
How Did Our Medical Notes Become So Useless? - mrestko
https://blogs.jwatch.org/hiv-id-observations/index.php/how-did-our-medical-notes-become-so-useless/2019/01/02/
======
goldcd
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 checkup/shot. I've only got a hazy
recollection of what shots I've had when, so my notes were consulted.
Seemingly, according to my paper notes produced from the cabinet, 40 years ago
"I was an adorable wee thing" (aged 2).

~~~
giobox
I'm not entirely convinced the UK/NHS should ever be used as a good example
for handling medical notes, at least by today's standards.

As a Brit who left the UK a while ago, I recently had cause to request my
"medical records" from my former GP. Of course such data can presumably be
requested via the UK's Data Protection Act, but the lack of any kind of
standard process or checks really shocked me, given the care they are treated
with in places such as the US via specific legislation such as HIPPA and so
forth.

My GP posted my entire history after one phone call to their receptionist via
Skype, did no checks what so ever on my identity beyond confirming my name and
DoB to look me up, I was left close to speechless following the call. I can't
profess to be an expert on the topic of rights to medical data in the UK, but
the above was true of my own experience and others I know, I've heard similar
stories from a handful of GP friends and family. There is literally nothing
stopping someone pulling your name and DoB from a Facebook account or similar
and doing the same in many cases.

The number of GPs without electronic record keeping of any kind in the UK
frankly amazes me as well, supposedly the NHS will be paperless by 2020...

~~~
Spooky23
Don’t worry, US medical practices will give you a big show about doing
anything in the name of HIPPA.

Rest assured, it is a show, and most of your information is fed in real time
to a half dozen different entities whom you have never heard of. The people
who sell prescription data provide it to the pharma company before your
insurer even gets the claim.

~~~
balfirevic
Is what they're doing illegal or is that behavior not prohibited by HIPPA?

~~~
Spooky23
It is legal. HIPPA protects you from chatty employees and gross incompetence.

~~~
redbeard0x0a
"Protects" you. It just gives some penalties to the companies for gross
negligence, kind of like the GDPR is trying to do for all of personal data in
the EU.

------
arielweisberg
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.

~~~
rhcom2
In the US you're legally entitled to your medical records too but every time
I've done it the response is always defensive, ie "why do you need them",
"send me the doctors information and I'll fax it to them myself".

~~~
dvtrn
_every time I 've done it the response is always defensive, ie "why do you
need them"_

I was asked this once after requesting mine. I flatly said "I don't", and
waited. The person on the other end of the line was clearly thrown off by
this, probably expecting something they could dish out a canned response to,
hoping I'd give up. It was obvious from their voice they were scrambling for
what to say to that.

A bit of rigmarole later, I had my medical records.

~~~
ams6110
Side question, would the "right to be forgotten" also entitle you to call your
doctor and demand that all your medical records be destroyed?

~~~
conanbatt
Docs need to keep a history for multiple reasons, from insurance to
malpractice lawsuits, so no.

------
petermcneeley
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.

~~~
jlamberts
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 stranglehold on the market. Finally, a lot of
medical folks have been burned by technology in the past, and, in my
experience, often view a lot of the tech they have to use as an insurance and
government mandated evil, rather than a way to make their lives better.

Not to say things can't be improved, but there are a lot of factors that make
it more difficult than a traditional B2B or B2C product.

~~~
nradov
The Epic ecosystem is actually pretty open now. They have multiple web service
APIs with full documentation, and even provide a developer sandbox you can use
to test client applications.

[https://open.epic.com/](https://open.epic.com/)

Epic also has an app store. You can write your own SMART on FHIR apps, then
deploy them inside the EHR with full access to patient data.

[https://apporchard.epic.com/](https://apporchard.epic.com/)

~~~
arkh
The full FHIR standard can be a lot at first sight
[https://www.hl7.org/fhir/](https://www.hl7.org/fhir/) but I'd recommend
anyone having to store names, addresses or contact information to check how
they do it. The last example for names is always fun:
[https://www.hl7.org/fhir/datatypes-
examples.html#HumanName](https://www.hl7.org/fhir/datatypes-
examples.html#HumanName)

------
SL61
There's a recent New Yorker article by Atul Gawande covering this from a
slightly different angle: [https://www.newyorker.com/magazine/2018/11/12/why-
doctors-ha...](https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-
their-computers)

He puts much of the blame on the generalization of computer systems, i.e. that
the notes have to be readable by all sorts of staff and need to be
systematized to accommodate that.

