
Why Doctors Hate Their Computers (2018) - aarestad
https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers
======
duffpkg
I created the open source ClearHealth/HealthCloud EMR system, have managed
hundreds of medical facilities large and small and am the author of "Hacking
Healthcare". There are a lot of layers to this and competing concerns. This
article is misguided at best. The quote "Doctors are among the most
technology-avid people in society" is hilariously off the mark. The average
age of doctors in the US is 51.

Amongst many difficult problems related to this:

-Medicare/Medicaid/Federal spending is half to 2/3 of all medical spending. They are insanely bureaucratic and simultaneously penny pinching. They require lots of things that make everyones jobs harder with no obvious benefit to anyone. They dictate in many ways how software must work in medical settings.

-Doctors in most institutions are not given an adequate amount of time to accomplish all of the things that need to be accomplished to deliver quality care and also get properly paid for the interaction. This in part is financially driven but I would say it mostly occurs because there is little to no accountability for medical systems to operate well or efficiently. In many situations there are perverse incentives to operate inefficiently.

-Doctors make an absolutely shocking amount of substantive errors, 25% of interactions or more. Preventable medical error is almost certainly in the top 5 causes of deaths in the united states.

I could go on and on but cherry picking but I think I made my point that this
article looks only at one perspective of one facet of disgruntled personnel
involved in a single implementation.

~~~
entee
First of all thanks for the book, it was a formative read for me as I started
out in healthcare data and programming.

Second of all, I can’t just upvote, this is so so accurate.

The thing to remember in US healthcare is there’s actually not a single entity
that has an incentive to be efficient. There are some incentives scattered
through the system to pay less or to not get sued, those are not the same.

To a first approximation nobody spends money in healthcare except insurers and
the government. The government just says what they’ll pay, and where they
can’t, they have limited negotiating ability. You’d think an insurer would
care about paying less, but they actually don’t. They care about
predictability. How much are costs going to rise next year? If you’re right,
you make money. If you’re wrong you lose money. That’s not really an incentive
to reduce costs in the absolute because the people who pay for insurance are
not patients but employers.

As an employer I care about my health insurance plan’s cost. BUT I also have
no clue about what one plan vs another really means or how they’re maybe gonna
save me money long term. I simply don’t have the time to understand that, and
I’m probably more informed than most on the subject having worked in the
sector. I too care about predictability more than cost.

Crazy part of the pandemic, during a historic health crisis many medical
systems were facing bankruptcy. Why? Most of the money being paid with a good
profit margin into these systems is for “elective” care. This includes cancer
treatment, because surgery can take place today or a week from now and it
doesn’t matter that much. Contrast to a heart attack, which is non-elective.
When a pandemic rolls around, all elective care gets shut down, so hospitals
lose money despite being needed more than ever.

The whole system is a zombie with none of the right incentives, no clear way
to even measure the right outcomes, and worse: nobody is driving the ship.

~~~
TeMPOraL
> _When a pandemic rolls around, all elective care gets shut down, so
> hospitals lose money despite being needed more than ever._

Sort of off-topic, but I'm increasingly starting to believe that this kind of
complexity in business models should be disallowed in general. I mean in
particular the cases of selling something with a high margin in order to fund
something else that's sold at or below costs. Be it related items ("razor and
blades model") or unrelated (elective vs. non-elective care).

My usual reason is that it's anti-competitive and allocates incentives in the
exactly wrong way, leading to ridiculous waste (that's how we get throwaway
printers with expensive cartridges), but healthcare example points to another
problem: stability. A critical system whose functionality is strongly
subsidized by "extra offerings" is a system that fails when those extras
aren't being bought for some reason.

In engineering, simplicity is desirable. So should it be in business. After
all, transparent pricing is important for proper functioning of free markets,
and such schemes confuse the pricing.

~~~
maxerickson
This would destroy the ability of businesses to take on fixed costs.

Or imagine a hospital that only did high margin elective care. Instead of
keeping the low margin service available while it struggled financially, it
just wouldn't offer any services. Winning!

Interestingly, loss/waste aversion has caused problems in US healthcare. CON
laws haven't done anybody any good, save incumbent hospitals.

