duffpkg

I am pretty hard on phones. Been using lineage for years now on google pixel unlocked phones. 5a and now 6a. I have found both to have some real durability problems. Are there any good alternatives that are unlocked to use with lineage?

I am sorry. That is a terrible disease. To my knowledge John Hopkins currently has the most promising trials for ALS but generally speaking there is not currently a full understanding of the underlying mechanisms of that disease and little, even in the most experimental ends of the pipeline, for it. I am not aware of anything that has even the slightest promise of effectiveness that would be available in mexico or china that would not be available in the US if they met eligibility criteria for currently open trials. The ACT for ALS passed in 2021, amongst other things, specifically opens what paths are available to patients with ALS and in certain circumstances offers grants.

First, do no harm. This is a foundational tenant that permeates healthcare. As a former health system executive I have been in positition to influence decision making about high risk experimental treatments in certain cases. In the US currently, in most states, you as a patient have a more or less unlimited right to try experimental treatments if you are facing a reasonable likelihood of death otherwise. The FDA plays a very limited role in one-off situations though they are frequently made to play the villain. The reality is that there are legal avenues available much of the time that providers and companies are loathe to employ. Much of the time drug companies and doctors have lots of reasons not to want to roll the dice if they think the odds of success are low enough. The risk/reward is a very different outlook for the patient than the providers and companies that may need to be a party to the treatment. There are reprecussions to all patient deaths as a result of an experimental treatment however well intended and consented.

A complicating factor that weighs over everything is that there is a long history of terrible abuse of informed consent with less privileged patients, puerto rico is a trainwreck of abuse going back a century but there are many more. As an administrator I always felt that patients who are freely giving informed consent always have the right to try, however slim the chance of success. But, it can be brutally difficult to parse out those instances where influence, coercion or even misrepresentation are at play with a particular patient and family. Family dynamics of course can play a large role too.

Doctors are using it inappropriately to diagnose and advise treatment on their phones without telling patients. It is being rolled out in all manner of automated classification, huge amounts of behind the scenes healthcare involves manual review of charts for classification purposes that is associated with various streams of funding. Low level employees are turning to general purpose AI to assist with this, leaking data, not understanding how unreliable these tools can be for this. Billing departments are "secretly" using it to "refine" coding. Pretty much all of the dumb irresponsible things you can think of.

It is infiltrating healthcare in all of the worst possible ways at present. It is sneaking into diagnosis and treatment in ways that are outright dangerous to patients.

This is a much easier fix in Cerner. I would guess based on the limited information at hand there is something wrong in the setup of the order release rules. IT should hire a Cerner specialist and the problem should be able to be resolved in days/weeks.

Specifically with handwashing which is a problem I have been very successful at solving, time is not the main factor. It is wear and tear on the hands and this comes down to the soap used and water quality, really. If you get those too things right people mostly find it no problem to wash their hands when appropriate. Also for non-medical people this is not washing your hands before surgery washing, this is routine washing between patients, bathrooms, and duties.

Regarding gloves, gloves don't solve disease transmission from dirty hands. You need both hand washing and gloves.

Webvista and HealthCloud are still utilized by some facilities and maintained as an internal system. EMR as a standalone line was <10% of ClearHealth's business when it was acquired in 2017, I remained involved in some capacity until 2019. ClearHealth's main business was as medical/hospital management company.

I am lacking all the information as to whether we are even talking about Epic but Epic is a lousy tool. It is still just a tool though. For the unititiated Epic is not some tiny little software program to manage an ICU, it's a city scale platform to run most of a hospital city. You can do a lot of good things with it and a lot of stupid things with it. If in fact orders are being randomly cancelled in the ICU that's a problem that should have never reached a live rollout to an ICU without some sort of consideration for how to resolve it, that isn't a software vendor problem, that's a management problem. This is nicking an artery and blaming the scalpel. Maybe if it happens once but if it happens consistently the problem isn't the scalpel. The problem is with how the scalpel is being used. Epic dates some of it's underlying pieces to the 1980's at least, it has some well known problems and bugs. Better managed facilities develop workflows that successfully route around those problems.

In-N-Out does not as I understand it develop it's own Point of Sale system, they work with a vendor. What do you think would happen if In-N-Out had a location that was consistently failing to ring up orders or lose them randomly? Would the cashier blame the POS vendor and store management stand by and do nothing while the problem persisted? Would the system be rolled out without definition and documentation of workflow, reliability testing and proper training of the cashiers? Can we not operate our hospitals at least as well as we operate a burger stand?