------
deckar01
I recently built my mom a basic web app to automate building patient
evaluations. She has been using paper forms with checkboxes for decades and
they started requiring the info in digital format over the last few years. She
had been copy and pasting from the digital version of the blank form into MS
Word. It was time consuming, but still faster than typing it by hand. To be
clear, a paragraph containing sentences is the format medical professionals
are required to present this information in. Automating the boilerplate stuff
actually gives my mom more time to type in the information that the paper
forms don't anticipate and provide actual care to patients. The problem is not
automation. The problem is unscrupulous executives who maximization profits at
the expense of quality of service. The examples provided in this article are
unethical and anyone who is caught dumping irrelevant data into important
medical records should be held responsible.

------
yumraj
My kids' pediatrician was part of a small office, which merged with a larger
office that is affiliated with a large hospital and hence uses EPIC. She used
to take hand notes on paper and was quiet efficient when she was with the
smaller office. After the move I have seen her struggle with EPIC, and then
recently hire a medical transcription service and be followed by a person
taking notes so that she can focus on the medical stuff. And, of course I have
no idea if the quality of her notes has suffered.

~~~
organsnyder
Believe it or not, Epic is one of the more provider-friendly solutions out
there, according to many providers I've talked with (I work in the healthcare
software industry).

~~~
JshWright
Epic _can_ be not as awful as some (it's still a far sight from "friendly" in
my opinion). The problem is that it's highly customized in each installation,
and the vast, vast majority of them "customize" it in very provider-unfriendly
ways (tons of irrelevant required fields for billing, etc).

Even in the best case scenario though, it's a lot of clicking around to find
clinical information that may be relevant to a patient (which means it can
often go unnoticed).

------
telchar
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 but there
is a lot of noise. Still, some things require us to look at the notes. For
these things we would much rather have them than not.

While it's preferred to have the information entered in a structured way,
doctors find that more of a hassle than entering in the data free-text and
it's also no good for retrospective analysis where we didn't know several
years ago we would be interested in something and so no structured field
existed.

~~~
abrichr
Interesting insight! Where do you work?

~~~
telchar
I work for a hospital/health system.

------
tdeck
Here's a fun thing about our system in the US. If you're taken to the
emergency room, they'll ask your medical history. And not just once - they'll
ask it in the ambulance, radio it ahead to the hospital, then make you wait
while they ask you the same questions again and enter them into their system
_at_ the hospitsl. Then the next 3 doctors or nurses who come into your room
do the same thing, asking you questions you've already answered. Doesn't seem
to matter if it's obvious that speaking is painful for some reason (in a case
I'm describing a family member had broken ribs).

~~~
arkades
We do this for a reason. Not only do different people ask specific questions
that try to elicit different things, but patients stories evolve with each
repetition. People don’t realize how much, but by the third time you’re
getting that history, the picture is usually quite different from what the
first history depicted.

And since history is 90% of diagnosis, this isn’t some little quirk. It plays
a huge role in helping patients. Huge.

~~~
cperciva
As a patient, I've been guilty of doing this deliberately. At ER triage, my
priority is "get into a bed". Once I've been admitted, my priority is "get
well". (And once I'm feeling better, my priority is "get out of here"...)

As a type 1 diabetic, if I have high blood glucose and nausea, I'm going to
say the letters "DKA" to the triage nurse. I'll never bring it up again --
because the first blood chemistry test answers that question one way or the
other.