~~~
TeMPOraL
> _Instead of keeping the low margin service available while it struggled
> financially, it just wouldn 't offer any services._

Margins are controlled by businesses. If there was no way for anyone to do
"high margin X to subsidize low margin Y", then previously below-cost prices
would raise to better reflect the real costs of providing a good or service.

~~~
themacguffinman
Then you'll find that in many cases, these "real costs" are too high for many
who need it, leading many low margin services to stop being offered and many
consumers turned away. Hardly a win.

Complex subsidies can broaden the market and serve the underserved, that's a
win. It's classic engineering arrogance to dismiss all complexity as
unnecessary or harmful, as if the economy is a passion project that should not
deign to serve those who can't or won't bear the full cost of each individual
product.

------
phren0logy
I'm an MD, and most medical software is objectively terrible. I've worked in
private hospitals, campus student health clinics, jails, juvenile detentions,
VAs, group homes, state hospitals (in the US) - and in clinics and hospitals
in New Zealand.

I have never used an electronic medical record that I would willingly inflict
on another person.

The reasons vary, and almost all of them have at least a couple of things that
they do very well. But the bottom line is that this exactly the kind of
"enterprise software" that is sold to people who will never have to actually
use it. They are overwhelmingly sold as ways to increase reimbursement for
services provided, as a part of the arms race of insurance companies refusing
payment, and hospitals billing more and more.

Even in public sector settings that aren't billing, the only viable options
available are built with this problem in mind.

~~~
husarcik
What is your opinion of Epic?

~~~
phren0logy
It's among the least bad, but nobody would ever mistake it for software sold
to general consumers in this century. I know it's complex and specialized, but
so are IDEs, and those are (in my limited use and understanding of them)
worlds better in their engineering.

That said, I'm not crazy about how actively Epic appears have tried to keep
medical records created in Epic locked in to Epic.

The spirit, if not the letter, of the legislation requiring a move to
electronic records was due to record portability. From where I stand, they
have actively prevented that (or at a very minimum sandbagged) to expand their
market share.

~~~
phobosanomaly
Another unintended consequence of this is that it makes it extremely difficult
for doctors and nurses to pull data to do basic research or look at patient
outcomes.

For example, if you wanted to see what the outcomes of giving a specific drug
at a specific dose to a specific group of patients at your hospital was,
you're in for a real fun time manually copy-and-pasting thousands of entries
from the EMR to a spreadsheet.

Now more than ever it is important to look at data relating to patient
outcomes with various COVID treatments that haven't been thoroughly vetted
yet. But, guess why your local hospital isn't doing anything like that?
Because what should be a simple 3-hour exploratory data analysis that can be
breezed through IRB now has to involve a budget component of hiring a
professional copy-paste person. Can't even use med students to do it anymore
because they aren't allowed to hang around the hospital due to COVID, and you
can't access those records remote due to HIPAA.

~~~
josephpmay
That’s just completely untrue. First of all, Epic has a built in tool called
Slicer Dicer for clinicians to perform pretty complex population data analysis
without having to do any database queries. Second, every healthcare
organization extracts much of their patient data to a data warehouse where you
can perform direct SQL calls on it.

~~~
phobosanomaly
Thank you very much for sharing that. I'll look into it more. The clinicians
(head of trauma Evidence-Based Medicine as well as the head of the trauma
department overall) I have talked to at my non-academic Level II trauma center
do not have any clue this exists. They are currently exporting thousands of
records by hand.

Edit: Do you know offhand of a good guide to SlicerDicer I can share with
them? I will google around, but if you had something you personally liked?

~~~
josephpmay
I work at Epic, so the resources I have are all internal training/document.
That being said, the best way to learn it is probably to have someone who’s an
expert in it, ideally another doctor, walk them through it. If you want, I can
see if I can find some specific customer-facing documents/training to link
them to.

~~~
owowow
Lack of public documentation has to be my #1 pain point with proprietary
software over the years.

Especially in the EMR space, putting up barriers to access basic documentation
is quite unreasonable.

Public documentation is not going to suddenly allow your competition to gain
an advantage, while your own firm benefits from users being able to easily
google and get authoritative answers from your own official documentation.

------
cs702
Doctors hate their computers because the software they are forced to use
_sucks_.

And it sucks for the same reason that most enterprise software sucks: because
_the people who budget for it, choose it, and pay for it are not the people
who use it_.