I've managed large enterprise health organizations across multiple sites that use Epic. We built an adjunct system that is still used by some of them that papered over serious problems that doctors using them never knew wasn't only Epic. We defined, documented and tested real world workflows before we subjected patients to them. There are a lot of other ways to address those issues operationally. You have management, IT and operations problems, not software EMR vendor problems. No software is perfect, Epic less perfect than most. Your facility chose that system and decided how it was implemented in a way that is dangerous or potentially dangerous to patients. No software vendor can fix that. That's really the heart of my rants in response to this article.

I built that EMR, it was/is called ClearHealth/WebVista/HealthCloud. Your facility would never have bought it because incompetent management will only buy Epic. We solved the problem by buying organizations and replacing the incompetent management.

This sounds a lot like Epic. Respectfully I don't understand how your facility can face those issues with a system like that and also be considered to have great operations and results. With Epic it is possible to workaround a lot of notorious problems but management has to understand and have in place the operational capacity to do it. If a system is allowed to persist in an organization that may have or actually did result in patient deaths in the ICU and it was up to me I would see the facility shuttered until that got sorted out.

I also want to be clear that doctors are not by any means the only obstacle to resolving workflow problems. You being put in a position to protect patients from a business process of the facility that may accidentally result in their death is the literal definition of incredibly bad / incompetent operations. That software didn't magically appear and become responsible for ICU ordering magically on it's own. In this instance whatever insane people have been given responsibility for that implementation are responsible.

After consideration, this comment from a doctor, in a nutshell encapsulates so much of what is wrong. A doctor on the front lines alluding to staff burnout, thinking that people almost or actually dieing because orders are being cancelled inappropriately in the ICU is somehow "a software problem", while simulatenously praising the management, operations and results of their institution. Welcome to healthcare.

A lot of facilities run on a McDonalds type thinking when they should be looking at how In-N-Out is able to deliver a very similar product that is both dramatically better and either the same price or even cheaper. In-N-Out staff is well compensated, customers rate the institution as one of the most beloved in american life. McDonalds achieves neither of those things. What makes In-N-Out different? The difference is competence in operations. A lot of healthcare today delivers an inferior product at an inferior price, it doesn't have to be that way. A lot of people think that quality is only possible at an increased "price". A change in thinking is what is needed to achieve a change in quality (result/price).

Responding to the request below for a specific example. Hand washing, you wash your hands when medically appropriate to prevent facility acquired infections. If you don't you are progressively warned ultimately leading to termination and/or loss of license. If instituted nationally this alone would save at least 5,000 lives a year. Good luck getting it instituted at most facilities.

A different example, diesel fuel and generator maintenance is a meaningful part of medical facility physical plant. A shocking number of facilities place procurement responsibility and oversight of this in the hands of a doctor who also has medical responsibilities. The results are as financially and operationally disasterous as you would expect. Data centers have similar requirements. Who do you think pays more and operates better?

Formularies are a sort of default medication lookup table. Most organizations have one that was created decades ago by people who aren't with the organization anymore. Review and revise them with someone who understands both the medical/pharmacological aspects of the drugs involved as well as their costs. Win for doctors, win for patients, win for insurers, almost no one does this. They have some clueless administrator carry forward last years formulary with minor changes or alternatively have a medical professional with absolutely no idea what costs are involved do it.

At ClearHealth/CLH we defined thousands of core business processes in a typical over 100 bed acute care institution. These are complicated animals. A hospital of any size is pretty much a city unto itself. There isn't one thing, there are a lot, a lot of things from how items and equipment are procured which is very complex to simple things like making sure that people wash their hands when they should. How laundry and trash are handled. HVAC and plumbing are insanely complex in a hospital setting. It is absolutely absurd how viscious the fights get between staff and management over parking assignments. It requires virtually a threat of termination to make a lot of doctors follow even a 3 to 8 step evidentially developed checklist for certain situations.

ACHC, joint commission, CLSI for laboratory, are groups that outline some very basic frameworks of how facilities should be operated. Less than half of facilities can meet even these extremely low bar standards for operations. It is difficult for me to see how many patients have been harmed by ransomware impacting hospital opertions, this is entirely preventable and no one on the hospital side has been meaningfully held accountable so very little will change.