------
Thriptic
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 for note taking. For example, diagnosis X based on
Y Z. Other probabilistic diagnosis A ruled out because not B not C yes D.
Reduce free form notes to be as sparse as possible. Also there should be a
reference system to point back to other notes / lab values / imaging which
when clicked will bring up that data. Finally, a timeline which charts
pertinent diagnoses, lab values, and changes over encounters. I'm not sure how
viable it would be given the complexity of notes that my physician colleagues
have showed me / what I've seen in research, but I'm curious.

~~~
sxg
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 acuity (there are 5 levels, with
level 5 being ICU-like care). I looked into how the billing level is
determined, and I found this article explaining how components of the notes
are tied to billing levels [1]. Basically, by including 6 elements to the
physical exam rather than 5, you can bill at a higher tier. There are several
other areas that are tied to billing like this, including the family history,
social history, etc. My PCP had completely filled out her standardized note to
include every little detail I had mentioned—many of which were totally
irrelevant to my current issue.

I talked to some other physicians about this, and I learned that hospital
departments use their standardized notes to include as much detail (i.e.
bloat) as possible so that physicians can bill at higher tiers since billing
is tied to the number of details included in the note.

[1]
[https://www.aafp.org/fpm/2003/0100/p29.html#fpm20030100p29-b...](https://www.aafp.org/fpm/2003/0100/p29.html#fpm20030100p29-bt4)

~~~
Scoundreller
Why did a visit to your PCP get billed as a hospital visit?

And which acuity scale was this? Usually the higher the number, the less acute
you are.

~~~
sxg
I meant outpatient visit. My PCP is in the main campus of the hospital, and I
wasn’t being rigorous with the terminology.

I’m using the CPT codes within the site I linked to. 99211–99215 are the codes
that correlate to acuity, with 99215 being the most acute. I am aware of other
systems like level 1 vs level 2 trauma centers. In that case, yes the level 1
is higher acuity. Maybe that’s what you were thinking of?

~~~
Scoundreller
Got it. I perused the link but didn’t see any 1s,2s,3s,etc. I was just worried
that the US started implementing a triage scale opposite from the rest of the
world.

I’m more familiar with the (pre-)hospital triage scales in non-US countries:
[https://en.m.wikipedia.org/wiki/Triage#Canada](https://en.m.wikipedia.org/wiki/Triage#Canada)

------
cabaalis
I deal with various EHRs every day of my life, and 4-digits-worth of
providers. The primary barrier is that practice managers are working to get
data standardized, but get pushback from the providers who are busy doing
their jobs being doctors and not data scientists.

Some EHRs can streamline via templates and workflow. Others don't. I've
literally had practice admins not implement new practices that would document
properly and facilitate easy reporting because they would not be able to sell
the change to the providers.

I'm not blaming providers for the data issues. They have a job to do and they
do it. It just doesn't always get documented in a reportable manner. There
needs to be an easier way to document, or some kind of Middleware that
documents for them.

I see people a whole lot smarter than me trying to use ai to interpret notes.
I personally think they are just facilitating the ongoing poor documentation
problem. And things will slip through the natural language cracks, and it
could be a potential health hazard.

~~~
egillie
Agreed that 95% correct (or even 99%) AI probably isn’t the solution here, I’m
surprised to see so many startups doing AI/NLP for doctors’ notes

------
DanielBMarkham
My Primary Care Physician is unable to speak coherent sentences.

I'm half-joking, of course. The guy is top-rated, elected head of the state
association. He's widely-regarded as a combination of both brilliant with
diagnostics and good with people. He just can't complete a sentence when we
meet.

Why? Because he's got some pad he carries around that takes up all of his
attention span. He comes into the room, sits down -- and there's this struggle
for his attention that I watch play out. It usually involves a lot of verbal
grunts.

"So we've got this .... er.. .. and it looks .. hmmmm. .... So this is...."

This could go on for a bit. Eventually we get to either a statement or a
question.

Frankly I'd think the guy was having some sort of mental issues if it weren't
for the facts that 1) he used to be fine before they all started carrying
around pads, and 2) he's fine outside the clinic.

I really hope that the tech community has helped make healthcare better. It's
certainly had an impact.

~~~
mikekchar
Maybe not relevant for you, but one thing that has helped me with my doctor is
that the first thing I do when I go in is sum up what happened in our previous
couple of visits. My doctor doesn't have enough time to prep for my visit. I
mean, he should, but he doesn't (been there, done that). So I give him the
executive summary to speed things up. I visit my doctor a lot, so he now
trusts me to give him accurate and useful information.

------
samsolomon
I've done a good bit of thinking about medical note taking.

