Why Doctors Hate Their Computers (2018)
newyorker.com
newyorker.com
Amongst many difficult problems related to this:
-Medicare/Medicaid/Federal spending is half to 2/3 of all medical spending. They are insanely bureaucratic and simultaneously penny pinching. They require lots of things that make everyones jobs harder with no obvious benefit to anyone. They dictate in many ways how software must work in medical settings.
-Doctors in most institutions are not given an adequate amount of time to accomplish all of the things that need to be accomplished to deliver quality care and also get properly paid for the interaction. This in part is financially driven but I would say it mostly occurs because there is little to no accountability for medical systems to operate well or efficiently. In many situations there are perverse incentives to operate inefficiently.
-Doctors make an absolutely shocking amount of substantive errors, 25% of interactions or more. Preventable medical error is almost certainly in the top 5 causes of deaths in the united states.
I could go on and on but cherry picking but I think I made my point that this article looks only at one perspective of one facet of disgruntled personnel involved in a single implementation.
https://hub.jhu.edu/2016/05/03/medical-errors-third-leading-...
IIRC there’s a chapter in the book about patient safety correlating with how “friendly” the OR nurses perceive a surgeon. The implication being that if someone makes a mistake they’re more likely to fess up a nicer surgeon (who will then have the opportunity to correct the error) and more likely to cover it up or ignore if they might get chewed out for bringing it up.
How can we change this culture though? For some reason doctors attract insane lawsuits seeking hundreds of thousands of dollars in damages. People don't seem to be so litigious when they're against rich corporations with lots of lawyers at their disposal.
If this continues, the only possible result is defensive medicine since doctors will need every bit of proof and documentation in order to prove their innocence in the event of a lawsuit.
However that doesn't mean this is the global optimum. There are probably ways to reduce hand off errors, e.g. by introducing hand off check lists. Sleep deprivation errors on the other hand can only be reduced by reducing sleep deprivation, giving crystal meth to the doctor (probably unethical and unsustainable) and by general poka yoke style changes that will have benefits even when not sleep deprived.
So the global optimum can probably be shifted to somewhere where the doctor is not sleep deprived and the hand off is organized. Which is also more humane towards the doctor.
After eg 6h of work, don't accept any new patients, but finish treating the ones you already have, if possible.
In this case one procedural way to make this better would be to teach doctors to write up anything unusual they notice during the day, and read this list of unusual events during hand-off to the next doctor.
Presumably the constraint here is having an integer number of shifts per 24-hour day - 3x8 hour, 2x12 hour, 1x24 hour and so on.
There are articles on how the early aviation had too much pilot egos and cowboy attitude, and how the aviation industry was able to change that and reduce human errors. And how medicine should learn from them, and maybe already is.
Medicine is for a large part trial and error (try this medicine and come and in one week to see if it helped), under high time pressure (general practitioners in the netherlands have 10 minutes to see a patient, including reading up on previous visits, and following up with hospital research results, etc).
Even if you'd try to determine learnings from every error, and put these in protocols to instruct healthcare people to avoid same mistakes next time, would they be able to effectively use this knowledge within the 10 minutes allocated?
Would you mind taking the time elaborate on this? Inefficiency in the US healthcare system is something everyone talks about but concrete examples are few and far in between. I would love to get an insiders perspective on this!
It’s obvious why this might sound like a good idea, but only slightly less obvious why it’s a terrible one. It means that the primary mechanism available to increase profits is to drive up care spending as much as possible. Because if the 80% is a bigger number, the 20% will be too.
https://www.npr.org/sections/health-shots/2018/02/01/5822161...
and especially through unnecessary (and very, very expensive) tests:
https://www.npr.org/sections/health-shots/2019/12/23/7874035...
The people who decide what treatments and tests are necessary are the doctors, so the marketing for this would have to be "buy our cheap insurance, we deny coverage to more testing and treatments than the other insurers do". Which is obviously not a winning strategy.
If you combine that with the increase in insurer owned clinics and hospitals (which unsurprisingly saw a sharp uptick around the time the ACA came into effect), then the insurance company gets to profit more twice. Once when they jack up the premiums, and a second time when those expenses show up as revenue in their other businesses.
https://www.beckershospitalreview.com/hospital-management-ad...
I'm all for giving more power to consumers, but when you have a regulation that creates such a strong incentive for raising premiums, layering more haphazard regulation on top of it isn't going to help.
And from my experience, the best healthcare is provided by Kaiser Permanente, which offers health insurance and healthcare under one company.
Pricing in medicine is jacked up because of low supply of workers (the grunt work is undesireable and doctors take a long time to license as well as residency funding restrictions), and infinite liability and legal costs that have to be priced in. On top of that, medicine is very complex, so you have to pay two or more very highly qualified people to double and triple check things.
Also, healthcare cost increases have slowed drastically since introduction of ACA:
https://www.healthsystemtracker.org/chart-collection/u-s-spe...
> Health spending growth has slowed, and is now more on pace with economic growth
So what's another way to increase profits in addition to letting care spending keep creeping up? Add non-insurance lines of business to the company, i.e. vertically integrate by acquiring some of the middle men you're paying.
Insurers snatching up PBMs[1] (or in some cases, PBMs snatching up insurers) is one insidious example. For those unfamiliar, PBMs are the companies that manage your prescription benefits. Insurers negotiate a predictable rate card with the PBM for the drugs on their formulary, insulating the insurer from market and regional pricing volatility. The PBM then negotiates with all the various pharmacies on actual prices. So when you purchase a prescription:
1. You pay your share (a fixed copay for many plans) 2. If the price the PBM negotiated was more than your copay, the PBM pays the pharmacy the difference 3. The insurer then pays the PBM whatever pre-negotiated rate they have for that prescription
With the PBM deriving their revenue/profit from the spread they're able to generate in the process[2]. But when the insurer and PBM are one-in-the-same, that spread is really just an inter-company accounting transfer that ultimately rolls up to the same P&L. But it's a _magical_ inter-company transfer, as the insurer side of the books count it as a medical cost (part of the 80% spending requirement) and the PBM side of the books (that show it as revenue) aren't subject to the 80/20 requirements. And best of all, the insurers spent so many years letting cost inflation run rampant[3] that such egregious slight-of-hand easily passes the arms length test for transfer pricing[4].
[1] https://www.statnews.com/2018/06/01/mergers-health-insurers-...
[2] They also have other revenue streams, such as squeezing rebates out of drug manufacturers as well. But the simplified scenario above covers the gist of things, and illustrates the primary conflict of interest involved.
[3] As [1] mentioned with the CVS/Aetna example, PBMs can be far more profitable than insurers. CVS generated 2.5x more profit than Aetna when they merged.
[4] https://blog.freedmaxick.com/summing-it-up/got-intercompany-...
-Most hospitals and larger primary care installations are monopolies. There is not and cannot be for practical, zoning and regulatory reasons any sort of meaningful "competition". As a result most regulation and enforcement is toothless because no one wants the resulting problems of closing, even temporarily, a facility that is the only care for tens of thousands of people.
When there are no consequences for bad behaviors things tends toward a lowest common denominator. There are many examples but MLK Harbor Hospital strikes me as a particularly horrific one. It operated as one of the worst facilities in the US, by many objective and subjective measures, for 35+ years before it was finally closed.
-Healthcare, at it's base, is a resource allocation problem. When I last calculated what it would cost to provide every american with all of the healthcare they might reasonably consume which was 2019, that number was ~92 trillion dollars a year. We actually spend ~4 trillion. How do we decide who doesn't get the thing they should get at the time they should get it? We employ a pseudo-random system and as a result it is incredibly inefficient. Without getting into the deep dive that is healthcare costs I will just point out that the US has by far the largest number of acute care, ICU and trauma center services per capita anywhere in the world. For example we have seven times the number per capita that a country we are commonly compare to does, England. This is astronomically expensive. Without ultimately capping in some way the total resource expenditure per person this will continue. Is it a worthwhile use of resources to expend hundreds of thousands of dollars to extend someones life for 2 weeks? Maybe it depends on the someone, an 85 year old? An 8 year old? It's a very difficult set of questions that mostly just gets avoided.
-Patients do not have a rational sense of value when it comes to healthcare services. The US has very low taxes compared to much of the world and when you take that into account it has relatively low healthcare insurance premiums. I'm not saying they are low to people on an individual basis but it's a complex thing. Take canada. Every canadian individual including children is paying, at a minimum, ~$600 a month for healthcare in taxes. They don't think of it that way because it is lumped in to the tax bill. Many people in the US pay much less than this.
I have a friend who was recently complaining to me about a $700 ambulance bill. They were doing this as they were holding a brand new $1,000 iphone in their hand. I sat down with them and in a "napkin" spreadsheet created a fictitious ambulance service. They walked away thinking $600 was a pretty good deal. The inefficiency is patients put off a lot of things that are small due to cost. Those things dramatically exacerbate inefficiencies. See points 1 & 2.