For more on this, see this now-classic Twitter thread by Princeton CS Prof
Arvind Narayanan:

"Why Enterprise Software Sucks"

[https://twitter.com/random_walker/status/1182635589604171776](https://twitter.com/random_walker/status/1182635589604171776)

~~~
pavon
To expand on that EMRs, much like SAP and other enterprise offerings aren't so
much fixed pieces of software as ridiculously flexible frameworks for making
software. And the people deciding how to configure Epic, and deciding how the
doctors and nurses need to use it aren't practitioners, they are
administrators who are making decisions for bureaucrats reasons, CYA being
high on the list. Anytime an accident occurs, rather than understanding why it
occurs, the solution is always to add more administrative controls, to record
more details in the chart, more busy work to do that makes each step of the
process take longer.

As a result, the number of things that practitioners need to enter into EMRs
keeps growing, and every year they spend more and more time charting. This in
turn decreases the signal-to-noise ratio of the information in the charts,
resulting in the practitioners getting less information out of them despite
the fact that more information keeps getting put in. Which results in more
accidents rather than less.

~~~
nednar
Most people don't know that always writing tickets, even if they get refused
and ignored, will have an impact. Your goal is not to convince level1 support
to be your friend, but to turn the statistics into a way that forces
administration to consider your concern. So always write tickets and encourage
your colleagues to do the same. And if they get ignored make a screenshot and
send it with the headline "lol, got refused again" to the watercooler mailing
list and laugh about it together.

------
treis
This is an extremely long article and admittedly I started skimming halfway
through, but this statement:

>But we think of this as a system for us and it’s not,” he said. “It is for
the patients.”

Is wrong. It's a misnomer to call them medical record systems. They are
primarily billing systems. Sure, improving patient care or reducing paper
records are nice. But the #1 thing is to document the care to allow them to
bill insurance or the government.

~~~
nikisweeting
I don't think that's entirely accurate. It's true that billing is a core part
of most EMRs, but out of the hundreds/thousands of features in a big platform
like DrChrono or EPIC, a large portion of them are not billing related.

There's tons of operational utilities like e-prescription, lab ordering,
patient problem tracking, vital sign tracking, imaging and diagnostics
tooling, etc. You could argue that all of those are somehow related to billing
because they help doctors see more patients per day, but billing would still
be possible without them, and they largely exist because doctors need them to
work effectively and treat patients more efficiently, not because they
directly serve the billing pipeline.

~~~
conanbatt
If you didn't have to bill insurance for the visit, you can document on a
paper chart in a minute and that would be it.

~~~
nikisweeting
Good luck using a piece of paper to e-prescribe a medication such that it's
shipped to the patient's pharmacy before the patient even shows up. Ditto for
lab orders, imaging analytical tools, custom vital tracking with automatic
flagging, diagnostic hardware integration, etc. there is lots of stuff in
modern doctors offices that would be significantly more difficult on paper.

Not to mention all the issues of paper management and physical security once
you have thousands of patient documents scattered around in filing cabinets.

------
dctoedt
The author, Dr. Atul Gawande, is more than a bit of a rock star. He's a Rhodes
Scholar and MacArthur Fellow "genius grant" recipient. He wrote, among other
things, _The Checklist Manifesto_ , having headed up (IIRC) a World Health
Organization project to implement short, bang-for-the-buck preincision
checklists for surgeries, which apparently improved outcomes dramatically.

[https://en.wikipedia.org/wiki/Atul_Gawande](https://en.wikipedia.org/wiki/Atul_Gawande)

~~~
anitil
This article is what led me to read The Checklist Manifesto. What I loved
about that book is that it works through all the traps around how these
checklists can be implemented.

An example - Administrators typically want _everything_ on a list, because
everything is important, right? However these lists need to be concise enough
to be useful otherwise people just ignore them.

------
nitwit005
I wonder how often people are pissed at the software companies, when the real
villain in this story is their hospital. They're actually upset at
customizations the hospital insisted on.

At my last job I tried to get some fields in our bug tracking system made
optional. You could run reports showing they were garbage most of the time.
Naturally, I failed, and those fields are still required to this day. I
started putting "supercalifragilisticexpialidocious" as a value in some of
them. No one ever commented on it.

------
scarier
Part of the problem: medical software isn't designed to facilitate efficient
patient care. It's designed to facilitate billing.

------
canadaj
My first "real" job out of college was database reporting at my local hospital
that used Epic. I was young and starry-eyed, but I remember sitting at these
Epic trainings and using the software. I knew something must have gotten lost
in translation during development, because the software was absolutely a mess
of confusing menus and screens. After all, I was a budding software developer
with absolute computer literacy, if I didn't get it, who would?!

