to maximize these informal interactions (for example, through co-locating specialists and primary care doctors in ambulatory practices). Their hope is that this structure allows primary care doctors and hospitalists to deliver appropriate care, less expensively than requiring that specialists be involved every step of the way.

A complete prohibition of curbside consultation would create only two options when it came to generalist-specialist interactions: purely educational forums (aka CME) and formal consultation. There’s a lot of good care and information exchange that lives in-between these poles. In a 2005Annals of Internal Medicine article, Ferrer and colleagues addressed the need for flexibility when it comes to generalist-specialist interactions:

Generalists should work with specialists to address the following questions: What are the volume–outcome relationships for a specific condition in both primary and specialty care and how can they be optimized? When is referral too early, and when is it too late? They should create communication patterns that support the proper selection of steps along the referral continuum of advice, formal consultation, co-management, or referral.

To thrive in the next decade, healthcare delivery systems will need new models of generalist-specialist information exchange that produce the best outcomes at the lowest cost. To be successful, these models must leave all of the involved clinicians feeling professionally satisfied, protected from undue malpractice risk, and fairly compensated. I’m pretty sure that they will not include an outright ban on curbside consults.

In 2003, cutting residency duty hours seemed like a straightforward solution to a tangible problem: resident fatigue. Yet we now know that this change did not result in improved safety (or education, for that matter), because we failed to address the many collateral issues, ranging from resident scut work to the dangers of handoffs, nor fully appreciate how care is actually delivered in the trenches. Banning curbside consults is similarly seductive: it seems like a straightforward solution to a palpable problem. But I’m afraid it would likely have the same unfortunate outcome. Let’s be smarter – and more imaginative – this time around.

Robert Wachter, MD, professor of medicine at UCSF, is widely regarded as a leading figure in the patient safety and quality movements. He edits the federal government’s two leading safety websites, and the second edition of his book, “Understanding Patient Safety,” was recently published by McGraw-Hill. In addition, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine and is chair of the American Board of Internal Medicine.  His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.