
What we lose with data-driven medicine - cassowary37
https://www.nytimes.com/interactive/2018/05/16/magazine/health-issue-what-we-lose-with-data-driven-medicine.html
======
gleb
The business of medicine in United States is about extracting reimbursements
from payers while keeping regulators happy. Well-being and satisfaction of the
patient is important only incidentally. Since most doctors would prefer to be
in the business of helping patients, finding themselves in the business of
billing insurance causes burnout.

Blaming the automation software for this fundamental misalignment is silly.
Software is just a tool that optimizes for the needs of the business and the
customer. And in American healthcare the patient is not the customer.
Insurance companies and the government are the customer.

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epmaybe
So I'm a medical student, as you can probably tell from my comment history. I
once helped write a proposal for the American Medical Association related to
medical scribes - individuals that record all the data from physicians into
the EHR. The idea for these scribes were to allow physicians to focus on the
patient care aspect rather than the documentation and billing.

Our proposal was approved almost unanimously by the student section of the
meeting, but was argued extensively by the physician section, not on the
proposals actual merit, but on the usefulness or lack thereof of scribes. Some
delegates thought that they led to errors in documentation (our proposal was
to study this), others thought they would be leapfrogged by newer technologies
and thus unnecessary.

Long story short, I have two comments. The first, that having more scribes
would be beneficial in letting doctors being doctors, perhaps being a simple
solution to the problems demonstrated in the article.

The second is that doctors from all kinds of specialties probably agree on
many issues affecting patient care and physicians at large. However, all I see
are disagreements.

~~~
assblaster
The fact that you feel that additional personnel are necessary to document
what another person does speaks volumes as to the unnecessary documentation
requirements. We should pare back documentation requirements so that one
person can do it without another person's help.

~~~
epmaybe
How is it any different than being a client of an accountant or lawyer? Or
being an assistant to an executive?

Regardless, looking at the present, in my opinion having scribes available
would provide a simple solution to a problem often bemoaned in medicine.

~~~
assblaster
You're confusing mid-level practitioners with scribes. Lawyers have
paralegals. Physicians have PAs or NPs.

The existence of someone whose sole job is just following a clinician and
documenting for them is absurd. Medicine in the past was fine with paper
charts. Sure there was some inefficiency with collecting information. Medicine
these days is actually less complex than in the past because answers are more
readily available with diagnostic testing. Why is more documentation required
today compared to the past?

We should all strive to simplify medicine, not facilitate ever increasing
unnecessary complexity.

------
philipkglass
These EHR systems sound difficult and time-consuming to use. If they
can't/won't be _directly_ improved any time soon, why don't nurses and doctors
have data entry specialist partners to do the clicking and typing? Why not
take some people with a 2-year medical data entry certification and train them
to use $INSTITUTION's customized EHR system? It seems crazy to make people who
are qualified to actually _diagnose and treat patients_ spend half their time
on clerical work using cumbersome software.

Maybe people are worried that EHR quality would suffer if people with fewer
credentials entered the data. According to the article EHR systems are already
full of garbage data entered by physicians. Does it actually get worse if data
entry specialists do the entry instead? This appears to be readily testable.
You can have them do it in parallel with the physicians who enter their own
EHR data now, and compare after a year.

~~~
whowouldathunk
They do, they’re called scribes.

~~~
philipkglass
That makes sense. Do you know why they aren't more common, to the extent that
many doctors apparently spend much of their day on EHR data entry?

Maybe I'm just relying too much on this article plus a few similar complaints
I've read in the past. Maybe most doctors _don 't_ spend much time on data
entry but I only see the grievances of the few that are forced to.

------
assblaster
Lamenting documentation requirements is as old as Medicaid itself. With more
and more oversight by governing bodies and the burdens of "quality-metrics",
the personal connection with carers will be increasingly distant.

I love electronic records because I don't have to handwrite anymore, and all
the data I need is just a few clicks away. The problem isn't the electronic
nature of the records, but rather the reporting and documentation requirements
that come with it. Why are there increased amounts of documentation required?
Because it is a form of rationing: make patient care so time consuming that
fewer patients can be seen, and less can be billed long term. It really is a
pernicious way to decrease healthcare expenses, but it comes at the cost of
depersonalizing patients, physicians, and nurses.

That, and also legal protections because lawyers exploit any "bad outcome" as
negligence, even though no negligence occurred.

