
The Doctor vs. Char Limits - robg
http://well.blogs.nytimes.com/2010/12/30/the-doctor-vs-the-computer/?hp
======
kevingadd
“Well, we can’t have the doctors rambling on forever,” the tech replies.

Is medicine like this elsewhere now, too? The idea of having the quality of my
medical care determined by grade-A morons in an IT department terrifies me
even more than having the quality of my medical care determined by bureaucrats
at the HMO main office.

Knowing which specific insurers/hmos/etc have restrictions like this on
medical documentation would also be great when choosing where to get your
coverage, but I bet regulations like HIPAA would prevent people from naming
names.

~~~
Semiapies
A guy at a help desk says something inane like that to dodge being recorded
("for quality assurance") as bad-mouthing the product. He didn't code that app
or set that field size.

Setting a field size that stupidly small could have a lot of causes, from a
lazy coder who figures 1000 characters is enough to an actual directive from
an executive saying that they don't want long assessments. (I've had higher-
ups in a client's company tell me to do just that, in other contexts.)

In any case, it remains fucking terrible.

~~~
burgerbrain
A more acceptable response would be _"Thank you for your feedback, I'll pass
it on."_

In fact _"we did that on purpose"_ is possibly one of the worst things he
could say. What authority does he have for making that assertion, was he on
the design team? He's putting (rather rude) words into the mouths of the
people who built the system.

~~~
Semiapies
Agreed on the more acceptable response, but the corporate culture of the
company may _not_ make that the worst thing he could say in terms of staying
employed.

He clearly wasn't coached to say "I'll pass it on" and was floundering to
respond to a person who was upset over what the help desk guy could easily
recognize was a real flaw in the software, while obviously not feeling
_remotely_ secure in saying anything that might even suggest that this _was_ a
flaw.

~~~
flatline
Agreed, there is probably _no_ feedback system whatsoever, and the IT guy is
almost certainly more powerless than the doctor. Which points to the real
problem - it's usually the administrative staff that signs off on the software
requirements with feedback only coming from other administrators. At least,
that was the predominant trend for electronic medical records during the 90s
and the earlier part of the past decade.

------
niels_olson
I'm a doctor, this sort of thing happens all too often. In my case, yesterday,
a module of AHLTA crashed in the middle of my note and I had to restart to
continue. The mouse functions in AHLTA don't support cut and paste, but
luckily no one coded out ctrl-c and ctrl-v, so I was able to save a copy of my
new patient's three separate complaints under ctrl-v while the system
reloaded. Our system is designed with the idea of writing the note with the
patient in the room (we don't even have a separate office, just the exam room
and a corpsman). Fortunately my patient was herself in IT (one complaint was
... low back pain) and she was very understanding. But I'm also faced with the
problem that I either choose to look at the patient or the computer. The
computer is not at a convenient angle for this.

So I'm forced to either spend less time with patients and write the note
afterwards, physically not look at them, see fewer patients, or write my notes
in the evening after the patients have started to fade and blur together.

I actually brought in my iPad yesterday, but didn't even get through the door
before I realized there would be no HIPPA-compliant way to move the
information from my iPad to AHLTA, especially since I don't have ready access
to encryption tools. I thought about issh, but it only adds a third computer
to the security perimeter.

Anyone interested in developing a web-based medical records system with a
doctor who can at least work through code, I would love to talk with you.

~~~
lukev
Sounds like an interesting problem... I sent you an email.

EDIT: Could you email me? The only email address in your profile bounced...

~~~
niels_olson
that's my email, it works. I don't see anything from lukev and your email is
unlisted.

Since I can't edit my original post any more, let me also add that I did a
summer internship with Edward Tufte and have done analytic design consulting
work and helped build and design one web app (tmedweb.tulane.edu).

