Hacker News Board Hacker News, browsed like a classic message board
Live data from Hacker News

Everyone hates the electronic medical record

logicmag.io

Post reply on HN
Print view View original

281–290 of 343 posts

Re: Everyone hates the electronic medical record

#281

Post by speed_spread »

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.

If you quit, they'll just hire someone who's willing to do the crappy stuff. As a bonus, they'll probably pay less for that person. Or they'll spread the burden over the remaining staff. Or they'll outsource the whole team to some remote hell. Quality is not a bottom-up thing, everybody has to be in on it.

Most management will exchange quality for quick gain whenever they can because they're there to make money and don't plan for long term. Because they can also leave the ship when the sum of their mistakes starts to sink it.

Re: Everyone hates the electronic medical record

#282

Post by repelsteeltje »

asoneth wrote: post #275
repelsteeltje wrote: post #262

Earlier quoted context omitted.

> [..] 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 even…

I hear you.

Felt the same when saying goodbye to my colleagues, stranded in a golden cage, when the startup we worked for was acquired by Oracle after 8 years. Our beloved product was eventually killed (years after I resigned), but Oracle — despite its obvious mediocre halo — is still alive and kicking.

Re: Everyone hates the electronic medical record

#283

Post by analogj »

iav wrote: post #245

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.

Disclaimer: I built an Open-Source PHR

The thing that most people don't realize is that the legally enforced HIPAA protections they take for granted no longer apply when they request their medical data from a healthcare institution and store it in a third party app -- like Apple Health.

The only thing protecting your medical records from being data-mined and monetized is Apple Health's privacy policy and (current) technical architecture. You've seen examples of it in the news with women's period tracking apps, but it'll become even more common as apps start leveraging APIs opened by the 21st Century Cure's Act.

I'm not a tin-foil hat wearing engineer, but I can forsee a day when Apple's reputation of being "Privacy-conscious" might not be worth as much money as the medical data they've collected from their customers.

It's one of the reasons why I decided to build my own open-source PHR, so that the incentives between the software and me as an individual are kept in alignment.

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

Re: Everyone hates the electronic medical record

#284

Post by tuna74 »

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…

Health care staff in the Nordic countries hate their systems as well.

Re: Everyone hates the electronic medical record

#285

Post by BobaFloutist »

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.

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

Ok, all the programmers with a sense of ethics have quit. Now what, boss?

Re: Everyone hates the electronic medical record

#286

Post by hobs »

repelsteeltje wrote: post #244
hobs wrote: post #217

Earlier quoted context omitted.

And then we have about 90% of working sw devs quit tomorrow - it sounds great but people are not going to leave when they know the next place is basically the exact same.

I beg to disagree. Although I've only worked for European and US companies, my experience is that even bossy bosses appreciate quality design and understand that lack of time, pressure and exploitation cause products to degrade. But pressure can only exist if there is an equally opposing force — you, me, us. If my recommendation to bluntly quit sounded harsh, I'm happy to tone that down. There is value in compromise,…

I don't think it sounds harsh, and I have worked with dozens of tech companies and directly for a dozen or so - the only one that wasn't obsessed with cheating out on quality to make a buck was bilking his customers so much that he didn't care.

At every phase of the conversation is management saying they have this hard deadline and

I have been fired multiple times for being too vocal about the failures of process or technology, though mostly I just get ghosted for pushing back when things are unreasonable, at this point I exclusively go for visualizations, gantt charts, etc - to communicate that the timelines are not possible with the current investment in the team/tech/whatever.

I just got laid off for (as far as I can tell) being the person who kept asking the question about why we were doing a thing that provided no technical or business value for a year, and in most of these cases some exec thinks they know best because they read some magazine equivalent that tells them this is the new hype revolution.

Basically if you can find some highly skilled or highly profitable company that's concerned about losing their edge you might be able to do this, but your next boss might change the entire equation.

