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Everyone hates the electronic medical record

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Re: Everyone hates the electronic medical record

#231

Post by nradov »

voicedYoda wrote: post #221
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…

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…

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.)

Re: Everyone hates the electronic medical record

#232

Post by danielovichdk »

complex1314 wrote: post #111
hyponatremia121 wrote: post #86

Earlier quoted context omitted.

"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…

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...

Denmark transitioned to Epic some years ago. It was a major frustration on many levels.

https://www.sciencedirect.com/science/article/abs/pii/S13865...

Re: Everyone hates the electronic medical record

#233

Post by htechenjoyer »

captaincraven wrote: post #31

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 pr…

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.

Re: Everyone hates the electronic medical record

#234

Post by philwelch »

jq-r wrote: post #181
ako wrote: post #124

Earlier quoted context omitted.

I'm from Europe, have never heard of In-N-Out before, don't know how they work, nor the quality they provide...

Am too from Europe, and never heard about it until last year when visiting my colleagues in LA and was taken to a In-n-out. It was packed and I agree that it’s tastier than Mcdonald’s. My colleagues were very surprised that I didn’t hear about that company because “everyone knows it”. What they don’t understand (until explained) is that what we get in a European countries are just a small selection of big franchises…

In-N-Out isn’t a national franchise, it’s mostly just a California one. There are different franchises in different parts of the country.

Re: Everyone hates the electronic medical record

#235

Post by nradov »

bdw5204 wrote: post #225
bombcar wrote: post #200

Earlier quoted context omitted.

The only way change will come is if some actually independent hospital develops open-source in-house software (under the strongest possible non-cooption license available, likely GPL3) over literal decades until it becomes a standard. It’ll be fought every step by the entire healthcare industry.

I don't think there is such a thing as an actually independent hospital anywhere. In most countries, the medical system seems to be a government monopoly. In America, it is an oligopoly that egregiously violates the anti-trust laws and whose real customers are the government and the health insurance companies. The entire industry seems like a politically connected bureaucratic nightmare of one kind or another in ever…

Medical malpractice insurance has only limited economies of scale. It's still possible for solo practitioners or small partnerships to afford in most cases. This isn't the biggest factor in driving provider market consolidation.

The real factors driving consolidation are IT costs, negotiating power, and practitioner preferences. Even with modern SaaS products it's expensive for a small organization to operate an EHR and other IT infrastructure. Payer organizations have consolidated through M&A activity and are constantly trying to drive down prices so providers also consolidate to force payers to keep them in network regardless of prices. And many doctors just don't want to manage a small business; they would prefer to focus on treating patients and collect a steady paycheck.

Your family members are wrong. There are standard file formats for sharing medical records across different software. The most common format is HL7 Continuity of Care Document (CCD) which can accommodate an entire patient chart in a single XML file. Every major EHR has supported CCD export and import for years under federal government certification criteria. If your family members had to do manual data entry then either their software wasn't configured correctly or they didn't know how to use it.

https://www.healthit.gov/topic/certification-ehrs/certificat...

Re: Everyone hates the electronic medical record

#236

Post by acuozzo »

wharvle wrote: post #9
jackvalentine wrote: post #3

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 othe…

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…

> We made everyone their own secretary

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

Re: Everyone hates the electronic medical record

#237

Post by philwelch »

bogwog wrote: post #208
ako wrote: post #151

Earlier quoted context omitted.

Initially the In-N-Out example was made without explaining what it is, and even with the added context i think it doesn't really explain how In-N-Out differs from McDonalds. Their operations are better, what does that mean, how does that impact customers, how does that impact cost, etc.

If you ever go to one, you'll understand. They're like the Rolls-Royce of fast food burgers.

I’ve been. It’s nothing special.

Re: Everyone hates the electronic medical record

#238

Post by submain »

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…

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.

Re: Everyone hates the electronic medical record

#239

Post by goda90 »

nradov wrote: post #226
naijaboiler wrote: post #203

Earlier quoted context omitted.

I have tried a lot of tools. Epic is terrible. capital T terrible. And its still better than just about every other thing out there. Epic suffers from "it has to be all things for all people". so it is nothing for anyone. It is bloated, big, overly customizable, yet doesn't fit. Steep learning curve, bad UI/UX, expensive, just all around terrible. And yet it is still better than everything else i have ever seen, exce…

Part of the problem is that every provider organization wants to have their own unique forms and workflow; there is a lot of "not invented here" syndrome and everyone falsely believes that their institution is special. This forces a lot of customization in the EHRs and actually makes the UX worse. If providers nationwide could get together and agree on standardized forms and workflow (at least within practice special…

I've started joining design meetings for a new streamlined way for nurses to do their tasks in the EHR. Multiple times now we've got stuck in a little back and forth about how to do something, and someone suggests a setting to allow either option. And each time I try to interject "no settings!". It's a pain for support and code maintenance, increases potential bugs, and means that some organizations could get left behind on new features that aren't compatible with niche settings that they refuse to change.

Re: Everyone hates the electronic medical record

#240

Post by kayodelycaon »

repelsteeltje wrote: post #184
beretguy wrote: post #176

Earlier quoted context omitted.

I am such dev. It’s not up to us. It’s up to our management. We would love to engineer good quality EMR, but upper management wouldn’t let us.

That, my friend, sounds a lot like The Cat Ate My Source Code [The Pragmatic Programmer] Price, lead time, quality, (and scope) — pick any two. When the stakes are high, don't rely on your manager to pick quality — that is your responsibility. And if you can't convince your "boss" to give you enough time to deliver something that meets your bar, quit.

We don't live in an ideal world where we can all find perfect jobs that give us the agency to deliver the quality we want.

I'll happily compromise on quality if it means I can comfortably afford medical care for chronic conditions that limit my employability.

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