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Everyone hates the electronic medical record

logicmag.io

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Re: Everyone hates the electronic medical record

#271

Post by karmajunkie »

submain wrote: post #238
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…

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 ju…

100% this.

EHRs almost universally suffer from usability problems. people actually love having their medical records available. They hate the UX they have to go through to see them.

The source of the problem is that the people deciding which EHR to use are almost never the people using it. it’s ultimately the CFO or CEO who’s ultimately going to make the call, and they do it based on metrics like price tag or how many accreditation checkboxes it fills, not on user satisfaction scores. Until those user satisfaction numbers make it into CMS guidelines for reimbursement, the situation’s never going to change.

Re: Everyone hates the electronic medical record

#272

Post by karmajunkie »

briffle wrote: post #247
complex1314 wrote: post #111

Earlier quoted context omitted.

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...

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

my team is about to start working on an epic integration and i can safely say we’ve all thought briefly about staging a revolt…

i just keep telling myself “at least it’s not meditech…”

Re: Everyone hates the electronic medical record

#273

Post by macspoofing »

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…

>HNers by and large don't understand the economics of PowerShell.

That's not true ...

PowerShell is the "lingua franca" for Windows system administration, I think everyone understands that. Much of the power of Powershell isn't the syntax (which is unnecessarily cumbersome), but rather that most core windows system services have PowerShell bindings.

Powershell isn't a tool you would use for Linux scripting and administration, because it isn't ubiquitous the way bash is.

So what exactly is your point? That Linux administrators adopt PowerShell? Or are you arguing a strawman that HNers advocate for using bash in Windows?

Re: Everyone hates the electronic medical record

#274

Post by mike503 »

submain wrote: post #238
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…

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 ju…

It's not just EMR, it's just capitalism in general. Everything is about squeezing the most value out of the least budget.

If there was a way to factor in costs due to downtime, poor usability, anything like that, might be able to push back and bake some of that in to begin with... but even that is a can they'd kick.

Re: Everyone hates the electronic medical record

#275

Post by asoneth »

repelsteeltje wrote: post #262
asoneth wrote: post #249

Earlier quoted context omitted.

> 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.

I don't regret the decision but I do feel a little guilt for what I left behind.

I have friends who moved out of struggling towns and states who describe similar feelings about being part of the "brain drain" death spiral that is hollowing out the place they grew up.

> Hopefully, given a free market, the service will eventually be replaced by something better.

I too believed that something like that would happen eventually but their business is still booming. In the decades since I've learned that the "fitness function" of companies that serve governments or large enterprises do not reward product quality (at least not commensurate with the cost of quality) so companies or teams that insist on wasting effort making quality products do not survive. It's not malice or incompetence, it's just a survival response to misaligned incentives.

Re: Everyone hates the electronic medical record

#276

Post by Nemi »

submain wrote: post #238
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…

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 ju…

I agree. I also worked on EHR software and what people don’t realize is that the “customer” isn’t the doctor. Not to be disparaging, but the doctor is “just” an employee.

The purchaser of the software is the administrator. And because of harsh regulations and legal liabilities in their industry, they need software that is compliant with regulations and limits legal liability on the institution. Full stop. If they can get that with a good UI/UX, then great! But in the end, this is just another case of “No one ever got fired for buying IBM”. It is all about incentives.

Companies like Epic could make their UX better, but that costs money. And what drives sales is being regulations compliant, and that is hard. It takes a ton of time. There is little time left over to make something work well considering no other software is challenging them on that front. It really is a situation of regulatory capture.

Re: Everyone hates the electronic medical record

#277

Post by mandevil »

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…

In the US malpractice insurance is mostly orthogonal to the costs of health care. I hate having to write the check every year (my wife- a pharmacist- needs this insurance just like doctors do, though it doesn't cost as much because suits aren't as common) but it's really just an annoying drop in the bucket. You can tell this because some states (most prominently, Texas) have put caps on malpractice pain-and-suffering payouts, and they don't have lower medical costs, in fact parts of Texas are some of the most expensive in the country. So if malpractice isn't driving it, what is?