Re: Everyone hates the electronic medical record

#287

Post by hyponatremia121 »

karmajunkie wrote: post #271
submain wrote: post #238

Earlier quoted context omitted.

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 man…

"The source of the problem is that the people deciding which EHR to use are almost never the people using it. "

Yes, this. We are a Cerner (now Oracle, yaaaaa) site, not Epic. The Cerner folks I've met in smallish meetings are nice/great on the front lines. However, the deal that our CEO/CFO/COO/CMIO made with Cerner was years ago and, per rumor, involved large financial penalties for early cancellation. Subsequent people in those roles have chosen to uphold the contract. The local management and healthcare teams in my particular facility are great but I take a dim view of our c-suite as do the majority of the work force. Things are reasonable locally for most people, I think, except for the EHR.

So, I would plead with leadership teams of EMRs, EHRs, healthcare systems, and shareholders of these entities to do the right thing and give healthcare workers working in high-risk settings the proper tools they need. You are currently failing us. No one wants unreliable, difficult software installed in critical settings such as ICUs.

I've submitted tickets, emailed leadership and had conversations with the CMIO. If there is improvement it is so slow that I cannot discern it.

In anecdotal conversations over the years I've observed that the vast majority of healthcare workers hate all EMRs but give Epic the nod because it is the least worst, and for some, reasonable. I have met a few Epic users that are enthusiastic about the software but that is after they arrived at our Cerner site and were in shock.

@duffpkg - my original comment was under yours and I wasn't intending to malign your project. I'm not familiar with it but do like that it is open source.

Respect to the developers that work on EHRs. I recognize you are held down by management.

I'm perplexed by UX/UI problems in EMRs. This must cost more to fix than I suspect. It seems to be the easiest of the issues from my layperson/healthcareworker/tech-enthusiast viewpoint.

One more thing to add: an effect of bad EHR is healthcare worker burnout. Bad EHR is a known contributor. Burned out healthcare workers are at increased risk to make medical errors. Bad EHR -> burnout -> errors -> adverse outcomes. This is a well known flow to us in the clinical setting that we attempt to mitigate. The executive teams of orgs that produce or purchase EHRs are never held accountable for bad outcomes even though, to my view, they share responsibility.

Edit: government regulators (CMS, etc) also share in the blame for bad EHR and outcomes.

Re: Everyone hates the electronic medical record

#288

Post by repelsteeltje »

speed_spread wrote: post #281
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 quit, they'll just hire someone who's willing to do the crappy stuff. As a bonus, they'll probably pay less for that person. Or they'll spread the burden over the remaining staff. Or they'll outsource the whole team to some remote hell. Quality is not a bottom-up thing, everybody has to be in on it. Most management will exchange quality for quick gain whenever they can because they're there to make money and d…

> Quality is not a bottom-up thing, everybody has to be in on it.

I like it. But I've seen at least one place (a start up) where (to some extent) quality was a bottom up thing. Eventually it became a share value, but it was rooted in developers saying: No, we need more time.

On the other hand, I don't know of examples where quality was forced top-down — places where a senior developer would say: I'm done/I don't care/this is good enough and their manager telling them to spend more time on a feature or teaching them about software design.

Re: Everyone hates the electronic medical record

#289

Post by Nexxius »

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 wouldn't say Rolls-Royce, more like Lexus. Fuddruckers would be closer to Rolls quality as they actually allow for something other than well-done, preformed, meat pucks.

Re: Everyone hates the electronic medical record

#290

Post by analogj »

glimshe wrote: post #163

What's the point of electronic medical records if I have to fill out the same stupid paper form every time I go to a doctor?

There's actually a "Patient-contributed data" initiative being run by the standards body (HL7) that's gaining traction. In an ideal world it would allow patients to "push" their electronic records to a new practitioner, meaning that intake forms could be much simpler. In practice I think the implementation is going to start with Observations/Lab Results first though.

I hope to eventually support it with my open source personal health record (PHR) Fasten Health. IMO this would be a "killer app" for PHRs.

Post reply on HN