This, by itself, realistically rules out any sort of "free market" healthcare system.
See eg https://slatestarcodex.com/2017/02/09/considerations-on-cost... and look for 'certificate of need' (or certificate-of-need). Basically, other hospitals in the area get to veto new hospitals.
I’d like to point out that US public health care expenditure per capita is higher than Canada’s public expenditure per capita.
https://en.m.wikipedia.org/wiki/List_of_countries_by_total_h...
> They [Canadians] don't think of it that way because it is lumped in to the tax bill. Many people in the US pay much less than this.
There’s a good chance that most Americans are paying less toward gov health expenditures than the average Canadian due to income inequality. But in aggregate, it is more per person.
Ex: put 130k CAD here: https://simpletax.ca/calculator vs 100k USD here: https://smartasset.com/taxes/california-tax-calculator#bG0AW...
The history is fascinating - in order to promote more transparency in the cost of healthcare, the gov't passed a law that defines "usual, customary and reasonable (UCR)" prices. This was because insurers used to just pay the bill, no questions asked (50+ years ago). Then they realized that the price for the same procedure varied a lot. So the law said that one could only charge the "usual and customary" price.
Sounds good right? Who wouldn't want to know the typical price?
Well, a part of that law was that the UCR price was the maximum that could be charged. There was no law about charging less.
So insurers start to negotiate discounts. Some insurers would get a discount, otherwise they pay UCR. That creates a huge incentive to push UCR as high as you can, otherwise you're potentially leaving money on the table if you get a random insurer willing to pay UCR.
So fast forward a few decades and the UCR prices have undergone astronomical inflation. No insurer pays U&C any more. In fact, they might pay 20-30% of U&C. It's nowhere close to "usual, customary and reasonable".
It wouldn't be a disaster if everyone had insurance because nobody pays it. But we do have uninsured and that's the price they're quoted now. $15,000 for an MRI that an insurer would pay $1500.
As they say, the road to hell is paved with good intentions.
https://en.wikipedia.org/wiki/Usual,_customary_and_reasonabl...
They do something similar with drug prices for Medicare called Average Selling Price (ASP). That system gets gamed as well. In fact, it actually causes prices to rise.
Medicare requires hospitals to report pricing, so they have a decent sense as to what actual costs are. You could create a law saying you have to be within 20% of that price. It wouldn’t be perfect, but it might help.
Too bad the politics in USA prevent this and dismiss it as "death panels", and people are led to believe the hard trade-offs in healthcare can somehow magically go away.
Would it be possible for an EMR software vendor to ship both a "canonical" client interface that meets all the specs/requirements; and then a separate, secondary client interface, for the same backend, which isn't included in the "package" of EMR software sold to the clinic/hospital/etc., but rather is instead a "bottom-up adoption" play, with download links to it being passed around under-the-table between doctors?
If there's any potential for doctors being liable for such-and-such if they were found to not be "using" the primary client, then said secondary interface could be implemented as macro+screen-scraping software, that operates the primary client-interface underneath—much like Mint used to do before banks supported OFX export. Then just get it classified as accessibility software, like a screen reader, and let those doctors claim a need for it :)
There are two reasons for this: one, medical terminals are super, hilariously locked down. The medical systems I've worked on are ultra-hostile instances that are often centered around detecting and eradicating non-explicitly-authorized applications, even to the point of kneecapping actually-needed software.
Second and more practically, malpractice suits are vicious wars of discovery and bitter, knock-down-drag-out compliance fights. As with so many things, the legal fiction of accessibility software sounds nice but would not stand up to the scouring scrutiny of legal counsel and defendants with critical reasoning skills and powers of discussion (and deduction) above that of policy and compliance controls. I don't mean to belittle your idea at all, but much like the doctrine of Sovereign Citizens, all is well and good until you actually encounter a judge or human with reasoning skills and the ability to trivially perceive what's /actually/ going on, and then it all falls apart.
Not disagreeing at all! My suggestion was predicated on the idea that this particular medical regulation might be a "Type II" law. To explain — I feel like there are two types of law:
• Type I: law that has a logical "spirit" behind it (usually because it was drafted all-at-once by a small number of authors) where judges will interpret the law and violations against it as reasonable human beings do;
• Type II: law (usually more "regulation", but let's call it all "law" here) that is effectively the output of a continuously-iterating bureaucratic process; or law with a "spirit" that is obviously contravened by newer laws, but which still stands because no case has yet come to knock it down; or where there's no "spirit" to the law at all, just an infinite stream of under-the-table negotiated compromises, encoded as a huge book of requirements and exceptions.
Type II law includes, for examples: tariffs; statutory crimes; and created-by-fiat licensing schemes. Judges can't think like humans when deciding whether someone has violated a Type II law, because there's no human-legible rationale behind why the law exists. They have to just plug in the formula specified in the legal code, and see what happens.
I suspect that much of medical regulation is Type II law. Insofar as that's true, you could get away with a lot as long as you still adhere to the precise wording of the relevant requirements.
This particular case (EMR software) may indeed fall more under the provision of a Type I law/regulation, though.
My exp is before the big conglomerates. Doctors when I did this were crazy cheap on what they would spend money on. This has sort of moved over to the cost center now and the doctors are the ones who get shorted along with everyone else.
These systems also create a sense of not knowing what is going on. They create a system to disincentive people for looking at ways to make it better. Only the bean counters and shareholders look into that. So you end up with very strange cost cutting initiatives.
Then we added mega insurance into the mix. Which has seemed to found out it is just dandy to pass the bill onto everyone while the costs go up and up. They were supposed to keep a lid on the prices. But they didn't. I do not hold out any hope for a 'medicare for all' system doing any better. The insurance companies have a good incentive to do better. The gov not so much.
In fact, my experience with doctors (coming from a place where I worked closely with them specifically on IT matters) is that doctors believe that because they're good at medicine that they are good at everything, specifically making good business decisions and understanding and correctly using technology.
Tongue-in-cheek of course, there's no need to downplay your own abilities and knowledge. But if anything, I'm no longer feeling like I'm missing out in the rat race. I'm missing out on the whole AI / machine learning thing but that's all right because it just doesn't pique my interest.
The worst cases seem to be when there's an article (seems like it's always on Medium) about some complicated multi-part technical thing going wrong, a top level comment slings blame around as if they know exactly where to sling it and uses a PopSci understanding of the subject matter to justify it. Then someone who actually knows the relevant industry says "well actually it's a little more nuanced", proceeds to explain and then gets down-voted and flagged for it. Seems like a great way to send the message that technical knowledge and experience is not welcome here if it's going to go against whatever the convenient narrative is. What it definitely doesn't do is instill trust in comments about things I am less familiar in.
He sounds more confident.
Reminds me of hackers :P
jurisprudence is the science of everything, both human and divine
:-)
You are being unfair. Show offs are found everywhere, and all in all docs are not particularly worse than many others such as scientists, economists, CEOs, whatever...
Unless this is one of those "everything's weird and 'normal' is particularly weird" arguments.
If so I agree that "everything's stupid and therefore it's especially stupid to think anything could be 'smart'"
This is like telling someone in poverty "well you're actually in the top 1% of worldwide income, and the top 0.1% of all-time worldwide income, so things are pretty great!"
It's true, but it's a useless thing to say.
- polymathy, don't specialize too much, it's good to walk in other fields
- listen, being able to discuss, see the situation from all parties POV, exchange well
It's indeed rare to find this, also, I tried being less stuck up and listen but you quickly get stomped on by less knowledgeable but more dominant minds, it's tiresome.
I'm very weary of "people are dumb" arguments because they seem to lead to "and that's why we should dumb down our product, remove their freedom and treat them like crap" with an alarming regularity.
Perhaps there needs to be some type of continuous formal evaluation system as is applied to airline pilots.
Second of all, I can’t just upvote, this is so so accurate.
The thing to remember in US healthcare is there’s actually not a single entity that has an incentive to be efficient. There are some incentives scattered through the system to pay less or to not get sued, those are not the same.
To a first approximation nobody spends money in healthcare except insurers and the government. The government just says what they’ll pay, and where they can’t, they have limited negotiating ability. You’d think an insurer would care about paying less, but they actually don’t. They care about predictability. How much are costs going to rise next year? If you’re right, you make money. If you’re wrong you lose money. That’s not really an incentive to reduce costs in the absolute because the people who pay for insurance are not patients but employers.
As an employer I care about my health insurance plan’s cost. BUT I also have no clue about what one plan vs another really means or how they’re maybe gonna save me money long term. I simply don’t have the time to understand that, and I’m probably more informed than most on the subject having worked in the sector. I too care about predictability more than cost.