~~~
aaavl2821
it does seem shameful that payers so frequently rely on denying care / making
billing hard to cut costs when there are so many other things they could do
that are harder but higher impact

Also, I'm only recently learning how pernicious the fear of malpractice suits
is, and how this fear makes doctors reluctant to collaborate informally -- if
you can't see a patient yourself or get their full chart, the perceived
liability risk is high enough to prevent informal collaboration

------
tuke
Yes, doctors should focus on the patient and the family, not the computer.
Technology should be scrutinized to be more supportive.

Yet a significant problem with this article is that it provides no comparison
to other professions.

"A clinician will make roughly 4,000 keyboard clicks during a busy 10-hour
emergency-room shift" \-- I doubt that 4,000 "keyboard clicks" is unusual for
any profession at present, even one where attention is moving across
interactions with patients, colleagues, machines, and the computer. A page of
text is about 3,000 characters.

(Aside: I'm actually not quite sure what is meant by a "keyboard click" is --
maybe the author is talking about mouse clicks or toggling checkboxes;
elsewhere in the article the phrase is "4,000-key-clicks-a-day" \-- if it's
just 4,000 taps to keyboard keys, that's a pretty low number. I don't think
that 4,000 checkbox or mouse clicks is even really such a big number. Answers
here ([https://www.quora.com/What-is-the-avarage-number-of-mouse-
cl...](https://www.quora.com/What-is-the-avarage-number-of-mouse-clicks-a-
person-does-daily)) suggest between 5000 and 7000 mouse clicks/day. Another
resources says a doc does about 2500 clicks/day --
[http://www.healthcareitnews.com/infographic/infographic-
one-...](http://www.healthcareitnews.com/infographic/infographic-one-docs-
clicks-day) \-- and that's for a 16 hour shift.)

In any case, is there something distinct about clinician work with regard to
the use of computers, compared to what we're all doing? A claim that there is
would strike me as special pleading. If there is an argument to be made, it
must be made comparatively.

The author also claims that "Even if the E.H.R. is not the sole cause of what
ails us, believe me, it has become the symbol of burnout" \-- do doctors
_really_ suffer from more burnout than other professions? _Doctor-authored_
studies may say so, but we need to have unbiased studies of burnout across the
professions, and understand generally how being lassoed to a computer affects
morale.

------
solotronics
I realized the other day we find ourselves increasingly influenced by
algorithms. Intentionally or not people are forming their lives around
arbitrary algorithms. The YouTube guy who reacted outrageously in a Japanese
suicide forest was forming his life decisions according to YouTube's
algorithms to generate views. Now doctors are making medical choices based on
algos, what's next?

At what point does the hivemind merge with algorithmic ML to form a sort of
distributed AI?

------
tomohawk
This is one of the really sad thing about medicine today. For those of us who
remember how going to the doctor used to be, the experience these days is so
disheartening. All that slavish tending to to the computers and data entry
instead of spending time with the patients. Nurses and even nursing assistance
have also been greatly impacted by this.

~~~
nickthemagicman
This is not an EHR problem. This is a poor bedside manner problem.

------
bsg75
I wonder what the actual split of those two hours of EHR per one hour of
patient care is actually targeted for _medical_ information vs cost accounting
and risk management?

My experience (and resulting skepticism) in data collection for business
suggests that “the business” side is the driver behind many or most of the
inefficiencies.

------
taipan100
There are so many ideas here for how computer systems could be improved. It
reads like an argument against the computer in a medical setting (or at least
a move away from current, perceived, over-reliance) and yet systems could so
easily fix 99% of these problems.

~~~
cassowary37
Yes, but - this is a highly regulated environment and barriers to entry are
quite high. Very hard for new ideas to get a hearing.