A counter example is the pricing transparency regulations. Failure to meet those is resulting in multi-million dollar a year fines which is resulting in change. It is happening slower than people like or had really conceived of but it is causing some real meaningful change.

99,000 americans a year die from hospital acquired infections that are entirely preventable using procedures and operations (not surgeries) that are known and evidentially proven. It's just really hard to get all of the parts of the orchestra to play the same tune so those people die needlessly.

I created the ClearHealth/HealthCloud open source (GPL) EMR which to my knowledge is the only open source one to receive full federal certification. Operations (not surgery) are so incredibly bad / incompetent in most healthcare settings that software frequently gets the blame for much deeper problems. This article is a doctors perspective on how software did not fix a completely broken workflow. I don't begrudge him that but there is no software in the world that can ever address those types of problems. In my experience doctors are a tremendous barrier to resolving problems in healthcare operations, they are chasing their own incentives that are in some ways opposed from those of the patient just like the insurers are. It is very tortured process to institute proper operations in a medical setting, I spent most of my career doing it, no one complains about the software when operations make sense to begin with. In-N-Out instead of McDonalds, is something that should be incredibly aspirational to healthcare as an industry but doctors tend to despise the comparison.

Wrote Hacking Healthcare, managed hospital systems, blah, blah... I remember first learning about cancer treatment and encology in detail when we took over management of a health system with a large set of encology centers. It was very eye opening to understand that one word, "cancer", is really an inappropriate blanket term for hundreds of more or less distinct diseases. Yes, they share a base element of disease mechanism but in terms of diagnosis, prognosis, treatment and morbidity, they are wildly different.

I think the HN crowd may be interested in learning more about TNM staging (https://en.wikipedia.org/wiki/TNM_staging_system) and the staging process in detail (https://www.facs.org/media/j30havyf/ajcc_7thed_cancer_stagin... pg 457 for prostate) . This was once "open source" but is now locked behind a proprietary API of sorts (https://drive.google.com/file/d/1sa2Qlv03-E-nBJuUynZuFxIaMsO...)

These are US oriented resource links.

Regarding the posted article, there are two big related factors that the average patient has a difficult time appreciating. First is that "doing nothing and or waiting & seeing", even in 2024, is still the best course of treatment for a huge array of situations. The second related factor, is that the rate of preventable medical errors is absolutely staggering. In my multi-decade experience it typically hovers over 20%. As a patient myself I have been the victim of three near fatal preventable medical errors. So 1/5 of the time doctors are creating new problems and complications that are preventable if all of the known best practices at the time are employed, while attempting to resolve whatever is wrong with you. A troubling amount of the time the treatment can be worse than the disease.

Wrote Hacking Healthcare, operated/managed hospital systems, blah blah. The study being referenced here is https://doi.org/10.1001/jama.2023.23147. The conclusion of the study is that the identified set of hospitals performed worse on some key metrics, hospital acquired infections are in my opinion a pretty good bellweather of other problems. However, what they are defining as "private equity" seems to be pretty amourphous. Most of the studied hospitals were in private ownership that a lot of people would call "private equity" and then bought by different "private equity". I previously was involved in ownership and management through my company ClearHealth, of some of the facilities studied. Most people would identify that ownership as "private equity". I don't dispute that the hospitals seem to be performing worse after the ownership change (after our interests were divested in 2017-2020). As "private equity" we took over operations and management of many facilities of both public and private ownership and made them run really a lot better for both patients and owners, we were very very good at doing that.

Bottom line there are a lot of very incompetently run facilities out there, of both private, "private equity" and various form of public ownership/management.

It makes a great headline to say that a hospital can be "bought" but ownership and management of hospital systems takes a book to explain. Outside entirely vertical systems like Kaiser and even that has some complexity, hospitals are much more like medical malls than anything else. An ownership and or management company does not dictate what happens under their roofs in anything like the manner a private corporation like Coke, GE or Google would. 29 states make it outright illegal for non-licensed persons to own or manage an entity that engages in the practice or medicine. Most hospitals of any size over 100 beds involve at least dozens of seperately controled and managed entities. See "corporate practice of medicine (CPOM)" laws.

Finally I would add that measuring outcomes on an apples to apples basis is more or less an impossible thing to do. Lots of people don't like to hear that. Again something like HAI I think can be a useful general indicator as well as other measurements of preventable complications, but comparing outcomes at different facilities especially across size and location is more or less useless.

