Doctors ask engineers to spend more time in the hospital before building apps
cnbc.com
cnbc.com
In the US healthcare system, clinicians and the business often have opposing objectives and values. This is starting to change with value based care becoming more popular, but it's still all about providing what the business wants, it just happens to align with the clinicians more these days. You'll still need to support IE9 due to that botched Vista upgrade, build out a custom EMR integration, and deliver whatever random feature the sales folks promised (can you automatically fax things?) before you can move on to the features that the clinicians actually want.
The system itself is how we ended up with billing-driven documentation EHRs like Epic. Paradoxically, due to massive adoption, I think Epic and Cerner are some of the only places where real innovation could happen. I think even huge companies like Apple, Amazon, and Google will have a hard time breaking into the space, no matter how much cash they throw at it. For them, the only answer is to go fully vertical like Kaiser-Permanente, but I doubt they have the stomach for this.
Q: Okay, how do I pay?
A: You don't pay for health care.
Q: I'm American. I'm not part of your health care system.
A: That's all well and good, but we have no way of knowing how much to charge you, how to take your money, or where to send it. Have a nice vacation.
The clinic probably maintained some accounting records, but they simply had no billing system.
When I was an American military wife, I mostly just flashed my military ID, made an appointment, picked up my meds, etc.
I was diagnosed with atypical CF in my mid thirties and some of the things I was prescribed were not on the formulary of the military hospital. I went in town and had a co-pay of (IIRC) $13 per prescription. One day, I tripped across an old receipt: More than $1200 worth of pills with a $39 co-pay. Probably three months worth of digestive enzymes.
I was also seeing a specialist at a clinic at UC Davis Medical Center in Sacramento. I had been a few times when I noticed a sign prominently displayed on the front desk announcing that they would not see you if you owed money. I asked the person at the desk if I owed anything as I had never paid them anything at all. Surely, I owed some co-pays.
She checked my records. Nope, I didn't owe anything. I was all good.
Well, that was weird. But I was fighting for my life, so I shrugged and moved on with my life. I didn't have the energy to figure out what had happened.
Some years later, I was talking with folks on a CF email list and, silly me, I remarked that "I guess the CF Foundation picked up the co-pays or something." People vociferously informed me that, oh, no, that is not what happened. That's not something they do.
No clue why I was never billed at all by UC Davis Medical Center. But I (apparently* ) wasn't.
I don't know how the military handles it. But when I was a military wife, no, I generally did not see medical bills of any kind.
* I was extremely sick. It's possible my husband paid the bills and I just didn't realize it. But I don't think that's what happened.
We don't need to look to other countries at all to try to figure out how that's done. It's done right here on American soil every single day for military members, military retirees and their dependents.
All we need to do is figure out how to expand on that existing system. And perhaps one first step would be to change the rules such that anyone who serves in the military gets medical benefits for life, even if they don't stay long enough to retire and get all those other benefits.
It's never sat well with me that it is possible to be a veteran and have no benefits at all. Giving all veterans medical benefits would begin expanding coverage in the US under a system where billing is the exception, not the rule.
I hate the civilian US medical care system and it's fucked up coverage. I've been a military dependent basically my entire life. My experience of medical care is vastly different from that of most Americans and it's a crying shame we don't do more for our citizens in that regard.
I can tell you active duty is different from what retirees deal with. Also "vets" doesn't necessarily mean they are retirees. If they didn't serve long enough to qualify for retirement, it's possible to be a veteran without still being part of the military benefits system.
You actually have insurance in the military. When my husband was on recruiting duty, we did not live near a military base. I had to deal with insurance at that time.
But when you get treated at a military facility, you show your ID and there is no bill -- at least, this was true back when I was a military wife.
That is, the healthcare system she's talking about is the one provided to members of the military.
What fraud? Going to the doctor is literally useless unless you're ill.
They will literally send you away home if they find you to be fine. The doctors and nurses and personnel and what have you will also get mad at you for wasting their time unjustifiably (and I've done this myself and oh boy they left an impression on me).
If you mean Government fraud, from the ones planning the system yes, indeed, all documentation about how much a healthcare center "costs", how their location and capacity is decided, and etc... should be open and easily accessible to the public.
Medication is partially subsidized and never given for free at a medical center or hospital unless it's an emergency, older than 65+, disabled, etc...
Recently, the government ordered to make like 1200 common meds cheaper (link in Spanish) https://cadenaser.com/ser/2018/12/29/sociedad/1546084258_187...
And also, what abuse? If medical care is free and drugs are cheap, the only real abuse is drug abuse (by either seekers or medical personnel). With free access to proper care those drug abuse problems will sharply decrease, killing the market (the cause of the other half of drug abuse).
The only reason there is medicare fraud to worry about right now is because not everyone is supposed to be on it, the "fraud" is attempting to get free health care. Which wouldn't exist if everyone had it.
This is naive. The source of income (whether it's insurance companies, the government, patients) are not the people who actually buy medical supplies for the hospitals. The simplest way to commit fraud is to charge the insurance company (in a privatized system) or the government (in a public system) for large amounts of care for fake patients in fake cases, which is only caught if an audit shows a mismatch between claims and supply, e.g. a hospital claims that it dispensed 5,000 doses of a $10,000 drug but can only show a purchase order for 100 doses (leading the hospital to fraudulently get $499 million).