Crazy part of the pandemic, during a historic health crisis many medical systems were facing bankruptcy. Why? Most of the money being paid with a good profit margin into these systems is for “elective” care. This includes cancer treatment, because surgery can take place today or a week from now and it doesn’t matter that much. Contrast to a heart attack, which is non-elective. When a pandemic rolls around, all elective care gets shut down, so hospitals lose money despite being needed more than ever.
The whole system is a zombie with none of the right incentives, no clear way to even measure the right outcomes, and worse: nobody is driving the ship.
As an employer, my insurance brokers are able to show me very easy to compare tables listing premiums/deductibles/oop max/copays.
It’s all pretty comparable as long as you’re comparing within the same types of networks (HMO/PPO/EPO/etc), especially with metal levels.
If anything, HDHP PPO plans or Kaiser Permanente type HDHP HMO plans do have an incentive to keep costs down as they compete with each other for my business. I’ve been able to go to my health insurance website, and type in a healthcare procedure or exam and it will usually tell me the cost at various facilities. Nowhere near perfect, but a good start towards price transparency.
This all would work a lot better if everyone was forced to buy health insurance from healthcare.gov and employers were completely removed from the equation.
Kaiser is a very interesting example actually. Because they own both sides of the business (provider AND payer) they have a big incentive to be efficient. They do pretty well! There’s a few issues: 1.) they are still part of a larger market, so they have to pay for doctors, which means they can’t be TOO far below market salaries. Many doctors are paid on both salary and based on how many and what procedures they do i.e. how much revenue they bring to the hospital. Your doctor in many cases is paid on commission. Kaiser doesn’t do this, which some docs like, but others don’t. 2.) they are regionally limited. You can’t get Kaiser in a lot of places in the US. I’m not sure why it hasn’t scaled nationally, I’d really love to know.
Oddly, I’m told by a friend who works there that Kaiser is run internally as two halves, the insurer and the provider, they then negotiate somewhat independently and keep each other accountable.
Anyway, my pet project is something like what you suggest, decoupling insurance for employment. As an employer (and by extension an employee) I pay no taxes on a health plan I buy. I pay with pre-tax $$. As an individual if I buy insurance I pay with post tax $$ unless it makes up a certain percentage of my income and that falls above some threshold and... I lost track it’s too complicated. It shouldn’t be, there should be a way to properly decouple employment and healthcare.
You're definitely right about this, but in my experience, they're all the same negotiated pricing. And the insurance companies will conveniently group different doctors/healthcare facilities based on their costs into different tiers.
You can also be sure prices will keep going up, and I like to assume that I am liable for my out of pocket maximum since healthcare providers just bill willy nilly anyway, so I know I need to keep enough cash for 2 years worth of out of pocket expenses (in case something happens in Nov/Dec of one year and carries into next year). Hint: plan to have babies in April/May, so any complications all get stuffed into one plan year, and you hit out of pocket maximum sooner. Plus you avoid the new inexperienced resident doctors coming in during June.
>It shouldn’t be, there should be a way to properly decouple employment and healthcare.
It's really simple, remove the tax benefit from employers purchasing health insurance, and give it only to individuals purchasing on healthcare.gov. Ideally no one would have a tax benefit period, and everyone would be forced to go to healthcare.gov and employer plans and whatnot would be outlawed. Politically, big business will fight that though since price transparency helps people compare job offers properly and makes it easier for people to change jobs.
As an Australian medical student I'm horrified to think that this would be a genuine "hint" that would be relevant in a first-world country.
Even in Germany my (private) deductible is 3000 EUR so if I thought I might need "something done" I'd try to do it early in the year: if I spend 2999 in December the counter resets on January 1st. And I'm told I have a pretty sweet deal compared to America.
Also, I’m not sure if the out of pocket savings make up for the compounded investment earnings of a triple tax advantaged HSA contribution. However, it could work if both spouses get insurance from employer and they already have a kid, and the husband chooses an HDHP with HSA and puts one child under his insurance so he gets to contribute max amount to HSA, while wife chooses low deductible low out of pocket max plan and puts new baby under that.
But I wouldn’t waste my time figuring that out or doing that paperwork, it can’t be worth the different in out of pocket maximums and deductibles if you account for the headache of doing the paperwork.
>It's really simple, remove the tax benefit from employers purchasing health insurance... and employer plans and whatnot would be outlawed.
How do you get from here to there without it turning into a boon for certain employers at the expense of their employees? That is, how do you ensure that the money currently paid in benefits is passed along to employees to purchase their own plans and not pocketed (partially or in total) by companies.
If anything, people will have mobility to move to different jobs and the ability to actually see which job pays more or less, so employers will have to actually compete.
And half the people the US already don’t get health insurance from employers.
1. Employee buys their own plan from healthcare.gov.
2. Employee can choose to pay directly, using pre-tax dollars. Tax law is changed to that healthcare premiums are deducted from AGI for everyone who pays them.
3. Employee can choose to submit plan documentation to employer, who will pay some/all of the premium on the employee's behalf. In this case, employer gets the tax break. If only partially paid, employee pays the rest and gets to deduct that portion.
Financially, it's a wash either way. It gives the employee control over their health plan, and it changes the 'perk' status of employer-paid healthcare. It also gives time for employers to transition away from the "reduced salary + healthcare premium" model, because they'll be competing with employers who pay higher salary and no healthcare premium. Many employees will probably prefer the higher salary, because it's more flexible and feels better. That transition can occur over time without disadvantaging any employees, because the overall costs and tax implications are the same.
I've been fortunate to leave me with little need to deal with medical issues, and further fortunate that I don't have to optimize for price. But it means that every year I get shown a chart and tick off an entry more or less at random. Maybe on that day I'll guess that the more expensive plan would give me a better experience if I need it; maybe I'll decide that I might as well save money.
I assume that people who have to deal with health care systems have learned which kind of system fits their needs. I've been unable to figure it out from the charts. They make the prices clear enough, but the value is largely opaque.
So sneaking some tax free compensation to your employees was just as valuable.
I guess just copy their methods?
Anyway, it's an unnecessary cost.
[We do have private healthcare provides but even they seem much cheaper than the US system]
Edit: Any time the US healthcare system is described on HN it all sounds rather bureaucratic and stressful - as if being sick wasn't bad enough already!
Sort of off-topic, but I'm increasingly starting to believe that this kind of complexity in business models should be disallowed in general. I mean in particular the cases of selling something with a high margin in order to fund something else that's sold at or below costs. Be it related items ("razor and blades model") or unrelated (elective vs. non-elective care).
My usual reason is that it's anti-competitive and allocates incentives in the exactly wrong way, leading to ridiculous waste (that's how we get throwaway printers with expensive cartridges), but healthcare example points to another problem: stability. A critical system whose functionality is strongly subsidized by "extra offerings" is a system that fails when those extras aren't being bought for some reason.
In engineering, simplicity is desirable. So should it be in business. After all, transparent pricing is important for proper functioning of free markets, and such schemes confuse the pricing.
The ads convinced me to buy overpriced Mach 3 blades for 20 years, but at no time was I prevented from buying a safety razor and having cheap blades and a better shave. I could even buy one from Gillette if I really wanted to.
I'm not sure I'd want regulation protecting me from being a wasteful consumer, but I do think that something as important as a hospital shouldn't be allowed to run on whatever Ponzi scheme is momentarily profitable.
Perhaps we could regulate them more like we do banks? Something about maintaining certain critical capacity, or you lose your license to facelift?
Or imagine a hospital that only did high margin elective care. Instead of keeping the low margin service available while it struggled financially, it just wouldn't offer any services. Winning!
Interestingly, loss/waste aversion has caused problems in US healthcare. CON laws haven't done anybody any good, save incumbent hospitals.
Margins are controlled by businesses. If there was no way for anyone to do "high margin X to subsidize low margin Y", then previously below-cost prices would raise to better reflect the real costs of providing a good or service.
Complex subsidies can broaden the market and serve the underserved, that's a win. It's classic engineering arrogance to dismiss all complexity as unnecessary or harmful, as if the economy is a passion project that should not deign to serve those who can't or won't bear the full cost of each individual product.
I guess you can probably re-frame your argument using some other similar measure though.
So I suppose if that applies where you live, and you had a business selling only the low-margin type of item, and your competitor was selling below cost, then you'd have standing for action. I'm not sure if consumers ever get a say though outside of regulatory agencies like the ACCC.
This is untrue, a very common myth based on a questionable study out of Johns Hopkins, which included known complications of medical procedures in the classification of "medical error."
https://sciencebasedmedicine.org/are-medical-errors-really-t...
But the Micro$hit Window$ kludges I've seen in pretty much every doctor's office, with many instances of the doctor entering their credentials for login, and then waiting an ungodly amount of time to get in and to the medical s/w interface, is not helping either.
