CHICAGO — In his address to the House of Delegates at the American Medical Association (AMA) Annual Meeting, AMA CEO James L Madara, M.D. today outlined the challenges and opportunities facing medicine in today's rapidly-changing digital economy. Madara drew a direct line between the technological innovations happening today and the challenges that dotted the health landscape at the time of the AMA's founding, when the AMA played a leading role in stamping out quackery and creating standards for medical education.
"Today we have really remarkable tools—robotic surgery, new forms of radiation treatment, targeted biologics; and we live in a time of rapid development in the digital world—telemedicine as an example," Madara said in prepared remarks. "But appearing in disguise among these positive products are other digital so-called advancements that don't have an appropriate evidence base, or just don't work that well—or actually impede care, confuse patients and waste our time.
"From ineffective electronic health records, to an explosion of direct-to-consumer digital health products, to apps of mixed quality – it's the digital snake oil of the early 21st century."
Dr. Madara also spoke about how the AMA is advancing its mission by partnering with leaders across healthcare that are keenly focused on technologies that work better for our patients and physicians and seeking ways to bring the physician voice into the innovation space. Recent efforts to create an AMA innovation ecosystem include:
- Health 2047, the AMA's integrated healthcare innovation company in Silicon Valley, was launched earlier this year to conduct rapid exploration of innovative solutions to the biggest challenges facing the nation's 1.1 million physicians and the patients they serve. Health2047 is working to catalyze collaboration across a network of partners including technology firms, product companies, providers and payers to drive rapid change and make new solutions possible.
- The AMA Interaction Studio at Matter, the Chicago based healthcare community hub and entrepreneurial incubator, which is enabling physician perspective in ideation and collaboration with hundreds of entrepreneurs working on early stage technologies and solutions.
Through its innovation ecosystem, the AMA is building bridges to tech innovators and entrepreneurs so that physicians have a seat at the table as new products and services are being developed. This ultimately ensures new medical products address real-world challenges for physicians and patients to help improve the health of the nation.
Additional remarks, as prepared for delivery, from Dr. Madara's speech:
"Even those digital products that might be helpful often lack a way of enriching the relationship between the physician and the patient."
"More and more we're seeing digital tools in medicine that, unlike digital tools in other industries, make the provision of care less, not more, efficient. And these digital tools often don't connect with each other—interoperability remains a dream."
"We were told that interoperability was the future; we didn't expect that it would always be in the future."
"The future is not about eliminating physicians, it's about leveraging physicians."
"That means leveraging physicians by providing digital and other tools that work like they do in virtually all other industries – making our environments more supportive, providing the data we actually need in an organized, efficient way, and saving time so we can spend more of it with our patients."
Dr. Madara's full remarks, as prepared for delivery, are below:
Address to the House of Delegates
James L. Madara, MD
Executive Vice President and CEO
American Medical Association
American Medical Association
Hyatt Regency, Chicago
June 11, 2016
Madam Speaker, Mr. President, members of the board, delegates and guests:
Over the last five years I've used these opportunities to outline the progress in our strategic plan:
… Creating the medical school of the future;
… Dealing effectively with chronic disease as modeled by pre-diabetes and hypertension; and
… Creating tools and resources to help physicians better thrive.
We've made significant—and now nationally recognized—progress in all three areas.
I'll provide a full update at the Interim meeting this November. At that time I'll also outline our approaches to help physicians adapt to the MACRA legislation—work that's already started but will be more refined once the final rule is established this fall.
But today, I'd like to provide thoughts on the emerging digital environment we find ourselves in: and what we might do to move toward digital tools that lead to professional satisfaction and improvements to care, rather than to further practice disruption.
First, I'd like to reflect on the work of our predecessors; it provides lessons for today.
When the AMA emerged in the mid-19th Century, medicine in the U.S. was poorly developed; lagging well behind our European counterparts.
Our AMA predecessors engaged the very heavy lifts of stamping out quackery, creating standards for medical education, and developing the first code of medical ethics.
Simply put, the AMA stopped the flow of the snake oil remedies of that time.
