“You can’t learn more from the system,” she said. “You can’t do more. You can’t take on extra responsibilities.” Even fixing minor matters is often not in her power. She’d recently noticed, for instance, that the system had the wrong mailing address for a referring doctor. But, she told me, “all I can do is go after the help desk thirteen times.”
Jacobs felt sad and sometimes bitter about this pattern of change: “It’s disempowering. It’s sort of like they want any cookie-cutter person to be able to walk in the door, plop down in a seat, and just do the job exactly as it is laid out.”
Sadoughi felt much the same: “The first year Epic came in, I was so close to saying, ‘That’s it. I’m done with primary care, I’m going to be an urgent-care doctor. I’m not going to open another In Basket.’ It took all this effort reëvaluating my purpose to stick with it.”
Gregg Meyer sympathizes, but he isn’t sorry. As the chief clinical officer at Partners HealthCare, Meyer supervised the software upgrade. An internist in his fifties, he has the commanding air, upright posture, and crewcut one might expect from a man who spent half his career as a military officer.
“I’m the veteran of four large-scale electronic-health-records implementations,” he told me in his office, overlooking downtown Boston. Those included two software overhauls in the military and one at Dartmouth-Hitchcock Medical Center, where he’d become the chief clinical officer. He still sees patients, and he experiences the same frustrations I was hearing about. Sometimes more: he admits he’s not as tech-savvy as his younger colleagues.
“But we think of this as a system for us and it’s not,” he said. “It is for the patients.” While some sixty thousand staff members use the system, almost ten times as many patients log into it to look up their lab results, remind themselves of the medications they are supposed to take, read the office notes that their doctor wrote in order to better understand what they’ve been told. Today, patients are the fastest-growing user group for electronic medical records.
Computerization also allows clinicians to help patients in ways that hadn’t been possible before. In one project, Partners is scanning records to identify people who have been on opioids for more than three months, in order to provide outreach and reduce the risk of overdose. Another effort has begun to identify patients who have been diagnosed with high-risk diseases like cancer but haven’t received prompt treatment. The ability to adjust protocols electronically has let Meyer’s team roll out changes far faster as new clinical evidence comes in. And the ability to pull up records from all hospitals that use the same software is driving real improvements in care.
Meyer gave me an example. “The care of the homeless population of Boston took a quantum leap,” he said. With just a few clicks, “we can see the fact that they had three TB rule-outs”—three negative test results for tuberculosis—“someplace else in town, which means, O.K., I don’t have to put him in an isolation room.”
In Meyer’s view, we’re only just beginning to experience what patient benefits are possible. A recent study bolsters his case. Researchers looked at Medicare patients admitted to hospitals for fifteen common conditions, and analyzed how their thirty-day death rates changed as their hospitals computerized. The results shifted over time. In the first year of the study, deaths actually increased 0.11 per cent for every new function added—an apparent cost of the digital learning curve. But after that deaths dropped 0.21 per cent a year for every function added. If computerization causes doctors some annoyance but improves patient convenience and saves lives, Meyer is arguing, isn’t it time we all got on board?
“I’m playing the long game,” he said. “I have full faith that all that stuff is just going to get better with time.”
And yet it’s perfectly possible to envisage a system that makes care ever better for those who receive it and ever more miserable for those who provide it. Hasn’t this been the story in many fields? The complaints of today’s health-care professionals may just be a white-collar, high-tech equivalent of the century-old blue-collar discontent with “Taylorization”—the industrial philosophy of fragmenting work into components, standardizing operations, and strictly separating those who design the workflow from those who do the work. As Frederick Winslow Taylor, the Progressive Era creator of “scientific management,” put it, “In the past, the man has been first; in the future, the system must be first.” Well, we are in that future, and the system is the computer.
Indeed, the computer, by virtue of its brittle nature, seems to require that it come first. Brittleness is the inability of a system to cope with surprises, and, as we apply computers to situations that are ever more interconnected and layered, our systems are confounded by ever more surprises. By contrast, the systems theorist David Woods notes, human beings are designed to handle surprises. We’re resilient; we evolved to handle the shifting variety of a world where events routinely fall outside the boundaries of expectation. As a result, it’s the people inside organizations, not the machines, who must improvise in the face of unanticipated events.