As far as I can tell, the real reason for the costs are consolidation. In my wife's world, independent pharmacies are being killed by PBM's(1) which literally set reimbursement rates for the small guys at below the wholesale cost of the medicine. The user experience here is you go to an independent pharmacy, you hand them your script, and they run the script through their computer systems, then say "Sorry, I can't fill this for you, because it cost me more than the insurance will pay me" and then you have to go to one of the big three which have enough market power to negotiate with their PBM's for higher rates (and even here PBM's routinely end up at least temporarily dropping one of the big boys as part of their hardball negotiations with each other).

There are basically three PBM's for the whole country, they have enormous, basically monopoly power (80% of the insurance market), and if you are a small shop your rates are crap. So the small pharmacies close/sell out and the big three drug stores get bigger. And that is happening in medicine as well, as I understand it, though I haven't seen it from the inside.

The core idea behind the ACA ("Obamacare") was that clear competition from insurance companies (and medical providers) through the exchanges would lower the total costs of health care, and it doesn't seem to have panned out, because there hasn't actually been much competition, instead there has been massive consolidation. Most counties in the US don't actually have much competition on their ACA Exchange(2), and most counties don't have much competition from medical providers either- they've all consolidated to get better rates from the insurance company- so you have monopoly insurance and monopoly providers competing with each other to see who gets more rents, not trying to compete on lowering costs.(3)

1: Pharmacy Benefit Managers, https://www.vox.com/2023/5/10/23709448/what-are-pbms-pharmac... for an explainer

2: https://www.vox.com/mischiefs-of-faction/2017/7/20/16005598/...

3: This is why many Democratic health care wonks are looking more seriously at single-payer over the past decade. If we in practice have unchecked monopolies dominating health care, let's at least have them be government run and therefore responsive to something, even if it's just politics it's still better than the alternative.

Re: Everyone hates the electronic medical record

#278

Post by analogj »

firejake308 wrote: post #219
makeitdouble wrote: post #61

Earlier quoted context omitted.

Same disclaimer: not in the US. From the other side of the table, as patients that were very regularly ill and bouncing between medical professionals, EMR were a godsend. For instance in vacation at the other end of the country, we lost an Anapen with a luggage mishanded at the station, though we had a spare but we actually didn't (was in the same bag...). We went to the closest doctor, showed the insurance card and…

The problem is that in the US, many EMR's don't automatically connect to each other. If you're going from a hospital owned by one chain (say, Hospital Corporation of America) to another hospital owned by the same corporation, then yes, it works like you said and doctors have access to your historical data. But God forbid that you should ever end up at a hospital owned by a different corporation, because then you have…

This is not quite the case any longer

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.

It doesn't matter that I've had 6 different insurance companies over my career, or that I've visited more than 2 dozen different healthcare institutions, as a Patient we have the unique ability to collate and generate our own longitudinal health record.

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

Re: Everyone hates the electronic medical record

#280

Post by CommieBobDole »

msteffen wrote: post #125
duffpkg wrote: post #80

Earlier quoted context omitted.

A lot of facilities run on a McDonalds type thinking when they should be looking at how In-N-Out is able to deliver a very similar product that is both dramatically better and either the same price or even cheaper. In-N-Out staff is well compensated, customers rate the institution as one of the most beloved in american life. McDonalds achieves neither of those things. What makes In-N-Out different? The difference is…

Some of these suggestions seem like non-trivial management problems, though, I think? Diesel fuel and generator maintenance: how do you hire for that? Does that position require experience? In what? Where do you post that job ad to get qualified candidates? If you hire wrong, it seems like the results could be worse than foisting the task on a doctor, no? Revising formularies: how many doctors at a hospital have the…

>Diesel fuel and generator maintenance: how do you hire for that?

This is typically part of the job of a facilities manager, someone who is in charge of maintaining the physical structure and amenities of a building or complex of buildings. You hire for it the same way you hire for everything else; you find someone in the category that you want, who has apparent success doing something similar to what you're doing.

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