Quack remedies—snake oil—were all the rage back then. Here's an example: Clark Stanley, raised as a cowboy in Texas, sold a unique remedy which, he claimed, healed a variety of ailments.
Stanley claimed his body was covered with scars from hundreds of rattlesnake bites … any of which might have killed him but for the benefit of his magical elixir, his snake oil remedy.
Since the elixir contained no alcohol, Stanley extended the sell, saying it was suitable for everyone, of any age, without regard to temperance.
(Incidentally, a skeptic, who was Governor of Texas at the time, heard these claims and responded: "Who would believe there's a better remedy than whiskey?")
It was the AMA that identified these fakes and set standards.
Our predecessors did all of this by inserting themselves into the enterprises of the day—public and private; leading massive change by engaging broadly with society.
Today, snake oil elixirs are a comparative rarity.
Rather, we have really remarkable tools—robotic surgery, new forms of radiation treatment, emerging biologics; and we live in a time of rapid development in the digital world—telemedicine as an example, as discussed in detail by this House.
But you know something, appearing in disguise among these positive products are other digital so-called advancements that don't have an appropriate evidence base, or that just don't work that well—or that actually impede care, confuse patients and waste our time.
From ineffective electronic health records, to an explosion of direct-to-consumer digital health products, to apps of mixed quality.
This is the digital snake oil of the early 21st century.
Even those digital products that might be helpful often lack a way of enriching the relationship between the physician and the patient. It's like trying to squeeze a 10-gallon product idea into a 2-gallon health care knowledge base.
More and more we're seeing digital tools in medicine that, unlike digital tools in other industries, make the provision of care less, not more, efficient. And these digital tools often don't connect with each other—interoperability remains a dream.
We were told that interoperability was the future; we didn't expect that it would always be in the future.
The age of digital snake oil.
Energizing this rush of new products we find popular books predicting a future of digital health care, that in the near future, will bypass physicians altogether—where patients can largely look after themselves.
These extravagant claims did achieve their primary goal: Lots of books were sold. These claims also drew the attention of the lay press and private sector, two groups that couldn't have known any better.
One highly praised book touted how patients could order their own blood tests by the hundreds—do it today!—then follow algorithms to essentially self-treat.
Snake Oil Stanley would be so proud!
Anyone been reading the papers of late? Been following the many evolving investigations and apparent fraud of such touted new pathways? … That hallucination didn't turn out so well, did it?
As one of our presidential candidates might tweet: "DUMB!"
Fortunately, more sober analysis of the current state can be found elsewhere, as in Bob Wachter's wonderful book, The Digital Doctor.
A more promising digital future can be envisioned that enhances the physician-patient relationship, produces better and more efficient care, and allows more time for physician-patient interactions—the type of outcome that has been so falsely promised by much of the current digital snake oil.
But Wachter provides no false illusions as to the current state, and well describes the present. Something I'd call our digital dystopia: from direct-to-consumer digital health devices—which, only in the fine print say "for entertainment purposes only"—to our clunky electronic records, to ICU's that sound like primitive swamps abuzz with a cacophony of bells, alarms, and whistles.
Just as in the mid-19th Century when we separated the useful anti-toxins and compounds like aspirin from Stanley's snake oil remedy, today we're tasked with separating the digital snake oil from the useful —and potentially magnificent—digital tools.
The future is not about eliminating physicians, it's about leveraging physicians.
Leveraging you by providing digital and other tools that work like they do in virtually all other industries—making our environments more supportive, providing the data we actually need in an organized, efficient way, and saving time so we can spend more of it with our patients.
A new AMA study analyzed a variety of settings and type of practices: 50 percent of physician time was devoted to the keyboard—50 percent!
Only a third of their time was free to interact with patients.
To compound this, physicians also spent two hours each evening on the keyboard finishing the data entry from the day… evening hours that used to be spent reading JAMA or decompressing with family.
Our current state? American physicians have become the most expensive data entry workforce on the face of the planet.
What a waste. How frustrating.
Let's face this 21st century digital snake oil the way our predecessors confronted their task in the 19th century: by inserting ourselves into the processes from which digital tools emanate.