I remember thinking that there was no way self respecting developers would
allow this to happen, but I was so naive!

~~~
bitxbit
HCIT is a sh*tshow. It’s mind boggling how nearly 7 years of billions in
“investments” have yield minimal improvements. Tax dollars down the drain. And
I‘ve seen enough to know that it’s all by design. The entire HC industry does
everything within its power to keep the system as opaque as possible.

------
prerok
> the design choices were more political than technical: administrative staff
> and doctors had different views about what should be included.

I worked at a company that designed such a system. I was not involved with the
project but when the system came out there was a lot of heat in the press
quoting medical professionals about how bad the system was. Suddenly, with the
new system, the workarounds used in the previous one stopped working. The
problem, of course, was not in the "programming" part, even if the press
portrayed it so. The problem was the requirements and the insanity of the
medical management to force the users to stick to the exact documented work
process.

The article addresses this as well later on and describes how solutions are
then added by workgroups for specific fields. Just another example how you
should design such a system along with the users and not by encoding work
process some administrative entity proscribed.

------
vedtopkar
Having spoken to a lot of doctors during medical school, it really does feel
like a generational thing. Physicians who were trained in the pre-EMR times
have a really hard time transitioning. This is partially a UX design failure
on the part of EMR companies.

The newer crop of physicians have a much better time using EMRs. Don't get me
wrong, they are acutely aware of the ridiculousness that is modern billing-
centric medical records. But having been trained in that atmosphere, it
definitely appears less painful to their day-to-day.

~~~
euthymiclabs
Perhaps. The older generation has a lot of trouble with computerized systems
in general. The younger generation of doctors (including me!) can handle them
just fine but find them still to be an overwhelming waste of time.

I'd love it if we just had a great API that workflows could be build upon. And
I'd kill for a command line EHR!

~~~
dogmatism
I'm older, and maybe this speaks to my age, but I also daily dream of a TUI
EMR. Orders done using awk for text field processing, grepping for results,
editing notes in vim with medical syntax highlighting and completion...

Alas, I spend my days cursing as Cerner re-draws the unnecessary html and the
focus refuses to follow the mouse, and that no one along any of multiple
points took the time to write an interaction checker that didn't result in
getting three popups to acknowledge that epi boluses given at separate times
during a code (and now the patient is dead) don't interact.

~~~
vedtopkar
Oh man, this would be a dream...

------
bigtones
Epic was a medical records system built up since the 1970's in Verona
Wisconsin, first developed to turn paper based medical records into a database
computer system. A good 8 minute YouTube video from January this year on the
sole female founder and the quirky company culture is at:

[https://www.youtube.com/watch?v=8lPMYk09nUg](https://www.youtube.com/watch?v=8lPMYk09nUg)

~~~
chromatin
It’s too bad they spend their billions on Harry Potter Hogwarts themed campus
instead of UI/UX studies

~~~
goda90
Epic does do UI/UX studies. It's got a lot of legacy code to plow through,
combined with regulatory and customization demands that lead to best UX
practices having to be bypassed sometimes. Striking a balance between too much
information and having a clinician miss critical information because it was
hidden behind a click or hover bubble is always a concern.

Regarding the campus, the theming is actually quite cheap. The bigger expenses
come from employee QOL stuff like roomy underground parking to keep cars out
of the snow.

------
jungletime
I hate my dentist's computer. She's looking at my xrays on the computer,
touching the mouse then my mouth. Should I freak out? What are the odds she
autoclaves the mouse between patients.

~~~
Something1234
I hate watching the nurses typing on the keyboards that they wheel around from
room to room, and touching patients after touching the keyboards. Especially
considering that those keyboards are not easy to clean, and just standard dell
keyboards. It's absolutely disgusting.

~~~
Aeolun
Considering what’s just floating around in a hospital, or what is on a
doorknob, I wonder how much effect this actually has.

------
jfkdkdnaahhdnd
I used to work for an EHR vendor. Users don't drive features, hospital
administrators and CMIOs[1] do. In general, we give hospitals the ability to
get better reimbursement from insurance companies by embedding more detailed
billing information in the patient's chart and documents. We also help shield
hospitals from liability by helping add more details demanded by their
lawyers. Information about the patient from healthcare providers for other
healthcare providers runs a distant third.

If your old paper chart didn't get misfiled or fall behind the cabinet, almost
everything in it was relevant to your care, because there wasn't enough hours
in the day to record anything else. Now, it's a sea of compliance bullshit and
autocompleted lies -- the unscrupulous practitioners insert multipage reports
on tests that were never performed with just a few clicks. (I think the EHR
vendors now also sell tools to detect that sort of fraud.) For users who
ultimately want to provide care, dealing with electronic medical records is a
nightmarish situation and it's leading to burnout at record rates.

