

Electronic Medical Records, Built For Efficiency, Often Backfire - jeeshan
http://www.npr.org/blogs/health/2014/11/07/361148976/electronic-medical-records-built-for-efficiency-often-backfire?utm_source=facebook.com&utm_medium=social&utm_campaign=npr&utm_term=nprnews&utm_content=202507

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killdevil
I'm a resident physician. EMRs are simultaneously awesome and awful. Awesome
because most of the data and past records on a patient are a click away, just
as promised.

Awful because they're invariably run by underpowered servers and delivered via
laggy-as-hell Citrix windowing to crappy end-clients with smallish monitors.

Awful because they are all proprietary silos, and good luck migrating your
hospital system off one and onto another. The idea of a portable electronic
health record is largely a fiction at this point.

Awful because so much of the documentation you have to write has nothing to do
with patient care, and more to do with defensive medico-legal CYA, and
everything to do with the hospital getting reimbursed at the level it wishes
to for each patient seen.

Awful because the software is legacy enterprisey garbage with a codebase
written in MUMPS (look it up!) or some other esoteric language in the 1980s
and carried forward with ongoing encrustation and decay since then. Awful
because the UI actively gets in the way of our patient care workflow, and not
the other way around. Need to look at lab data while writing progress notes on
a patient? Too bad, you can't open both at once! Need to look at lab data or
inpatient notes while discharging a patient from the hospital? Too bad, there
are two layers of modal dialog boxes related to the discharge blocking access
to anything else while you're discharging.

I've used the two market-leading big-enterprise EMRs in the US, Epic and
Cerner, and they're both like this.

I used to write software for a living. The crappiness of even the most
expensive EMRs (the ones that will set a big hospital system back a couple
hundred million for an initial install, like Epic) completely floors me.

~~~
clay_to_n
Do you have an opinion on or know much about newer / more user-friendly EMR's?
I'm specifically thinking of PracticeFusion, but I imagine there are others.

Why doesn't stuff like this take-off? Is it the product of slow-moving
hospital bureaucracy, or are there other reasons?

~~~
daigoba66
The CFO of large healthcare organizations is historically who decides what
software is purchased and used. Why the CFO? Because most enterprise
healthcare software is built to support the billing/accounts receivable
department.

It's very difficult to find an EMR that focuses on patient care and
communication. The cynical side of me thinks that there isn't an incentive to
build this kind of software. Doctor's aren't paid to make you healthier;
they're paid to submit to insurance companies the correct diagnosis and
procedure codes.

~~~
killdevil
Well, there isn't an incentive because typically it isn't physicians (or, at
best, it is physicians who are primarily administrators and somewhat out of
touch with clinical practice) who are making the purchase decisions.

I can tell you that most clinicians would be jumping for joy if software that
was more physician- and patient-oriented became the norm.

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dworin
Electronic Medical Record systems, and their non-healthcare counterparts in
Enterprise Resource Planning systems, never delivered the cost savings and
efficiency they promised because, at the end of the day, they're designed to
streamline the billing/finance department, not the rest of the organization.
The user interfaces are universally awful because they're designed to 'get
finance/billing the information they need' rather than 'streamline the process
for practitioners,' and at the end of the day the people buying the system
aren't the ones who have to use it.

Someone once joked to me that an EMR installation was where you replaced all
the people in your billing department with the same number of people, at a
higher salary, in your IT department.

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indymike
I had a client that made an EMR that was built on the concept of disease
management. The basic idea was that by giving the doctor the right data and
questions to ask, the doctor would help the patient manage their chronic
condition and help them not need to come to the office so often. Doctors loved
it. Patients loved it. Management didn't buy it because it lowered per patient
revenue.

~~~
yuhong
_Management didn 't buy it because it lowered per patient revenue._

Another flaw of insurance covering normal doctor visits.

~~~
FireBeyond
My insurer denied helicopter EMS for a patient due to lack of prior approval.
Hmm, "On scene of an MVA, patient needs trauma center, call insurer".

Imagine this in auto insurance. "Sorry, your car accident coverage was denied
because you didn't get prior approval."

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phren0logy
Speaking as a physician, I can tell you that EMRs range from "mostly not
awful" to "warcrime."

~~~
sfall
did you ever do paper records or have you always done electronic records?

~~~
phren0logy
I have done all paper, all EMR, and a combination of the two. The combination
is the worst. So far paper alone is the winner for most situations, although
even crappy EMRs have advantages over paper. Most of the problems, as I see
them, come from the general baggage of enterprise software (not sold to the
people who use it, likely focus of dev time is on accounting/billing stuff I
never see) and an attempt to slavishly emulate paper in digital form.

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superuser2
EMR is not dysfunctional because it's EMR; it's dysfunctional because it's
enterprise software for the Windows desktop.

It's very easy for the HN demographic to forget what it's like to use an
"average" Windows machine. Startup and login times in the minutes to tens of
minutes, extreme disk latency everywhere, nagging popups to update Java (has
happened in my doctors' office more than once) and virus definitions, etc.
Cheapass hardware is frustrating by default.

A surprising number of network-based Windows line-of-business applications are
written with inexcusable naïveté - the application simply doesn't respond
while waiting for network/server and a request that gets dropped or whatever
will render the entire application inoperable for several minutes (or some
other irrationally high timeout, if there even is one) unless you kill and
reopen it.

Because Windows desktop management is so brittle/difficult/expensive and so
many applications don't play well with MSI, updating is a manual process of
walking around the practice and waiting for computers to be unoccupied so that
you can load the new .exe onto them. In practice this sometimes just doesn't
get done.

Add on the incredibly poor software quality that comes with lowest-bidder
offshore development, zero attention to UX, and very aggressive and well-
funded sales teams, and you get roughly the situation we have today.

I can't wait for somebody to take this on with a well-written web or Linux
application. Even better if it targeted a domain-specific, stripped-down,
locked-down Linux distro that could be netbooted by thin clients around the
practice and deployed in a high-availability setup inside the firewall.