Hope you can get back to me.

~~~
lukev
Ach, sorry, didn't realize mine was unlisted. Ok, I tried using the
HackerNewsers contact link, we'll see if that gets through.

------
Semiapies
Not just absurd text-entry limits, but UI designs affecting data-use habits.

 _"Nobody, for example, leafs through a chart anymore, strolling back in time
to see what has happened to the patient over many years. In the computer, all
visits look the same from the outside, so it is impossible to tell which were
thorough visits with extensive evaluation and which were only brief visits for
medication refills. In practice, most doctors end up opening only the last two
or three visits; everything before that is effectively consigned to the
electronic dust heap."_

That's a fucking terrible design.

~~~
DanI-S
So is this:

 _The system encourages fragmented documentation, with different aspects of a
patient’s condition secreted in unconnected fields_

I'm pretty sure that problem was solved in the 60s, with the concept of
hypertext. Decades of progress resulting in the Internet have somehow escaped
these guys.

------
mistermann
This is depressing in so many ways...just a few:

The software he is using is obviously extremely poorly designed:

"It turns out that in our electronic medical record system there is a
1,000-character maximum in the assessment field."

\- Unreal. No further comment necessary.

"In practice, most doctors end up opening only the last two or three visits;
everything before that is effectively consigned to the electronic dust heap."

\- Opening individual windows for each visit is ridiculous, this should be
viewed through a historic report at least (as well as a thousand other subtle
smart features).

"As I type away, I feel like I’m doing the right thing, explicating my
clinical reasoning rather than just plugging numbers into a formula."

\- Why is a doctor be typing this stuff in? This should be spoken and recorded
permanently, and transcribed by a qualified person into text.

And, maybe it's just me....I don't expect doctors to be experts in software
design, but I would like to think doctors would be of average to above average
intelligence...these shortcomings should be obvious to him as poor design _as
a reasonably intelligent person who has interacted with many forms of software
in his day to day life_ and recognized as such - but from the article, he
seems to think these are natural tradeoffs that must be made when switching to
an electronic format.

~~~
brendano
Medical electronic record systems are almost always poorly designed like this
one. That's why doctors perceive such deficiencies as "natural."

~~~
mistermann
I would hope that my doctor uses mainstream technology (internet, iPad) and
could differentiate between what is "common" and what is possible.

If one isn't able to do that, I would seriously question their ability to
properly diagnose complex ailments.

~~~
sethg
“Enterprise” software, as a rule, has horrible user interfaces. The people who
buy this kind of stuff are three layers of management removed from the people
who actually use it, the software is often customized, and quality of user
experience is not a critical factor in the purchasing decision.

From the perspective of a non-geek who works in a medium-to-large company, bad
“enterprise” software is just an irritation that goes with the job, like bad
coffee. You may complain about it but you don’t seriously expect it to be
fixed.

~~~
dkarl
If you pick up a book on best practices in development of enterprise software,
it is basically a catalog of obviously beneficial things that people fantasize
about in the pages of a book because they are never allowed to do them in real
life.

For instance, talking to prospective users. The importance of this has been
stressed over and over again and is no longer disputed. In fact, when an in-
house team started designing changes to an accounting app my friend had to
use, there was an official user expert designated to work with the developers.
The user "expert" was her manager, who had never used the application that was
being changed, had never used a similar application, and had never even done a
job similar to the one done by the users. What's more, she forbade the
developers to speak to the users because she didn't want the development
effort to affect their productivity. Oh, it did affect their productivity
eventually, believe me it did.

(It's an exaggeration to say it's uniformly terrible; I had a good experience
with the one enterprise app I built, but it was for a network operations team,
so they understood a lot about software and about the need to be generous with
time and access.)

------
bena
Healthcare Informatics is a ghetto (to paraphrase Zed Shaw). No one who cares
enough about healthcare cares enough to learn how to develop decent
applications and no one who knows how to develop decent applications cares
enough about healthcare.

So what you get is a bunch of people who would rather be doing something else
but for some reason cannot. Strictly middle to low tier developers. Anyone who
is decent gets out of the industry quick due to the huge amount of inertia the
established companies have.

