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Why Doctors Reject Tools That Make Their Jobs Easier

blogs.scientificamerican.com

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Re: Why Doctors Reject Tools That Make Their Jobs Easier

#51

Post by jrumbut »

Fomite wrote: post #24

An alternative headline is "Tool Makers Make Tools That Don't Help Doctors". I know a ton of colleagues who flinch every time someone mentions that this'll just hook into the EMR system, because they know everything will be broken and tedious for years before another vendor comes along. At a conference I was at recently, I'm nigh positive "Decision Support Tool" was a dirty word.

One of the problems I see here, and would love to find a way to solve it, is that software is best developed interatively. I see a lot of software that has some cool ideas, it just needs some tweaks to get rid of ridiculously annoying flaws, or needs to put some more control in the user's hands.

Unfortunately, and inevitably, a little tweak in medical software may as well be a tweak on a satellite in space.

Like I said, changes need to be prevented from making the software bad, but the difficulty of making changes also makes the software bad. I don't know what the solution is, but I would like to see this aspect addressed more explicitly.

Re: Why Doctors Reject Tools That Make Their Jobs Easier

#52

Post by 08-15 »

DrJaws wrote: post #21
anon4lol wrote: post #9

As someone who has had several CT scans (and paid for CT scans), the idea that a CT scan is better than a physician feeling your abdomen is absolutely ridiculous. Pumping contrast agents into everyone who has pain is a very bad idea. Moreover, enforcing decisions by algorithmic rules is problematic, especially considering who might be making those decisions.

Plus radiation. Every CT scan increases your odds of cancer. Also, mammography or even colonoscopies have been proved for most of the population to do more harm than good. cochrane is full of meta-studies about it. The medical industry is very shady.

> Every CT scan increases your odds of cancer.

There is no evidence for that statement. More specifically, there is no evidence that a single radiation dose below 100mSv is harmful at all, but plenty of evidence (Taiwanese radioactive apartment buildings, nuclear navy worker study) that it isn't. Muller made it up for political reasons.

Re: Why Doctors Reject Tools That Make Their Jobs Easier

#53

Post by telchar »

skwb wrote: post #49
escherplex wrote: post #47

Earlier quoted context omitted.

Also, for seasoned professionals you have to factor in malpractice and insurance coverage as contributing to the inertia.

I've found mostly these are given mostly as cover. Those are important considerations, but: A) most CDS is considered educational, and therefore is not supposed to replace an expert's opinion B) insurance coverage is sorta BS because most health systems are moving away from pure fee for service revenue models. Besides, I feel like you should maybe do your job as a doctor to ensure the best care for your patients than…

Nevertheless there is concern about any data that goes into an EMR. There is always concern about what happens in the worst case scenario where something very bad happens to a patient and their whole record is examined in a courtroom after the fact. If, say, a machine learning model predicts that thing X will happen to the patient and it wasn't acted on, a hypothetical lawsuit may go worse for the provider than if the predicted risk of thing X weren't part of the record.

This doesn't mean that the doctors bury their heads in the sand, but it is a part of the reason providers are resistant to adopting these tools. Relying on their own knowledge and intuition may not be better but it won't hurt them as evidence in a hypothetical malpractice suit. The decision support tool has to be sufficiently better to outweigh this.

I hold no opinion on the validity of this line of thinking, but I can say that it is part of the calculus, at least for some.

Re: Why Doctors Reject Tools That Make Their Jobs Easier

#54

Post by zdragnar »

jrumbut wrote: post #51
Fomite wrote: post #24

An alternative headline is "Tool Makers Make Tools That Don't Help Doctors". I know a ton of colleagues who flinch every time someone mentions that this'll just hook into the EMR system, because they know everything will be broken and tedious for years before another vendor comes along. At a conference I was at recently, I'm nigh positive "Decision Support Tool" was a dirty word.

One of the problems I see here, and would love to find a way to solve it, is that software is best developed interatively. I see a lot of software that has some cool ideas, it just needs some tweaks to get rid of ridiculously annoying flaws, or needs to put some more control in the user's hands. Unfortunately, and inevitably, a little tweak in medical software may as well be a tweak on a satellite in space. Like I sa…

Safety first, full stop, no exceptions.

