Everyone hates the electronic medical record

https://logicmag.io/policy/why-everyone-hates-the-electronic-medical-record/

286 329 2 years ago

analog31• 2 years ago

My mom would just bring a briefcase full of printed medical records to every appointment.

rkagerer2• 2 years ago

You may jest but I wouldn't mind this model. i.e. Records are under a digital lock to which I hold the key, and can grant access to a medical professional service provider for a period of time with set access expiry.

Written records at least provided some physical locality that made me feel less at risk, and it was also easy for me to ask for a photocopy for my own records (I'm surprised how many people just entrust this to their institutions).

hashishen2• 2 years ago

the issue arises when you are unconcious and there are certain risks to treating you the staff needs to know about. Maybe your throat closes for benedryl but you're showing obvious signs of an allergy? Maybe you have a pre-existing condition which gives you symptoms that signal a stroke? the risk is always going to be there

mindslight• 2 years ago

How does this work out in practice, given that doctors generally only give you 10 or maybe 15 minutes before they start pushing you out the door?

jackvalentine2• 2 years ago

Disclaimer - I work for a health service that isn't in the USA and has a very extensive EMR.

I don't disagree. I started my career dealing with paper folders of records that were fastidiously organised by a team that made sense of them. Now everything is electronic and fucking _everywhere_. The work didn't go away - but giving everyone a computer made it everyone's problem and nobody's job.

A really good EMR (or other records project) makes the 'work doers' jobs easier and is intuitive. We often severely miss that mark or only do half the job required.

wharvle• 2 years ago

This is everywhere. We made everyone their own secretary but gave them crappy tools and no training. Also they’re never gonna be doing it more than very part-time, so will always tend to be bad at it and find it a distraction from the work they’re actually good at.

I’m skeptical computerization has even been a net benefit for productivity for most jobs, for that and other reasons. I think it’s been such a huge boost in a few areas that it looks productive overall, but actually it’s been a step back in most jobs. The high of eliminating positions and of centralized command-economy-style technocratic visibility into everything keeps management hooked on it anyway.

whatshisface• 2 years ago

It's all visibility and no observation.

perilunar2• 2 years ago

Yes, we should have given the computers to the secretaries and librarians (and a few other jobs), and kept them away from everyone else.

jackvalentine2• 2 years ago

We made everyone their own secretary but gave them crappy tools and no training. Also they’re never gonna be doing it more than very part-time, so will always tend to be bad at it and find it a distraction from the work they’re actually good at.

This is, 100% exactly it. Then we have to design systems for the absolute lowest common denominator to get any semblance of sense from it and anyone with the slightest bit of clever just has to deal with it.

Stranger432• 2 years ago

The problem with the computerization brings benefit lines is that it was demonstratively true back in the mainframe days but became less and less so once the big beast with dedicated attendants and handlers got replaced by "not quite foolproof enough" wintel desktops managed by nobody.

This is also why so few PC centric modernization process are truly successfull.

acuozzo• 2 years ago

We made everyone their own secretary

Which is absurd when you consider just how many jobs are so-called "bullshit jobs".

NoPicklez• 2 years ago

I wonder if perhaps you work in South Australia, we might be thinking of the same EMR...

j16sdiz• 2 years ago

Clinic can't organise their file in their own way is a big time waster.

Each clinic have their own speciality and therefore their own way of filing stuffs

rtpg• 2 years ago

is there any good research or information on various clinic's organizational style? I feel like there are plenty of places where digitalization took its time to get there.

I feel like in general there's gotta be a lot of good sociological research on how stuff is kept straight. I only see stuff regarding DX work, but organizing was a problem even before computers, right?

makeitdouble• 2 years ago

Same disclaimer: not in the US.

From the other side of the table, as patients that were very regularly ill and bouncing between medical professionals, EMR were a godsend.

For instance in vacation at the other end of the country, we lost an Anapen with a luggage mishanded at the station, though we had a spare but we actually didn't (was in the same bag...). We went to the closest doctor, showed the insurance card and they got access to the allergologist's diagnosis and original prescription, gave us a new one with a memo in the file, and done.

Same way having two generalists looking at us, one near my work and another near home wasn't an issue. At no point did we have to bring folders full of papers to explain long treatment histories etc. (it still helps to have the key files, in particular scans)

I moved away and everything is back in small silos at each doctor/clinic, and it's a real PITA.

I'm truely sad it's such a pain on the care giving side, because there's so much potential and I think it merits investing a lot to get something decent. It's such an important part of our forseable future.

firejake3082• 2 years ago

The problem is that in the US, many EMR's don't automatically connect to each other.

If you're going from a hospital owned by one chain (say, Hospital Corporation of America) to another hospital owned by the same corporation, then yes, it works like you said and doctors have access to your historical data. But God forbid that you should ever end up at a hospital owned by a different corporation, because then you have to call the Medical Records department to release the data, which often takes a couple business days to go through. The system doesn't work if it isn't open, and unfortunately, our patient privacy law (HIPAA) is often used by corporations as an excuse to silo their data away and prevent others from accessing it.

JusticeJuice4• 2 years ago

I wrote a thesis on EHR's 7 years ago. They really haven't seemed to improve much. I personally think a big part of the issue is actually scope, these systems are expected to do everything - medical notes, script ordering, appointment management, billing of course, and 3000 other things. This weirdly leads to a distribution problem, you can't be a serious competitor in just one area, you have to do everything. Only the monolith can shift the monolith. Then combined with the risk (or perceived risk) of working with medical data, and you're left with something that just never improves.

If your curious, here's where I discuss these points in the thesis https://barnett.surge.sh/welcome/complexity.html

sixothree• 2 years ago

Yea. But in that time there has been an absolute revolution in what can be done with that data. FHIR specifically has completely changed the landscape.

nradov7• 2 years ago

FHIR is great for interoperability but it doesn't really do anything for the EHR user experience.

JusticeJuice4• 2 years ago

Yes. FHIR was pretty well established when I was writing the thesis, but I am very pleased to see it get more and more usage since then. Apart from interoperability the opportunities to do much better data mining from free-text medical notes with AI, are huge now. Back when patient prescription lists ot structured, so many new drug interactions were found, now there's the chance to do similar stuff from open medical records.

Patient-accessible medical systems are more common now too, which is great. EHealth got way more common. At the end of the day though, what your doctor is clicking on still sucks, which is the sad part.

FwarkALark4• 2 years ago

Is this something where a public competitor might help? It surely can't be worse than private industry.

timekiller• 2 years ago

Oh it could be much worse. You should see how bad government run HIE’s are.

nradov7• 2 years ago

There is (or was) a public competitor. VistA was largely developed by the federal government. Some organizations still use it and it's available for free, but independent reviews have generally rated it as worse than the private industry products.

https://worldvista.org/AboutVistA

JusticeJuice4• 2 years ago

The UK government tried this, wasted 12.4 billion pounds over 10 years, and ultimately wrote most the project off. The dream of an EHR is just deceptively tricky, so many smart, well-funded, well-connected teams have tried and failed.

ref: https://barnett.surge.sh/welcome/intro.html

thaumasiotes3• 2 years ago

Private industry is already worse than the older system of keeping notes with pen and paper. (Source: my mother operated her own medical practice and applied for a government subsidy to switch over to electronic medical records, then complained about how it reduced the functioning of her practice.)

YetAnotherNick2• 2 years ago

Is there any industry in which public competitor is better than private one?

boxed2• 2 years ago

In Swedens capital region they failed with this too. It's dominated by a system that is largely quite well polished but has some scaling issues that has lead to down times. The region decided to develop their own in cooperation with other regions, but instead of just hiring two-three developers and putting them in a room inside some small hospital, they decided to make a Grand Political Project out of it.