You would think that the way to deal with that issue is to vertically integrate, i.e. the hospital issues orders for medical supplies which it doesn't pay for directly, and the medical supply company is compensated in some other way, probably by government funding. But this turns into a government-run market and it has all kinds of issues. Without pricing as a guide, hospital doctors over-prescribe supplies whose real price is far higher than older but similarly effective alternatives. Drugs which the hospital didn't order, but are absolutely crucial for patient X, are either completely unavailable (if the official supplier doesn't stock it) or tied up in medical bureaucracy (to get a special exemption for a special delivery of the drug). The quality of patient care suffers as a result.
> The simplest way to commit fraud is to charge the insurance company (in a privatized system) or the government (in a public system) for large amounts of care for fake patients in fake cases
Insurance fraud is a problem for the insurance company. They deal with that already so it's not relevant here. And a govt hospital can be audited just like any other govt entity.
Since almost all healthcare in the US is private (hospitals, doctors, clinics, etc.) then, yes, it needs to involve money since all those entities will want to get paid. And, no, the government can't take it all over since everyone will fight it (and win).
>Just a "here is the medical care we dispersed, on this date, to this person, it took these resources, these people administered the care." No following up every record for payments, no arguing with insurance companies over the price.
This is basically existing medical billing without the follow through (what was done, why, when and by whom). Not sure why you think money (ie: paying hospitals, doctors, etc.) needs to be removed from the equation for it to work.
>The only reason there is medicare fraud to worry about right now is because not everyone is supposed to be on it, the "fraud" is attempting to get free health care. Which wouldn't exist if everyone had it.
Fraud is also doctors, hospitals, etc. billing for things they didn't do or didn't need to do.
a clinic could mis-report (over-report?) how many patients they treated, and/or the procedure. They can then claim back more money than they actually spent, netting easy profit.
Some years ago, I met a doctor on vacation - bit of an ass, but whatever
Last year, I found out he’d gone to prison for “performing procedures” that he was mot present for, including some whilst he was on the beach in Fiji with me!
So, the federal government already has procedures to catch cheats at every level.
A year or so later I switched to a dentist who was closer to my office. I told him I had had three cavities but they weren't showing up on the x-rays he took. We did two or three sets of x-rays before we figured out they were never going to show up because he had just been billing my great insurance for work he didn't actually do.
This is not possible without socializing the entire economy. At some point, you have to pay doctors, nurses, staff, equipment manufacturers, etc.
And in the US it's not.
Assuming that you can simply remake a massive chunk of the economy (hospitals, doctors, nurses, clinics, etc, etc) to be government owned is silly. People will protest, lobbyists will be paid and it won't happen. If your only solution to the problems people point out is essentially magic then, no, it's not a valid solution.
It is never "free" (almost nothing is). Costs are usually covered through (forced) mutualization (usually through taxes).
All of which depend on public subsidy.
Well you are conflating a few things here, it not black and white. It is funny to see how stating something that seems obvious to me gets me downvoted and categorized as an extremist anti-socialism...
I see some evils in socialism, but probably not the one you believe. For instance claiming that healthcare is free in a socialist country is one of the most evil aspect of it. My main grief is that people treats it as something that they can waste and don't need to be careful about. Same for "free" universities: student thinking it is "free" don't have much pressure to actually take the most of it and be careful about their choice (let's do a first year of sociology studies after high school because I don't know what I really want to do, and then I can still do a first year of psychology studies, and I'll figure later what I'll do with all this...).
On the other hand, after growing up in France and now living in the US, I learnt that this is all not free and I consider this very previous for the French society. I won't advocate against these welfare benefits, on the opposite I think they should reinforced in many ways however I would like the state of mind of people to change with respect to these "free" benefits, starting by stopping to use the word "free".
As a concrete action, I would send the full healthcare statements to patients, showing how much it costs and how much the taxpayers money is offsetting. I was in the hospital in France multiple times, I have no idea how much it costs, I didn't pay anything as far as I remember, and didn't have a statement. The same approach can be used for University and other welfare benefit.
2. Why do you expect people to refrain from using services they've been forced to pay for?
So the question could have been: do you think we should have free/socialized streets/hospitals? If not how do you think they are different?
But suggesting people who oppose publicly funded freeways should boycott publicly funded freeways is silly.
Imagine an office Christmas party where everyone is told to chip in for refreshments and then the refreshments will be whatever the boss ends up buying with that money. I may not like that arrangement, and may prefer to keep my money and bring my own food for myself. But, given that I have to pay in, I feel no need to abstain from eating the salad that the boss ends up providing using everyone's money.
But this is the point, you were "forced" to pay for something and you would be okay with not getting it. If only the people who paid for the Christmas party were invited that would be okay.
Do you think this reasoning should also apply to streets and hospitals?
(I am specifically referring to using the word "forced" and the moral implication of using it)
Probably not.
But neither do I find it hypocritical to utilize publicly funded medicine (since you already paid in) while also opposing it (because you would be willing to forgo it to avoid paying in). The opposition is perhaps cruel or inconsiderate of others, but certainly not hypocritical. People who construe it as such are either confused or intellectually dishonest.
We want an audit trail, but most of the transactions are made within a single business entity, e.g., from the stockroom to an assembly area. We've had process improvement projects that reduced the number of SAP transactions required to make something.