So windows 95 came out the year they left medical school, and had just finished residency when the internet became particular popular and broadband started being normal.
I just left a govt agency clerk job. I couldn't resist making automation scripts. Due to politics I didn't talk about it. But on my last day I showed it to a tech-saavy dude saying this might help you going faster or at least give them a case to show the hierarchy things can be improved.
I wonder if this insider hack is the only way to push things around ..
Are you planning to release an updated version? Or you think most topics are still up to date.
I have never used an electronic medical record that I would willingly inflict on another person.
The reasons vary, and almost all of them have at least a couple of things that they do very well. But the bottom line is that this exactly the kind of "enterprise software" that is sold to people who will never have to actually use it. They are overwhelmingly sold as ways to increase reimbursement for services provided, as a part of the arms race of insurance companies refusing payment, and hospitals billing more and more.
Even in public sector settings that aren't billing, the only viable options available are built with this problem in mind.
That said, I'm not crazy about how actively Epic appears have tried to keep medical records created in Epic locked in to Epic.
The spirit, if not the letter, of the legislation requiring a move to electronic records was due to record portability. From where I stand, they have actively prevented that (or at a very minimum sandbagged) to expand their market share.
For example, if you wanted to see what the outcomes of giving a specific drug at a specific dose to a specific group of patients at your hospital was, you're in for a real fun time manually copy-and-pasting thousands of entries from the EMR to a spreadsheet.
Now more than ever it is important to look at data relating to patient outcomes with various COVID treatments that haven't been thoroughly vetted yet. But, guess why your local hospital isn't doing anything like that? Because what should be a simple 3-hour exploratory data analysis that can be breezed through IRB now has to involve a budget component of hiring a professional copy-paste person. Can't even use med students to do it anymore because they aren't allowed to hang around the hospital due to COVID, and you can't access those records remote due to HIPAA.
Edit: Do you know offhand of a good guide to SlicerDicer I can share with them? I will google around, but if you had something you personally liked?
Especially in the EMR space, putting up barriers to access basic documentation is quite unreasonable.
Public documentation is not going to suddenly allow your competition to gain an advantage, while your own firm benefits from users being able to easily google and get authoritative answers from your own official documentation.
At population levels I could concede that these errors may well be inconsequential though.
On the radiology side, I know there are extensions and tools for PACS that the vendors can't be bothered to come explain/train, even though the company sold it to the hospital. It's like pulling teeth.
There are certainly a million reasons why a doctor may not have access to or be able to use tools like Slicer Dicer, but most of those come down mainly to hospital policy. Amount and quality of training is certainly the biggest differentiation between clinician who are satisfied with Epic and those that hate it.
So, thank you!
The person who told you that is misinformed. I have personally worked on products that allow physicians and staff to access patient records remotely in a safe and fully HIPAA compliant manner. It's incredibly common.
Do you know of a good way to leverage this API in a way that can be directly used by clinicians to pull and work with data?
Client applications can be written using the HAPI FHIR library.
Then use the search operation to find the resources you need.
We'll see what it works out to in practice. But data sharing is definitely still possible, today, even with Epic (they are quite good actually). You are limited to certain reasons but they are pretty broad.
Full disclosure: I work on this full time. It is a strange world, that works on its own standards and practices for good and bad reasons.
I think EHR vendors sometimes get unfairly blamed. The fault often lies with provider organizations who simply haven't turned on the available functionality.
Edit: Not a doctor/in health care. Just basing this on the link above.
Of these links, there are four duplicate pairs, at least. Two of these sets of pairs lead to indistinctly named pages (/Home/InteroperabilityGuide and /Home/Interoperate)
I would start by having all of these links be at the top, and adding some descriptive text to each of the fields in the main body, as opposed to meaningless graphics/marketing numbers.
Addendum: Also, I wouldn't want to do the split in thirds thing that occupies the majority of the page. Each of those can get a description of at least a paragraph, and go one after the other. If there's not enough info to fill a paragraph, then they probably need to be merged.
Edit: ambiguously -> indistinctly
There's a legitimate case for high-density, specialized interfaces that aren't focused on usability in the sense that you might find in more consumer-targeted software: the end users of these systems don't necessarily need something that's easy to learn or that presents only important info up front. Arguably they need the opposite: something that packs a lot of complex functionality and dense information into a small space is _good_ when your users are highly-specialized and frequently run through similar complex workflows. It's akin to a phone camera interface and a camera designed for professional photographers: the former eschews having ALL THE THINGS for accessibility, whereas the latter eschews accessibility for high info density and rapid access to tools because its users are okay putting in the time to learn something complex when getting over the learning curve will afford them a high degree of control and quick feedback.
Where things break down is customizability: expert tools, and especially expert software tools, suffer from "the user knows best, they can design their own UX" syndrome: this is true to a degree, but in the case of shared tools oft turns into one user (team lead X, who's been doing this shit for years! they know their shit!) designing something that works for them, or that replicates an existing workflow from elsewhere (just make it EXACTLY like the old paper charts! why would you do anything else? what do you mean the design considerations for a paper system might not perfectly transfer to a computer system?) in total ignorance of things they fail to do well. Computer systems, I think as an artifact of their relative novelty, lead users to believe they're experts in UX design by virtue of having (a) experience in the field the system serves and (b) having used a computer interface at some point in the past (and, in America, (c), broader cultural hubris about individual competency across disciplines based on competency in some unrelated highly-skilled field). Designing a truly good interface requires a dialog between user and designer, but we too often tend towards a "skilled user must be right, they're good at SOMETHING and therefore good at EVERYTHING" mindset. Enterprise software design provides customizability to a fault--we hear users want it, don't have enough time to actually sit down and try workflows with them, and they say they're skilled enough to do it themselves independently, so let em have at it.
I sometimes wonder what it'd be like in a world where "cars" were sold to ENTERPRISE DRIVING CABALS, full of VERY SKILLED DRIVERS, where the "car" in question ended up being a pile of sheet metal and control surfaces, a collection of engine and power train components, a big tub of asphalt, and a rough map of places people need to go, entrusted to a multitude of very experienced horse carriage drivers who each sought out to build their own bespoke personal vehicles and interstate highway system as they saw fit based on their own intuition and cunning, with nary a notion of needing to design something that worked for anyone else or wanting to take advantage of the new tech's more novel features. I doubt it would be a good one, but it would probably be hilarious to look at having driven on a somewhat saner system in a more thoughtfully designed vehicle.
Conventions which would help:
- add vertical padding between elements
- simplify illustrations or using icons
- use a consistent color palette
- use color sparingly
- at least one of black text and white background should be off-black or off-white respectively
- cookie request background should be a neutral color rather than yellow
- cookie request should be at the bottom of the screen rather than the top
- choose one hover event: animate the illustration or underline the text
- the footer should be at least 3 times the height
- replace "over the last year as of date" with "each year" then restore standard font weight
Fixing all of the above should take about an hour.
Epic is completely customizable, but the people who make the decisions in nursing management aren't always the same people using the software. That and funding to make the changes.
If you want to see really bad software take a look at Meditech it defaults 800x600 (!), and doesn't resize well at all.
I love getting little tours of software I'll likely never use even though I'm not in a position to fix any of the problems. It's just interesting.
They're of the opinion that everything needs to be "as few clicks" as possible. As if "number of clicks" was the only worthwhile message.
Nobody would read a book where the keyboard was pressed as few times as possible. Sometimes, complex actions require complex input.
We should be shooting for discoverability, not "number of clicks".
I was specifically talking about things they do hundreds of times a day (at least) like dispensing medication, requesting medication, inputting vitals, taking notes, etc. Those things shouldn't require 10-15 clicks and 4 different modals/menus each time. They're extremely common use cases that a nurse will likely be performing a number of times in every single room they enter.
And why shouldn't they have an opinion on what is important? They're the ones using the software all day!
I once got in trouble for using autohotkey for something like this. Like, wow were they upset with me.
The issue is also what's important for one use is not important for another. The person dispensing medication may not be the same person taking vitals, etc.
And it might be the common use case for that nurse, but another nurse may have a different workflow. What works for cardiovascular doesn't work for ophthalmology.
And all these people think they're equally important. They all want the same priority.
Not to mention, most people are bad at UX design. So while they should have opinions, they should not be the only consideration.
If my software takes 10-15 clicks to do something any of the users does 100s of times a day, I’d consider that a failure on my part.
1, 2, 15, 100, the number of clicks doesn't really matter.
It's like measuring code quality by line count.
It's Spinal Tap. "But it's one less click, innit?" If it takes you 10 seconds to find the one place to click or requires such heavy front-loading that it slows down the system on every click, you've already failed. Doing more of the thing that caused you to fail is a hole with no bottom.
