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Post-apocalyptic life in American health care

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Re: Post-apocalyptic life in American health care

#121

Post by knightofmars »

trowawee wrote: post #69
nradov wrote: post #63

Earlier quoted context omitted.

Standardize what? With a complex medical condition like that every patient is different so it's tough to apply evidence-based medicine practices. The technology for sharing patient records is gradually being standardized. But that won't help if the doctors don't actually take time for a detailed review of the patient's records.

Personally, from my observations as a software engineer married to a doctor and friendly with lots of doctors, and as an occasional participant in the American healthcare system, the general inadequacy of electronic medical systems is one of the most maddening aspects of our system. Epic is a monstrosity and none of the other systems are much better. The tech is outdated, the interfaces are awful, they're incredibly…

Maxander is correct. As they say, "Don't judge a person till you've walk a mile in his shoes." As a someone who has been writing healthcare software (not EPIC but close enough) for nearly 10 years I can tell you it's not the software engineers.

The regulations (often vague and open to interpretation by the customer) often play a part in creating the monstrosities that power our healthcare systems. Because of the subject to interpretation aspect customers often say, "No. This is how it has to work because our processes say this is what we do to meet the regulation." Inevitably it's implemented to be configurable because that's what's required.

Another culprit is the institutions and lack of standards surrounding process. There's a reason EPIC software is customized for every institution it is installed in. It's because every institution wants to do things differently. Even in the space which I work, it's the same. Every institution wants "some specific change" that they can't live without and won't go live until it's available. I'm saying this is neither a good nor a bad thing. It's just a reality.

And the ever present legacy, take EPIC as the example, it was founded in 1979. I'm not saying that their code is all from 1979 but there's definitely a fingerprint of what was in their modern day applications. There are layers upon layers of data from mergers and acquisitions translated into various codes and mapped to various databases for any number of uses. Any day of the week your state code may be two letters, three letters, full name, a custom internal legacy code, you name it you'll see it.

Spend a year working for a company with a regulated legacy healthcare product and significant user base. You'll have to become proficient at security, regulations, data standards (HL7, FHIR, etc), legacy data migration, and any other number of skills. If you're lucky enough to have all of those in place then you're still going to spend time coming up to speed within the specific healthcare domain you're working in and where it touches other healthcare (and non-healthcare eg financials) domains. Oh, and often you won't be allowed access to production instances to troubleshoot issues and a copy of the production instance isn't available because HIPPA and the customer is uncomfortable giving access to engineers. You get really good recreating problems purely via error logs and staring at the code where the issue "might" have occurred.

Re: Post-apocalyptic life in American health care

#122

Post by pnutjam »

maxander wrote: post #111
trowawee wrote: post #69

Earlier quoted context omitted.

Personally, from my observations as a software engineer married to a doctor and friendly with lots of doctors, and as an occasional participant in the American healthcare system, the general inadequacy of electronic medical systems is one of the most maddening aspects of our system. Epic is a monstrosity and none of the other systems are much better. The tech is outdated, the interfaces are awful, they're incredibly…

> whoever the members of our profession are who are building those systems are doing a crap job. They're doing an excellent job, probably producing a level of functionality comparable to Amazon web developers or Oracle database writers. They're doing an excellent job at navigating the unholy mess of archaic regulations, mismatching institutional requirements, and hostile corporate interests, without getting sued or c…

American EMR systems are designed around billing systems. This is almost entirely the problem.

Re: Post-apocalyptic life in American health care

#123

Post by ceejayoz »

megaman22 wrote: post #99
Joeri wrote: post #95

Earlier quoted context omitted.

Any theories on why the US government is so much less capable than governments in other countries?

Scale? If you look at governments that are comparable in size and number of citizens to the US, you don't see many that are all that effective. Most of the comparisons that people like to bring up are European countries the size and population of US states.

Scale is supposed to make things more efficient, not less. That's the whole idea behind "economies of scale".

Sure, if you want to pretend the EU doesn't exist, and that the US doesn't already manage Medicaid on a state-by-state level, there's a significant population difference... but Germany has nearly 100M people. We have strong evidence single-payer healthcare already works with large numbers of people.

Re: Post-apocalyptic life in American health care

#124

Post by conanbatt »

frgtpsswrdlame wrote: post #96
conanbatt wrote: post #83

Earlier quoted context omitted.

> Well no, because I'm speaking in general. But I'd love to know your example. Instead of wasting time with examples that dont go for the core of your stance, can you share what would change your mind in the general? Mine is that lightly regulated free healthcare markets will be efficient (though might not be equitable).

>Mine is that lightly regulated free healthcare markets will be efficient (though might not be equitable). And what is 'efficient'? I think a major component of a well functioning healthcare system is that it's equitable. Our problem with healthcare is driven by the generalized problem of 'economization.' A rich person doesn't have some intrinsic quality that makes them more deserving of quality healthcare. A healthc…

> What I'd say is that the US is pretty terrible at both and that's sad.

Right, inefficiency tends to harm both equitability and value/cost(loose efficiency definition), but the US market is not what it is because it is efficient or because it is equitable, which is a classic dichotomy of microeconomics.

> Some evidence that shows that mostly private healthcare systems generally function better than mostly public ones or some evidence that healthcare regulation in the US has led to worse outcomes and not better ones would at least give me a jumping point.

