Everyone hates the electronic medical record

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.

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.

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.

EPIC is flashy, has a gorgous campus in Madison, WI, and has lots of marketing. but at its core, it runs on MUMPS as both a language and database.

I know many people that have worked on their integration teams, and could not imagine having to deal with what they do.

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

> if you can't convince your "boss" to give you enough time to deliver something that meets your bar, quit.

I did this and while it solved my moral dilemma it made things worse for our users.

Many years ago I started my career working for a startup that got bought by a big government contractor. The most incredible people I've ever worked with tried harder than you can imagine to deliver reliable, usable software for the American taxpayer that met the very high bar we set for ourselves.

Because the incentives weren't aligned, most of the good people eventually quit to work at places where they could deliver something that met their bar and were replaced with junior devs and senior clock-watchers.

Every good person who left made that problem slightly harder for those of us who stayed because there was one less person fighting for quality and usability, but the contracts were as big as ever and the new people were less likely to rock the boat so management didn't care that product quality was dropping off a cliff.

In the end it was primarily our users who suffered.