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The Unexotic Underclass

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Re: The Unexotic Underclass

#21

Post by Cyranix »

arkades wrote: post #8
kyllo wrote: post #3

I noticed that devs on HN often sneer at CRUD apps because they're boring to build, but meanwhile a simple CRUD app could do something like make all these veterans' medical benefit claims paperless so that they can get filled out and approved in minutes rather than months , and they could get the care they need sooner. One could do a lot of good by just making CRUD apps for people who need them and can't afford to pa…

The VA has the largest, best-maintained electronic medical records system in the country. It is open-source and available to the public. The problem with vets is not the absence of software. I am rather tired of seeing this particular horse beaten.

Can you take this comment a step further and attempt an explanation for why a gargantuan pile of paperwork does exist despite such excellent software?

Re: The Unexotic Underclass

#22

Post by greghinch »

Before you can fix any of the problems that would require you to be a US government contractor, you first have to fix the problems of how US government IT contracts are awarded. There is an entire sub-industry of IT service firms who have perfected the art of bidding on government contracts, and win them regardless of their ability to build the best solution. They just have to present the lowest cost solution that meets all the requirements outlined. They are often monolithic corporate entities with multiple sub-entities, with so many layers of bureaucracy it's amazing anything get's built at all. I did some contract web work for on a government project, and just to get paid I had to set up accounts with 3 separate government agencies which had similar but separate account management and payment distribution software (most likely built by separate IT service contractors).

It's an industry that's ripe for disruption if you can figure out how to break down the walls, but those walls have been erected pretty damn high and solid.

Re: The Unexotic Underclass

#23

Post by kylebgorman »

scrumper wrote: post #13
mikeash wrote: post #6

Earlier quoted context omitted.

All the technology in the world won't make those veterans' benefit claims go through any faster. The problem there isn't the technology (it's not all that hard of a problem) but getting it into the right place, past all the gatekeepers who want to keep it out. It's not that nobody is building the technology because they're concentrating on other things, but rather nobody is building it because they know it won't sell…

Maybe that's the problem to solve then: navigating (or, dare I say it, disrupting) government procurement.

A procurement reform program was Philadelphia's submission to the "Mayors Challenge" this year (http://mayorschallenge.bloomberg.org/index.cfm?objectid=184A...). It lost out to Providence, RI's proposal (I have argued elsewhere that Providence's proposal, while noble, is probably a boondoggle: http://wellformedness.com/blog/on-the-providence-word-gap-in...)

Re: The Unexotic Underclass

#24

Post by abraininavat »

We have clear ideas of what the exotic underclass looks like because everyone is clamoring to help them.... The exotic underclass are poor Black and Hispanic children (are there any other kind?) living in America’s urban ghettos.

Yeah, they're wiping their asses with the money that gets thrown at them. What a fucking joke.

Re: The Unexotic Underclass

#25

Post by raylu »

kstenerud wrote: post #5

All of this moralizing and "solve big problems" talk is really getting old. On average, chances are pretty low that a particular individual will ever solve a big problem, so stop worrying about it! It's not for others to say how you "should" spend your energy anyway. The moralistic fluff is unnecessary. Those who aren't motivated will ignore it, those who are motivated don't need to be reminded, and the moralizers wi…

On average, chances are pretty low that a particular startup will ever make even a hundred thousand dollars, so stop starting new companies!

It's not for either your investors or your customers to tell you what to build anyway.

And just never talk about morals, which I deem "fluff".

Re: The Unexotic Underclass

#27

Post by zdw »

Cyranix wrote: post #21
arkades wrote: post #8

Earlier quoted context omitted.

The VA has the largest, best-maintained electronic medical records system in the country. It is open-source and available to the public. The problem with vets is not the absence of software. I am rather tired of seeing this particular horse beaten.

Can you take this comment a step further and attempt an explanation for why a gargantuan pile of paperwork does exist despite such excellent software?

I'm going to guess that they're two separate things.