Billions of Swedish crowns later, having written ZERO lines of code, they quietly cancelled the entire thing. This enormous boondoggle didn't even make the news because the waste was all man-hours and consultancy, and not a building or something the media found sexy.

I think a big problem is that politicians need Grand Political Projects to get reelected, but that's not how you build software. Or make meaningful small incremental improvements to science, infrastructure, schools, etc. The incentives are wrong...

atlasunshrugged• 2 years ago

I believe the Estonian government has long had at least a basic EHR that they use across their public and private medical facilities that is part of their larger e-government system

https://e-estonia.com/solutions/healthcare/e-health-records/

Zanfa4• 2 years ago

This is absolutely true in my experience as well.

Ironically, it's also a somewhat of a circular problem, given the inherent complexity of medical processes, every organization has organically formed their processes over decades. When choosing software solutions, they pick software that caters to their specific needs, rather than change processes to fit existing software. This results in vendors building endlessly configurable products that add even more complexity. As a potential new entrant, this means you'd need to not only support N processes, but something like (number of clients) * N processes.

There are some initiatives towards EHR interop (e.g. FHIR), but from what I've seen so far, they suffer from similar problems. As in the standard is made so flexible to cover all situations that you can make things that are 100% compliant, but completely incompatible.

JusticeJuice4• 2 years ago

Yeah, I've seen the term "sociotechnical" used to describe this relationship between software and process. A process is built in part for a system, and therefore the system in part needs to support the process. Changing the setup isn't just a technical challenge, it's a challenge in creating sociotechnical change. I think it's a very easy thing to underestimate.

jharsman• 2 years ago

This is very true. There several reasons why most EHRs are so bad:

1) The people who pay generally do not use the system. This is true for enterprise software in general and leads to vendors prioritizing having all features organizations ask for (regardless if they are a good idea or not) and also prioritizing features management deems important over fundamental workflow, UX and polish in general.

2) EHRs are very large and complex and can almost always gain more customers by gaining even more features and replacing smaller more specialized systems. A typical EHR will have features for ordering tests and viewing results (for clinical chmistry, microbiology, radiology and more special stuff like physiology etc), appointments and resource planning (rooms, equipment, personnel, staffing), clinical notes including computing scores and values based on other values, medication (ordering, administering, sending prescriptions electronically) and administration (admissions, discharge, payment, waiting lists). That is a lot of different stuff!

3) Once a vendor wins a contract and installs their EHR, very little can be gained by improving the lives of users. Contracts and sales cycles are very long, and the vendor gains very little financially by improving the system. So many vendors are focused on charging money for customer specific features or adding new features to win new tenders.

I'm not sure what the solution is, public alternatives have failed spectacularly since they are typically run by public administrators who have even less of a clue how to develop software and what users want than the vendors.

Terr_5• 2 years ago

So many vendors are focused on charging money for customer specific features or adding new features to win new tenders.

In turn, this enterprisey anti-pattern creates unfocused products which can be configured to sort-of-solve every niche customer requirement that might block the sale.

The result is a massive ball of muddy configurations and feature-flags, so that learning isn't very portable and backend integrations are very painful.

namdnay6• 2 years ago

I would add the point that these dynamics are also present for any large IT system. Just search for people having issues migrating to SAP or Amadeus or whatever

lotsofpulp• 2 years ago

I personally think a big part of the issue is actually scope, these systems are expected to do everything

If I were to guess, the goals of admin and workers might not match because the primary goal of the admins deciding and implementing the EHR is to avoid liability for the organization in the event of an error, but errors are inevitable. And if liability for individual errors are so costly (as they are in the US for healthcare stuff), then the primary goal for the workers also becomes avoiding liability.

In this situation, I can envision something like a crew of people working in the hospital that do good, quick, but undocumented work 99% of the time, are now being slowed down by documentation or other cover their ass needs. Obviously, it is possible that the new documentation needs are also uncovering malpractice that went unnoticed before. The question is are the tradeoffs worth it, which does not have a simple, objective answer.

Gravityloss• 2 years ago

Archive.org link: https://web.archive.org/web/20180625225731/https://barnett.s...

demondemidi• 2 years ago

They’ve improved tons since the 1990s. Let’s have some perspective.

KennyBlanken• 2 years ago

Patient R was in a hurry. I signed into my computer—or tried to. Recently, IT had us update to a new 14-digit password. Once in, I signed (different password) into the electronic medical record

That's IT infrastructure incompetence, not an EMR issue.

At the two healthcare systems I go to, both utilize RFID badge readers plus PIN. In the ER and urgent care, nurses need only tap their badge and enter a quick pin and they're in. It's taken them seconds to pull up my records and I've never noticed a delay in care.

In the PCP's network, everyone seems to get smooth and quick access often while we're conversing, and I can see all my visits, lab results, and so on. The major annoyance is that I get emails notifying me I have a "message", instead of even offering me the option of receiving an email with the actual message.

I don't think people understand how expensive and time consuming the non-electronic stuff was. I remember my mother spending considerable amounts of time trying to get records from labs and doctors and having to shelp a lot of it by hand.

Spivak• 2 years ago

That's IT infrastructure incompetence, not an EMR issue.

The two cannot be unlinked so easily when I have never met someone so doesn't have the same story of hospital IT. Even the IT workers hate hospital IT. The deployment of an EMR has to take into account the regulatory and security requirements imposed on all digital systems.

I get emails notifying me I have a "message", instead of even offering me the option of receiving an email with the actual message.

You need to bash the right heads together and get your email provider and sender in DirectTrust https://directtrust.org/what-we-do/direct-secure-messaging

Not gonna say it's not a bitch and a half to implement but you can send sensitive data directly via email. And if you're the SaaS provider you're part of DT that's a huge value add for your offerings.

mrcarruthers• 2 years ago

The email thing is probably a privacy requirement. Email isn't encrypted meaning your email provider (and the EMR's) can fully read the contents of said email.

8organicbits3• 2 years ago

I think people want to waive that privacy concern. My email provider has access to tons of my private data including lots of health data. Given the option, I suspect many would prefer to just get an email.

D13Fd• 2 years ago

Yes but it should be the consumer’s right to simply say they don’t care about the risks, and prefer the convenience.

jrockway2• 2 years ago

Yeah, as a patient I don't have any problem with EMRs. When I visit a specialist I can fill out all the forms and pay the copay online. The app notifies the office when you arrive, so you just sit down and get called in. I used to go to NYU Langone but switched to Mt. Sinai and all my records came over fine.

I'm a "visit the doctor once every 0.9 years" kind of a person, so I guess my needs are not incredibly complicated, but I've found the experience to be pretty fine overall. Good, I'd say, honestly.

bongodongobob2• 2 years ago

I could see that badge system easily costing a million+ dollars, fyi. RFID identity management is an entire platform in itself and is extremely expensive.

Scoundreller• 2 years ago

A lot of hospitals already use it for things like door access. Sometimes parking tagged on too.

RajT88• 2 years ago

I used to work at an EHR software company. All of this is true.

The most interesting thing I think on the horizon is gluing the ever-increasing intelligence of AI bots with voice assistants. The company that can reliably take a HCP's dictation, store and retrieve that information accurately is going to transform the industry by drastically reducing the administrative overhead, and letting doctors treat more patients.

perilunar2• 2 years ago

I spent two hours this morning helping my elderly mother fill in a hospital admission form online. The session timed out just before submission, but we logged in again and everything was saved. I'm grateful that it was online, so I could help her remotely via screen sharing and not have to travel to fill in forms (I'll visit when she goes in, just don't want to have to travel repeatedly for paperwork.)

Entering medical history and current medications was a pain in the arse though, and is something we have done many, many times over the last few years. FFS just implement an standard text format that we can upload or link to.

consp• 2 years ago

Entering medical history and current medications was a pain in the arse though, and is something we have done many, many times over the last few years.