So maybe the key isn't so much having a government run system, but simply reducing the number of entities. For instance a hospital doesn't have to make a claim to Medicare, if the hospital is Medicare. Also, the game of figuring out how much to bill the patient goes away.
We don't even know how many entities there are in the medical system, or how much money is going to each one. Were I inclined towards cynicism, I'd suspect that this is by design.
Right now even Medicare/Medicaid need lots of process to verify you are eligible and/or enrolled. That wouldn't be a problem if everyone were covered automatically.
Folks who view single-payer as a system without checks need to know how those checks do in fact occur.
Other countries have figured this out. The US could use the experience of our allies that already have systems that are working to design a system for us.
But almost every American I've ever spoken to who hasn't experienced decent national healthcare seem to have a bizzare view that "if it's free then obviously it will be abused", not realising that it's just as open to abuse as a system where end customer are also involved because shockingly customers arent usually the ones committing the fraud.
It genuinely feels like theres a view that some people might not "deserve" healthcare, and the way we determine who "deserves" healthcare is not the very humane "well they need it, therefore they deserve it" but rather "capitalism. Definitely the answer."
Makes me a little sad, but I guess when you have nothing else to compare it to...
The concept of abuse seems hilarious. What abuse? That people might visit their local doctor more frequently? That's a good thing! Many ailments get more expensive to treat the longer they are left untreated.
Once you come to terms with the fact it's permanently cheap/free, the psychological incentive to be wasteful ("use it or lose it") disappears completely. By comparison the American capitalist health system continually reinforces the notion that healthcare has monetary value, which means failing to take advantage of it feels wasteful.
In the UK A&E is flooded with people with minor ailments that could have been treated at home with a first aid kit, or people who are just drunk. The system is definitely taken for granted. People even call ambulances for a ride to an appointment, not even an emergency.
Source: once spent 5 hours waiting to be seen in A&E, sitting on a plastic chair with a broken leg, while kids with grazed knees and people with minor colds were seen before me. If I needed the bathroom or a glass of water, I had to get up and hobble there on my broken leg. The NHS were great once I actually got seen, but they are swamped with idiots demanding unnecessary medical attention, because it's free.
In Australia, ambulance rides are not free unless you have a membership plan or private insurance.
It is absurd that the UK could not at minimum issue fines against abuse of ambulances. (Not to mention abuse of 999 calls!) The fact that this was an issue for more than five minutes is absurd and cannot be used as an indictment against public systems.
And even if the ambulance issue was unsolvable (ha!) it would still represent a fraction of a percentage of the waste occurring in the American system.
We also have issues with prescription abuse, such as people getting prescriptions filled who no longer need them, and don't take them anyway. The NHS tried to fix this by printing the real cost of the drug on the label, so people would be aware of the waste. But they had to stop because it was making people who genuinely needed the drugs feel guilty about how much it was costing. No easy answers to this, but something will need to happen because as I say, it is simply taken for granted by so many people.
Unfortunately, the NHS is something of a "sacred cow", any criticism no matter how evidence based of it is seen as a heinous blasphemy. Which means its problems are always brushed under the carpet and will never be fixed. "The envy of the world", we're told, but I doubt the French or the Germans or the Canadians or the Japanese or any number of other nations are envious of it!
I had half of my face stop working and had recently moved (and not yet registered with a new GP.)
I went to my previous GP and they turned me away (no longer in the catchment area) so I eventually ended up in A&E.
It doesn't help that the local ones near me at the time seem to live in the past... No call queuing or online scheduling, have to call within a 1 hour slot for appointments (so that's an hour of busy tones, oh well let's try again tomorrow)
A GP practice is a private business, usually all the GPs are partners just as lawyers or accountants would be, and the staff such as receptionists are not NHS employees, they work for the practice. If they can't bill the NHS for their services because you're not on their books, they aren't interested. It is surprising perhaps, but many people in the UK are unaware of this, they think the GPs surgery is directly a branch of the main NHS, and get angry about "privatisation" without realising that GPs have always been private.
I'm not sure they are. Here's the (admittedly complex) book: https://www.england.nhs.uk/publication/primary-medical-care-...
Note this is only for England. I have no idea about the rest of the UK.
There is a hospital in my town but it's A&E was closed in 2007 IIRC, so if you can't see a GP you can't even go there, you have to drive a couple of towns over.
If you're outside the catchment area the GP can chose to offer full service; offer limited service; or offer no service.
The full service includes things like home visits, so it's not surprising that GPs seek to limit that to patients who live far away.
For people who are travelling there are temporary registrations, but also GP walk in centres and GP out-of-hours services.
(Note: This anecdote was ~15 years ago. Things seem better now.)
Having failed to get an appointment the normal way, because they didn't have any slots available, I decided to test a theory.
I woke before 8pm and continuously dialled during the time slot from 8am-9am when it was, theoretically, possible to book an appointment. I'd wait for the busy tone, then immediately hang up and dial again. For an hour.
I did not get past the busy tone for the first 2 weeks.
After 9am I'd get through, and they told me there we no bookings available and I would need to call back the next day, and they recommended I call between 8am-9am...
In the end I got an appointment but it took 2 weeks and literally hundreds of call attempts to get one.