Last fall, the night before daylight-saving time ended, an all-user e-mail alert went out. The system did not have a way to record information when the hour from 1 A.M. to 1:59 A.M. repeated in the night. This was, for the system, a surprise event. The only solution was to shut down the lab systems during the repeated hour. Data from integrated biomedical devices (such as monitoring equipment for patients’ vital signs) would be unavailable and would have to be recorded by hand. Fetal monitors in the obstetrics unit would have to be manually switched off and on at the top of the repeated hour.
Medicine is a complex adaptive system: it is made up of many interconnected, multilayered parts, and it is meant to evolve with time and changing conditions. Software is not. It is complex, but it does not adapt. That is the heart of the problem for its users, us humans.
Adaptation requires two things: mutation and selection. Mutation produces variety and deviation; selection kills off the least functional mutations. Our old, craft-based, pre-computer system of professional practice—in medicine and in other fields—was all mutation and no selection. There was plenty of room for individuals to do things differently from the norm; everyone could be an innovator. But there was no real mechanism for weeding out bad ideas or practices.
Computerization, by contrast, is all selection and no mutation. Leaders install a monolith, and the smallest changes require a committee decision, plus weeks of testing and debugging to make sure that fixing the daylight-saving-time problem, say, doesn’t wreck some other, distant part of the system.
For those in charge, this kind of system oversight is welcome. Gregg Meyer is understandably delighted to have the electronic levers to influence the tens of thousands of clinicians under his purview. He had spent much of his career seeing his hospitals blighted by unsafe practices that, in the paper-based world, he could do little about. A cardiologist might decide to classify and treat patients with congestive heart failure differently from the way his colleagues did, and with worse results. That used to happen all the time.
“Now there’s a change-control process,” Meyer said. “When everything touches everything, you have to have change-control processes.”
But those processes cannot handle more than a few change projects at a time. Artisanship has been throttled, and so has our professional capacity to identify and solve problems through ground-level experimentation. Why can’t our work systems be like our smartphones—flexible, easy, customizable? The answer is that the two systems have different purposes. Consumer technology is all about letting me be me. Technology for complex enterprises is about helping groups do what the members cannot easily do by themselves—work in coördination. Our individual activities have to mesh with everyone else’s. What we want and don’t have, however, is a system that accommodates both mutation and selection.
Human beings do not only rebel. We also create. We force at least a certain amount of mutation, even when systems resist. Consider that, in recent years, one of the fastest-growing occupations in health care has been medical-scribe work, a field that hardly existed before electronic medical records. Medical scribes are trained assistants who work alongside physicians to take computer-related tasks off their hands. This fix is, admittedly, a little ridiculous. We replaced paper with computers because paper was inefficient. Now computers have become inefficient, so we’re hiring more humans. And it sort of works.
Not long ago, I spent a day following Lynden Lee as he scribed at a Massachusetts General Hospital primary-care practice. Lee, a twenty-three-year-old graduate of Boston University, is an Asian-American raised in Illinois, and, like many scribes, he was doing the job, earning minimum wage, while he applied to medical school. He worked for Allan Goroll, a seventy-two-year-old internist of the old school—fuzzy eyebrows, steel-wool hair, waist-length white coat.
Lee, wearing the scribe uniform of neatly tucked oxford shirt and khakis, went to get the morning’s first patient from the waiting room. He’d developed a short speech to introduce himself: “I help take notes, so that Dr. Goroll can spend more time with you instead of typing at the computer. But, of course, if there’s anything you need to say, or would like to discuss with Dr. Goroll, in private, I can certainly leave the room.”
“It’s fine to know your ABCs and your colors, but really you just have to be able to sit still and control your bladder.”
Cartoon by Barbara Smaller
The first patient was Zoya Shteynberg, a fifty-seven-year-old immigrant from the Soviet Union with copper-red hair and red-rimmed glasses. She is the wife of a dentist, who is also a patient of Goroll’s. “I take care of his whole family—his mother, his wife, their daughters,” he said. “Zoya runs the office.”
Goroll faced Shteynberg across his desk. To his left, his computer sat untouched. To his right, Lee stood behind a wheeled laptop stand, his fingers already tapping at the keys. He’d pulled up information for Goroll to review as he came in—the notes from Shteynberg’s last visit with him, and recent visits to other specialists—and was starting to write a new medical note. The story Shteynberg told was complex, and unfolded, as medical stories often do, in pieces that were difficult to connect. She had been having sudden, unusual episodes. They sometimes made her short of breath, at other times nauseated. While driving her car, she had an attack in which her heart raced and she felt so light-headed that she feared she might pass out. She had a history of high blood pressure, and she had frequent ear congestion.