Second, the engineers and UX designers aren't the people really driving the design process. That's a problem. The people driving the design process don't know what they're doing. Because everyone things UX design is easy. It's not. It's hard. People think they know what they want, but the don't really. What they know is what they want to do. But they get it wrapped up in their mind that what and how are interchangeable. So "I want to prescribe medicine easy." becomes "Prescriptions need to be one click".
Maybe they don't really. Maybe to make them easier to do, they need to be in a context menu or something else. I don't know either. I'm not a UX designer by trade. Because I know it's hard.
I don't think it is, at all. And counting clicks isn't a fools game - it's a direct metric for how buried simple tasks are. Do you need 15 clicks to restart the process you're debugging? No, it's one click on the debug window. This is no different.
>"But it's one less click, innit?" If it takes you 10 seconds to find the one place to click or requires such heavy front-loading that it slows down the system on every click, you've already failed. Doing more of the thing that caused you to fail is a hole with no bottom.
Why would it take the nurse 10 seconds to find a button or place to click for an action they've performed thousands of times?
We've already established that new nurses have a training program to get familiar with the system. You don't think they are just hired and then thrown into 'go take care of this hallway by yourself' do you? And whats better - front loading so they can select a patient as they enter the room and let it all load up while getting ready to treat (confirm name, start gathering data, etc), or waiting 5 seconds every single time they click anything? Oops, clicked the wrong thing there - thats 10 seconds to let it load, back out, then select the right thing.
You can argue discoverability all you want - but go stay a week in a hospital and observe the people actually using the software. Watch how 3/4 of the time they're in your room they're fighting with the computer to perform simple tasks. Tasks they know how to do, but take way too long because of the clutter and poor design of the system. Watch them click 15 times through 4 different windows to dispense a medication - which they'll do 8 times a day just for you. Multiply by that by all the patients they're responsible for. Do you see the problem yet?
It feels like I'm saying 'make it easier to use for the people who use it' and you're saying 'no make it shinier so anyone off the street can use it' lol. Maybe we're actually saying similar things - just not aligning thoughts well?
You've made the claim. But really, that's just washing your hands of the problem. I've been part of that training. I'd call it a joke, but there's nothing funny about it. You aren't going to get familiar with these systems in an afternoon seminar with the vendor's representatives.
You say this:
> You can argue discoverability all you want -
Then just make my argument for me.
> because of the clutter and poor design of the system
Reducing clutter would make things more discoverable. Making things discoverable is part of good desing.
I'm not saying "make it shinier". That's a poor inference on your part.
I'm saying the metrics by which we are using to design these systems are just flat out wrong. They are confusing the what with the how. And I'm not even getting into how sometimes you actually want things to be complex or hard to reach because you want the action to be deliberate.
Counting clicks is wrong. And anyone who advocates for it is also wrong. Discoverablity makes things easier to use. For the people who use it. You have this platonic ideal of a user who always knows the software in and out. That user does not exist. Any given user will only really use about 20% of the software, but every user will use a different 20%. So that other 80% needs to be discoverable. You shouldn't need to memorize or hunt down on a screen of options for it.
And since that 80% is different for all users, it logically follows that the entire system needs to be discoverable.
And that's not to say you can't implement shortcuts and hotkeys and what not. But really, any software shouldn't be making people think to much about how they're doing something so they can focus on what they're doing.
The idea that users themselves know how to make something usable is just as misguided as what you're accusing me of. It's like assuming that most people are good chefs because they have a lot of experience eating.
They can tell us whether something is bad or not, but they can't tell us how to make it good. Don't confuse the former for the latter.
I don’t think discoverable and efficient are mutually exclusive.
Something can be discoverable and still usable in 5 clicks or less (example: most menu bars).
But "number of clicks" isn't a measure of efficiency.
What's the time from thought to action? That should be our main concern. If that takes one click, five clicks, ten thousand click, it doesn't matter. Thought to action.
FWIW, my goddamn opinion: Epic is probably the best EMR I've used, but I can still see some random dude's dog in Bolivia on FB faster than I can pull up a patient's critical lab values during a procedure. Not too worried about missing out on "Now your EMR comes with customizable colors! [dismiss]"
I guarantee that Facebook has more computing power dedicated to showing you Bolivian dogs than any hospital has to showing you patient data.
This is probably my single largest source of frustration with building/implementing any enterprise product.
Regardless, best of luck!
"least bad" is not saying much, they're all pretty bad.
That said, during my student years I felt like Canvas was steadily converging on being as unusable as Blackboard, which maybe hints at some underlying pressures in that industry. I was involved peripherally in the decision-making process on a small university purchasing a new LMS, and the decision was amazingly political and driven by niche needs from vocal users, and I say this as someone who was pretty used to university politics at the time.
It seems like the way to get an LMS contract is to throw every feature you can possibly think of into the bucket, usability and quality isn't something that really gets evaluated very well. This probably could be changed but I'm not sure how. For example, the university I was with performed student surveys related to the food service vendor and incorporated the results of those surveys as a performance standard in the contract. Nothing like this was done for the LMS purchasing, no student input was collected at either the purchasing or performance stages, and a combination of purchasing methods and institutional politics meant that faculty input was extremely limited (the vendor was basically chosen before the faculty were invited to provide feedback). I don't think higher-ed IT departments often have a user-focused culture but instead a cost-focused one.
Compared to Pearson's crummy web learning platform and the mess of perl that constituted my college's homegrown infrastructure, Canvas was the bright spot where when things went wrong you could get ahold of someone technically competent and helpful at 11pm the night before your test on Saturday.
Desire2Learn appears to be the big competitor now (the university i worked at was completing the migration from Blackboard to D2L when i started. and the Uni System of Georgia followed suit.
"Speed" (latency of response) has always been the number one user interface problem of all interactive software and it still is.
No one really wants to do EMR software. Or medical software in general. They do it until they can do something else.
That and you have to work with doctors. And sorry to say, that is not exactly fun. You have people who think because they did a lot of school, that that makes them an expert in everything. And that their bikeshedding is the "real" important issue.
When I last worked with it, databases were the hot new thing. And I don't mean databases were new tech. I mean medical software was just catching on to storing data in databases.
I think one company was pushing a solution that was essentially a collection of Word templates. As if they had hit upon something not only novel, but that no one in history had thought to do.
If you're a software developer, eventually you get tired of pissing up rope and get a better job.
My latest complaint is that the authors of our EMR, who I know to be legions of fresh out of college young twenty somethings (hardly anyone lasts long enough to be a senior engineer at this vendor, I am told), have not used any sort of helpful SDK for text input boxes, but instead have written their own, having inconsistent and wrong behavior with respect to keyboard based text selection, Ctl+backspace behavior and a variety of other well standardized functionalities.
...and they have written multiple different wrong implementations, as the text boxes behave differently in different parts of the EMR. Even the inconsistencies are inconsistent, like atrial fibrillation.
Individuals don't have much power to change an organizational culture riddled with NIH syndrome (the goddamn ticketing system, timekeeping system, and at some point in the dark past, the email system used internally were ALL written on top of the core EMR codebase) and cargo cult development (the people that /do/ stick around have a healthy share of people that couldn't easily get hired elsewhere on their merits, but do thrive in an environment where accumulating and regurgitating questionable tribal knowledge is crucial).
The system is a testament to the inertia of enterprise software: you can muddle along with a product end users hate while making a damn good profit because the system does deliver on its promises to its actual customers, the hospital admins that are primarily charged with reducing costs and increasing revenue.
The US medical system is so flush with cash and has such high barriers to entry that it doesn't really matter if software isn't great in some (important, but not important in a way that matters to decision makers) ways. The money keeps flowing, and continues concentrating power in the hands of major players. Something like the HITECH act /was/ needed, but lol if you think the people that bought a seat at the table to design it (but totally didn't--that would be corruption, and we don't have that in America!) didn't have a vested interest in pushing certain provisions. Save money by putting an EMR in place sooner, and accelerating vendor lock-in with the existing players? Sure, why not, everyone (for certain values of everyone) wins!
https://www.motherjones.com/politics/2015/10/epic-systems-ju...
Nice. It's a feature of crappy teams that I hadn't been able to put my finger on.
The back story (for Denmark) is that we have been building our very own system since the 1990's at massive cost without getting very far, so by now the biggest commercial offering probably looks like a safe heaven.
Reasons the "in-house" systems never got far are a good story. First, there is the normal insanity of hiring consultancies on cost-plus contracts to design and build a system that is "spec'd" by collecting wish lists from everywhere. Despite this, things might have worked: A lot of my friends from uni started work at these consultancies and the story is that there was not much naked greed and cynicism, and that people really tried to come up with good systems. The real killer was that Denmark, despite being a completely homogeneous country of 5m people with state-funded healthcare, did not opt to build a single system!? Healthcare is provided by the "regions", and the regions could not agree on buying a single system. Since Danes expect their medical records available across regions, the ministry of health then had to step in and provide a data interchange standard. Picture an insane XML-schema for every conceivable piece of medical information, coupled with granular access controls and origin metadata. And then mapping this schema faithfully to 5 different alternative representations...