Apparently this was because the clinics keep statistics on how long people have to wait between making an appointment and attending.
To keep this number down, they set a limit on how far an advance it's possible to book an appointment.
Unfortunately, it had the side effect of preventing people from making appointments when all slots within the limit were filled.
The _true_ waiting time was therefore grossly hidden from reported statistics. And for many, it was enough to make them give up trying to get an appointment at all, further distorting the reported figures.
It took quite a long time before government, which had set the reporting requirements, learned how they were having the opposite of the intended effect.
In single payer systems, doctors and hospitals bill someone for their service, it's just that the 'insurance company' is the government.
Someone 'out of system' cannot provide the health/ID necessary, ergo, no way for them to bill. But otherwise they do bill.
I used to work at Epic and have seen in the field the requirements the immediate people need as I listed above. Billing driven documentation is an accurate way to label it. The software is implemented to maximize revenue for the hospitals and organizations, without reliable targeted information coverage agencies won't pay for what was supposedly done. There are whole teams in health care and applications from suites like Epic for such teams just for refining billing. A physician knows what they are ordering for a patient, a temp worker downstream refining billing data doesn't, therefore prioritizing accurate data from the physician will result in better likelihood of obtaining claims downstream. That however competes with the immediate need of the patient.
To anyone interested in AI in healthcare, I suspect that datasets of procedure and diagnosis billing codes could be some of the most accurate and immediately usable of their size.
[1] http://docs.smarthealthit.org/ [2] https://cds-hooks.org/ [3] https://apporchard.epic.com/ [4] https://code.cerner.com/apps
I do think that SMART on FHIR makes it easier to turn clinicians into software developers, so hopefully that will spur some innovative apps.
If responding to internal emails had a billing code, I think they would fight over who gets to respond.
It would be better if we allowed departments to build their own software, because our in-house software is honestly the only stuff that truly does the job right, but I don’t see that being prioritised. So having contractors hire a few doctors is probably the best we get.
This is my current experience. The person bankrolling the project delivers lists of requirements, and nearly half of them end up being removed later when someone "in the trenches" either says they don't need/want it or it's too confusing of a feature.
Another part of the problem? "Confusing features" for doctors includes some very standard app features, like back buttons and refresh buttons. This honestly frightens me. We had to remove the back button -- which was requested by the buyer -- because it became a patient safety issue.
At least we don't have to target IE9.
For larger outpatient practices that are participating in value based programs (ACOs, care bundles, etc.), such as the type apple amazon or google may choose to work with or, less likely, build, there’s less of a need to rely existing EHR vendors and a greater likelihood to rely on a variety of tools that are able to interact with each other.
The trend is for more and more care to move outpatient. There’s opportunity for innovation there.
Having a nice audit trail of who gave that Tylenol and when makes life a lot easier.
For instance, when I sign lab results I get to see the references for twenty year old subjects. It would be much more helpful to see the patients last lab result (in 60+% of the cases this is available).
Another example is in the ER where we have a list of all the patients. There is a column for my name so that I know which cases I am handling, unfortunately that column is too the far right and only visible after resizing the other columns. This setting is also not saved so each time I open the list I have to resize over and over again. If you could move that column to the left would be great, or even just bold font my patients' name.
The major problem that I see is that we have:
- huge monolithic software that make any change a living nightmare
- all changes are treated as we were doing open heart surgery. Most stuff we do is trivial but having a standard that high makes it almost impossible to deploy updates - especially the minor changes that really would change things.
- 80% of users complain about the software but very few understand the underlying problem.
- much of our software is spec driven - I can sign my lab results and I can see the patients in the ER, no one bothered to add the last tweaks to actually make it easy.
For some reason we keep getting features that few of us actually requested but that often make sense in that they are life saving, that is if people actually used them. I have a ton of indicators flashing all-over the place and after a while your brain simply adapts and ignores them. I doubt that anyone has actually done any analysis to see if these tools actually save lives.
I've been involved in some projects when I've spent 30 minutes with UX people and then never heard back from them. When the final product arrives it is full of annoying flaws, e.g. the latest software I was involved in the work flow is: 1. click on "open software" from the patient chart 2. a new window opens where I manually have to click on "log in" (note, I'm not adding a password) 3. the UI goes into authentication 4. the UI goes back to the login screen 5. the UI asks me a question that I _always_ answer the same thing to 6. I actually get to the data I was interested in
The most annoying part is number 4 - if I accidentally click on "log in" everything breaks and I have to close the window and redo everything from start.
Most of these UX issues fall under the category - murder by a thousand cuts. It is mentally tiring to be faced with all these issues but none of them is like open heart surgery where one mistake can be fatal. What happens is that doctors/nurses become tired and don't put the effort into the patient interaction where the actual value in healthcare is created. I'm pretty sure that bad UX in the end kills many more patients through this than malfunctioning critical hardware.
I truly wish that people in this forum that create health-care software think of UX and actually use their software more than just "I clicked through and everything works". Your bosses will probably never ask for UX features because they have a deadline, but you are in charge of designing and during that process it is easy to fix many of these annoyances (e.g. just disable the log in button).
Healthcare software exists in a weird trap where it can't move too quickly because hospitals are resistant to change, but it's software, and the software world normally moves quickly (including things around software like UX and SDLC concepts and ideas).