Isn't this something what electronic records should have solved? I know doctors always ask the patient but they all have access to that data here (not us). Especially the pharmacy looks at it to check for cross interactions (or a note waiving them).

lostlogin5• 2 years ago

The idea that patients take the prescribed medications is one that many people believe. Another problem is that people believe the patient’s reply when they are asked what medication they take.

morsch• 2 years ago

just implement an standard text format

Standards and protocols would go a long way in solving many of the issues in public IT infra. Force the big players to speak them. Enable the small shops to outcompete them (and each other) by sucking less in one area.

PetitPrince• 2 years ago

FFS just implement an standard text format that we can upload or link to.

This exists, and it's older than the Web: https://en.wikipedia.org/wiki/Health_Level_7 .

However agreeing on how to use is another can of worms, see https://www.ihe.net/

ianso• 2 years ago

Popping up here to mention OpenMRS, a healthy open-source EMR used by hundreds if not thousands of facilities across the world, mostly in Africa and Asia. An old version is packaged/integrated with some other apps into Bahmni, which is a full-blown hospital management system.

Honestly, people complain about software all the time and all software sucks to some extent, some more than others of course. Complaining about all EMR just because the USA bodged a national rollout in their uniquely messed up healthcare situation is a bit myopic.

yannis• 2 years ago

Very true, people complain about software, but my recent experience in a Gulf country, was stellar, all my medical records, were entered properly including procedures, it takes approximately 12 minutes to get medicine from the pharmacy and can view the records online. The patient interface could be improved a bit but did its job perfectly. The article was stellar, as it summarized the state of the art and the issues well.

boxed2• 2 years ago

I believe this article is only about this specific system. The problem is that the name of the system is "Electronic Medical Record", which makes the article sound like all such systems are hated.

amarant• 2 years ago

If this is the case, the name of the system needs proper capitalization in the title.

autarch• 2 years ago

I don't think that's the case. AFAIK there's no such system. The article specifically reference Epic, which is one of the biggest (_the_ biggest?) EHR software company in the US. My wife used it as a nurse and I've watched my own providers struggle with it. It sucks.

potatoman22• 2 years ago

All such systems are hated by most users. Source: I work in the industry.

cmoose97• 2 years ago

I would not dismiss his complaints as broad brush IT disparagement. Despite the title, I think the author is referring to the EHR (Electronic Health Record), specifically of Epic which is unique in that it is essentially a "benevolent tech dictatorship" imposed upon 90% of hospitals through owner/lead programmer Judith Faulkner at Epic (no medical background) lured initially by federal incentives then married to it in perpetuity. That's not really anything like operating system software you can uninstall today (e.g. Microsoft, Linux, Apple). With the onerous hospital system transformation contracts and non-disclosure agreements - Epic exec customers are more like cult followers than standard software consumers.

timlin• 2 years ago

Judith Faulkner at Epic (no medical background)

I suppose that's technically true although wikipedia states that she cofounded Epic with a medical doctor and is married to a medical doctor. As a software developer, I rely on subject matter experts frequently. I'm not an expert in radiology, chemical engineering, or any of the other businesses that I support.

https://en.wikipedia.org/wiki/Judith_Faulkner

captaincraven• 2 years ago

Disclaimer: Worked at Epic for > 3 years.

EHR’s have all the problems of enterprise software, plus some. At the end of the day, the software is made for the people who pay for it. This isn’t the patients, or the providers. It’s the admin, billing, and bureaucracy layer who get to make all the decisions. It’s not surprising that these people don’t prioritize good software.

EMR’s need to do more, but the root of the problem is systemic.

repeekad• 2 years ago

Also, even if Epic offered its platform free of charge, it’s incredibly expensive to setup and train staff. Just that initial expense of plugging everything in is a huge risk that many hospitals on a tight budget likely can’t afford to take.

ako5• 2 years ago

Agreed, you see the same issue with other enterprise software that tries to everything: SAP (including more specialized parts like Concur), Workday, and many others. They’re trying to do everything, then are often badly configured, mostly by following internal (financial) procedures, without considering end user experience.

There’s a whole industry of tools to help you build better interfaces on top of these big systems of records to improve the user experience. So much so that Gartner has even describes it as a desired way of designing system: used to be Pace Layer model, now it’s called Composable Enterprise.

htechenjoyer5• 2 years ago

I think they need to do less. Part of the problem is they are trying to be everything for everyone. A hospital is an aggregation of what is really several different businesses into one - and they all have to use the same monolithic application. Each medical speciality has their own unique data and technology needs, as does each specific unit (ie different ICUs for surgery, burns, etc), then add pharmacy, labs, admin, etc.

If the priority is billing, then focus on aggregating and correlating billing data, expose an API for consumption with other systems being used that may or may not be from the same EMR company.

I do agree that there is an issue with stakeholder bias towards admin. Every pet project from admin results in a bolt-on fix to the EMR configuration bloating clinical processes. They are the ones that make the rules and decisions and are often disconnected from both technology and clinical expertise which is perhaps the worst combination for health care technology decisions.

oldgradstudent• 2 years ago

When my Israeli health care provider switched to electronic records in the mid-late 1990s, a typical medical appointment had two parts, roughly similar in length.

During the first part, the doctor would complain about how the system crashes, how hard is it to type with two fingers, and how computers are pointless. In the second part, I’d complain about my flu/cold symptoms.

lostlogin5• 2 years ago

It could be worse. You could both be complaining about viruses.

someonehere• 2 years ago

As a patient it benefitted me a month ago.

I was looking to get Ozempic through a different medical provider. They were offering a discount at the end of 2023 before rates go up in 2024. So in a rush before the end of 2023 I was able to log into One Medical and get a copy of my lab work and medical records from them within 10 minutes. Sign into my account and export the records and lab work and send them to my new provider.

I was impressed I didn’t have to jump through a ton of hoops to get the info I need to get the medicine.

m463• 2 years ago

I wonder if it can just be a market. Standardize the data format and install apps that manipulate it.

Let pediatricians choose one editor, surgeons another, nurses another, etc...

Maybe the surgeon's app is text to speech. The pediatrician hooks into his stethoscope.

friendzis2• 2 years ago

These parts are largely irrelevant at large as they make at most single digit percentage of complexity

duffpkg9• 2 years ago

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.

danielvaughn• 2 years ago

This was my experience trying to create technology in the real estate world. Realtors are the same way.

Terr_5• 2 years ago

Many of the most painful technical problems are actually three business problems in a trenchcoat.

Sometimes too many people are too invested in the crazed/idiosyncratic way of doing things... and unless the humans can be convinced to fundamentally change their process, adding software will only give you... well, craziness with a computer.

namdnay6• 2 years ago

It’s the reality for anyone doing “IT”, whatever the domain. Travel, banking, hospitals, police, social security etc ad nauseam

bogwog3• 2 years ago

HN is (probably) read by mostly software development (-adjacent) people, and this thread is basically software developers blaming users for using their software wrong. Maybe that's true, but I think it's at least worth pointing out before someone mistakenly thinks this isn't an echo chamber.

cmiles742• 2 years ago

In my opinion, this is less about the field (health care, real estate, etc.) and more about automating someone's core role. Many people have learned to do a particular job a particular way: some things they have picked up through trial and error, others were handed down from a more senior co-worker. There are other steps that are taken because something else (regulatory requirements, etc.) require it or don't and have been misunderstood.

When we try to automate part of a person's work, we have to encourage the person to take a look at themselves and the way they do their work. This is not easy for people! A lot of times we're asking someone to admit that they don't actually know why something is done a particular way. Or we point out that they are doing the work of another person in another department. And, all the time, this person is worried that at the end they will be replaced by software and lose their job.

