How Did Our Medical Notes Become So Useless? • Hacker News Board

Re: How Did Our Medical Notes Become So Useless?

#121

Post by Scoundreller » Sat, Jan 05, 2019, 12:16 AM UTC

nickda wrote: post #103

Scoundreller wrote: post #48

Earlier quoted context omitted.

It seems like most of these articles focus on the documentation side. There are other elements, like med/consult/lab/diagnostic imaging orders going to the relevant person/department instantly. With a handy interface for following them along, cancelling or re-scheduling them at any time. A nurse doesn’t need to follow a provider around to find out what the new orders are, they show up automatically on their own task…

This is true, but the interaction between the doctor and the nurse was invaluable. The context of those orders and the nurse's knowledge of the patient were used to come up with a plan together. Reducing that interaction to "order giver" and "order taker" greatly reduces the quality of patient care. I was recently in the hospital for a week and this was an issue several times.

That asynchronous behaviour happened in the paper world too. Make chart entries, send paper orders to pharmacy/lab, flag it for the other care providers.

Re: How Did Our Medical Notes Become So Useless?

#122

Post by abrichr » Sat, Jan 05, 2019, 12:41 AM UTC

telchar wrote: post #89

I do NLP with medical notes. What I have observed is that the redundancy between the note and information available elsewhere in the EHR in structured formats is pretty high, as is the amount of boilerplate (e.g. section headers and list templates that may not be filled in). This makes machine learning using the notes difficult since the content is so muddied up. It's far from impossible to do useful things with them…

Interesting insight! Where do you work?

Re: How Did Our Medical Notes Become So Useless?

#123

Post by ivalm » Sat, Jan 05, 2019, 12:41 AM UTC

sxg wrote: post #40

Thriptic wrote: post #12

This EHR data problem is something I've pondered for a bit. One "simple" solution is to have departmental standardization of note format with thoughtful inclusion of what fields are typically pertinent. This doesn't solve the problem of care transitions but it might help standardize review in a hospital context. The other thing that I've been pondering is something resembling a formalized data structure and language…

Many departments do standardize their note formats. The problem is that the note is directly connected to billing, and the billing requirements are absurd. I'm a medical student, and I recently visited my PCP for a medication refill. I have no significant medical history whatsoever, and the visit took no more than 15 minutes as expected. A month later, I was given a bill for $330 stating my hospital visit was level 4…

This is pretty unsavory, most visits are billed at 3.

Re: How Did Our Medical Notes Become So Useless?

#124

Post by VikingCoder » Sat, Jan 05, 2019, 12:57 AM UTC

skwb wrote: post #74

VikingCoder wrote: post #59

1. Money 2. Legal liability (CYA) 3. We don't use outcome-based medicine

1. There's an old saying in healthcare that patient care is always first, but money is a close second. 2. Sort of yes, but I've heard it more time from managers who use it more of an excuse for not wanting change rather than it being a legitimate argument (i.e. from people with little to no legal training). 3. This is changing slowly. The Affordable Care Act and it's little known cousin MACRA have started to shift th…

3. No, it's not.

If you go in for a wonky heart, and you get some kind of imaging done on your chest, and then spot something in your lungs, they SHOULD ignore it. Outcome-Based Medicine says that's what they should do. They CAN'T ignore it.

Cardiologists actively want the lungs REMOVED from the images they order, because they don't want to accidentally notice any lung nodules. That's crazy!

And that's just one example.

We don't know how to properly ignore the things we should.

And if something IS there, and there COULD HAVE been action taken on it, then the people who looked at the images are potentially liable in court. Or at least in settlement.

The whole thing sucks.

Re: How Did Our Medical Notes Become So Useless?

#125

Post by MisterTea » Sat, Jan 05, 2019, 1:02 AM UTC

jlamberts wrote: post #8

petermcneeley wrote: post #7

Medicine seems like a technological wasteland. They put "notes" into text boxes and call it "using computers". I wish I had both CS/SE experience and Medical experience so that I could understand what keeps this field in the 1970s. I have suspicions.

In my experience, it's a combination of a couple of things. First off, the field is heavily regulated (in the US anyway) and the penalties for violating regulations like HIPAA are incredibly high. Second, the field is currently dominated by major players such as Epic, so its pretty important to be compatible with them, but they don't really have an incentive to open up their ecosystem since they have such a strangleh…

> First off, the field is heavily regulated (in the US anyway) and the penalties for violating regulations like HIPAA are incredibly high.