Simultaneously, hospitals can be slow getting off of deprecated platforms because of dysfunctional IT leadership, bad budgeting, and staff that can't or don't want to learn new software.
Healthcare has a lot of issues, EPIC was a stone-walling garden, Siemens wanted to steal stuff, OpenVista was a non starter, Philips talked a big talk but never followed through, Not everyone was truly HL7 compliant, Users didnt believe on Apps on the iphone/ipod-touch as the screens were too small and the average age of users was ~57, The number of employees in a large hospital is in the thousands, Patient Entertainment systems were snake-oil-jokes, "medical grade" devices were a fraud, and selling into them at this time was a unique process for every hospital -- and while the users (clinical staff) really really want to (and do) provide good care, training 1,000+ Staff/Nurses on your new tech is very daunting.
Obviously we have made a ton of progress in tech in healthcare, but finding a way to consume more time with staff/processes can be a difficult problem to figure out access.
Silicon valley needs an actual research hospital for tech - if I were throwing my billionaire last name on SFGH/UCSF/Oakland etc's hospitals - I'd do a lot more than just buying the name of the building - seeking how to work together to make an SV research hospital happen in an innovative way.
(We had a fully integrated HL7 iphone app which could interact with OpenVista, and other systems like Vocera and Philips and Siemens systems. We had a channel to work with hospitals around here but the screen size and costs of providing handhelds to nurses were too high for 2007. YC Turned us down, Epic and Cerner would allow integrations... We opensourced it to Openvista.)
Too bad Theranos salted the earth for much of this innovation for the next decade. But it's still happening, starting with EKG and ultrasound.
Whole-body ultrasound? How would an AI understand how to interpret images with low signal:noise? Who will be performing the actual ultrasound image capture? Who will be ordering the imaging tests? How will an AI understand a patient that can't meaningfully interact with an AI?
What's the utility of "EKG" [sic] for diagnosing non-cardiac problems? Or, do you come from the perspective that all medical problems can be diagnosed with an ECG, urine analysis, ultrasound (of what?), blood test, and CT scan? Do you realize that an ECG is more complex than a single vector ECG via Kardia mobile?
I thought we were trying to reduce healthcare costs, but you're recommending over-utilization of expensive diagnostics?
Why are you limiting treatment to doctors only, why not have AI do everything?
Everything you've written demonstrates an extremely limited understanding of the practice of medicine, a characteristic far too common shared by those who are trying to "disrupt" medicine.
> What's the utility of "EKG" [sic] …
What’s the Difference Between ECG and EKG?
The fact of the matter is that an ECG and an EKG are the exact same thing. That’s right, the most surprising difference between an ECG and an EKG is that there is no difference at all. Both ECG and EKG stand for electrocardiogram.
So, if an ECG is the same thing as an EKG, then why are there two different abbreviations? It’s actually quite simple—when the word electrocardiogram is translated into the German language, it is spelled Elektro-kardiographie. EKG is just the way some people choose to say ECG based on this translation.
From http://neurosky.com/2015/05/ecg-vs-ekg-whats-the-difference/
This is where things are at, whether you like it or not, especially for the working poor who can't afford to fork over a few hundred dollars every time something feels "off". The current crop of devices is not affordable to them, but 5-10 years from now they'll be bundled in cereal boxes. Hook up sensors to wearables, catch diseases early and at a massive scale, cure or treat them before they get extremely expensive. To me it looks like it's the only way out of the ripoff "healthcare" scheme we're in right now. I'm pretty convinced the solution to the US healthcare problem will be technological in nature.
And don't tell me universal healthcare will fix things. It won't, because US doctors (unlike their counterparts elsewhere) expect to be earning a pretty penny after they go through the trouble (and expense) of educating themselves for a decade, and that's not going to change. There simply needs to be less demand for doctors, and the ones that remain should be able to use their time efficiently.
But you think they'll fork over hundreds of dollars for misguided tech toys that won't even address their actual medical problem?
>Hook up sensors to wearables, catch diseases early and at a massive scale, cure or treat them before they get extremely expensive.
Which diseases are you talking about? Hypertension? Diabetes? Obesity? Smoking? You don't need fancy medical toys to diagnose these problems, yet they're responsible for most morbidity.
Do you think a medical toy will somehow detect cancer? How exactly do you think this would work? Someone feels "off" one day so they plug in a "device"... ECG? Ultrasound? Urine analysis?
>To me it looks like it's the only way out of the ripoff "healthcare" scheme we're in right now.
The ripoff isn't from physicians practicing medicine, it's from outsiders who interfere with the patient-physician relationship to get their slice of the pie, ie insurance companies, healthcare MBAs, device manufacturers, pharmaceutical companies. You think tech will replace physicians, but it's obvious you're completely misguided regarding the actual source of problems in healthcare.
It doesn't even have to be acute symptoms, either. A large healthcare company a friend worked at was working on a smart heart monitor that for some reason they wanted to connect to an app. In their head, the app would be used by both the patient and their doctor who would check on the patient. If they have a lot of patients, that's an overwhelming amount of data streaming in 24/7. The time commitment to really evaluate those data for anomalies was too high, as were the stakes. Doctors were scared that if they missed something they might be held liable for unrelated medical emergencies which is terrifying for them. At the time, algorithms were really not good enough to catch the really subtle markers of an impending medical problem. At least according to the guy that told me this, he was a biomed/hardware engineer not a programmer or statistician by any means.
