Everyone hates the electronic medical record • Hacker News Board

Re: Everyone hates the electronic medical record

#91

Post by hyponatremia121 » Tue, Jan 30, 2024, 8:03 AM UTC

hyponatremia121 wrote: post #86

duffpkg wrote: post #49

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…

"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…

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.

Re: Everyone hates the electronic medical record

#92

Post by dgellow » Tue, Jan 30, 2024, 8:04 AM UTC

dieortin wrote: post #63

JusticeJuice wrote: post #24

Earlier quoted context omitted.

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

If I’m not mistaken, the Spanish healthcare system has a fully electronic medical record.

Germany too

Re: Everyone hates the electronic medical record

#93

Post by duffpkg » Tue, Jan 30, 2024, 8:05 AM UTC

hyponatremia121 wrote: post #86

duffpkg wrote: post #49

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…

"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…

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.

Re: Everyone hates the electronic medical record

#94

Post by DANmode » Tue, Jan 30, 2024, 8:06 AM UTC

hyponatremia121 wrote: post #86

duffpkg wrote: post #49

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…

"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…

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?)

Re: Everyone hates the electronic medical record

#95

Post by JusticeJuice » Tue, Jan 30, 2024, 8:10 AM UTC

Zanfa wrote: post #84

JusticeJuice wrote: post #4

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 t…

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 co…

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.

Re: Everyone hates the electronic medical record

#96

Post by Flibble21 » Tue, Jan 30, 2024, 8:12 AM UTC

JusticeJuice wrote: post #24

FwarkALark wrote: post #7

Earlier quoted context omitted.

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

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

I have a friend that has worked on this project for over a very long time and the issue is not that the UK tried to implement EHR records from scratch but rather that GPs (General Practitioner, think local doctors surgeries) had mostly all implemented EHR systems already. The issue is that these systems are created by several (6-8 if memory serves) different private companies and the UK Government can't force the GP to change or adopt a standard system.

The different GP EHR systems record patient information in their own ways. Think of a database entry for chemo medication, one EHR provider having a db column labeled "Drug X" with the patient entry listed as "Yes" with separate columns for dosage, frequency etc. Another will list the drug, dosage and frequency in the same field. Even if they have the same column e.g. frequency, different EHR's may list "5d" or "5 Days". There are also spelling errors, doctor's personal shorthand abbreviations etc.

The problem is that the UK interoperability system has is to implement a safe translation layer that will allow records to be transmitted between these systems that doesn't kill anyone. The astonishing amount of different types of information that are used and all the oversight needed to ensure that information is accurately transferred has made this project way more costly and time consuming that originally thought.

There is, of course, waste and profiteering, both internally to the Government project (huge contract salaries) and also with the private EHR companies (overruns and re-builds are all handsomely paid for).

Re: Everyone hates the electronic medical record

#97

Post by foofie » Tue, Jan 30, 2024, 8:12 AM UTC

hiAndrewQuinn wrote: post #90

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 fuck…

> 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?

Re: Everyone hates the electronic medical record

#98

Post by hiAndrewQuinn » Tue, Jan 30, 2024, 8:16 AM UTC

foofie wrote: post #97

hiAndrewQuinn wrote: post #90

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 fuck…

> 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, bec…

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.

Re: Everyone hates the electronic medical record

#99

Post by ClikeX » Tue, Jan 30, 2024, 8:16 AM UTC

foofie wrote: post #97

hiAndrewQuinn wrote: post #90

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 fuck…

> 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, bec…

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

Re: Everyone hates the electronic medical record

#100

Post by jharsman » Tue, Jan 30, 2024, 8:20 AM UTC

JusticeJuice wrote: post #4

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 t…

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.