I think it's really hard to get to a place where everyone is comfortable enough to be frank about what they do, what the software might be able to do, and what makes sense.

ako5• 2 years ago

How should operations be changed to address the problems?

duffpkg9• 2 years ago

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.

mbesto• 2 years ago

For one, the payment setup in the US is a massive burden to proper care. For every screen and procedure that gets logged into an EMR system, there is some resulting billing setup that is complex, overburdensome and user hostile. The billing setup is so bad in the US that there are whole armies of companies who's job is literally to just collect revenue for unpaid bills (RCM - Revenue Cycle Management), many of which are the result of a confusing billing and invoicing system.

Source - I've done diligence on at least 75+ EMRs/EHRs.

persnickety• 2 years ago

In-N-Out instead of McDonalds,

What is this comparison trying to illustrate?

duffpkg9• 2 years ago

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.

hyponatremia1213• 2 years ago

"Operations (not surgery) are so incredibly bad / incompetent in most healthcare settings that software frequently gets the blame for much deeper problems."

"In my experience doctors are a tremendous barrier to resolving problems in healthcare operations,"

I'm a hospital-based physician that works in a system with great operations and results. The physicians, nurses and other staff work amicably together. Management is reasonable/nice. The EMR, though is universally despised. No one likes it. It is a major factor in burnout. The UI/UX is inconsistent. There are slowdowns and outages daily. There is a well known lag in the appearance of text in text boxes after typing that seems to be variable. I've caught the EMR cancelling orders I placed on critically ill patients in the ICU more times than I can count. We have to actively protect the patients from the EMR. Healthcare workers aren't perfect but they are trying to do their best for very ill people in a high-risk setting and the EMR is well-known blocker. I long for the days of paper records because this is worse. Paper charts didn't go offline, have slowdowns, didn't lose orders, were easily located, and easy to enter data into.

hyponatremia1213• 2 years ago

I know that devs that work on EMRs might read this thread. I'm pleading with you to take the EMR to the next level when it comes to UI/UX and reliability.

duffpkg9• 2 years ago

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.

DANmode3• 2 years ago

So you and your colleagues are protecting the patient (thank you).

Who's been protecting this EMR?

(Who likes using it?, who doesn't lose their job by continuing to choose that vendor?, who gets kickbacks from that vendor?)

complex1314• 2 years ago

One of the biggest scandals in Norwegian health care at the moment is a botched transition to Epic in one of the biggest university hospitals. Doctor dissatisfaction has gone to the roof at the point where 50% of the doctors are considering quitting.

https://www.nrk.no/trondelag/70-leger-soker-aktivt-ny-jobb-v...

submain• 2 years ago

As someone who worked at a fortune 500 company making such EMR software:

There's no incentive to make the UI or workflows better. They don't pay the bills. Software is sold to the suits during dinners and baseball games, not doctors or nurses.

Besides, a great portion of the development is outsourced chasing lower costs. The code reviews were so bad that a coworker used to joke that "we'd get more stuff done if we just fired the overseas team".

The biggest and most well funded dev team was the one that worked on Revenue Cycle.

I quit a few years ago and haven't looked back.

elevaet2• 2 years ago

This aligns with everything I've heard from multiple nurses and doctors in my circle who work with the EMR here.

Justsignedup• 2 years ago

The classical "the executives bought software because it ticked checkboxes, and they'll never be the boots on the ground using it"

cmiles742• 2 years ago

I'm not seeing substantial investment back in the EHR, wherever the money is going it's not being spent on improving the product. Epic remains a thick desktop app served over Citrix sessions, their web-based workflows still haven't materialized.

xcrunner5292• 2 years ago

Are you running Epic? As a patient it has been amazing to use and have everything available. My doctor uses it effectively and it’s quite cool she can do all prescription management etc through it. Now even virtual meetings.

davak• 2 years ago

HypoNa --

I think you made a throwaway account for this reply, but I would really appreciate continuing this conversation with you. My email is available under my profile.

mjfl• 2 years ago

Idk this reads like apologetics for the software industry, which I know people will be more sympathetic to here. But. I know doctors that tell me their EMR log them out after a minute of inactivity and take 3 minutes to login. This can happen multiple times during a patient visit and are totally disruptive. I've heard that it's even begun to affect the throughput of the hospital. So I wouldn't be so dismissive of doctors complaints.

namdnay6• 2 years ago

I very much doubt it’s the software vendor who has chosen to implement the automatic logout after a minute. Most probably someone wrote that down in a requirement because that’s how the previous system worked or that’s what they saw on the internet, and once that’s done it’s set in stone

htechenjoyer5• 2 years ago

This is entirely a data security issue. Depending on the environment, without a logout this is seriously risking a HIPAA violation. Say you're in the hospital and your doctor pulls up your record on a computer in the hallway after they've done rounds on you to put in their observations and notes. However just as he's finishing, his pager goes off, he's off to an emergency, and he forgets to log off.

How many minutes are you okay with your medical record being open for inspection by anyone that walks by? Other medical staff, admin staff, janitorial staff, other patients getting steps in, other patient's families?

It's one of many instances where there's a valid reason for the technology to be implemented as such but since doctors usually aren't thinking about the technology or security aspects they just perceive it as annoying.

dboreham2• 2 years ago

I worked for a couple of years in a company that both developed EMR software and ran clinics -- we employed care providers directly. I assumed going in that this would present amazing opportunities for applying modern technology to improve efficiency, outcomes and both patient and provider experience. Of course that didn't work out the way I expected. I'm not sure if doctors were the problem because to be honest I didn't get to interact with doctors much. The medical providers I did talk to were very interested in using software to improve things, and also extremely smart -- much brighter than the average s/w engineer to be honest. What I did see however was that the need to make (more) money began to dominate, and nothing that we were doing to improve our EMR really had much of an impact on that, at least not a direct or profound one.

dboreham2• 2 years ago

In-N-Out instead of McDonalds

Whenever I make this analogy here people jump in to say how much better McDonalds is :(

MOARDONGZPLZ• 2 years ago

Make a less divisive or controversial analogy then. If people are getting hung up on the analogy and not focusing on the point you’re making, you’re making a bad analogy.

pif2• 2 years ago

Why do you care about the opinion of people who care about comparing fast food chains?

voicedYoda• 2 years ago

Hey Duff, you're right, healthcare is broken in so many places, and insurers are probably the worst in this morass. They selectively follow Milligan care guidelines, build tools that actively discourage anyone from understanding and/or fighting for fair care and bills, and basically pretend they're doing you a favor but making you pay for your services, then showing a marked down EoB that pretend like they saved you money but knocking off 80% of a bill that was prenegotiated, and you're the one footing the bill. Insurers have no incentive to make healthcare better, and though hospitals are disjointed they still make so much money, it doesn't matter how badly they are run.

But aside from the insurance companies, the first large scale emr systems (Cerner, McKesson, and even Epic) were built as operational tools to essentially give accounting access to Crystal reports. Sure, electronic charts should make the patient's life better, and assist trained medical staff in tracking, however they ultimately are used to figure out how the CBO can game the insurer financial incentive system. CPT + ICD +modifiers (oh, and 85% of those cpt codes are under copyright by the corrupt AMA - yup i have a different bone to pick with them).

I agree that operational dysfunction is the biggest problem in these behemoths, and there's so much ineptitude in administrative staffing that it's a nightmare. Doctors like to believe they're the bees knees and everyone should kowtow to them, but they usually can't run a business to save their lives. It's easy for them to simply blame an EMR than to acknowledge the truth of a dysfunctional system they are a part of.