Even if you had some legalese associated with the product to make this a non-issue, doctors still wouldn't trust the idea. So they pivoted the technology to something else that was more traditional. It is much harder to pursue justice for an algorithm than a human. I guess what I want to get at here is: sometimes the software and hardware are working as intended, but subtleties can be lost on the technical side (programmers, biomed engineers) can kill a product. Stuff like market research, liability and legality, and public perception of the tech.
There's no rational reason why I need to drive to a lab for bloodwork or simple diagnostics, and have a human do it: a robot at a local convenience store should be able to do the job. There's no rational reason why I need a doctor to misdiagnose my elbow pain as something requiring surgical intervention (I just stopped using my laptop in bed and it went away). Another doctor ordered a ($900) MRI to diagnose pain in my left shoulder and then told me I have a SLAP tear there based on extremely blurry results (again $$$$, surgical intervention, and 6 months of recovery). Bullshit, bud, I don't - it's a non-dominant arm, and I'm someone who doesn't do a lot of throwing or work above shoulder level. It was that dang laptop in bed again. Someone with weaker critical thinking skills and google-fu would be thousands of dollars poorer thanks to taking that doctor's "advice". In fact they could end up with a permanently fucked up shoulder and elbow, too.
Did you know that medical errors are the third leading cause of death in the US, right after heart attack and cancer? Seems to me that "human" doctors are also a dangerous proposition.
Honestly, what are you talking about? A doctor's visit costs between $0 and $150, depending on insurance/government, and it is a focused encounter to determine the source of a medical complaint and a most likely effective treatment for that problem.
You want to stick a one-lead ECG on someone and expect that it's supposed to spit out a diagnosis, or heaven forbid, a recommendation to see a doctor who can actually figure out how to diagnose and treat the patient.
Your statement in fact points to the uselessness of this proposed medical device if it can't actually figure out what's going on and instead will send you to an actual expert (physician). How reliable would it be for everything else it "diagnoses"?
And who do you think covers the remaining $150-infinity?
>> You want to stick a one-lead ECG
You're not arguing in good faith. Goodbye.
You haven't come up with a single situation where a non-cardiac medical problem can be diagnosed solely with a handheld single vector ECG.
You don't mention anything about false positives or false negatives, sensitivity, specificity, pathophysiology, anatomy, pharmacology, diagnostics, or medical decision making.
You have no understanding of how your magical tech device would bridge every aspect of the practice of medicine, but you make an audacious claim with a bit of hand waving, saying "this will work better than physicians, and cost far less".
Primary care office visits of low complexity are typically less than $150. Suggesting otherwise is a sign of profound ignorance.
Where's your citation?
Here's what the CDC says about leading causes of death:
https://www.cdc.gov/nchs/hus/index.htm
Heart disease 257.6 (2000) 168.5 (2015) 165.5 (2016) Cancer 199.6 (2000) 158.5 (2015) 155.8 (2016) Chronic lower respiratory diseases 44.2 (2000) 41.6 (2015) 40.6 (2016) Unintentional injuries 34.9 (2000) 43.2 (2015) 47.4 (2016) Stroke 60.9 (2000) 37.6 (2015) 37.3 (2016) Alzheimer's disease 18.1 (2000) 29.4 (2015) 30.3 (2016) Diabetes 25.0 (2000) 21.3 (2015) 21.0 (2016) Influenza and pneumonia 23.7 (2000) 15.2 (2015) 13.5 (2016) Nephritis, nephrotic syndrome and nephrosis 13.5 (2000) 13.4 (2015) 13.1 (2016) Suicide 10.4 (2000) 13.3 (2015) 13.5 (2016)
https://www.npr.org/sections/health-shots/2016/05/03/4766361...
If you go into the hospital because you have stage IV colon cancer, and you die because a palliative surgery resulted in infection, you died because of the colon cancer, not the infection.
So you were attempting to provide charting capabilities on the first generation iPhone? Honestly even now with larger screens, etc I can't imagine that working well on anything smaller than a tablet, and HL7 would only be a selling point to potential partners or investors - 90+% of potential end users wouldn't have a clue about it. You might as well say "our app supports JSON and EDI!"
In 2007 that would have been a dancing bear - amazing to see, but not because of how well it dances.
WEll - we had an ESB appliance which would tie into the various HL7 capable systems such that we could integrate for certain services, and provide interfaces/applications which turned an ipod touch into a quick duty/assignment/nurse-call/alert/control device.
Basically the intention was initially to integrate the ipod touch as effective a remote to the hospital.
Tie in with RTLS, assignments, results, orders...
So, yeah - it worked pretty well. Had support from nurses and doctors, but it was too early...
We were told by too many people it was too expensive and too small and nobody would want to interact on the phone.
We knew the ipad was coming... but failed to convince people.
About two years afterward, the iPad came out - we had already folded and released what did open source to OpenVista, and then Dr. Chrono was able to get traction where we couldnt.
(We were only two founders, no funding.)
Recall that scene from (was it silicon valley) where they did the whole thing on the whiteboard at the VC - where they stole the idea from there... yeah that happened to us.
https://www.vocera.com/solutions-support/easter-eggs
> costs of providing handhelds to nurses were too high for 2007
Perhaps you should have looked at integrating with the Ascom handsets.