~~~
fnordfnordfnord
>Even better if it targeted a domain-specific, stripped-down, locked-down
Linux distro that could be netbooted by thin clients around the practice and
deployed in a high-availability setup inside the firewall.

I can hear it now...

 _" This looks great, but my staff only knows about how to use Windows
computers; I'll have to retrain them to use these strange new Lee-nuks things.
Can't you just make this run in a little box like on the other guys' systems,
so I can keep my Windows PC workstations? I'd like that because our time-clock
software is only available for Windows and that will save us having to keep
two CPUs and screens on the desks."_

~~~
superuser2
Maybe because it was their first (and only) EMR system, but in the practice I
worked at, all the initial infrastructure was put in by Allscripts explicitly
for EMR, with all other applications being secondary. They sold the boxes, set
up the Windows domain, and managed everything. Only relatively recently did
they start using it as their own infrastructure, instead of just the magic to
make Allscripts EHR work. In that kind of scenario, it could just as easily
have been Linux.

~~~
fnordfnordfnord
> In that kind of scenario, it could just as easily have been Linux.

In any of these systems, any general purpose OS would suffice. There is no
real problem for people to move from one platform to another that can't be
overcome in a short time.

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clueless123
The worst part of "billing" driven EMR's is that doctors get really good at
recording procedures and diagnoses to fit what the insurance companies want to
hear, not what the real medical condition is. This has the effect of
distorting the patients reality polluting the medical data, rendering it
mostly useless or of poor quality for any decent medical research work.

You got a throat ache, but that is not payed by the insurance? uhhmm immediate
upgrade to a pharyngitis.

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lucidrains
There is a great chapter in the book "Hacking Healthcare" that addresses the
challenges met with writing software that bests paper. I have linked it below
for any software engineers interested in this problem space!

[https://www.safaribooksonline.com/library/view/hacking-
healt...](https://www.safaribooksonline.com/library/view/hacking-
healthcare/9781449309602/ch04.html)

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bastawhiz
This isn't a problem with EMR. This is a problem with poor UX in the software
that the doctors are using. Here's the thing about paper records: they're
costly as well. Paper records need to be photocopied, faxed, paged through,
sorted, filed, unfiled, etc. God forbid the doctor needs to physically move a
wall of patient records, or a disaster in the office. EMR are theoretically
just O(1) to access, update, save, and send. Not true with paper records.

I obviously don't know the true statistics, but I'd hasten a guess that
although EMR costs doctors a few extra minutes per patient but cuts the
overhead of maintaining and handling those records by an order of magnitude.
If the biggest complaint is information overload (as the article seems to
suggest), the whole system could be completely "fixed" with a simple OS X
system preferences-style quick search box.

~~~
Scoundreller
Don't forget about the inherent difficulty in doing retrospective analyses on
paper records.

Want to see how drug X affected lab levels of Y on your organization's
patients for the past Z years? Good luck with paper records.

~~~
Spooky23
Reminds me of my employers Oracle Financials rollout, which makes submitting a
travel voucher a 30 minute chore that takes 3x longer to process.

Sure, somebody could analyze our 150,000 annual vouchers and figure out some
sort of insight. But that's unlikely, as the people who have access to the
data care only about payment KPIs, and accessing any data in the system is a
nightmare for anyone else.

The scenario you describe is problematic as well. The liability associated
with drawing conclusions about the efficacy of a drug based on
unscientifically collected data would probably make it difficult to use it to
drive decisions.

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cheriot
If these medical records were in an open/standard/unencumbered format there
would be startups all over this.

~~~
Scoundreller
Here's an open-source one in Canada that has about a 20% market share in
Ontario: [http://oscar-emr.com/](http://oscar-emr.com/)

Built by an engineer-turned-physician.

~~~
yuhong
Thinking about it, it is probably no coincidence that this was done in Canada
which has public healthcare.

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ams6110
Pre-EMR, I thought most docs dictated their notes on tape that were then
transcribed to the medical record by clerks. Why are doctors having to
keyboard this stuff now?

~~~
riahi
Because no hospital system wants to pay for transcriptionists when they can
mandate the MD do the data entry themselves. You hear the big backlash from
the private practice MDs who still used a combination of paper chart and
dictation that are just now being forced to move to EMR through MU 1 and 2.
And with the cost of buying a whole new EMR rollout and support contract, find
they can't afford to pay the transcriptionists too.

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gxespino
I'm a nurse/programmer and working with EMRs are maddening. The problem is the
requirement that EMRs are built to protect against every potential thing that
could go wrong. As a nurse, I'm spending a minimum of an hour a day clicking
boxes and copy & pasting CYA lingo for all of my patients to protect against
the 1% scenario.

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clueless123
The issue with most (if not all) EMR's is that they are driven by the business
side of things, not for the medical providers.

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shamney
what do the equivalent systems look like in countries with nationalized
healthcare systems?

