The Digital Revolution and the Department of Medicine
The practice of medicine is undergoing several revolutionary changes. Perhaps the two largest are the growing pressure to provide high value care and the digital transformation of healthcare.
Today, the value pressure is the more powerful of the two. Just think about the time, energy, and money we now invest in improving quality, safety, patient experience, and efficiency. All of these activities are driven, in large part, by our recognition that our ability to thrive, even survive, as a healthcare delivery organization will be determined by the value of the care we deliver. (This has a slightly different flavor depending on which delivery system – UCSF Health, the VA, SFGH, or Fresno – you work in, but the forces are ubiquitous.)
Yet I’d argue that in 10 to 15 years, the second change – the digital transformation of medicine – will more profoundly alter the work we do. Why? The value pressure, it seems to me, is creating predictable (albeit substantial) changes: more attention to measurement, more training and systems to improve performance, more emphasis on the patient experience. Just look at the changes in our own department, including the number of faculty and staff who focus on these issues, the amount of research we do into them, and the emphasis on them in our training programs. I think we’ve made a great start on building the competencies and systems to provide high-value care. We’ll surely be surprised along the way, but I think we have a sense of how this movement will play out.
On the other hand, I think we’ve only scratched the surface of the digital revolution in healthcare – and we have no idea how this movie will end. Yes, we have functioning electronic health records, and – to the great credit of UCSF’s IT leaders, many of whom are in our department – we are taking advantage of them in ways that are beginning to make care better and safer. But the disruptive parts of the digitization of medicine – Big Data, intense transparency, unprecedented levels of patient engagement, massive shifts of care to telemedicine and other digitally enabled forms, and the entrants of new business models into healthcare (think Uber or the digital disruption of journalism or retail) – well, all we can be sure about is that things are changing fast, and that we’re just getting started.
In this, our location can be either blessing or curse. To the degree that we can engage with Silicon Valley – helping to create and study some of the new tools, recruiting trainees and faculty who are excited about the opportunities that emerge from such partnerships, doing work that gets IT entrepreneurs and funders excited about partnering with UCSF – we should have an appreciable advantage. To the degree that we fall behind, we may find ourselves among the first places that are disrupted by new technology-driven models currently being developed in our own backyard.
In other words, this may well be a case in which that old quote is apt: If you’re not at the table, you’re on the menu.
For this reason, I’ve decided to devote a considerable amount of energy during my tenure as Interim Chair to helping position our department to thrive in the digital era. Over this year, including at our department retreat on October 30th, we’ll be looking at several key areas:
Research
There are already examples of digitally enabled research being conducted by members of our department, such as Health eHeart and PRIDE. How do we build on these successes? Should the department or the campus create an infrastructure to support digitally-enabled research? And should we doing more research looking at IT itself? If so, do we have the faculty and staff we need?
Big Data
Clinical Care
Over the past decade, we have become a leader in our clinical IT systems. (Not all Epic implementations are alike and ours is, correctly, seen as a well implemented and managed system.) But, as I described in my recent book, the implementation of health IT has been a mixed bag, with great advantages and some striking challenges.
On the one hand, witness innovations like our eConsult system, which takes advantage of our electronic health record to reimagine the nature of subspecialty consultations. On the other hand, our outpatient clinicians are spending several hours every night trying to empty their electronic inboxes. Moreover, our digital world has compromised important relationships, including the physician-nurse relationships that used to center around the charts at the nurses’ station. (At Moffitt, we’re moving the residents’ room to the 14th floor to try to decrease the separation between our residents, now tethered to their computers on the 9th floor, and the ward-based nurses and other staff on the 14th and 15th.)
How do we reimagine our work in a digital environment? How do we train people to do this work? What are the new tools we need to develop, either by ourselves or in partnership with digital entrepreneurs? Here, too, we don’t have to look far for inspiring examples. Much of the foundational work on eConsult was done by Ralph Gonzales and Nat Gleason at Parnassus/Mt. Zion and by Hal Yee at SFGH. The UCSF Center for Digital Health Innovation (CDHI) – created to promote UCSF-industry relationships in health IT – is led by Mike Blum, and many of its leaders are in our department. We are clearly capable of developing breathtaking innovations. How can we do even more? How can the department help?
Education
In the development of the Bridges curriculum, Catherine Lucey and her colleagues have been reinventing medical education for the 21st century. What is the best way to educate people, taking advantage of digital tools? The flipped classroom? MOOCs? Some new model not readily apparent? And how should we be educating all of our trainees in digital medicine? UCSF is co-leading an AMA-sponsored program that, among other goals, tries to answer that very question.
Finally, how about training our future leaders in informatics and big data? Should we scale up our limited informatics fellowships? Do we need a new training model for clinical data scientists? Whatever we choose to do as an institution, if it’s going to work the department of medicine will need to play a central role.
Communications
In trying to figure out how to communicate with nearly 1000 faculty, and an equal number of trainees and staff, I came to believe that blogging was the most efficient strategy (if you’ve gotten this far, you’re helping me make the point). I am also a big fan of Twitter. (Though if you choose to get involved with Twitter, make sure you have the time. Several years ago the humorist Andy Borowitz wrote the following tweet: "Signing off Twitter for a while. My family has left me and I need to find out when.")
We have several examples in our department of digital tools being used to great effect for internal and external communication. Our geriatrics faculty runs the popular "GeriPal" (geriatrics/palliative care) blog and actively tweet divisional events and accomplishments. In my own division of hospital medicine, we frequently send out short electronic questionnaires, sometimes only 2 or 3 questions, when we’re trying to take the pulse of our faculty. Should we be doing more of this? Should there be some departmental support to help?
Twenty years from now, I believe we will look back at our current era and say, "That was when healthcare went from being an analog to a digital field." I hope we will also look back and say, "… and UCSF played a central role in helping to make healthcare better, safer, and cheaper, and more human." This is an ambitious agenda, but someone needs to do it and I don’t see any institution, or department, that is better positioned to lead.
I look forward to hearing your thoughts on this, now and throughout the year, as we begin to chart this course.
Robert Wachter, MD
Interim Chair, Department of Medicine