From what I've read it seems that most of the users are very unhappy about it (https://www.dr.dk/nyheder/regionale/sjaelland/ud-af-tre-laeg...) and crucial integrations to outside systems (like Medicine Card) still don't work properly after 4 years (https://www.dr.dk/nyheder/regionale/hovedstadsomraadet/ny-br...)
Because people stand to lose profit if GNU Health is used.
EHRs in the USA, Germany and other countries with numerous health insurance providers are primarily there to ensure every service and tools used is billed fully (or overbilled).
GNU Health’s support for the whole set of pre-authorization, billing, payment, and related transactions seems to be...generating manual invoices.
Most medical records don't capture enough information about a person longitudinally over time. I worked in a bank that had fantastic customer relationship management software that captured every interaction between the bank and customer and acted as a integration layer ontop of all services the bank provided. It was a stack based model where recent interactions went ontop and nothing could be deleted. You could find old scans of documents, letters the bank had sent and replies. The interaction between bank and customer over internet banking were all captured. I saw my own records from when I got my own account as a child and could see everything from then till now.
I've had a bunch of touch points with medical professionals relating to an eye injury in the last few years. From Emergency to Surgeons and specialists. A lot of information had to be repeated by my wife along the way whilst I a sat there blind.
I don't think special form support or really even business process support would be that useful. I just think having a single pile of client information that's in chronological order would really help doctors be able to stay on top of the issues at hand and then creating a culture of active documentation of actions by all staff so that patient records such as whats on the chart at the end of my bed get's onto my medical record by the end of shift or earlier each day.
This seems like a good place for an ISO standard.
But as you saw (pun intended), it hasn’t gone far. Every time I see my doctor I have to fill out the same forms and repeat the same information. Too bad my work didn’t go far.
Microsoft Health Vault was supposed to do something like this. The promotional materials said it was going to be a system that you and your medical professional could securely access, and be a central repository of your medical records, so you wouldn't have EMR vendor lock-in. It did OK for tracking immunizations (but I have a yellow WHO booklet for that..)
Tell me more! I've had issues for decades with tracking my immunizations.
Edit: rogue capitalisation
I wish I had the time to make my own software... At this point I'd be most happy with just a text area where I can write anything I want. I'd love IDE-style features such as autocompletion for medications and tests. An inference engine for simple calculations would also be great. For example, if I write the patient's height and weight, the software should notice that it has enough information to derive the BMI and just do it.
And it sucks for the same reason that most enterprise software sucks: because the people who budget for it, choose it, and pay for it are not the people who use it.
For more on this, see this now-classic Twitter thread by Princeton CS Prof Arvind Narayanan:
"Why Enterprise Software Sucks"
https://twitter.com/random_walker/status/1182635589604171776
To properly architect enterprise software, you need to capture the competing needs and goals of hundreds of different roles in different departments. You will uncover underlying political and organizational issues that you will need leadership to sort out before you can ever start to determine the business-logic. To be successful, you have to be an expert at playing politics, business analysis, and mediating conflict.
I wouldn't say "enterprise software sucks"... more like, the lack of cooperation in many organizations sucks, and enterprise software puts a big spotlight on it.
Sure, users don't know what a system needs to do to meet their needs, but if you had modestly competent business analysts work with them to specify the system, you'd have good results.
The role of systems analyst (nowadays confusingly called business analyst) seesm to have largely vanished in the beliefs that either COTS enterprise software would be used as it came, or that users know what they need (as opposed to what they want) and can rationally set priorities and tradeoffs.
Turns out neither of those beliefs was true, and systems analysts are needed. With the passage of time the role has largely been forgotten.
Classical systems analysts were, as I understand it, usually the more experienced programmers on a project, and had a role that combined the more recent technical architect and business analyst roles, so they aren't interchangeable with BAs, who often are nonprogrammers, and in any case are viewed as less technical than developers.
> seesm to have largely vanished in the beliefs that either COTS enterprise software would be used as it came, or that users know what they need (as opposed to what they want) and can rationally set priorities and tradeoffs.
In theory, the kind of requirement that is the role of a system or business analyst in other development methodologies seems to be largely shoveled into the responsibilities of the omnicompetent development team in Agile methodologies, though some of it also seems to fall into the product owner bucket in methodologies with that role.
I do think that that the requirements elicitation and analysis skills that go with that role have become undervalued because there is an idea that incremental iteration means you never need to look at requirements in a structured way. I don't think this is even approximately correct, but it seems to be the thinking.
Often, organizations that try to do this internally have their business analysts inherently shackled to a specific department or division by nature of the org chart. It is the interdepartmental conflicts that are the hardest to mitigate.
This is one of the lesser-spoken reasons that higher-ups call in consultants -- they have a better ability to short-circuit the org chart and haven't been around long enough to piss off that one director, Karen.
As a result, the number of things that practitioners need to enter into EMRs keeps growing, and every year they spend more and more time charting. This in turn decreases the signal-to-noise ratio of the information in the charts, resulting in the practitioners getting less information out of them despite the fact that more information keeps getting put in. Which results in more accidents rather than less.
With a desire to conquer the computer, open source, and exchanging knowledge online, actually many private enthusiasts who can't afford medical care or won't get the right one can already help themselves. And they have not studied as long or hard as most medical people do. I.e. a doctor with the right spirit should be able to achieve a lot more than such hobby enthusiasts.
And with that passion and knowledge the medical community as a whole would slowly also force better software into their work environments. They know how to hold conferences and argue with facts.
It's hard to blame others if you belong to one of the smartest tribes on the planet.
>But we think of this as a system for us and it’s not,” he said. “It is for the patients.”
Is wrong. It's a misnomer to call them medical record systems. They are primarily billing systems. Sure, improving patient care or reducing paper records are nice. But the #1 thing is to document the care to allow them to bill insurance or the government.
There's tons of operational utilities like e-prescription, lab ordering, patient problem tracking, vital sign tracking, imaging and diagnostics tooling, etc. You could argue that all of those are somehow related to billing because they help doctors see more patients per day, but billing would still be possible without them, and they largely exist because doctors need them to work effectively and treat patients more efficiently, not because they directly serve the billing pipeline.
Not to mention all the issues of paper management and physical security once you have thousands of patient documents scattered around in filing cabinets.
The result is that the number of companies offering a system that meets all the bureaucratic requirements is small, because doing so is arduous and expensive and disheartening. So the few that exist don't have a lot of competition and people still use their product even if it's miserable. People not using their product would have been their incentive to make it better to use, and the disincentive that making it better costs money is still there, so they don't.
You're kind of right though in that it never felt like we did anything because it's what patients or providers wanted. We didn't do things if we were afraid providers wouldn't like it, but a lot of work seemed to be mostly driven by regulatory requirements (meaningful use, icd10, etc.).
An example - Administrators typically want _everything_ on a list, because everything is important, right? However these lists need to be concise enough to be useful otherwise people just ignore them.
At my last job I tried to get some fields in our bug tracking system made optional. You could run reports showing they were garbage most of the time. Naturally, I failed, and those fields are still required to this day. I started putting "supercalifragilisticexpialidocious" as a value in some of them. No one ever commented on it.
I remember thinking that there was no way self respecting developers would allow this to happen, but I was so naive!
The newer crop of physicians have a much better time using EMRs. Don't get me wrong, they are acutely aware of the ridiculousness that is modern billing-centric medical records. But having been trained in that atmosphere, it definitely appears less painful to their day-to-day.
I'd love it if we just had a great API that workflows could be build upon. And I'd kill for a command line EHR!
I would kill for a command line EHR, especially if I could edit notes in vim!
Alas, I spend my days cursing as Cerner re-draws the unnecessary html and the focus refuses to follow the mouse, and that no one along any of multiple points took the time to write an interaction checker that didn't result in getting three popups to acknowledge that epi boluses given at separate times during a code (and now the patient is dead) don't interact.
I had to switch from my primary care about a year ago. (He was getting out of doing primary care work because, he said, he had a small practice and just couldn't deal with the paperwork.) From the beginning, he really resisted the computerized systems and probably complained about them pretty much every time I was in for a physical.
My new primary care, in the same hospital system, and not that much younger at least gives the appearance of encouraging things like tele-medicine, using the medical portal, and so forth.