Until correctness can be done easily in accessible programming languages with a decent developer pool, iteration in this space, along with other life-critical spaces such as trains, planes (and wouldn't automobiles be nice too?) is sadly a long, manual process compared to web development.

Edit: to expand a bit on correctness, think Coq but with the ease of Java or Typescript. Even Rust's safety isn't yet formally proven; that's not a knock on rust, but a demonstration of just how hard it is to do.

Re: Why Doctors Reject Tools That Make Their Jobs Easier

#55

Post by yellowapple »

Fomite wrote: post #24

An alternative headline is "Tool Makers Make Tools That Don't Help Doctors". I know a ton of colleagues who flinch every time someone mentions that this'll just hook into the EMR system, because they know everything will be broken and tedious for years before another vendor comes along. At a conference I was at recently, I'm nigh positive "Decision Support Tool" was a dirty word.

And of course "just hook into the EMR" is fraught with problems as it is, what with HL7 quirks and proprietary APIs and homegrown interfaces and all that jazz.

Even "better" when there's no concept of "the EMR". My foray into healthcare IT was at a hospital/clinic district that used no less than 4 EMR systems (one new and one legacy for the main two hospitals, plus one new and one legacy for all the satellite clinics). That's not including the specialized systems for ER, Oncology, Obstetrics/Gynecology...

All for the pursuit of Meaningless Use.

Re: Why Doctors Reject Tools That Make Their Jobs Easier

#56

Post by thinkharder »

wccrawford wrote: post #39
mamon wrote: post #31

Earlier quoted context omitted.

>> Now if I take the medicine and it's not better in a day or two, maybe then I will want that CT scan. That's what most doctors in my country would do. Are you saying that US doctors will send you to CT right away, just to be sure?

I went to the ER complaining of stomach pains. They heard my description and immediately put me into a room. A few hours later, I had a CT scan confirming that I had appendicitis. I had surgery that same that and was out of the hospital 2 days later. Had they sent me home, medicine or no, things could have gone a lot worse. I'm glad they do the CT scan here and not just send people away until they get worse.

I had a similar experience. I show up at the ER and they do their thing. Doctor says, "the symptoms indicate appendicitis, but the tests (which are mostly just poking you in the side and seeing how bad it hurts) are inconclusive. Normal procedure is to send you home and see how it goes, but I'd really feel more comfortable if we took a CT scan to be sure". At this point I'm in so much pain if he said he wanted to do a voodoo ceremony, I'd have been all in. CT scan reveals I had a weirdly shaped appendix, hidden behind a couple of folds of intestine, in a slightly different area than they are usually in. So the poking test didn't work cause they were poking around in the wrong area. If they'd sent me home I'd have come back with a burst appendix, which is potentially fatal. Ironically, just as they were wheeling me into the operating room, a woman came into the ER with an actual burst appendix so they wheeled me out and took her first.

I had a dog who started having a runny bloody nose all the time. 4 xrays, 2 nasal endooscope procedures and several thousand dollars and still can't figure out what's wrong. In desperation took him to a really good emergency/surgery vet clinic, they did a CT scan and it reveals a large tumor growing on the nasal cavity side of the soft palate. Confirmed with an endoscope going into the mouth and back up into the sinuses, couldn't see it from the front. Super frustrating because it was too late to do anything at this point.

I think using CT scans in the context of a checkup, to look for problems, is bad, because as discussed elsewhere on this thread, if you go looking for something, you'll find something. But if you already know there is a problem, they're the best tool we have for looking inside the body without cutting.

Re: Why Doctors Reject Tools That Make Their Jobs Easier

#57

Post by EB66 »

Fomite wrote: post #24

An alternative headline is "Tool Makers Make Tools That Don't Help Doctors". I know a ton of colleagues who flinch every time someone mentions that this'll just hook into the EMR system, because they know everything will be broken and tedious for years before another vendor comes along. At a conference I was at recently, I'm nigh positive "Decision Support Tool" was a dirty word.