------
pg_bot
If anyone in this thread is a physician, and is looking for more autonomy in
the way that they practice medicine my email is in my profile. We're working
on fixing these problems at our clinic and what we've built could be of
interest to you.

------
nicodjimenez
It's not like the doctors themselves are going to drive down the cost of
healthcare. Machine driven medicine is the only way we can replace overpaid
doctors who aren't doing anything much more intellectually challenging than
car mechanics and yet are exploiting the American health care system for all
it's got. At first the machines are going to be used for those without good
health insurance, as those machines get smarter eventually even rich people
will use them, and we can finally start to lower health care costs for
everyone.

~~~
nickthemagicman
Exactly.

------
chersk
Some thoughts on why the system is broken. 1) The ONC certification process.
([https://www.healthit.gov/topic/certification-ehrs/about-
onc-...](https://www.healthit.gov/topic/certification-ehrs/about-onc-health-
it-certification-program)). It is way too complex to explain here, but it
started with the incentive program CMS established in 2011 to push doctors to
electronic health care records. Like a lot of CMS programs, the intention was
there, but so was the opportunity for fraud and abuse. I can't remember the
exact numbers, but the amount of certified EHR vendors dropped dramatically
between the 2011 and 2014 certifications. The next round (currently 2017 stage
3) will further reduce that number. The 2014 round of certification definitely
weeded out a lot of crappy EHR systems that were thrown together and sold to
clinics. The problem now is twofold. First, it's becoming so burdensome and
expensive to keep an EHR system certified, that only the well-financed (EPIC,
Cerner, etc.) can afford to stay in the game. Second, it's extremely expensive
for a clinic/hospital to switch EHR systems. Even if you have developed the
most amazing EHR system known to man, getting a big hospital or clinic group
to switch systems again will be next to impossible. 2) CQM and PQRS/Meaningful
Use reporting. It's complicated, time consuming, and expensive. Prior to 2017,
doctors were required to report to two different systems PQRS and CQM, both
administered by CMS. PQRS has since been replaced by MIPS. Measures that
appear to be identical between the two systems (i.e. CMS 69 and PQRS 128)
sometimes have slightly different parameters. The measures themselves have
versions and can change year to year. The entire system puts a huge financial
burden on doctors. I get the intent. It’s the implementation that sucks. 3)
Imagine if, on your job, you had to use a system of 70,000 different codes to
identify each and every thing you did at work, and you had to justify each and
every thing you did with up to 6 different reasons (out of a possible 70,000
reasons), and you had to submit this report each and every day, and if you
made any mistakes, or if your reasons weren’t sufficient to justify your work,
you didn’t get paid, and you then had to file an appeal to fight it, and it
might be several months before you finally got paid. That’s the health care
claim system. With the adoption of ICD-10 in 2015, the number of available
diagnosis codes went from ~14k to ~70k. The number of Procedure codes went
from ~4k to over 70k. If you’re into data analytics you probably had an
orgasm. If you are a doctor, trying to get a heath care claim paid, your life
got a lot worse. Does it really matter whether a patient got hurt because of a
collision with a roller skater (ICD-10 V00.01). Guess what? Your doctor
doesn’t get paid if he uses ICD-10 code V00.01. That’s because he has to
indicate whether the collision was an initial (V00.01XA), subsequent
(V00.01XD), or sequela (V00.01XS). The more complex the system, the more ways
insurers can deny claims. It’s easy to get frustrated because your
doctor/nurse spends all their time staring at their tablet/laptop clicking
away instead of talking to you. Don’t get mad at them. It wasn’t their idea.
To the people who are quick to paint the doctors as greedy, overpaid clerks
who can and should be replaced by computer and AI, read this
[https://www.nytimes.com/2018/05/18/opinion/artificial-
intell...](https://www.nytimes.com/2018/05/18/opinion/artificial-intelligence-
challenges.html) . Keep on dreaming about your Elysium/Expanse fantasy where
patients are hooked up to a machine and diagnosed/cured. It’s not happening
now, it’s not going to happen any time soon. In the meantime, the most
effective way for a doctor to treat a patient is to look at the patient, talk
to the patient. It’s not reading tea leaves. There are subtle, non-verbal cues
that are impossible to pick up if a doctor has his back to you because he/she
is forced into a clerical role (see points 1,2,3 above). We are decades away
from a computer and AI being able to do this. I hope I am wrong. I watch the
Expanse too but it is just science fiction, the key word being fiction.

To the commenters claiming “scribes” can do this. It’s just not that easy. I
was involved in developing a scribe system. It worked for a couple doctors. We
thought we had the next big thing. The doctors were able to go in and actually
talk to and look at the patient while a scribe sat in another room and
listened to the conversation and watched a mirror of the doctor’s tablet (all
with patients consent). By the time the doctor left the exam room, the
progress notes were completed and prescriptions, follow-ups etc. were ready
for order. The doctor just had to review and complete. System was great.
Doctors were able to go home at a decent hour instead of spending 2 hours in
the evening going over each patients encounter. When we tried to expand it
failed. In hindsight it was easy to understand why. The scribes we initially
used were CAs who had been working with these doctors for years and they could
pick up on subtle verbal cues generating complete encounter notes just based
on a few comments. In our experiment, it just didn’t work once we brought in
scribes who had never worked with or around the doctors. I’m sure there’s a
way to make this work and hopefully someone will one day. It would be nice to
have a conversation with my doctor again. Anyway, just some thoughts. I see a
lot of posts in here discounting the article and claiming the world is ready
for computers to replace doctors, and it’s just the greed/ignorance of doctors
holding us back. If you’re ready to put your life in the hands of AI and
computers, I wish you the best of luck. I just want a system where doctors can
actually be doctors again. The greedy people in our health care system don’t
wear white coats. They run around with titles like “Hospital Administrator”,
“Pharmaceutical Rep”, “Health Care Lobbyist”, “Senator/Congressperson” and
“Insurer”.

------
nickthemagicman
Nothing we lose nothing. It's so frustrating...people LOVE to drum up fear
about technology. But technology is an enhancer! It doesn't prevent anyone
from doing anything they did before. If you want to use a horse and cart go
for it. If you want to use a old fashioned rolodex instead of Facebook go for
it. Use the tech or don't. The problem is people resist change even if it's
for the objective scientifically proven better.