I worked at a company that designed such a system. I was not involved with the project but when the system came out there was a lot of heat in the press quoting medical professionals about how bad the system was. Suddenly, with the new system, the workarounds used in the previous one stopped working. The problem, of course, was not in the "programming" part, even if the press portrayed it so. The problem was the requirements and the insanity of the medical management to force the users to stick to the exact documented work process.
The article addresses this as well later on and describes how solutions are then added by workgroups for specific fields. Just another example how you should design such a system along with the users and not by encoding work process some administrative entity proscribed.
Regarding the campus, the theming is actually quite cheap. The bigger expenses come from employee QOL stuff like roomy underground parking to keep cars out of the snow.
If your old paper chart didn't get misfiled or fall behind the cabinet, almost everything in it was relevant to your care, because there wasn't enough hours in the day to record anything else. Now, it's a sea of compliance bullshit and autocompleted lies -- the unscrupulous practitioners insert multipage reports on tests that were never performed with just a few clicks. (I think the EHR vendors now also sell tools to detect that sort of fraud.) For users who ultimately want to provide care, dealing with electronic medical records is a nightmarish situation and it's leading to burnout at record rates.
1. Chief medical information officer --usually a doctor who became an expert EHR user and now decides what will work for doctors and what won't.
Unfortunately, there are too few of us that understand both the challenges of caring for patients and the barriers of writing (and maintaining!) good software. Our EHR is far from perfect, but the basic HTML interface has aged remarkably well into the era of smartphones. Our approach is to extend functionality of our EHR with APIs and an ecosystem of add-ons. Always looking for people with a passion for healthcare and flexible skills. Mumps/Cache, API design, JS (vanilla, JQuery, React), mobile (Swift, Java, React Native, Kony), and ML (computer vision and NLP).
It didn't make sense why this job existed until I actually started training on the system. The system is absolutely god awful in terms of UX experience, but after awhile (1-2 months) you get acclimated to it and could complete a chart in <5 minutes.
Some or most of the doctors I worked with absolutely hated the system itself. On many occasions, I have observed doctors input the wrong orders which if they were performed would have had severe consequences. Fortunately, 99.9% of the time the error was caught by the physician or the nurse assigned to the patient. The one instance where it wasn't caught was actually due to human error - nurse gave patient anti-hypertensive med instead of the ordered calcium channel blocker (Cardene vs Cardizem?).
On the worst occasion, one doctor I worked with struggled on a daily basis to input orders into the system. I think it would take 5-6 minutes just to input some basic orders. Someone ended up teaching him how to input the orders in free form text and the nurse(s) would just write up new orders based on that (eg, doctor would write a single order as "cbc,cmp,ua r/o uti, drug screen, CXR 1v r/o pneumonia" and the assigned nurse would recreate the orders in the system in a line-item fashion). Kind of sucks for the nurse, but I think it ended up working out better for both parties.
I ended up dropping out of the doctor career path due to this unique and eye-opening experience as a scribe (not because of the EHR software itself but figured the "doctor life" was not meant for me).
It has nothing to do with why pilots are/aren't epicures, and a more to do with their bosses deciding to serve them crappy food.
Another comment mentions that Epic is amazingly customisable. But that is not in the control of the people who use it.
In Australia at least, 85%+ of medical practices run one of two practice management systems. Both of these systems were originally developed by the same guy, and both have their centre of operations in the same small regional town in Queensland.
I don't think it's a surprise that top-tier developers are unlikely to be willing to move to the middle of nowhere. My experience with the version we use is that its UX is unpleasant, the platform isn't reliable, and it doesn't perform well at scale for larger clinics like ours.
I completely understand that the monolithic design of the software is mandated by too many competing interests (and regulations) for it to be simple. But I am sure it could be better.
I'm a developer at one of these companies, and we truly do want to make your experience better. If there's a workflow that you do for every patient that takes 3 clicks instead of 1, escalate. There's a good chance there's build that could help you out. If there's not, escalate anyways. Ask your IT department to contact the development company's staff. We want to hear any and all feedback about specific workflows that are a struggle.
1. Software tries to open Excel / Word (it actually failed to open Excel on a machine, but when I opened it manually, the export continued)
2. It copies a row in the software
3. It pastes the row into Word / Excel
4. If more data is available, go back to 2.
This is for the export of a data integrity check report in that software suite. It takes multiple minutes to export a report and you can watch live how the copy / paste happens. I was amazed that somebody has the balls to sell this and gets away with it.
Also, a bunch of the people reading HN work for different vendors, so light up the comments about specific problems with specific products and we can take them directly to the people who can fix it.
Not because it's a bad operating system, but because hospitals are constantly out of money and computer upgrades are never a high priority. Microsoft does a decent job of backwards compatibility with software, but the hardware requirements keep piling up. Windows has no equivalent of LXDE; the computer in the hallway takes 15 minutes to boot on Windows 7. It's a situation I run into over and over: the damn thing is slow.
It doesn't help that, as others mention, medical software is rarely built with the quality of software engineering we're accustomed to seeing. But it can't help that the software tries to display all of the information graphically and show as much as possible at once -- pictures I have to wait to load even if I don't need to see them. This comes back, probably, to how it's sold: look at this impressive flashy window with all these bells and whistles. Never mind the system resources, and don't get me started on wasting screen real estate. My workflow begins: turn on the computer, wait, log in, wait, open SNC Patient, wait some more...
I don't know how many billable hours are spent waiting for computers to load, but it can't be trivial.
Since the payers (insurance companies and the government) want to avoid seen making medical decisions, their only way to bring the cost down is to slow down the providers.
Therefore, they do not allow automation in the EMR/Health software. This is not a joke: for appropriate billing, the physician has to go through an elaborate dance of clicks, and write and rewrite fields with the same content, personally. In other words, if it was automated, or if the office staff filled those out, then the billing would be much lower.
It's not true software vendors would not be able to automate a lot of this, but they just can't, because the physicians are required to work in a manual way for proper reimbursement.
It's a strange world, where a doctor who is a faster typist makes more money...
It's very sad, but unfortunately it's working, at the cost of driving physicians to the edge of insanity.
In my experience, the contrast is stark to another high-paid professional group: lawyers.
I remember WordPerfect being very popular in law offices, but also dictation machines, so who knows?
There was a period during which PCs (as well as other word processors) were coming in when computers were seen as being increasingly important (in law and elsewhere) but the management at many companies weren't sold on it being a good ROI for professionals, especially those billing by the hour, to use them directly.
There was definitely a period of time in many places where there were computers but it was secretaries/paralegals/etc. who actually typed on them. And, remember, a lot of young professionals in the late 1980s had never really learned to type, even hunt and peck.
>In my experience, the contrast is stark to another high-paid professional group: lawyers.
Database systems like WestLaw & word processing systems in the 80s and 90s were killer apps for law offices, so if lawyers are tech illiterate it's a recent phenomenon.
I know several doctors my age and younger that cannot stand using any computer or laptop, while my best friend’s father, a surgeon, had one of the first HP color flatbed scanners (SCSI) and the only person I knew to have an ISDN line.
My cousin is about a decade older than me, and I remember spending the night at his house with his TRS-80 and Apple II computers. He is an attorney.
> Some people are pushing back. Neil R. Malhotra is a boyish, energetic, forty-three-year-old neurosurgeon who has made his mark at the University of Pennsylvania as something of a tinkerer...Soon, he and his fellow-tinkerers were removing useless functions and adding useful ones. Before long, they had built a faster, more intuitive interface...Malhotra’s innovations showed that there were ways for users to take at least some control of their technology—to become, with surprising ease, creators.
I have worked with doctors of varying age groups, including family, and it really just depends. Age is not a factor, it seems some people are averse, and others passionate.
Maybe the one-solution model isn't the best option.
Then there's mass-edit scripting. Have you ever told someone that you updated 200 records and added $4k income, while saving 4h of manual error-prone clicking?
turns out you can do take appointment at the gp, it wasn't impossible
turns out you can request exams trough email, it wasn't impossible
turns out you can have a pre-screening via photo and messaging apps, it wasn't impossible
turns out you can safely deliver prescription trough digital channels to both the person and the pharmacist so that you can just show up with your healthcare number and take the drugs home
it has been dragging medics and other professionals around then into the present kicking and screaming
She told them that she wasn't from the UK and therefore wasn't covered by their system. But they said that they had no way of figuring out a price or generating a bill for her. So she went on her merry way.
https://www.gov.uk/guidance/nhs-entitlements-migrant-health-...
The short version is that primary care services like consulting with a GP, visiting a walk-in centre, or emergency treatment in a hospital accident and emergency department are generally free to all, as are various other specific types of care.
Most secondary care services such as other hospital treatment are only free to people ordinarily resident in the UK, which roughly means anyone who is an EEA citizen or who has the immigration status of indefinite leave to remain, again with lots of other special cases.