I want to be clear that I agree there are significant problems. I understand this commonly held perception but more than 29 states make it outright illegal for a regular for-profit corporation to own anything which engages in the practice of medicine. Look up "corporate practice of medicine" laws. That isn't to say there aren't problems. As a former hospital executive I can tell you first hand there is no love lost between hospital systems and insurers. A lot of hospital systems operate with a level of incompetence and dysfunction that it is truly difficult for regular people to appreciate. In many many cases a medical provider may not have a clear picture or be able to get a clear picture of what they will actually be compensated by your insurance for a given procedure. I understand that sounds crazy but it's a real thing. Competent organizations handle that situation a lot better than incompetent ones.

If you go back and read the various dicussions, arguments and controversies from around 1984 regarding the enactment of HMOs it is my opinion that things aren't dramatically worse than at that point.

Executive compensation is an issue in a lot more industries than healthcare. I think that there are big problems there. The structure of hospitals as a medico-legal entity is a complicated business in most states. When you say "CEO of a hospital" it typically does not bear much relation to what you say when you say "CEO of Disney". In healthcare there is among other complicated things "corporate practice of medicine" laws which prohibit non-medical ownership of medical organizations. So a "Hospital CEO" may often be the head or a chairman of a foundation or entity that owns the real estate that a hospital uses or sometimes is just the practicing head of medice of a medical organization or any of a myriad of other byzantine structures. That doesn't make excess compensation any better but it's important to identify what someones role actually is and what they are compensated for. Most hospital systems are a little more like medical malls than any singular beast.

To clarify my point, your insurer spells this out to you, though you as a patient may not understand it to be the case. There is no surprise, its the expected behavior reading the literal minutiae of the giant packet your health insurer offers you. It's just that many people do not understand they have multiple additive deductibles for certain types of care.

This seems like a good thread to mention the book "Never Pay The First Bill" by journalist Marshall Allen. I've worked in healthcare for 20+ years. I've been on the collecting side of many bills, it's a good book for patients. Contrary to popular belief most hospital systems are not evil profit seeking corpratons but just trying to keep the lights on, it's still a business though and as a patient you have the right and oppourtunity to negotiate. Most of the time collecting something is better than collecting nothing which is more or less the default. Of course there are exceptions and abuses.

One other point I think is important, that I see come up a lot regarding deductibles, is that your deductible is most likely double what you think it is for a lot of situations. Particularly emergencies. This is buried in the minutiae of your insurance and relates to in and out and network/facility/doctor care having seperate deductibles.

I have worked a little bit with facilities in the italian health system in my career. As with any health system you build out to handle a certain idea of peak utilization which is much higher than average utilization. My experience in Italy was the there was a very modest difference between average and peak. It is extremely expensive to maintain a lot of unused capacity for modern health facilities. Bottlenecks around imaging, and ICU in particular. As with any health system you do the best you can with the resources that are available. Unfortunately, it is a very long lead time to add additional peak capacity.

I don't like the usage of "collapse". It's a weasel word. What they actually mean is that some meaningful amount of patients won't be able to receive a proper standard of care. That is a -- possibly avoidable -- tragedy.

Location: Phoenix/Los Angeles

Remote: yes

Willing to relocate: no

Technologies: Strategizer, Architect, Senior Engineer. Extensive experience in payments and healthcare including fortune 500. Created the open source HealthCloud/ClearHealth electronic medical record system.

Notes: I'm author of "Hacking Healthcare" for O'Reilly. Managed ClearHealth for 15+ years operating hundreds of US hospitals and clinics leading to a successful 2017 acquisition. Led the project that modernized Subway's payment infrastructure servicing 37,000 restaurants at 24 sandwiches a second.

LinkedIn: https://www.linkedin.com/in/duff-uhlman

Email: du@50km.com

Website: https://duffuhlman.com

I don't dispute the headline but this article is a total mess. First referring to the US health system but then citing anecdotes from the english health system. It then mingles US healthcare and dentistry. The US health system is as different from the UK health system as different can be and in the US dentistry is a fundamentally separate industry and education tract that has absolutely no connection to healthcare whatsoever.

In the US I can speak first hand as a former hospital executive that a lot more can be done to improve treatment paths for people with a wide variety of mental health diseases. Medical school can play a role but residency programs are a much more important element, at least in terms of how US doctors are trained. From history the best way to do this is to create a specific health system focused on treating those patients and to lead by example. I am not aware of such an effort but there may be one.