Glad to see you're still kicking ass, better than sameday.

nradov7• 2 years ago

Most patients who are unhappy about how much they have to pay should complain to their employer, not their nominal health insurer. The majority of US consumers reading this obtain their medical coverage from self-insured employers who use "insurance" companies mostly for network management and claims administration. It's the employer who ultimately pays for treatments. An insurance company will be happy to put together a custom plan for an employer under which plan members get as much care as they want for $0 out of pocket. This will be extremely expensive for the employer.

(We can argue about whether health plans should be tied to employers at all but that's a separate issue.)

tuxguy• 2 years ago

what about openehr [0,1]

it is fairly popular in europe. What is required for federal certification ?

0. https://openehr.org/ 1. https://openehr.org/products_tools/platform/

beaugunderson• 2 years ago

OpenEMR also touts ONC certification.

rurban• 2 years ago

I, as patient, love it though, the German system. In January they added electronic receipts ("Rezepte") and this was the deal breaker for me.

Lots of smaller doctor offices complained though. Only the bigger ones offer it.

avh02• 2 years ago

I can say this has its flaws too... I was recently trying to pick up a prescription but the first pharmacy i visited did not have it in stock, they gave me my card back and i went to another pharmacy who could not find a prescription on the card. Turned out the first pharmacy forgot to "release" the prescription back after they told me they don't have it in stock.

Had to go back to the first pharmacy, have them unlock it, go back to the second pharmacy, only to be told after they could read the prescription that they do not have it in stock either.

The problem here is not the digitalization itself but the tangibility of the implementation. how could i possibly tell that i was wasting my time on my way to the second pharmacy?

With paper i would see that someone forgot to hand me back my prescription and i would not have left the first pharmacy prematurely.

sullivantrevor• 2 years ago

i design an EMR for a veterinary company based in LA. can confirm our care team gets quite upset with the software at times. it is incredibly difficult to build a great user experience for all the different positions and use cases that occur throughout the day. with that said, it has been a fun and rewarding experience over the last 4 years. we are hard at work bringing AI into the EMR right now.

lostlogin5• 2 years ago

we are hard at work bringing AI into the EMR right now

I’m sure there are benefits so be had from AI in an EMR at some point, but many would see it as a vast upgrade just to have a system that responds to clicks, doesn’t lag and kind of does what it says it will.

stevebmark• 2 years ago

Wow, this is all over the place, not worth reading. Also it fails to point out a critical and very confusing distinction: EHR stands for "electronic healthcare record," as in an individual record / file / document, but in healthcare tech "EHR" usually refers to "Electronic Healthcare Record System" - a product like Epic / Athenahealth / etc. Also surprisingly no mention of the semi-garbag-y healthcare data interchange format FHIR.

The author seems confused - confusing issues with EHR system UX and data entry and data fidelity and interoperability itself.

singingfish2• 2 years ago

Relevant - paper here https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3250633/ - which is the paper that rescued my PhD (on electronic health records rather than medical records, but adjacent).

Note that Scotland got electronic medical records much more correct than England by making the whole thing a Clinician lead process rather than the English technocratic approach.

Finally it's very difficult to do "proper" scientific research on electronic health records, as control matched research is not achievable. Therefore you have to reach for things like single case study

Final brag - when I submitted my PhD it was politically quite sensitive so we had to find the right external assessors. One expert, one person whose judgement we trusted. The expert returned their report saying what a great piece of work it was and it should receive high commendation. The other person said it was solid and thorough but ultimately pretty obvious. Therefore I conclude that I received better than a high commendation for my work :D

pas5• 2 years ago

Clinician lead process

could you tl;dr what does that mean, why the English one relatively failed, and how it would have fared better with a clinician led version? thanks!

singingfish2• 2 years ago

Best outcome is when the people using these systems are the same people as those buying/specifying the systems. And best introduced with limited and constrained scope so you end up meeting the users actual needs. Pretty simple really and a tale as long as enterprise software itself.

hashishen2• 2 years ago

about %85 of my wowrk as a sys admin for a medical group was troubleshooting EMR software

wolverine876• 2 years ago

When I watch people use them, the UIs look like information overload and cumbersome for the user. It's just old corporate database development: Develop the database, then dump all the fields into a UI. Add some section headers. I would resent using that so often every day.

There is an illusion that technology automates work—instead it only changes it.

That seems like an odd statement. For example, some technology is automating delivering this text to HN servers, and then to you. HN wouldn't exist without that technology.

friendzis2• 2 years ago

I have worked for a company developing HMS/EHR and a hospital implementing/integrating these systems.

Before you think "my startup can do better" understand the core problem: legal and actual processes. Medical is heavily regulated, not only at the point of care, but likewise on the administrative side.

In the event of an adverse effect the hospital and medical team(s) involved must be able to provide clear track record of following the protocols. The administrative team must have the data to provide all the required metrics.

Suppose a simple bloodwork protocol: nurse draws blood, delivers to lab, lab does analysis, results are funky, lab releases invalid report indicating rejected sample, doctor issues redoing of bloodwork, nurse draws blood again and so on. Sample rejection is recorded somewhere, distorts statistics for admin, costs time. In practice, in the event of suspected badly drawn sample nurse is internally informed of that to redeliver the sample, lab releases clean report, sample vial is recorded as discarded by nurse, business goes on.

Medical is FULL of these tiny optimizations around protocols. However, any HMS must follow the protocol, implement safeguards against divergence from protocol, yet to be user friendly it must accommodate all those deviations while still providing "correct" track record with eventually consistent timestamps and so on.

Timings can be very important. For example at ER priority levels dictate not only queue ordering, but also time to care. With HMS implemented it becomes crucial to record times correctly (both from CYOA and metrics standpoints), therefore from the perspective of user, the HMS becomes first priority over caring for patient. Users inevitably complain :)

In certain protocols timings also play a huge role in determining care type. Discharge a patient in x hours and it is outpatient care, fail to discharge patient in x hours and the case promotes to inpatient care, with all the associated complexities of care and documentation. Patient returns in x hours - it's the same case. Fail to provide care in x hours - different treatment protocol.

Readers may think "just provide sane defaults for common case and let staff explicitly record uncommon cases". That simply does not work. Defaults are defaults and users submit defaults. Having insane defaults actually prevents hospital admin/it/legal from being overwhelmed with correcting submitted data. Users complain.

It's ugly. You have to juggle between good care, actual processes, legally required processes, metrics and what not to make the system usable and correct where every user is adversary.

EDIT to add:

On top of all that, every hospital has unique implementation of processes and structures. The differences may not necessarily be major, but there are differences.

Any HMS that intends to become a commodity instead of custom project for a single hospital or department must be highly customizable. first, high customizability typically misses optimization (especially workflow optimization) opportunities. Second, implementing HMS is akin to implementing SAP: the end result is amalgamation between core product developed by a vendor and implementation by hospital admin/legal/it. Many here have either first-hand experience or close knowledge why implementing ERPs (HMS is an ERP) typically lead to barely usable monstrosities. The stakeholders at organization typically have neither working understanding of underlying processes and policies and how they tie together nor will to implement processes and policies more suitable to be managed via ERP.

hiAndrewQuinn4• 2 years ago

My first job out of college was working at Epic Systems as a mostly Windows sysadmin. It was a fascinating (and great!) experience. I've never seen such an advanced Windows sysadmin setup before.

I only briefly touched upon EMRs and the MUMPS/Cache stuff they did there. However, I also learned PowerShell to a much deeper level than probably 99% of Linux folks ever do. We did TDD, code review, CI/CD pipelines for fucking PowerShell. It was painful right up until the point where I internalized the Tao of PoSH, and then I realized that PowerShell actually rules for readability and maintainability when you have people who know what they're doing.