I see. So the challenge here is that we can only compare apples to oranges over and over again: we could try to see east germand and west germany, but for other reasons the economics were different. We can compare same country public and private like Germany and Argentina, and get to different conclusions (in germany, private is for the rich, in argentina, public is for the poor). We can compare England to the US, but how do you adjust for cultural and income differences?

For example, healthcare in the US was relatively very cheap 50 years ago, where it was still private. What happened in the middle?

Instead of looking so broadly at private vs public, its better i think to focus on why its expensive. And I can assure you that the top 5 reasons why healthcare in the us is expensive is due to government irresponsibilities. If the government cant even fix its own mistakes, how is it going to handle a much larger responsibility?

> But I'd also ask you to answer your own question here.

I did.

Re: Post-apocalyptic life in American health care

#125

Post by riverstones »

grecy wrote: post #98
shrike wrote: post #25

About 8 years ago I broke my leg and eventually developed a methicillin-resistant infection where screws had been inserted. Fighting this type of infection in the bone is difficult. I spent 11 months in a hospital bed plus some time in a SNF. A total of 7 surgeries in the first 18 months and another 2 after that, the most recent 3 years ago. I can second the experience of the author. All in I had contact with over 40…

A few years ago my brother broke his leg horribly. The Ambulance drivers said it was the worst break they had ever seen. Multiple surgeries, months in hospital, rehab, got addicted to morphine in the process etc. etc. At the end of it all was a handshake and "get well soon". There was no bill. Australia.

I grew up in England. Same deal. In and out, no bill.

The Americans who decry "socialist" medicine have never used it. There has to be a way to divorce health care and profit. English, Aussie, and Kiwi doctors all make about the same pay as American doctors, but they work in a non-profit system. Go figure...

Americans are largely opposed to a system where there is no profit. The Americans are the Ferengi of medicine, this much is certain.

Re: Post-apocalyptic life in American health care

#126

Post by knightofmars »

pnutjam wrote: post #122
maxander wrote: post #111

Earlier quoted context omitted.

> whoever the members of our profession are who are building those systems are doing a crap job. They're doing an excellent job, probably producing a level of functionality comparable to Amazon web developers or Oracle database writers. They're doing an excellent job at navigating the unholy mess of archaic regulations, mismatching institutional requirements, and hostile corporate interests, without getting sued or c…

American EMR systems are designed around billing systems. This is almost entirely the problem.

Yes, this too.

Re: Post-apocalyptic life in American health care

#127

Post by nradov »

trowawee wrote: post #69
nradov wrote: post #63

Earlier quoted context omitted.

Standardize what? With a complex medical condition like that every patient is different so it's tough to apply evidence-based medicine practices. The technology for sharing patient records is gradually being standardized. But that won't help if the doctors don't actually take time for a detailed review of the patient's records.

Personally, from my observations as a software engineer married to a doctor and friendly with lots of doctors, and as an occasional participant in the American healthcare system, the general inadequacy of electronic medical systems is one of the most maddening aspects of our system. Epic is a monstrosity and none of the other systems are much better. The tech is outdated, the interfaces are awful, they're incredibly…

The EMR usability problem is tough and expensive to solve. Medicine is extremely complex and every specialty has a different workflow. Build a system that pediatricians love and oncologists will hate it, or vice versa. Instead of just complaining that Epic developers are doing a crap job, what specifically should they change?

The communications and integration problem is gradually improving. In order to comply with government mandates, most EMRs now include HL7 interfaces that comply reasonably well with current standards and no longer charge extra for that feature. But every system still has a different internal data model so something is always lost in translation.

Re: Post-apocalyptic life in American health care

#128

Post by nradov »

mr_overalls wrote: post #81
nradov wrote: post #63

Earlier quoted context omitted.

Standardize what? With a complex medical condition like that every patient is different so it's tough to apply evidence-based medicine practices. The technology for sharing patient records is gradually being standardized. But that won't help if the doctors don't actually take time for a detailed review of the patient's records.

ICD 10 is a medical classification system by the World Health Organization. It contains thousands of extremely detailed codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. It is used by all parties in the healthcare system. https://en.wikipedia.org/wiki/ICD-10

Everyone in the industry is well aware of ICD-10 and we've been using it extensively for years. It's only one small piece of the puzzle and not nearly sufficient on its own. Just within the terminology / ontology space most clinical systems will have to support a wide range of others that are mostly orthogonal to ICD-10 such as CPT, RxNorm, LOINC, SNOMED-CT, etc. And that's not even getting into issues with message and document formats.

Re: Post-apocalyptic life in American health care

#129

Post by InitialLastName »

justinhj wrote: post #80

She retired in 97 and still has health coverage by her employer. Is that typical in the US? Is it very expensive to insure someone in perpetuity like that?

I assume it's tied to some kind of pension (which is tied to the former employer), so the premium would be ongoing and taken out of the pension payout.

Otherwise, I'd imagine yes permanently insuring someone would be extraordinarily expensive.

Re: Post-apocalyptic life in American health care

#130

Post by yodsanklai »

I'm wondering, is the American health care bad for (upper) middle-class too? let say you have a good job in a big corporation, do you have to worry about healthcare? can you go to a decent hospital for any problem you may have and get appropriate care without spending any dime?
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