To me it's a little odd that hospitals are the ones who keep this information.
I'd think that the records should belong to patients—it's about them after
all. And that the patients would provide access to doctors or hospitals.

Right now I've got a personal medical journal that has things like:

* Sickness - Date Range and Notes

* Flu Shots - Date

* Injuries - Date and Notes

* Observations - Date and Notes

* Blood tests - Date and Photos of Tests

Before my yearly checkup (or if I have to visit a clinic) I review the last
entries and open them on my phone incase my doctor wants to see any of them.

It works well enough for me, but seems like there could be a ton of
opportunity for improvement. I'd love to have a system where my doctor could
be notified and comment on new notes or events. Also the ability to bring in
my scale, run tracker and other fitness data.

~~~
mikecsh
The problem with this is that a very small minority of patients are that
diligent or reliable, for various reasons (dementia, forgetfulness,
disinterest, mental illness, low IQ, substance abuse, not realising the
information is required, brought in by ambulance unconscious and peri-arrest,
etc.).

Here in the UK patients do have responsibility for some records - notably
anticoagulation records and maternity / child health records.

I have seen literally one patient present with their anticoagulation record. I
have lost count of the number of patients who come to appointments without
their maternity notes or child health notes.

Even trying to get an accurate medication history from a patient is near
impossible and we end up having to look at past hospital discharge letters,
call their GP, or look on shared record systems to try and piece together what
they are taking.

I'm all for patients "owning" their records but they must be held in a way
that is accessible when needed regardless of human variabilities.

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

~~~
notabee
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.

~~~
JshWright
It's not as uncommon as you think. I'm both a paramedic and a developer for an
EHR, and we have a number of other medical professionals (including a
physician) in various product related roles.

~~~
notabee
I know that EHR companies surely employ both engineers and medical
professionals, but are they able to freely innovate and explore, or are they
bound to top-down bureaucracy with, as another responder mentioned, misaligned
incentives? The kind of thing that I imagine would be a fully open source,
open standards implementation that could allow easy portability of records
between all providers.

------
ivraatiems
I strongly agree that EMRs are making this problem worse, not better. And
doctors seem to hate quite ubiquitously the extra amount of documentation they
have to do. While there is a lot of evidence in some areas that EMRs have
improved quality of care and patients' lives, I don't think this is one of
them.

~~~
classichasclass
I was working for a large multi-state HMO during their transition to a major
EHR (I'll let you guess, since I do not speak for either). I have a background
in IT and was a systems consultant for a number of years.

On paper, I could get a relatively uncomplicated chest pain case from the ER
to the hospital unit with all the orders for workup ready in 45 minutes.

With the EHR, we had abominations like double medication reconciliation and
poorly customized order sets that ballooned my average admit time to almost
two hours. And I was among the _fastest._ (I should note I am told these
issues have improved, but it took years.)

Given that there was so much other stuff to do now and that ordering had
become a nightmare of lookups and checkboxes, physicians under time pressure
are going to economize where they can. Where they do is in the documentation,
which is not generally reviewed and won't by itself prevent the patient from
getting where they're going.

Now move this to an outpatient office where patient loads have not lightened
and it becomes magnified.

It's a point of pride that I don't copy-paste my notes, but I have the luxury
of being mostly administrative these days and most of my patient contacts are
in a hyperspecialized clinic where I can do things like prewrite most of the
note even before I go in a room. But it's killing primary care and it's
probably making things worse at the very point where it needs to be made
better.

~~~
Scoundreller
What is a “double” medrec?

And what initial electronic order sets were implemented? Did the organization
not just implement (as best as possible) the previously on-paper order sets?