Some services, such as dental work and buying prescribed medication, are generally chargeable by default for everyone, though even then the NHS may set standard prices and there are various provisions to help those of limited means or in certain vulnerable groups.
But yes, if you have a nasty accident and need to go to hospital as a result, no-one is going to be asking for your credit card number here before sending the ambulance, and if you only need treatment in A&E and don't need to be admitted as an in-patient, you probably would get most or all of your treatment for free even though the equivalent in certain other places would cost a fortune if you didn't have insurance to cover it. There are a lot of reasons we are proud of our NHS here, and this is one of them.
Just in case anyone reads this later, let me add a final note that if you're coming here, please check the details for exactly where you're planning to visit. A lot of health policy is devolved, meaning policies can be different in England from in Wales, for example.
As for pay, pretty much as in the US, each visit to a doctor as a value, but the bill is handled by the local region. Denmark has five Regions, each responsible for the healthcare in that geographic area. The regions are given a sum of money by the state each year, to cover the cost of operating the healthcare system and pay for doctors, hospitals, ambulances and so on.
It's a little complicated, but for instant: I need to see my doctor tomorrow, he'll be paid a fixed amount for that consultation. A consultation is defined as 12 minutes. That's 12 minutes to say "Hi", diagnose, write a prescription (if needed), talk to me about treatment and document everything.
Committees composed of doctors know nothing about software design, so their advice to developers is not very useful.
IMHO you need developers, who are also doctors or other providers actually doing the clinical work, to make decent medical software.
(I say this as a paramedic/developer who works for a "clinical first" EHR)
Medical software seems like it is rife with mandated requirements, likely written by people with no regard to real-world usage implications. By this I mean decisions that are akin to attempting to increase security by password complexity and expiry requirements -- when the reality is that decreases security by making users write down and/or cycle through easily-predictable passwords.
I would also guess the purchase cycle is very disconnected from its users. The people actually making the buying decisions never actually touch the software. This is probably also like a lot of enterprise software: very expensive, long contract/license lengths, high switching costs.
A relatively minor point but there's also no dogfooding: The developers building the software are not medical professionals and thus never use it themselves. They don't get to see the daily pain.
The result of all this would be very little incentive to build anything beyond "working" software -- spending time on UX or UI design just eats into profits. The type of developers/PMs/etc that excel at and advocate for this type of work are likely not going to stick around (or even work there in the first place), making improvements even less likely.
Requirements come from the institutions that fund the solutions ("solutions," not products) and not the users themselves, so engagement with end users is limited. It's very waterfall, no product managers, just "business analysts," whose only leverage is their perceived relationship with "the client," who may or may not be represented by an actual user.
I've thought a lot about how to disrupt healthcare, and the only viable way I can think of doing it is selling new products into emerging markets that don't yet have ensconced bureaucracies running health. The most successful grassroots medical product I am aware of is "Figure 1," but any product going into western world healthcare is going to be %95 enterprise solution and %5 health related.
An "Uber for stitches" product would be illegal in most countries, but that's the only kind of innovation I can see driving change for most people.
Don't even get me started on the format of VAERS data...
You actually can email that scan, your email provider just has to be part of DirectTrust.
It doesn't matter if the signature is on paper since the files are digitized and thus exposed to attacks. Not to mention that fax isn't really more secure than email. I have yet to see a provider near me who will accept a scanned document through email, but maybe that's different in other areas. Medical files go for a high price on the black market, but they are still fairly prevalent.
This is different than a hospital, but quite cheaper than a normal primary care visit ($200ish). https://www.bloomberg.com/news/articles/2019-12-13/pittsburg...
Anyways, there are tons of problems and costs in the system.
I’m not saying that having them on paper makes them more secure or anything, just that signing hard copies is the best way to make sure the signer actually understands what they’re doing and the gravity of it. For you I realize this is not such a great feature but for a system that has to work for absolutely everyone pen and paper works really well. But yeah I’m sorry you had such a painful experience with it. It’s supposed to be one request, you fill out the sheet with the doctor’s info and it shows up at their office.
My bad, of course you can’t email documents to your doctors. The issue is that Gmail isn’t set up to process your medical data. Doctors can email other doctors though with that system. I agree that faxing isn’t exactly the panacea of information-theoretic security but it’s pretty good in terms of policy-security. You’re not going to accidentally have your faxes processed for marketing data and anyone who tries risks big-time jail. Plus faxing these days is all digital and encrypted beyond the last mile. Not super dissimilar to the evolution of email having to bolt on security features after years and years. Unless you’re using a literal physical fax machine it’s very likely that your fax was encrypted the whole way.
I’m surprised your office doesn’t have a patient portal of some sort with an document uploader.
I swear we signed a release at the primary that they can request the record from anywhere, but so far it seems to be a big fiasco. I strongly question the training and professionalism that our doctors recieved. My kid suffered an SVT 48 hours after recieving 4 vaccines. While I acknowledge vaccines as generally safe and a great modern accomplishment, the staff seems to be brainwashed into thinking they are infallible. Everyone said it can't possibly be associated. Show me the VAERS and PubMed data then? Looks like I have to submit to VAERS and do the data analysis myself. Who knows, maybe I will be published in a journal if I find some strong correlation. No one else will try.
I get an impression that hospitals are wasting many expensive workhours from highly trained professionals to operate these types of systems. I really wonder if it could make economic sense to let MDs have personal assistants for these purposes.
If we cannot get the government to do it, we should just do it ourselves.
The only issue is the absolutely massive upfront investment necessary :/
In a field as technical and regulation-laden as medicine it's hard enough as is. Without relentlessly validating it with users it could only go in one direction.
Parkinson noticed that the English ship fleet was decreasing in numbers but the number of administrators administrating the fleet was increasing. This rule can be generalized and said to adhere to all kind of public work. If we do not keep Parkinsons law in check doctors will spend more time at computers fulfilling rules administrators invented instead of doing real critical work helping sick patients. Our tax burden will also increase since the efficiency of the system goes down over time, more tax money needs to be allocated to serve the rules and laws the administrators have invented. Is critical that we limit the number of rules and laws administrators can invent so that we have efficient system that serves there original purpose.
Parkinson's law is the adage that "work expands so as to fill the time available for its completion"
Key take away passage from Parkinsons law: "The accompanying table is derived from Admiralty statistics for 1914 and 1928. The criticism voiced at the time centered on the comparison between the sharp fall in numbers of those available for fighting and the sharp rise in those available only for administration, the creation, it was said, of "a magnificent Navy on land." But that comparison is not to the present purpose. What we have to note is that the 2,000 Admiralty officials of 1914 had become the 3,569 of 1928; and that this growth was unrelated to any possible increase in their work. The Navy during that period had diminished, in point of fact, by a third in men and two-thirds in ships. Nor, from 1922 onwards, was its strength even expected to increase, for its total of ships (unlike its total of officials) was limited by the Washington Naval Agreement of that year. Yet in these circumstances we had a 78.45 percent increase in Admiralty officials over a period of fourteen years; an average increase of 5.6 percent a year on the earlier total"
https://www.economist.com/news/1955/11/19/parkinsons-law http://www.berglas.org/Articles/parkinsons_law.pdf https://en.wikipedia.org/wiki/Parkinson%27s_law
My hospital had, over the years, computerized many records and processes, but the new system would give us one platform for doing almost everything health professionals needed—recording and communicating our medical observations, sending prescriptions to a patient’s pharmacy, ordering tests and scans, viewing results, scheduling surgery, sending insurance bills.
But three years later I’ve come to feel that a system that promised to increase my mastery over my work has, instead, increased my work’s mastery over me.
A 2016 study found that physicians spent about two hours doing computer work for every hour spent face to face with a patient—whatever the brand of medical software.
My hospital had to hire hundreds of moonlighting residents and pharmacists to double-check the medication list for every patient while technicians worked to fix the data-transfer problem.
“Now I come to look at a patient, I pull up the problem list, and it means nothing. I have to go read through their past notes, especially if I’m doing urgent care,” where she’s usually meeting someone for the first time.
Many scientists complained to Spencer in the way that doctors do—they were spending so much time on the requirements of the software that they were losing time for actual research.
In 2014, fifty-four per cent of physicians reported at least one of the three symptoms of burnout, compared with forty-six per cent in 2011. Only a third agreed that their work schedule “leaves me enough time for my personal/family life,” compared with almost two-thirds of other workers.
There are messages from patients, messages containing lab and radiology results, messages from colleagues, messages from administrators, automated messages about not responding to previous messages.
Previously, she sorted the patient records before clinic, drafted letters to patients, prepped routine prescriptions—all tasks that lightened the doctors’ load.
She called it “a ‘stay in your lane’ thing.” She couldn’t even help the doctors navigate and streamline their computer systems: office assistants have different screens and are not trained or authorized to use the ones doctors have.