Someone mentioned HL7 CDA being an XML format. It is now. HL7v3 was published
in 2005. HL7v2 was standard before that and if you have to deal with equipment
or software made before 2006-2007, you will need to dive into the fun that is
HL7v2.

~~~
nradov
Just to be clear, it was the CDA R2 portion of the HL7 V3 standard that was
published in 2005. Other parts of HL7 V3 were published earlier, and some
parts are still not done yet. There is no HL7 V2 version of CDA.

Even older versions of HL7 V2, such as V2.3 published in 1997, specified a
minimum supported length for individual observations of 64K (OBX-5 field). So
we can't blame HL7 for this particular problem. Of course many vendors have
defective HL7 interfaces.

I can't speak for other vendors, but at my company we have been able to
attract top tier developers (and are hiring more).

------
davidw
He's not "The Doctor" - he's "a doctor". The Doctor would have fixed the
computer with his sonic screwdriver.

------
naner
So the software is shit, like most special purpose business software. The
tech's response isn't what justified the software limitations, it is the other
way around. Nobody really wants to design or build this stuff so this is what
they end up with. I've seen it hundreds of times. (I used to do consulting for
small businesses and interned with an engineering contractor before that.)

~~~
Semiapies
We clearly need a way to make medical data systems sexy enough that talented,
skilled folks build startups to try to horn in on the market.

No, I'm not being flippant or joking.

It would be a fantastic thing if even a handful of people see this story, go,
"I could _shit_ out better software then that!", look into HIPAA and other
complications, consider a moment, then say, "I could _still_ shit out better
software than this," and get to work challenging the status quo.

------
drinian
_1,000 characters?_ What, are they paying for storage by the byte? Was this
system designed in 1960? For that matter, were any doctors involved in the
design of the system?

How on earth do they store medical imaging, compress it down to 128x128 GIFs?

~~~
akavlie
Medical imaging is probably in systems and hard copies completely disconnected
from (and inaccessible by) the database.

~~~
drinian
You're probably right, although that's another problem. I've heard (this is
not my area) that most of the big, expensive machines all use their own
proprietary image formats.

Although I once had some emergency dental work done in New Zealand, and they
were able to give me a laser-printed copy of their digital X-ray along with a
printout of my EMR as I was walking out the door.

~~~
rdl
Actually, I unfortunately know a fair bit about medical imaging (since I
supported radiology systems for a couple years).

There's a ~1980s protocol called DICOM which is largely used to transport
images around. It is quite complex for what it actually, has lots of vendor
and device inconsistencies, and because medical imaging devices are expensive
and have a long duty cycle, you can have a 10-20 year spread of equipment on
your network.

Some of the actual imaging technologies (MRI, CT, US) are inherently low
resolution per image in a study (due to the limits of physics), but a study
can be composed of a bunch of images, and it can end up 5-10GB. The high-
resolution individual images tend to be x-ray, especially digital mammography.

------
pyre
The thing that isn't clear to me: Is this some sort of medical profession
electronic document 'standard?' Or is this doctor just running up against the
limitations of a single vendor's solution to an issue that has no standards?

~~~
nradov
The medical profession has an electronic document standard in HL7 Clinical
Document Architecture, Release 2.
[http://www.hl7.org/v3ballot2009may/html/infrastructure/cda/c...](http://www.hl7.org/v3ballot2009may/html/infrastructure/cda/cda.htm)
It's an XML format so there is no character limit on narrative sections.
Apparently that one vendor just decided to impose an arbitrary limit for no
good reason.

~~~
joe_the_user
Could it be for backward compatibility with something else?

A lot of medical data processing is spread through a huge series of SQL and
mainframe databases with lots of hacks to keep them roughly compatible.

A friend worked medical database where "sex" was a seven field containing
values from {"F", "M", "Male", "woman"...} etc.

This is horrific but it's possible to imagine that it arose as a compromised
between various equally terrible options...

~~~
icefox
Reminds me of a health insurance form I filled out where it asked you for your
gender, but never your sex.

~~~
joshzayin
For the curious: <http://www.who.int/gender/whatisgender/en/index.html>

Essentially, sex is biological while gender is social. Transsexuality is a
disparity between what someone was born biologically as (sex) and what they
identify as (gender).

See also: <http://www.docstyles.com/apacrib.htm#AppA>

------
ZachPruckowski
This article sounds like it's trying to say that electronic medical records
are a bad idea, but all I'm hearing is "our vendor's software sucks ass". I
mean, none of these limits are that tough to fix. If there's a need to tell
which visits on a list are long ones and which are short, we could color-code
based on duration or just display the duration of each visit in the list, for
instance.