It’s not a perfect approach (you can do things with an online form that you
can’t do on paper and vice-versa), but it seems like a good approach to avoid
(more) mass confusion on Day1.

~~~
brokenmachine
_> What is a “double” medrec?_

I think that's when you need a second doctor to approve orders for another.

------
bill_from_tampa
I worked at the VA for over 2 decades, including the transition from
handwritten to electronic notes. Wow. When I retired, the nursing notes for a
patient visit were usually 2-3X longer than the docs note. The nursing note
was entirely populated by templated text created by a hierarchy of supervisory
staff tasked with satisfying all regulatory requirements. The poor nurses
would ask the patient a series of prompted questions, click on the appropriate
box, and a page of templated text would emerge. Actually finding useful
actionable info in the nursing notes was impossible, or close to impossible.
The docs began to demand, reasonably, that actual patient problems identified
by the nurse be put in a specific area of the note rather than randomly
scattered throughout 4-8 pages of templated text (which without this demand
could be randomly intercalated with such useful info as "pt c/o chest pain
when walking, much worse", found on page 5 of 8.

The docs notes were, in many ways, even worse. The notes required manual
typing, and many docs are not trained skilled touch typists. So the two-
fingered part of the note was often very brief and succinct. The templated
portions were huge - impressive reviews of systems where you could not really
tell if the specific items had actually really been asked or if the template
just vomited forth a page full of text for administrative review.

Make a doctor function as a data entry clerk and this is what happens.

------
User23
The old school method of sticking the charts to the foot of the patient’s bed
has the same pleasant properties that using sticky notes on a board for tasks
does.

Anyone that’s struggled with JIRA and just said forget this due to tool
impedance will have a good idea of how painful this is. In hospitals I almost
never see charts pulled up except on daily rounds. Sure nurses are great and
smart people and usually remember everything, but they also work hard long
hours and the cost of mistakes can be very high.

------
Scoundreller
My favourite citation from the link:

“In fact, across this same EHR, clinical notes in the United States are nearly
4 times longer on average than those in other countries”

It seems that the EHR isn’t the root cause of the problem.

~~~
jcowdy
I was one of the people that gathered and analyzed the data that the cited
study used and can't agree with your conclusion more. Sure, the EHR makes
"note bloat" easier than paper but the difference in length across different
countries (using the same software) shows that note length is more a result of
the environment than the tool.

I think there is also a general misunderstanding of "the note" in an EHR
context. The progress note is really just one aspect of a provider's
documentation of a visit. Things like medications and allergies are generally
indicated as "reviewed" elsewhere in the chart and yet all of this information
is many times also entered into the progress note unnecessarily adding to note
bloat. In the days of the paper chart the progress note ended up being the
only summary of the visit and even though it's now just one piece of the visit
documentation, it's still written as though it will be the only source of
truth.

~~~
Scoundreller
It’s a sad situation.

Unhappy users are much louder than happy or neutral users.

As a result, when a non-US health provider wants to do some informal research
on implementing EHRs, they mostly read a lot of angry complaints.

------
xte
Problem of medical notes have a name: bureaucracy. The hope is leaving it
apart, and today it seems a bit utopia...

Also in terms of "numeric/digital" vs "paper" the point is ignorance: how many
people outside IT world (and _even inside_ ) do actually know enough a desktop
to take _their own personal notes_ in an ordered, usable and useful thing?

IMVHO a so small percentage that we can probably know them all by name. Just
take a look at a "common" mailbox: most of them are an utter pile of data, few
with some incoherent taxonomies, few even with the sole inbox as an archival
place. Than take a look a common "home directories": the very same mess. And
if this is for _personal_ and _generic_ data do you think that those people
are able to properly not only manage but share helpful information with
digital systems?!

------
bobowzki
The medical journal is one of, if not the most, important inventions of modern
medicine. I'm an MD and work with them every day.

But yes, the current infrastructure is not good.

------
VikingCoder
1\. Money

2\. Legal liability (CYA)

3\. We don't use outcome-based medicine

~~~
skwb
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 the entire system (albeit slowly) towards
more outcome based measures, primarily through Medicare. Major payers are
following in their steps. Not happening overnight, but any major healthcare
executive sees the writing on the wall and is taking these considerations into
account for their investments.

[0].
[https://www.healthaffairs.org/do/10.1377/hblog20180810.48196...](https://www.healthaffairs.org/do/10.1377/hblog20180810.481968/full/)
[1].
[https://www.healthaffairs.org/do/10.1377/hblog20180810.48196...](https://www.healthaffairs.org/do/10.1377/hblog20180810.481968/full/)

~~~
VikingCoder
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.

~~~
skwb
Yes, it is. You appear to be conflating my point of how healthcare is changing
with regard to payment structures with clinical guidelines which tend to have
potentially more subtleties.