So, how do we do this? What are we working on?
To begin with, we're intensively working with vendors and manufacturers as well as the federal agencies that regulate them.
You'll later hear from CMS' Acting Administrator Andy Slavitt on enhanced federal pressure for interoperability and efficiency in our health records. For EHR 3.0, not 1.0.
In retrospect, one might argue that our field was insufficiently embedded in the creation of the first wave of digital products. The result: defective products not informed by physicians.
Today, we're active in pursuits toward correcting this—toward having physician knowledge embedded in the development of new products. Here are a few examples:
First, we're conveying to manufacturers what physicians actually need. Digital tools that add layers onto our day are not helpful—those are digital snake oil, we hate them—hate, hate, hate them.
In contrast, digital tools that would simplify and better organize our lives, and also adapt to the natural variations in our practices—those that would free more time for patient interactions—that's what we want.
Tools like that we'd love—love, love, love. There are too few of these today.
Second, we're forming interactions with the emerging companies that produce health-related goods and services—for example, working with MATTER, a Chicago-based incubator for emerging health care companies.
More than 120 companies are now located in MATTER, as well as our AMA interaction space. There, we inform entrepreneurs of the exact needs of physicians at the creation of innovative ideas. Some of you have participated in this—and for that I thank you.
We do much better if new products and services are deeply informed by our actual problems and needs, rather than flying on an entrepreneur's incomplete views. We bring the granular understanding of the physician-patient environment. That's difficult to discern from the outside.
Third, in January we launched an innovation studio in Silicon Valley, Health 2047. Health 2047—(the 2047 in recognition of our 200th anniversary)—will take many of the problems identified by AMA studies and apply rapid prototyping and design to achieve tools based on physician need.
Emerging prototypes will be iterated with physicians until the tool gets it right. This effort is attracting high-level talent in Silicon Valley. Talent that'll be directed to the problems faced by physicians.
Fourth, while shaping this future, we also need to address the current state. That's why we're identifying workflow and practice adjustments that can produce higher practice satisfaction today.
These digital modules, which we call Steps Forward™, are available to all physicians and can be accessed through our website. I announced Steps Forward last year at this meeting; and since then more than 70,000 users have accessed these tools to improve practice.
New modules are being produced and tested, and CMS has recognized these as a form by which physicians can be acknowledged for practice improvement, under the MACRA law. These AMA Steps Forward modules have, in just the last few months, received more than five national awards in the digital product area.
Several of the new Steps Forward modules address pain points highlighted by physicians in a recent AMA crowd-sourcing exercise. Thanks to those of you who contributed ideas.
Another crowd-sourcing effort—the AMA Innovation Challenge—attracted 23,000 users, and over 100 fully-formed product ideas from physicians and trainees.
Five finalists have been selected and will present their ideas at MATTER this evening. Three winners will then be supported in design, planning, and development. Also in this effort, 1,000 physicians indicated interest in helping to pilot and evaluate such new products.
I emphasize that all of this work is being done while we're intensifying our advocacy work; our work on innovation is coordinated and integrated with our critical work on advocacy.
Thus, we're inserting ourselves in both public and private sectors on behalf of physicians.
In the mid-19th Century, our predecessors fought the snake oil of the day by interacting with all segments of society—both public and private. We follow their lead.
We're now fully engaged on many fronts—engaging not only the important aspect of legislation and regulation, but also directly engaging those who produce the products and services that'll feed our practices … pipeline products that are now being informed from the start—with the knowledge of what physicians actually need.
I'll end with something from Bob Wachter's book: quote —"Even when that wonderful day arrives when we have finally coaxed the machines into doing all the things we want them to do, and none of the things we don't, we will still be left with one human being seeking help at a time of great need and overwhelming anxiety."—end quote.
That relationship between the physician and the patient isn't a transactional one—but it's one that requires time; time that should be made available by helpful digital tools; tools that work effectively as they do in virtually every other field, but ours. We need that…..and we need to be directly involved to make it happen.
What we don't need, is more digital snake oil.
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