It was by far one of the coziest jobs I ever had. Low stress environment, redundant meetings, etc. But development of any kind of god awful. It was extremely sluggish, lots of red type, and seemed to follow a manual QA approach over any sort of automated testing. Things were just too lax in general.
Myself and another junior developer left after we noticed that an intermediate engineer on our time hadn't committed in over 3 months.
My point of this story is that hospitals didn't seem to attract/retain passionate software developers. With high turnover or apathetic developers, most software built custom for hospitals is probably Frankensteined.
The jobs are easy, and you can go months without doing any real work whatsoever. The company might not even care (since for hospitals, sales cycles are often measured in years, and minor upgrade cycles are often measured in months).
But this kills any desire to do anything. Almost no developer with any motivation or skills, wants to work somewhere where they do nothing useful and have no real work to do -- even if the pay is good, you can literally feel your brain rot out, and you start to be worried you'll never get hired at a "real job" ever again.
It's just a bad cycle of events all around.
With some effort and/or ingenuity, you can probably take time with your users, one way or another.
Yet in my whole professional life I've never had a chance to do it despite putting the idea forward.
One of my old colleagues who managed to observe a client was met with hostility and questions from the people he was observing.
Other times clients want to dictate and have no dialogue in defining requirements.
The entire project, of course, was eventually cancelled.
I agree that some developer probably shouldn't be talking to customers but overall they should. I have had many occasions where we received a spec and after discussion with users quickly saw how we could meet their needs in a much simpler way than the middlemen had come up with.
Been there, done that. Once spent months working on a project but when I finally got to talk to the users they told me it didn’t do what they wanted and even if it did they wouldn’t change their working practices (union rules maybe?)
At the end of the year the manager who had assigned me this project dinged me on my appraisal for not having delivered it.
> the most powerful method of requirements gathering was observation.
But the vast majority of my time has been at companies where engineers are never cleared to travel to meet with customers and gather information. It's insanity IMHO. It was the one bright spot about doing contract wor.
The problem though is that university curriculum hasn't caught up with the reality yet which is a role called 'Product Manager'. While I was in college there was a mention of 'System Analysts' whose job was roughly matched that of product managers of today.
In general though, I doubt any reasonably sized company will let engineers gather requirements. The divide between product manager and engineer has only hardened over last few years or so.
Neither is learning to fly a plane. What's prized is the ability to do it in such a way as to not crash. The same applies to software engineering.
It'll be so simple that it's equally maintainable.
The real issue is adoption, but that's expedited if you're a doctor who's also a software developer and makes it easier to sell.
Basically: individually these skills might not produce truly impressive results. Combined they produce great value.
I have yet to figure out what my second "talent" in my talent stack could be. When I do figure it out I have a feeling things come much quicker.
As a semi retired software engineer and currently 4th year Med student, I still maintain a dream of building a usable EHR that puts the clinical, patient-focused side of things first. Currently implementations allow for increased billing recovery, but at a cost to both doctors and patients.
I just don’t know how you’d start in competing with something like Epic or Cerner, from a business side of things.
Everyone I work with cares really strongly about making a really good product. We have great designers/UXers, a lot of experience in building different pieces of the workflows that tens of thousands of doctors and hundreds of thousands of nurses, MA, PAs, front-office staff _and_ patients, but when you spend a whole year readying for ICD-10 and then some yokels in DC push the deadline back a year... I belabor my point.
Engineers wanting to start a health care company should try working for a big EHR company first. Then go start somewhere else using modern technology, modern development practices with just a little more wisdom. Maybe.
They also have that they're not eClinicalWorks or descended from Medical Manager (Intergy), that has to count for something!
I don't work with them anymore due to some fundamental differences (it's been almost a couple of years) but thought it was related to what you're talking about and possibly something you'd be interested in.
Possibly the only way you could compete with Epic or Cerner is to innovate on things in a way that can't be denied. It wouldn't be the first time slow giant companies fall because they did not advance, but it is much harder because the barrier to entry is absolutely enormous.
Products like LIMS and hospital systems are hard to replace because of vendor lock in and the cost to replace it all, not regulatory hurdles.
One of my previous professional experience was working for a company that delivered a complete hospital information system that was used in two of the biggest health institutions in the Middle East.
Initial software development was done offsite, but then, the owner and CTO of the company thought it more wise to bring in the developers on-site. On-site here meant that our team was provided an actual area in the hospital where we were given freedom to observe, collect and synthesize as much information related to the system we were building.
One major challenge we faced was that, for example, we have three doctors all specializing in the same category, i.e. cardiologist. All of them would have different ways of wanting how the technology will support their process. One would want information laid out in a different manner, with quicker access to other information he need from other facets of the system. There's just no way to standardize a specific process. This lead to us delivering solutions that allow the doctors to customize as much as they can of the application based off their preferred procedures.
Being there in the hospital itself I would say has tremendously helped the team deliver a lot of innovative functionality that I have still yet to see at this day and age. I was interfacing HL7 data with Siemens and GE Radiology and providing the doctors to automatically perform dictation through Philips Dictaphone - where the recording is sent to an offshore transcription company in Asia, and the data returned and tied to the actual radiology exam it is designated for - all under intense security, compliance, and anonymity.