~~~
Semiapies
This is what happens when users get conditioned by really bad software in a
specialist market.

------
tgflynn
Are there any speech to text systems for medical records ?

It seems like speech recognition technology has reached a pretty high quality
level. Of course there would be some transcription errors. What if the system
had an editor window that required the physician to verify and sign off on the
transcription ?

Wouldn't speech be a better primary interface for this application ?

~~~
nradov
My company includes back-end speech recognition in our transcription workflow.
[http://www.axolotl.com/news/57-axolotl-adds-speech-
understan...](http://www.axolotl.com/news/57-axolotl-adds-speech-
understanding-to-its-elysium-product-range.html) Human editors review and
correct the draft report, and then it goes to the physician for a final review
before becoming part of the patient record

Some physicians also prefer to enter text directly into our web application
with third-party front-end speech recognition products such as Dragon.
<http://www.nuance.com/for-healthcare/index.htm>

~~~
tgflynn
It sounds like your system should be light years beyond the problems that are
being discussed in the article and in this thread.

------
LargeWu
This serves as a great reminder that great software is about a lot more than
great code.

For the most part, this sounds like a large but basic CRUD app, which is
basically a solved problem from a technical point of view. Most of the key
decisions in the software development process are not necessarily made by
programmers.

------
ok-computer
I'm not sure this is _why_ there is a limit of 1000 characters, but one
possible reason would be to limit the amount of unstructured data put into the
assessment field. This can be a way to force people to use structured data
fields and more generally to avoid excessive verbosity.

(TLDR probably applies to doctors too.)

------
miniatureape
These services will be in place for years and more and more institutions will
depend on them. The computer systems we design for health care will shape
health care service.

Add Joseph Weizenbaum's Computer Power and Human Reason to the list of books
that the developers of these systems should be required to read.

------
Lanark
A ton of usability research in this area has been done by The Microsoft Health
Common User Interface <http://www.mscui.net>

It's a pity (and rather ironic being Microsoft) that none of the major
healthcare IT suppliers seem to want to follow a common standard.

~~~
willholley
As a vendor in the UK, we have been integrating the CUI for the last few
years. The quality of the guidance is mixed - there is good evidence that
having a "Patient Banner" in a consistent format prevents "right thing, wrong
patient" problems. However, a lot of the evidence supporting the other
guidance is sketchy. They also lean heavily on MS implementations of the
guidance which I would think most vendors will avoid because it does not
likely fit into their technology stack (Silverlight / WPF).

However, the real problem is that the market does not value good usability. We
are lucky if a potential customer has even heard of the Common User Interface,
let alone specifying it as a requirement on a tender.

The "ghetto" effect described by another poster is largely down to the "market
for lemons" around healthcare IT, in the UK at least (many different vendors
promising a silver bullet to hospitals with no experience in procuring such
things - they just pick the cheapest / "least risky").

------
dowskitest
I think this is a good reminder to thoughtfully consider how we handle edge
cases.

I know that I often treat edge cases with the least care. This is certainly a
situation where the opposite required.

~~~
Semiapies
Why do you see this as an edge case?

~~~
niels_olson
doctor, here. This is definitely not an edge case.

------
jrockway
Yeah, but if we used TEXT instead of VARCHAR we might need two disk reads to
look up the data instead of one! Fuck human life, think of that poor hard
drive!

------
pragmatic
Start your own practice and get your own software?

How viable is that (genuinely curious)? How easy is it for a doctor to start a
private practice?

~~~
Devilboy
If you use your own system you're cut off from the rest of the medical
universe. These systems are integrated with the pathology guys next door, the
pharmacist down the road, the medical imaging center and so on. Everyone
benefits from this so if you decide to use your own homebrew system you'll
make life more difficult for everyone else around you.