As someone who has worked in healthcare for 20+ years now, at least in those circles it was widely known that phenylephrine was a placebo at best, when it was mandated as the on the shelf replacement for psuedoephedrine (Sudafed) nasal decongestant. Again in healthcare circles there was a clear understanding of this being a DEA driven policy to replace an effective medicine that could be abused to create methamphetamine with a different medicine that was ineffective but could not be turned into street drugs. As best as I can tell the policy resulted in harm to millions of people while not reducing the spread and availability of methamphetime one bit and ancillary costs to the healthcare system in the billions of dollars.

Off the top of my head, https://pubmed.ncbi.nlm.nih.gov/19230461 from 2009 but there are many earlier studies as I recall.

Location: Phoenix/Los Angeles

Remote: yes

Willing to relocate: no

Technologies: Operations Firefighter, Strategizer, Architect, Engineer. Extensive experience in payments and healthcare including fortune 500. Created the open source HealthCloud/ClearHealth electronic medical record system. AWS, Linux, everything web/cloud, Node/PHP/C/etc, React/Vue, AI/LLM.

Notes: I'm author of "Hacking Healthcare" for O'Reilly. Managed ClearHealth for 10+ years operating hundreds of US hospitals and clinics leading to a successful 2017 acquisition. Led the project that modernized Subway's payment infrastructure servicing 37,000 restaurants at 24 sandwiches a second.

LinkedIn: https://www.linkedin.com/in/duff-uhlman

Email: du@50km.com Website: https://duffuhlman.com

Blah blah blah wrote Hacking Healthcare for O'Reilly, managed large hospital and multipractice groups, ... Self checkout scenarios remind me a lot of the difficuly in building electronic medical record interfaces and workflows. UI really, really matters but is barely given a second thought by most vendors. These things frequently fail on UI but the blame is placed elsewhere. It took us roughly 8 years to create a solid reliable UI and workflow for most acute care and primary care settings that most of the people liked most of the time.

A good example I can think of personally is at McDonalds. It takes 22 finger clicks on the screen to order a medium iced coffee and approximately 140 seconds. There are numerous slow animations, the screens are slow to appear, slow to respond, multiple upsells, positions of buttons change on reflow after clicks. In person it takes "I'd like medium ice coffee light sugar", approximately 7 seconds for that and then the card processing time. Self service is 20 times worse.

Someone else mentioned theft reporting. Having recently spoken with a criminal defense attorney in a social setting, this is an out of control problem. He is in a medium sized city and has seen the number of shop lifting bans increase over 500-1000x. He would typically see a dozen or so per year but since self checkout became dominant in the area he is seeing thousands per year, nearly 1% of the population. This becomes a major problem in an area like this, if you get banned by walmart and safeway you have to travel 2 hours to get groceries, there are no other food stores. There is no recourse, the stores have no interest in trying to resolve these cases where, as the other commenter described, very common human errors resulting from terrible UI are criminalized.

From a policy standpoint this is an easy thing to say, however tens of millions of americans get a pretty sweet deal as a result of this. To change it you need to make losers out of them so you can make winners out of others. These games of winners and losers is what makes health policy making very very difficult and resistant to change.

Respectfully I would say there are a lot more problems than that going on. The federal government has an incredibly dark history with Puerto Rico regarding health, the rhoads scandal alone https://en.wikipedia.org/wiki/Cornelius_P._Rhoads#Scandal but also human experimentation and other misdeeds compounded by the complex status of it as an american territory.

That is the correct book. Acquire it however is most convenient for you, thanks though.

My opinion about the FDA is that it suffers from two major faults, it is always regulating the "last war" and it has the standard federal government incentive structure for policy making which is "do not do anything that according to civil service regulations can get me fired".

In defense of the FDA, which I promise is not an instituion I have much affection for, they are asked to strike an impossible balance. More or less the same regulatory impulse that allowed Richard Sackler to build an empire on the killing of millions of americans is the same one that allows very sick people to access very, at times dubious, drugs and trials that sometimes save their lives.

Most of medicine is very centrally built around the "first do no harm" approach, even at the cost of lives by non-intervention sometimes. With the FDA most people want a "do some harm, some of the time for the greater good" approach which is a really difficult thing for a federal agency to put into practice. I think they do an especially awful job with it but I appreaciate that it is a really hard balance to strike.