Medical records keeps track of medical procedure, patient history, what medications they're on, etc. In the private sphere, this is what a hospital would use.

What's probably at cause for the huge backlog is actually getting people into the system and approved for care. In the private sphere, this is what an insurance company would use.

Or this could be just your standard set of political exaggerations.

Re: The Unexotic Underclass

#29

Post by dr_ »

Cyranix wrote: post #21
arkades wrote: post #8

Earlier quoted context omitted.

The VA has the largest, best-maintained electronic medical records system in the country. It is open-source and available to the public. The problem with vets is not the absence of software. I am rather tired of seeing this particular horse beaten.

Can you take this comment a step further and attempt an explanation for why a gargantuan pile of paperwork does exist despite such excellent software?

Yes, part of it is registering vets into the system. The other part is a combination of the enormous number of claims and enormous amount of documentation required. As a physician, I worked in C&P (compensation and pension) clinics for a number of years at the VA, as a consultant. The amount of documentation required is astronomical, likely because vets are being compensated for their injuries with taxpayer dollars. Fair enough, but a physician providing these services could find other ways to use their time productively (for themselves). Then there's the volume. You don't just see vets who have lost an arm or a leg or have suffered traumatic brain or spinal cord injuries. You also see the guys who may have sprained a knee or ankle playing basketball in their free time but while they were officially on duty. Throw that into the mix, and you have too many people to examine so thoroughly. They tried to fix this by contracting with an agency and have vets come into a private medical office instead of doctors going to the VA, my partner did this for a while, but the reimbursement offered for the amount of paperwork required ultimately made it impractical. To fix it: 1) screen vets better, some are clearly more severely injured than others 2) better compensate providers who see all these vets and complete all the necessary documentation.

The screening part is tricky though, as it can quickly get political.

Re: The Unexotic Underclass

#30

Post by arkades »

Cyranix wrote: post #21
arkades wrote: post #8

Earlier quoted context omitted.

The VA has the largest, best-maintained electronic medical records system in the country. It is open-source and available to the public. The problem with vets is not the absence of software. I am rather tired of seeing this particular horse beaten.

Can you take this comment a step further and attempt an explanation for why a gargantuan pile of paperwork does exist despite such excellent software?

In part the problem arises from the interface between systems. If you walk into any normal hospital internal medicine floor you'll see about 5 different systems in use, with varying levels of interoperability: the VA, operating what is the largest network of healthcare centers in the country, takes that issue to the next order of magnitude. A lot of paper gets generated at these interfaces. Although the core VA EMR system is solid, there are multiple other systems laid atop it. The VA is attempting to address both the software and processes issue (people outside healthcare don't know this, but the VA is the place to take your career if you wish to do healthcare services research - they're, collectively, the single most innovative group of providers in the country).

The main problem lies with the paper backlog of attempting to get people into the system. I'm personally not aware of how/why military personnel's medical records don't transition directly into the VA, but what happens in practice is a gap between military med. and the VA, where vets find themselves forced to file claims. I suspect that this is in large part because the set of "Vets" and the set of people qualifying for VA care, while overlapping, are not the same (that assertion comes from anecdote: I had an ex in the military, and when she finished her tours I recall that she was not qualifying for VA care because she hadn't been disabled nor gone career, as she explained it). While it's fair to ask why this process is done on paper, it's worth-while to note that prior to just the last handful of years the portion of health records that had been digitized was nearly nil (up until about 5 years ago it was standard practice in most hospitals and private clinics to go digital-to-paper-to-digital). Essentially everyone's records were on paper, and all record transfers happened via fax (and still do, if a receiving physician is not inside the same hospital system on the same EMR as the referring physician).

source: work in hospital QI. I haven't worked in the VA, personally, so I am relating a lot of stuff second-hand, but the boundary between most hospitals' QI staff, the IHI, and the VA tends to be pretty porous, if you're in a healthcare capitol city - so I've heard a lot about the VA from co-workers that have worked there, or are currently engaged in ops research there.

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