HNers by and large don't understand the economics of PowerShell. There is a very low supply of competent PoSh devs on the market, and even fewer interested in credibly signaling their proficiency, but a very high demand for them, because a lot of places still run everything on Windows, and guess what's installed on virtually all of them? I've even been able to take on a few consulting gigs that boil down to "take our 100,000 line un-version-controlled PowerShell monstrosity hacked together over the last 13 years and turn it into something we can actually understand, please".

foofie2• 2 years ago

PowerShell actually rules for readability and maintainability when you have people who know what they're doing.

Isn't that true for all programming languages ever devised by mankind?

HNers by and large don't understand the economics of PowerShell. There is a very low supply of competent PoSh devs on the market, and even fewer interested in credibly signaling their proficiency, but a very high demand for them, because a lot of places still run everything on Windows, and guess what's installed on virtually all of them?

I don't see what point you're trying to make.

The fact that Microsoft decided to push PowerShell on virtually all versions of windows it ships only reflects a Product decision by Microsoft to push a Microsoft-only tool. It also shows Microsoft's decision to not offer the same level of support for any other alternative.

Where's the economics in that?

I also don't understand your broader comment on economics. Are you depicting it as a good or bad thing?

hiAndrewQuinn4• 2 years ago

One would hope, but alas! Perl was notorious for being write-only back in the day.

PoSh is closer to read-only for most devs. If someone makes sure to write things out the long way (or uses a linter to do this) it's very easy to grok. Actually learning to write it is the tricky bit.

ClikeX2• 2 years ago

The only exceptions are the ones that are specifically designed to be horrible. Like Brainfuck.

hiAndrewQuinn4• 2 years ago

Re/ the economics: It's okay, many people don't get a formal course in this stuff. First look at the graph with two lines on https://en.wikipedia.org/wiki/Supply_and_demand. Notice that the y-axis is P for Price.

Now imagine first off what happens to Price when you shift the downward sloping curve forward. That is what economists call the demand curve. Does Price go up or down?

Finally, imagine what happens to Price when you shift the upward sloping curve backward. That is what economists call the supply curve. Does Price go up or down?

jdietrich2• 2 years ago

Isn't that true for all programming languages ever devised by mankind?

The guy literally just mentioned MUMPS.

https://thedailywtf.com/articles/A_Case_of_the_MUMPS

ClikeX2• 2 years ago

The reason why we use Bash on Linux is because it’s ubiquitous. Even though my terminal is ZSH, all my scripts will be Bash because I can trust it to run on any system.

Same goes for Windows, I want to make sure those scripts can be run without having to install anything. Powershell is there, and it’s powerful.

I’ve got a job to do, and a problem to solve.

bogwog3• 2 years ago

Python is better for anything complicated. Even though Bash is ubiquitous, it's kind of a pain in the ass, and it's actually not that portable since there is no real "standard library", and everything basically depends on system tools being installed and/or configured in a particular way.

macspoofing• 2 years ago

HNers by and large don't understand the economics of PowerShell.

That's not true ...

PowerShell is the "lingua franca" for Windows system administration, I think everyone understands that. Much of the power of Powershell isn't the syntax (which is unnecessarily cumbersome), but rather that most core windows system services have PowerShell bindings.

Powershell isn't a tool you would use for Linux scripting and administration, because it isn't ubiquitous the way bash is.

So what exactly is your point? That Linux administrators adopt PowerShell? Or are you arguing a strawman that HNers advocate for using bash in Windows?

throwaway346434• 2 years ago

The one group who doesn't hate it: Australian patients.

New test result appears in your my health record app, the GP you are seeing has some crippled practiceware, you just show them your phone. Telehealth appointment to renew a script because my GP isn't available? $20 and done in 15 minutes with an eprescription.

This won't solve the hospital space issues, but at this rate I can see "tap to check-in with your hl7 2.3 adt a08" as a semi practical workflow

rswail• 2 years ago

Except that specialists (in particular) hate uploading results into the government EHR. They want to review test results and then communicate with the patient, and the only way to do that is to not upload the results.

I had to talk to the pathology supplier, then get a letter from the specialist approving it, before they were allowed to upload the test results that were bulk billed on Medicare.

There's no incentive to get specialists to change their record keeping.

I've also spoken to several friends that are leading specialists, they had a long list of reasons why it was a bad idea medically, but changes in workflow would solve most of them.

hoseja• 2 years ago

The seventh paragraph, "While medieval Islamic hospitals operated in the contemporary sense..." is pure meanspirited propaganda and renders the article repugnant.

junon• 2 years ago

Like other comments here I also went down the road of making an EHR system a number of times. It's not worth it. Competing with the hell scape that is Epic (not Epic Games, but another EMR software) is seemingly futile.

ako5• 2 years ago

Overall, while we as developers often prefer to focus on complex software engineering challenges, it looks like here the core problem is the user experience of complex data entry/administrative applications.

Designing for so many different types of users, different (customizable) processes/operations, different organizations using the software, is equally difficult to any engineering problem.

Unfortunately, the area of user experience is still very much undervalued for enterprise software, especially by the financial buyers. And without buyers valuing these aspects, vendors will not focus on these aspects.

noirscape• 2 years ago

There was a documentary around here (not-US) a couple years ago about the main EMR provider in the country. Because it's so onerous to install and set up a replacement (just a lot of demands and requirements), the market gravitates towards only a few "established" providers, one of which are overseas/US software that are infamous for their issues (Epic is the one that jumps to mind), but the focus was on the local provider.

The local one apparently is insanely expensive, doesn't have intranet support (because it started as some ancient Windows version as a surgeon-for-hires (the CEO of the company was one) payment record), meaning that hospitals have to move computers on wheeled desks around, lacks a lot of views for medical staff and the operator rolls in "service fees" for things that aren't fees and demands constant cash for upgrades that don't seem to change or fix anything. If a hospital indicates they're planning to replace any component, the CEO apparently just starts screaming and threatening to cut off the hospital out of their stuff entirely (which means that hospitals are unable to invest in startups that might provide the components they need).

It's pretty awful, considering the software is supposedly rather glitchy and has already resulted in numerous patient deaths due to inaccurate medicine prescriptions being loaded in (something which the company denies, but there's ~20 or so reported cases of this at different hospitals). I've heard doctors keep a second physical copy of any patient records, just because that system could screw it up and cause issues down the line, completely nullifying the use for it.

tempaway35641• 2 years ago

The answer is halfway through the article: "Healthcare isn’t structured around patient needs; it is a business that prioritizes profit."

glimshe• 2 years ago

What's the point of electronic medical records if I have to fill out the same stupid paper form every time I go to a doctor?

analogj4• 2 years ago

There's actually a "Patient-contributed data" initiative being run by the standards body (HL7) that's gaining traction. In an ideal world it would allow patients to "push" their electronic records to a new practitioner, meaning that intake forms could be much simpler. In practice I think the implementation is going to start with Observations/Lab Results first though.

I hope to eventually support it with my open source personal health record (PHR) Fasten Health. IMO this would be a "killer app" for PHRs.

phaedrus441• 2 years ago

This article (and many like it) often mention how intuitive and speedy the Dept. of Veterans Affair EMR is. I can guarantee not a single one of these authors has ever used it. CPRS (the VA's EMR) is easily one of the biggest reasons physicians don't want to work at the VA, and most facilities have fewer patients per team (compared to academic or community hospitals) because of how much extra effort is required to use it. It is just startlingly bad.

MarkMc• 2 years ago

My doctor was target of bitcoin extortionists. Now her system is so locked down and doesn’t interface with any other system. To transfer information to another system she prints it out and scans it into the new system

cik• 2 years ago

Sounds like people in a specific country, dislike a specific implementation. Clickbait.

