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Everyone hates the electronic medical record

logicmag.io

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Re: Everyone hates the electronic medical record

#261

Post by JohnFen »

Zanfa wrote: post #154
DANmode wrote: post #94

Earlier quoted context omitted.

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?)

I'm assuming the hospitals in Norway & Finland used some form of a public tender where the cheapest solution wins. I don't think you need malice or corruption to explain it, just good intentions.

> just good intentions

And yet the system is aimed at getting the cheapest possible bid? Perhaps the intentions are good, but the execution is horrible. So maybe not malice or corruption, but incompetence.

Re: Everyone hates the electronic medical record

#262

Post by repelsteeltje »

asoneth wrote: post #249
repelsteeltje wrote: post #184

Earlier quoted context omitted.

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.

> 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…

> [..] were replaced with junior devs and senior clock-watchers.

That is a sad story indeed.

I guess the silver lining is that you didn't waste your talent contributing to a mismanaged project. Hopefully, given a free market, the service will eventually be replaced by something better.

Re: Everyone hates the electronic medical record

#263

Post by dr_dshiv »

Eddy_Viscosity2 wrote: post #179
peteradio wrote: post #171

Earlier quoted context omitted.

There's malice on the sell side. If they can't integrate a trial period then its not worth attempting. Its dumb terminal work not like its actually expensive just very very lucrative because its run like a mafia.

Exactly, when selling a big software system like this to the government, the contractor will very deliberately ensure that it follows the requirements exactly (because requirements are never specific enough) so that the government will then have to go back to them for fixes and upgrades forever. If they see a poorly worded requirement that they can implement as-is knowing it will cause a problem, they celebrate becau…

See Foundation for Public Code: https://publiccode.net/

Re: Everyone hates the electronic medical record

#264

Post by nradov »

Zanfa wrote: post #248
nradov wrote: post #235

Earlier quoted context omitted.

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…

In my experience with FHIR, two documents from different sources can both be compliant while still semantically incompatible. The protocols are made flexible enough where human ingenuity lets you represent the same thing in so many similar, yet different ways.

That's why most interoperability requirements are written based on Implementation Guides rather than baseline standards. The base HL7 standards (V2 Messaging, CDA, FHIR) are intended to do pretty much everything everywhere in the world. As such, they're loose on specifics such as required data elements and coding systems. Then IG authors take those baseline standards and constrain them for specific use cases in particular countries (realms).

CCD is very well specified, although you might still find some EHRs that fail to comply with the standard in some minor ways. There is a project underway to migrate that data model to FHIR encoding but it's not finished yet; that will make document construction and parsing a bit easier but won't necessarily address compatibility issues.

https://www.hl7.org/implement/standards/product_brief.cfm?pr...

https://hl7.org/fhir/us/ccda/

Re: Everyone hates the electronic medical record

#265

Post by burnte »

ryanisnan wrote: post #251

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…

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.

Re: Everyone hates the electronic medical record

#266

Post by analogj »

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…

Interestingly your [1] citation may no longer be the case. The 21st Century Cures Act was signed 8 years ago (but compliance was only required as of 2023). It states that Healthcare Institutions (& EHR developers) must provide a mechanism for patients to access their health records electronically in a standardized format (FHIR).

It's what allowed my open-source startup Fasten Health to even exist. I was diagnosed with a chronic condition, and wanted a way to store my health records privately on my own devices. A bit of luck and a POC later, I was able to confirm that patients can access their own records with little-to-no barriers.

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

Re: Everyone hates the electronic medical record

#267

Post by timlin »

cmoose97 wrote: post #186
ianso wrote: post #29

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…

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 i…

> 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

Re: Everyone hates the electronic medical record

#268

Post by bongodongobob »

Scoundreller wrote: post #83
bongodongobob wrote: post #66

Earlier quoted context omitted.

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.

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

Door access and stuff like that is orders of magnitude cheaper. Integrating identity with all the proprietary systems is crazy expensive, I specced it out for about 100 users and it was 10's of thousands of dollars just for the hardware and thousands a month for the software.

Re: Everyone hates the electronic medical record

#269

Post by seized »

pif wrote: post #229
htechenjoyer wrote: post #218

Earlier quoted context omitted.

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…

> 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. No, there is never a good reason to prevent a professional from doing his job. If the user finds it annoying, it is annoying: that's it! Learn to work for the user rather than against the user, and y…

The specific example isn't a developer decision. It's a combination of vendor risk management teams, hospital InfoSec/security/compliance, legal teams, laws, and location of computers. Nevermind that setting is just as often a workstation GPO to lock the screen and not even the choice of the software.

(Work for a PACS vendor, subject to the same stuff).

Re: Everyone hates the electronic medical record

#270

Post by vel0city »

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…

Even a ton of Americans wouldn't know In-n-Out. They only really recently started expanding a lot. Until a few years ago its was pretty much a Southern California only thing. There are no locations east of Texas, and even then there are only locations in the core triangle of Texas. If you're in El Paso or Corpus Christi or Amarillo or Lubbock or McAllen or Brownsville you're several hundred miles from the closest location despite there being many locations in Texas. There are zero in New Mexico, Oklahoma, Kansas, or Washington. All of New England is about a thousand miles from a location.

These people acting like "everone knows it" essentially have the same world view that the entire world that matters is Southern California.

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