2,308 karma · joined April 6, 2019
Unfortunately I see the opposite trend right now, more silos, more lip service to interoperability, more tolls. I think driven by the burden of regulatory overhead. Moving forward there could be a shift to a "patient owned" record where providers and facilities feed standardized formats into a patient owned/managed "personal cloud". I hope that continues to pick up steam.
The underlying problem is that we need an economical way for doctors to have more time to spend in the room with patients but no one, patients included, wants to pay for that.
I really hope "concierge" medicine, a lot of that now happening on the lower priced end not only for "luxury patients", continues to take off. You pay some cash out of pocket but get care that is dramatically better and more preventative.
In part I think it happens more commonly because there is so much "other peoples money" in healthcare. Everyone is spending from someone elses checkbook and so transactions seem very distant.
HIPAA greatly complicates a lot of data sharing because of appropriate data privacy issues.
You can read quite a bit about open source in healthcare in my book, Hacking Healthcare. A bit dated but still in print.
Unfortunately there are massive headwinds against open source in US healthcare settings. Regulation requires certifications that cost upwards of $100K first time, $10K with each release, just in fees. Licensed data sets also make for real difficulties in licensing. Required 3rd parties like SureScripts are openly hostile to open source. Most largest buyers of systems are institutional and most current interpretations of law make it so that open source systems cannot be sold as "sole source" which makes life very hard to close and keep those deals. Finally, until a business model emerges that favors open source and patient health, everyone makes more money with lock-in and so that perpetuates.
Ask me anything.
Can confirm, a little concerningly, that code I wrote 17 years ago is still widely present in the OpenEMR codebase including my old office number for test patients, lol.
-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.
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.
As a model, I think the customer here is not so much a food buyer but a restaurant starter and that is a bottomless well. This concept is a natural outgrowth of the current trend in quasi-legal "instagram restaurants" . It also meshes well with the fickle appetites and food trends of modern day. A cronut kitchen can sell out for 6 months and then fade into a ramen burger for another 6 months, all from the same physical kitchen.
I think that it is more sustainable than the food-truck -> sit-down-restaurant strategy that hasn't worked for more than a handful of entrepreneurs. American's love to eat a cornucopia of tastes and dishes but we absolutely hate to pay more than a nickel for it. The underlying cost structure of the cloud kitchen is more amenable to that sentiment.