~~~
cassowary37
sorry, but this exhibits a complete disregard for (or lack of understanding
of) the practice of medicine. Many of us love technology - some of us even
read hn. But physicians have very little choice regarding use of this kind of
technology, other than to leave medicine or go into private practice where we
only take care of wealthy people. And re EHR in particular: is this technology
an enhancer as you claim? Because it sure isn't reflected in any objective
measures of clinical outcomes.

~~~
nicodjimenez
You poor thing, it must be really hard having so much job security and such
inflated salaries, due to artificial constraints on the supply of doctors by
the medical mafia. You're not going to get a ton of sympathy here on HN, where
your job or startup will get replaced in the bat of an eye whenever someone /
something comes along that's better / cheaper.

~~~
econochoice
> your job or startup will get replaced in the bat of an eye whenever someone
> / something comes along that's better / cheaper.

Anyone that works to eat is in the same boat.

~~~
nickthemagicman
Exactly and it will remove the artificial physician monopoly and put them in
the same boat with the rest of the world

------
sosuke
It sounds like the problem is in the people or procress then if they cut
corners and aren’t thorough.

I didn’t see the computer or data failing in my hastey read through of the
piece. It always contained what data the people entered.

~~~
skywhopper
People make mistakes in communication all the time. Other humans can notice
and interpret around those mistakes, but computers can't. Humans can infer
things that are missing or implicit in the data. Computers can't. So if we
build a computer system on top of data that we _know_ will be poor,
incomplete, and sloppy, and if we force reliance on that system, then that's a
major problem.

It's silly to assert "the computer didn't do anything wrong". The computer has
no agency or will. It doesn't matter if we run perfect software against a bad
dataset, or if we run perfect data through bad software. The only thing that
matters are the results. The computer and the people are all parts of the same
system.