There are some areas of healthcare where it is very cut and dry what defines
good healthcare management. These are where we've developed good reporting
outcomes that tie closely to clinical and resource utilization outcomes from
the published literature. Think of your high volume routines cases such as
diabetes (monitoring of A1C)[0] and knee replacements [1] that make of a large
portion of health care cases. These are certainly not covering all healthcare
episodes, but represent areas where significant fat can be trimmed.

With regard to your above clinical case, there are specific approaches for
(what I assume is an incidental finding from a coronary CTA) reporting lung
nodules and requesting follow up studies [2]. However, this represents an area
where there is significant good faith professional disagreement of reporting.

I will agree that high-evidence clinical guidelines are not always followed,
and payment reform has not been influenced all medical professions equally.
The way healthcare is delivered is changing, and is being highly influenced by
national policy level decisions.

[0]:
[https://www.healthaffairs.org/do/10.1377/hpb20121011.90233/f...](https://www.healthaffairs.org/do/10.1377/hpb20121011.90233/full/)
[1]: [http://files.kff.org/attachment/Evidence-Link-FAQs-
Bundled-P...](http://files.kff.org/attachment/Evidence-Link-FAQs-Bundled-
Payments) [2]:
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5903561/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5903561/)

~~~
VikingCoder
The medical field doesn't have the discipline to ignore signals that it knows
are meaningless. That's what I'm driving at.

Also, healthcare absolutely sucks at pain management, specifically in being
disciplined enough to say no to opioids.

------
brownkonas
I refuse to believe (beyond a bad email notification , which is not acceptable
for medical information) that being elaborate or non-concise is a problem. Why
is 4x more medical density a bragging point , in other words?

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nathan_long
One "solution" is sometimes to use speech-to-text. The mangled results would
be hilarious if they weren't frightening.

~~~
egillie
I know some places have scribes (often students), and I wonder why they aren’t
more common given how valuable doctors’ time must be

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NoblePublius
I read number 1 —- “money” — as “doctors lie about what they are doing to get
paid more by your insurance company”. Is that unfair?

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leovander
_Spec. Off 's_ [1]

    
    
      - Doctor enters your visit (encounter), cross your fingers that his system has the most up-to-date medical codes (e.g. snomed, cpt, icd, etc)  
      - Doctors notes for that encounter are potentially entered as a text area in one system (u/petermcneeley). Can be notes at the encounter level or for a specific diagnosis/lab result/etc.
      - The codes vs free text, is what we refer to as discreet and narrative/free text.
      - The current IHE spec. [2] (last updated in 2015?), allows for codes to be interpreted from narrative text if a valid code is not provided. I think there are a few startups that have popped up here that are trying to make sense of the narrative text.
      - That same spec would be great if everyone followed it but they have to get their system to bend a little bit or throw an integration engine in front of the problem to play nicely with others. (u/nradov)
      - Start sending those back and forth and you either end up losing those notes or butchering them up.
    
    
      - There are some orgs (e.g. DoD, VA, Sequoia, etc) that have everyone follow the basic requirements but then add their own flavor on top. [3]
      - FHIR [4] is here, but I think everyone is already scrambling or haven't had the need to make the cut over to it until its government mandated. I have to say this has been the easiest spec. to grok, but it is still way too flexible for these companies to mess up. A cut over to FHIR for everyone should ideally be that you have to use the Hapi FHIR models [5]. Maybe have a way for Hapi to sign the models on their way out?
    
    

Sorry, this turned out to be more of a rant, but I stare at this stuff
everyday. There are a few other folks on the thread that know the industry as
well that have some good info too.

[1]
[https://media1.tenor.com/images/af0c71048d5a130cefc335423c59...](https://media1.tenor.com/images/af0c71048d5a130cefc335423c597ce8/tenor.gif)

[2]
[http://www.hl7.org/implement/standards/product_brief.cfm?pro...](http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258)

[3] [https://xkcd.com/927/](https://xkcd.com/927/)

[4] [https://www.hl7.org/fhir/](https://www.hl7.org/fhir/)

[5] [http://hapifhir.io/](http://hapifhir.io/)