I agree. This article is off the mark. On the contrary, doctors want tools that will assist them in providing better patient care outcomes. In all my career, I've never met an anesthesiologist, trauma surgeon nor a hospitalist who has ever expressed a concern that technology will make them obsolete. On the contrary, almost universally these individuals are overworked and are thrilled to hear about anything that might save them a little time or make their job easier.

That being said, doctors do not want tools that are clunky, tools that force them to change their existing workflows, tools that run slow, can't pull in relevant data in real-time, rely on fragile HL7 interfaces, etc. Doctors want tools that work for them. Doctors do not want to be fighting or struggling with tools that are supposed to help them. While that may seem obvious, it's a very difficult bar for most software makers to meet -- particularly in the inpatient and ED space.

I can understand the author's perspective -- she's a new resident at Yale New Haven Hospital and previously ran a medical software start-up that closed up shop relatively quickly. It would be convenient to rationalize the failure of her start-up due to fears of new tech. While it may have been a fear of new tech that prevented her start-up from succeeding, it was not a fear of being made obsolete -- it was a fear that her product wouldn't do the job well.

Re: Why Doctors Reject Tools That Make Their Jobs Easier

#58

Post by Zelphyr »

EB66 wrote: post #57
Fomite wrote: post #24

An alternative headline is "Tool Makers Make Tools That Don't Help Doctors". I know a ton of colleagues who flinch every time someone mentions that this'll just hook into the EMR system, because they know everything will be broken and tedious for years before another vendor comes along. At a conference I was at recently, I'm nigh positive "Decision Support Tool" was a dirty word.

I agree. This article is off the mark. On the contrary, doctors want tools that will assist them in providing better patient care outcomes. In all my career, I've never met an anesthesiologist, trauma surgeon nor a hospitalist who has ever expressed a concern that technology will make them obsolete. On the contrary, almost universally these individuals are overworked and are thrilled to hear about anything that might…

> doctors do not want tools that are clunky

And yet every EMR system I've ever seen is comically bad. Why the medical providers haven't revolted over being forced to use those things is beyond me.

Re: Why Doctors Reject Tools That Make Their Jobs Easier

#59

Post by telchar »

Thriptic wrote: post #38
onetimemanytime wrote: post #30

Earlier quoted context omitted.

>> Plus radiation. Every CT scan increases your odds of cancer. If the doctor makes money from your CT Scan you are absolutely right to question the need. Conflict of interest and all. Sure you increase the chances of cancer but that has to be weighed by what can happen if you don't do the CT Scan.

Very few modern insurance plans pay per procedure and that will be done away with entirely as time goes on. Typically physicians are paid a flat rate per patient or a flat rate per diagnosis with a complexity multiplier. This creates an incentive to NOT perform imaging unless it's necessary.

In what country? The US is still mostly per per procedure. There are codes for procedures and for diagnoses and they both get factored into the bill.

Re: Why Doctors Reject Tools That Make Their Jobs Easier

#60

Post by EB66 »

Zelphyr wrote: post #58
EB66 wrote: post #57

Earlier quoted context omitted.

I agree. This article is off the mark. On the contrary, doctors want tools that will assist them in providing better patient care outcomes. In all my career, I've never met an anesthesiologist, trauma surgeon nor a hospitalist who has ever expressed a concern that technology will make them obsolete. On the contrary, almost universally these individuals are overworked and are thrilled to hear about anything that might…

> doctors do not want tools that are clunky And yet every EMR system I've ever seen is comically bad. Why the medical providers haven't revolted over being forced to use those things is beyond me.

They really are comically bad (Cerner, Epic, Meditech, all of them), but they are effective data silos which is a step up from having that data silo'ed in filing cabinets.

People outside healthcare really don't understand the sheer amount of time your physician spends trawling through the medical record in the regular course of doing his or her job. You can think of the patient chart as a shared "My Documents" folder on your computer. In modern multi-disciplinary care, you have many different parties taking care of the same patient and working in shifts. In order to get up to speed with what's happening for a particular patient, you need to open up each of the recent files in "My Documents" for that patient and review it. Lab results, progress notes, schedules, etc. Then repeat a couple dozen times for all the other patients you're caring for that day. Endless clicking. Constantly flipping between windows. Burn out.

That's not too much of an exaggeration of what the real EMR experience is like today.

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