In my country, we have and love EMRs. They enable me to change health authorities at will, as I move cities. They enable me to carry nothing, anywhere - including prescriptions. My phone can serve as my booking tool, and I have instant access to results (such as a blood test) at the same time as a doctor. EMRs enable activities - business and government decisions might limit them.

Centralization of data for me, in a socialist health care system, delivered by capitalist competition is ideal. It's allowed me to be a consumer, having my daughter's eye operation occur at a hospital far away, but her doctor, literally around the corner have access to all results, without my intervention. This is one of the best parts (by far) of living here.

miketery• 2 years ago

Related, I recommend watching Bill Gurley's talk [1] on regulatory capture from 4 months ago. It basically covers why the path to solving this is a difficult if not impossible one.

1 - https://www.youtube.com/watch?v=F9cO3-MLHOM

intalentive• 2 years ago

When you craft a solution around the needs of users, soliciting their feedback, then they might end up with something they appreciate.

When you force a solution on people and give them no say in the matter, then there’s a good chance they’re not going to like it.

Instructive case that reveals a lot about Soviet America.

hn_throwaway_99• 2 years ago

I thought this was an excellent, excellent read. This post, about how well-meaning legislation to increase EMR usage had some strong negative unintended consequences, dovetailed with thoughts I've had a lot recently about the concept of "bullshit jobs" (a popular discussion topic on HN). I've wondered what the true source is for these bullshit jobs. After all, corporations voraciously want to increase profits, which should be a strong incentive to eliminate unnecessary jobs.

The conclusion I've come to is that the side effects of government laws and regulations lead to a negative "codependent relationship" between government and companies that exist to implement the complexity required by the regulations. There is no incentive on either side to reduce complexity. To be clear, I am not blanket "anti regulation", and I've seen the benefits of strong (usually simple) regulations - for example, I live in Texas (usually famously anti-regulation), and there is good evidence that old laws restricting home equity loans, due to an old animosity of Texas farmers against bankers, helped uniquely limit the damage of the Great Recession in Texas: https://www.aeaweb.org/research/charts/texas-home-equity-lim....

However, I've also seen the damage and useless work created by well-meaning regulations that create a lot of complexity, and then companies spring up to "tame that complexity". For example, most people in the US are familiar with FSAs, flexible spending accounts. There is a HUGE amount of work that goes into managing FSAs. The rules around what is a qualified expense are complex, and lots of companies have sprung up trying to work around those rules (e.g. companies that will churn out a "medical letter of necessity" for any massage you want). And all FSAs do is let you save taxes on medical expenses. But since FSA money is "use it or lose it", it turns out that 23% of the funds go unused every year! So all this complexity was created to save consumers money, but at the end of the day it ends up being (in aggregate) basically a total wash! All we've gotten is tons of administrators and companies that are paid to manage that total wash.

I don't have a great solution, as again, I don't see incentives on either side to reduce complexity. But more and more "tear down the whole f'ing system" is the only answer I see.

just_1_comment• 2 years ago

I implement EMR’s and related software. They slow down the process of providing healthcare to the point that medical scribes - personal note takers / assistants - are basically necessary to keep things rolling smoothly.

crabbone• 2 years ago

There is an illusion that technology automates work—instead it only changes it.

And a number of follow-up attacks on technology totally in the spirit of Jacques Ellul.

My wife is a physician, and through her and some of my personal experience of working with hospitals, this is how I understand the problem:

* Programmers who write EMR systems critically lack the knowledge of how hospitals or physicians operate. There are multiple causes to this: the process of writing such software isn't a grass-root movement. It's heavy design-first of large, well, huge systems before they are implemented by grunts who never have any idea about how the whole of the system is intended to operate or even how the tiny slice of it they work on is supposed to be used. I should know this, since I was one of those.

* Doctors despise programmers. Doctors also don't want to be programmers. To a typical doctor, a hospital's staff programmer is similar to a medical secretary: a hoop they need to jump to get their work done rather than an actual aid. Being a programmer, try advising a doctor to do something differently, even if that's about how they use their computer, and be exposed to an hour-long lecture on how they studied for N long years, and how their education was so much more intense than yours, and how they had to endure and so on. Of course, doctors see doing programming work as being beneath them.

So, what happens is that instead of interfaces that could enable doctors to be productive at using their computers, they get absolute garbage that's impossible to automate and requires arduous manual labor. I.e. if doctors wanted to learn how to use SQL to access their hospital database, and, let's say, were able to write some short scripts that automated patient processing, communication with other departments and so on, they'd be spending way less time in front of their systems. But they don't.

Instead they get MS-Windows-styled GUI garbage. Impossible to automate, with the source locked away from them, written by someone they couldn't bother to meet and chat with for an hour because their paycheck likely has an extra digit.

My wife being in radiology department reported that, eg. most times patients are sent to them, even inside the hospital for some imaging, they don't get their forms properly filled by the sending doctor. Not only the sending doctors don't know how to fill those forms correctly, they don't want to know. An incorrectly filled form will result in the radiologist calling them back, and they'll be able to communicate what they want done to the patient in this way. It's both because the forms are too inflexible, because there's no trust in the system, and, especially that even if the form is filled correctly the receiving end might not know how to process it correctly.

And this doesn't depend on the country. Countries with mostly uniform, long-standing healthcare systems suffer the same fate.

----

To me, it's clear that the change that needs to happen is that doctors need to become more like programmers. It's unfortunate that they need to spend so much time learning their trade, and it seems like on top of that they need to study something far divorced from the rest of their main subject, but I don't see any other way.

It's not about technology failing doctors, it's the doctors who don't want to embrace technology.

Decabytes• 2 years ago

My time to shine. I work in the healthcare industry as an analyst and deal with all types of EMRs, Databases, and Molecular profiles. Before working in the healthcare industry, I would have assumed that the data quality in healthcare would be higher because you know, data quality errors can negatively effect patient outcomes. This is not the case.

A lot of these issue lie (lay?) with the UI of these systems. They are just not intuitive. This causes data to be entered incorrectly as honest mistakes. There are also fields which are free text, which should not be. I can't count how many times, I received data from a free text field for drugs, for example, and instead of information about drugs it said "The patient's pet passed away and they were sad today".

Furthermore, a lot of the data comes in separated value files, mostly CSVS (though I try to have them use TSVs if they can modify it). For such a ubiquitous format, at the volumes of data we receive, we get issues with the CSVs all the time. Lots of fields have strings that are improperly quoted, newlines in the strings, variable amount of fields per line, the usual.

That's on top of encoding issues. Randomly we will get files that aren't utf-8 and our parsers will blow up, and then we have to go back to the vendor and ask them to regenerate the data. Also trying to harmonize data across a bunch of proprietary file formats, and software is terrible

Also physicians and nurses are generally pretty skeptical when it comes to new technology even if you have a good product, and for good reason. They have been BURNED many times but companies coming in and promising the world, and delivering a half baked product. Anyone can get an MVP together quickly that kind of does what they need done, but to really support end users requires a lot more investment. I'm talking on-site trainings, software engineers actually watching the faculty USING THE TOOL, and taking notes when they struggle, being proactive about the wants and needs of the staff instead of adding features that seem useful. This almost never happens

Then there are factors outside of just EMRS and the user experience that just make the patient experience much more difficult, even when everyone involved is following standard practices. Data is king in this space, and companies are reticent to share it without lots of money and an books worth of clauses and agreements. You can win in this space just by having more data, or rare data. Lots of patient populations for obscure diseases require large sample sizes before you will have enough patients to perform a study. Pharma companies will approach you with prospective studies and the more data you have the more feasibility work you do that end up leading to studies where you get paid, and your name on paper. This HURTS patients and does nothing but help to keep competitive advantages.

On the bright side, since the U.S healthcare system is so capitalistic, we can usually find what we need coded in the billing data, because patients are nickle and dimed for everything that happens at a medical facility.