This is why heavy handed regulation is bad. The people on the end of the regulation have to deal with a ton of BS to the point where it becomes security theater. These systems need their own departments, experts, and even legal teams. The overhead is massive.You think a company is going to roll over and eat the costs without trying everything in their power to side step it? Loop holes to outright lies will be used. Anything to trim the fat.

Happened to a place I worked at. New regulations meant more overhead. During my tenure I watched the quality department grow from the side job of the head engineer to a department of three people (manager, assistant, engineer) and an outside contractor. I then watched the employee quality drop proportionately as they put more money into putting lipstick on a pig than actually fixing problems and improving quality. As long as you satisfy the auditor or customer you look like a well oiled machine. Just don't look under the rug.

Re: How Did Our Medical Notes Become So Useless?

#126

Post by hopler » Sat, Jan 05, 2019, 1:05 AM UTC

nradov wrote: post #34

ryandrake wrote: post #26

Earlier quoted context omitted.

Why would they be so hesitant? Surely it’s not that extra work for an office admin to pull something up and hit “print”.

Some doctors have been concerned that patients lack the education needed to interpret their own charts. So when patients don't understand something they call back and ask a lot of questions, which doctors see as a waste of time. (I don't agree with this perspective, just giving some context.)

In the US that's fine, because the doctor can bill for the follow-up consultation.

Re: How Did Our Medical Notes Become So Useless?

#127

Post by TheCoelacanth » Sat, Jan 05, 2019, 1:07 AM UTC

notabee wrote: post #27

qrbLPHiKpiux wrote: post #17

Doc here - spot on. 25% of my day is typing, reading, deciphering, referencing. I waste so much time not providing care.

I just want to say that I'm happy to see one of y'all on here. If doctors and engineers were to collaborate together directly to fill in each others' domain knowledge gaps instead of buying crap software from companies with poor incentives, some truly amazing things could happen.

I have a feeling it's more a case of misaligned incentives than just that people with the right knowledge are not involved. Medical professionals are certainly one set of stakeholders that EHR developers consider, but I'm almost certainly they aren't the ones given the highest priority. I would bet that billing, legal compliance and protection from accusations of malpractice are all given a higher priority than actually being able to effectively treat patients.

Re: How Did Our Medical Notes Become So Useless?

#128

Post by hopler » Sat, Jan 05, 2019, 1:09 AM UTC

RyJones wrote: post #67

arielweisberg wrote: post #3

Medical notes are largely fiction IME. You should request all your medical records from any doctor you have seen and start demanding they correct them. You will be shocked at the lies they tell about you. You will be even more shocked down the road when you find out how these lies can hurt you.

At one point recently someone noted on a X Ray that I had hepatitis. I asked my PCP; he said don’t worry, we don’t diagnose that with radiology. I asked that it be removed. No can do. AFAIK I’ll go to the grave with a note from a random radiologist that I have hepatitis.

Google search suggests hepatitis is diagnosed via x-ray/cat scan.

Or maybe it was hipatitis? ;-)

Re: How Did Our Medical Notes Become So Useless?

#129

Post by lostlogin » Sat, Jan 05, 2019, 1:10 AM UTC

goldcd wrote: post #5

In (the UK at least) your medical notes follow you as you sign on with a new GP (General Practitioner - first point of medical contact for anything non-urgent). Now knew this theoretically happened, but was quite bemused to see it happen in practice. I rescued a rat from the silken-jaws of my pseudo-homicidal cat, and the ungrateful rodent bit through half of my finger - I thought it would be sensible to have a check…

Funny-Looking-Kid (FLK) and other such diagnostic gems are present in notes of that vintage.

Re: How Did Our Medical Notes Become So Useless?

#130

Post by lostlogin » Sat, Jan 05, 2019, 1:16 AM UTC

dragonsky wrote: post #119

RyJones wrote: post #68

Earlier quoted context omitted.

When I carefully read my records, I saw a bunch of random errors. I asked my PCP and surgeon how that happened; they said “probably transcription errors” I don’t have a lot of faith in the quality of the records

And this is before you realise that your identity may have been incorrectly matched against someone else leading to you having somebody else’s treatment on your record.

It’s not always the healthcare provider at fault here (but must usually be). I’ve been peripherally involved in 2 cases where someone actively pretended to be someone else (one due to a sketchy immigration status and the other was a mental health situation).

Both were a complete nightmare to sort out.