I've also observed through working in different hospitals, there is a lot of variations in the workflows, hence the necessity for engineers to actually be present and on-site. This provides the developers a real-world picturesque view of what needs to be built that will make every hospital staff (doctors, nurses, aides) become very productive.
Maybe I'm just crazy!
It doesn't take years of experience in the target field. It just takes hours of watching and listening and figuring out what people are actually trying to do.
But, for companies that can't/won't (I consulted for one that wouldn't even hire professional BAs - they expected line staff to write the specs)... at least have the PMs and programmers go spend several hours in the client's dept. (around month-end is usually good) to get a feel for how things actually work.
Those data people are called "medical scribes," my doctor has started using one. Seems like they're mostly pre-med college students looking to get exposure to healthcare environments.
I don't think doctors (or anyone else for that matter) is going to tolerate being followed around by an assistant who's going to nag them about how to do their job.
The issues the NHS has with IT (with the glaring exception of WannaCry) are related to the vast fortunes they expend with outsourcing companies for custom software that doesn’t work. Doing the same thing but on Ubuntu won’t be any better. But the engineers don’t care, they have an ideological axe to grind so they focus on something irrelevant.
Additionally, in my experience the best engineers have been part product manager anyway, just as the best product managers have been part engineers.
This compartmentalisation in the name of efficiency is actively harmful. Developers should get out more and get first hand experience of the environments they develop software for.
I once had a PM tell us to do a feature a certain way, despite engineers saying we thought it was dumb. We shipped and had lots of user complaints, and lost millions of dollars ultimately in lost revenue due to cancellations that we think were at least in part to this. We eventually reversed course but much damage had been done.
Afterward there was a witch hunt (which I staunchly oppose, but I digress). It turned out that the PM had taken the word of another PM who in turn heard from another that had gone on location and misunderstood what the customer was saying. To save a few thousand bucks the company only sent one person and expected them to brief everybody else on their findings. In hindsight I'm sure that skinnier travel budget wasn't so worth it.
“Well, no, my secretary does that...”
If you're not solving problems you're just a medoicre code jockey. I want to work with people who build iseful things, not people who stop and understanding syntax and think that code is a goal into itself.
If you work in a place like that, I'm sorry, that sucks.
I had zero domain knowledge when I joined. However the majority of our support team were hired from our customers, and they know the domain very well. We include them when we need to implement new rule changes and other features, to make sure we don't miss things.
After a few years of working here I of course have a lot more domain knowledge, but it's always helpful to be able to quickly run some questions past someone who knows the domain well should I happen to get some doubt in the middle of coding.
Weren’t given any time to learn it. FTFY.
Rest assured that anything that makes a significant impact on health will cause people to completely freak out if it hasn't been vetted via the current medical system, even though this vetting process kills a lot of therapies that people then lament that they wish they had access to.
I also no longer belong to any CF lists. It's too much drama. I was constantly attacked and, among other things, accused of irresponsibly endangering lives for trying to talk to people about what I found helpful.
Sounds like userblaming. Works wonders when the users aren't the ones choosing the software to use, or have much input.
tl;dr: get to something most useful soonest by quick, small iterations until it's satisficing. No BDU project fails, and no assumption fails.
The article highlights how docs are spending too much time doing “desktop medicine” related to paperwork and billing. There’s a whole layer of adminstrative staff at every hospital doing this stuff too.
If we get Medicare For All someday, what will the impact be on the healthcare tech startup space?
For example I met someone at a bar the other day whose startup was all about managing medical bills. Consumers can scan their bills and they’ll look for optimizations and payment plans and budgeting or something. This would just go poof under M4A.
It really does helps to “eat our own dog food” and spend time in hospitals.
For example I spent few days in large New York hospital studying operations of secure drug dispensing cabinets before building solution for medications security analytics.
Tons of interesting data with valuable insights on how narcotics are secured and accessed.
Is there any health care practitioner around here with time for a 15-minutes phone interview or willing to exchange a few emails so I can better understand his/her needs?
So, admissions, for example, buys what they want, and don't care about the integration with, say, radiology.
It’s fun when some systems handle a bed-swap gracefully. But others don’t.
Or what happens when you figure out who your John Doe is and how to propagate that.
In other words, decouple system analysis from system design.
I've had the opposite experience. Good software developers are good at gathering and understanding requirements. The information loss from management consultants and software developers is pretty nasty. Frankly, if the the people coding the system are going off a requirements document that they didn't have a hand in then you might as well outsource the development. If the software developers don't become domain experts then you should be worried about the correctness of the software.
I often wonder if the general dislike of DSLs is caught up in this separation.
Customers are also often incredibly poor at defining their requirements, at least in my experience. Like having undocumented routines which are only recalled by that one employee once they have to actually perform them, once a year or so.
Of course it's usually a really critical, time-sensitive issue when they discover that the routine they never told us about hasn't been implemented and thus cannot be done... almost never fails that.
The goal is not to 'document how it's done'.
The goal is to understand 'what problems are being solved, and possibly how to do them better'.
Someone analyzing horses and coaches might have requested more horses or coaches, when really what was needed was this new thing called 'a car'.
So someone who is thoughtful, organized, who can communicate, and who understands technology. Would be a good start.
Without any kind of professional discipline however, it's hard to find and evaluate such people.