I have about twenty more pages of things I could talk about. This whole system is terrible and it doesn't have to be. On a more positive note, I love being able to track patient outcomes and see them improving, and I really enjoy working with huge datasets.

nurbl• 2 years ago

While I haven't worked with EMR systems directly, I have some experience working with care giver organisations, from the perspective of trying to use their digital records for analysis and prediction. My impression was that this is something nobody has time for, and therefore nobody is doing it, or even really interested in it. It would seem quite wasteful to have this big expensive machinery for producing data that nobody has time to look at. After all it's one of the big reasons to make it digital in the first place; being able to "crunch the numbers".

On the other hand, as soon as you get those numbers someone will turn them into "performance indicators" and use them for optimization, and we all know where that tends to lead... I can understand the feeling of being forced to work with a system designed to get rid of you.

htechenjoyer5• 2 years ago

Disclaimer: The electronic health record system in the united states is a mess. A monolithic monstrosity lacking interoperability, touching the most sensitive data, and leading to the worst possible outcomes if errors occur.

That being said, as someone that works in healthcare technology, has done clinical shadowing of physicians, worked the admin side of healthcare providers, worked technology for payers and providers, and has multiple close relationships with front line healthcare workers: I think this article missed the mark in several places. I've interacted enough with nurses and doctors to recognize rants about electronic health records and how they come from a valid place but use many poor examples.

1. Theres a weird implicit assumption throughout the entire essay that EHR implementations are uniquely bad in introducing friction and errors to the medical system. Take the example of his electronic orders to the lab and lamenting how in the old days that would be a simple note to lab on paper and that was somehow inherently better. As if errors around misreading notes or misplacing them didn't occur beforehand.

2. "There's an illusion that technology automates work - instead it only changes it". This is a faulty premise. There is a lot of work that has been completely automated away within healthcare not just changed. EHR enabled patient monitoring comes to mind. You can remotely capture and store vital signs for patients instead of rounding to each room and writing them down. With staffing shortages for all jobs in healthcare we would probably be in a much worse place if we were still relying on paper.

3. "There is also more clinical work. Increasing corporatization of medicine and staff shortages have increased the volume of patient care for each healthcare worker, accelerated since the pandemic". There is definitely blame on admin for some of this but there is also artificial limiting of the number of new doctors each year by the AMA and it's lobbying. If there were more medical professionals I suspect that much of the "burnout from EHR's" would decrease. Add in the authors vitriol for a profit maximization even though profit of a health system allows them to hire more and pay more to compete with other industries for workers.

4. The author does not understand why the technology is implemented in a specific way. He is one stakeholder - the doctor and while an important one is not the only one that needs the data generated by a clinical interaction. Example: his complaint for there being multiple lab types for HIV in a drop down for ordering. This is specifically to reduce ambiguity and resulting medical errors, allows for more precise audit and reviewing of a patient's history, and carries a different cost for billing. He also blames EHR's for issues with different implementations of UI and workflows between hospitals even though most times hospitals are to blame for adding their own customizations.

While the author brings up good points he has an explicit bias against the current system even when it doesn't deserve the treatment he gives it. Most of the piece is generated more from a hatred of capitalism and a desire to refute the libertarian paternalism that he talks about rather than a fair and even treatment of the problem with the electronic health record system in the United States.

Supermancho• 2 years ago

Re: 1. EHRs are great for people with chronic and severe issues, like me, despite the transferability issues.

iav• 2 years ago

Apple Health does a great job of integrating with EMR providers. I can see notes from every doctors visits, my blood test results, Covid tests, and so on all integrated into one app. I can see my sodium levels have gone down since 2019 in a plot chart, or when was the last time I got sick.

analogj4• 2 years ago

Disclaimer: I built an Open-Source PHR

The thing that most people don't realize is that the legally enforced HIPAA protections they take for granted no longer apply when they request their medical data from a healthcare institution and store it in a third party app -- like Apple Health.

The only thing protecting your medical records from being data-mined and monetized is Apple Health's privacy policy and (current) technical architecture. You've seen examples of it in the news with women's period tracking apps, but it'll become even more common as apps start leveraging APIs opened by the 21st Century Cure's Act.

I'm not a tin-foil hat wearing engineer, but I can forsee a day when Apple's reputation of being "Privacy-conscious" might not be worth as much money as the medical data they've collected from their customers.

It's one of the reasons why I decided to build my own open-source PHR, so that the incentives between the software and me as an individual are kept in alignment.

https://github.com/fastenhealth/fasten-onprem

ryanisnan• 2 years ago

The real reason EMRs are frustrating is that they attempt to provide structure around a chaotic underlay of insurance reporting schemes.

The way clinicians get paid for service is to report everything they do, in obscure and highly-specific codes. Practices on average have to consider arrangements with 25 or so payer entities, and must consider the varying requirements with each.

EMRs are still playing catch up, but there is hope. One of the best applications of AI is translation, something EMRs desperately need.

burnte• 2 years ago

Healthcare CIO here, there are more major issues and much bigger ones in the EMR space than insurance.

One is cost, the compliance cost is so high that it's a huge barrier to entry, and makes new competition difficult. The limited sales channel means you need to charge each of your small customer base more to pay the bills.

Another is interoperability. They're all garbage in one way or another so all the vendors work very hard to secure client lock in.

Another is medical regulations. We have a whole mess of buttons and check boxes providers need to fill out for regulatory reasons.

Yet another is needing to create a complicated system to do complicated things, but the people operating it generally get little to no training on an EMR, so the learning curve is STEEP, and breeds problems.

I could go on all day. I kind of wish I could lead a startup to create a new EMR from the ground up. With what I've learned over the years I really think it's possible, but would need real investment up front.

tuna742• 2 years ago

Health care staff in the Nordic countries hate their systems as well.

renegat0x0• 2 years ago

logicmag.io The site advertises itself as "tech with ideology". I hate that.

Quote from the site """ In 2023, Logic Magazine was relaunched as Logic(s), the first queer Black and Asian tech magazine """

I would hate tech with Christianity, tech with asian people, tech with conservatives.

As an engineer I do not care what color skin, or what your beliefs are. They are only important to me if I am uncertain about author biases.

tcmart14• 2 years ago

Is it that EMR is bad or is it market capture. About the only company I hear about doing EMR/EHR is EPIC. My wife is a nurse, and in all the places she has worked it is EPIC. Every doctors office I've been to, its EPIC. It seems like EPIC pretty much owns most of the market, so there isn't any competition to really encourage EPIC to be better and there is no will for medical systems most of the time to choose an alternative to EPIC.

yoden• 2 years ago

Having worked in medical software for a long time now, it's not surprising.

Medical software is purchased by upper management based on features. Usability is rarely considered, and hard to evaluate anyway since it depends on integration.

Hospitals themselves create this incentive because they will rarely if ever change their processes to fit more smoothly into a different workflow. The core purpose of an EMR is to integrate different parts of the hospital, though, so the only possible solution is a huge do-everything piece of software like Epic.

I spent years on a project to try to standardize exams between a major research hospital and its satellites. The ended up quitting about half-way through because they realized there just wasn't going to be enough political power at the main campus to convince the doctors at the satellites to follow their lead.

You'll even see this at smaller regional hospitals. We'll bring software and workflows developed in tandem with the top hospitals in the world, and they'll tell us that they don't care and they want to keep doing things the way they've always done them.

Everyone may hate EMR, but hospitals seem to be getting exactly the EMR they're asking for.

NanoYohaneTSU• 2 years ago

This is what the so called Free Market brings when combined with anything medical. It's a mess of systems that are incompatible with every other system, creates more work for everyone.

Everyone hates the electronic medical record

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