1\. Chief medical information officer --usually a doctor who became an expert
EHR user and now decides what will work for doctors and what won't.

------
fullstackmd
I'm an MD/Dev at one of the only major academic centers in US that still
maintains a home-built EHR. Atul Gawande is definitely a giant in healthcare
process improvement and a great writer. Many of us were eagerly anticipating
what he would do with the Amazon/JP Morgan/Berkshire Hathaway healthcare
initiative and disappointed when he stepped down
([https://www.geekwire.com/2020/atul-gawande-steps-ceo-
haven-h...](https://www.geekwire.com/2020/atul-gawande-steps-ceo-haven-
healthcare-joint-venture/)).

Unfortunately, there are too few of us that understand both the challenges of
caring for patients and the barriers of writing (and maintaining!) good
software. Our EHR is far from perfect, but the basic HTML interface has aged
remarkably well into the era of smartphones. Our approach is to extend
functionality of our EHR with APIs and an ecosystem of add-ons. Always looking
for people with a passion for healthcare and flexible skills. Mumps/Cache, API
design, JS (vanilla, JQuery, React), mobile (Swift, Java, React Native, Kony),
and ML (computer vision and NLP).

~~~
abhisuri97
Hoping to be an MD/Dev of sorts depending on this med school app cycle :) what
institution is this? Most of the ones I know are gobbled up by Epic.

~~~
fullstackmd
Good luck! Long road ahead, but it's worth it. I'm at BIDMC. Reach out (email
in profile) if you need advice or want an interesting project to work on.

------
xyst
I am not surprised at all. When I was a college student on the medical school
track, there was a unique opportunity to work alongside doctors in a hospital
setting. The job was to be the doctor's "scribe" and input all of the doctors
findings, patient history, and document the care provided by the physician
(eg, suture repairs, intubations, and other procedures).

It didn't make sense why this job existed until I actually started training on
the system. The system is absolutely god awful in terms of UX experience, but
after awhile (1-2 months) you get acclimated to it and could complete a chart
in <5 minutes.

Some or most of the doctors I worked with absolutely hated the system itself.
On many occasions, I have observed doctors input the wrong orders which if
they were performed would have had severe consequences. Fortunately, 99.9% of
the time the error was caught by the physician or the nurse assigned to the
patient. The one instance where it wasn't caught was actually due to human
error - nurse gave patient anti-hypertensive med instead of the ordered
calcium channel blocker (Cardene vs Cardizem?).

On the worst occasion, one doctor I worked with struggled on a daily basis to
input orders into the system. I think it would take 5-6 minutes just to input
some basic orders. Someone ended up teaching him how to input the orders in
free form text and the nurse(s) would just write up new orders based on that
(eg, doctor would write a single order as "cbc,cmp,ua r/o uti, drug screen,
CXR 1v r/o pneumonia" and the assigned nurse would recreate the orders in the
system in a line-item fashion). Kind of sucks for the nurse, but I think it
ended up working out better for both parties.

I ended up dropping out of the doctor career path due to this unique and eye-
opening experience as a scribe (not because of the EHR software itself but
figured the "doctor life" was not meant for me).

------
jld
It's like asking "Why do pilots hate airplane food?"

It has nothing to do with why pilots are/aren't epicures, and a more to do
with their bosses deciding to serve them crappy food.

~~~
CarbyAu
This.

Another comment mentions that Epic is amazingly customisable. But that is not
in the control of the people who use it.

------
cknight
That medical software is simply bad is also my experience, having been an IT
Manager for a clinic management company for a few years now.

In Australia at least, 85%+ of medical practices run one of two practice
management systems. Both of these systems were originally developed by the
same guy, and both have their centre of operations in the same small regional
town in Queensland.

I don't think it's a surprise that top-tier developers are unlikely to be
willing to move to the middle of nowhere. My experience with the version we
use is that its UX is unpleasant, the platform isn't reliable, and it doesn't
perform well at scale for larger clinics like ours.

I completely understand that the monolithic design of the software is mandated
by too many competing interests (and regulations) for it to be simple. But I
am sure it could be better.

------
Peepers
Medical professionals in this thread, I encourage you to reach out to the
people at your organization making the decisions for your EMR. Escalate, or
the development company will never hear about the issues that are hurting you
daily.

I'm a developer at one of these companies, and we truly do want to make your
experience better. If there's a workflow that you do for every patient that
takes 3 clicks instead of 1, escalate. There's a good chance there's build
that could help you out. If there's not, escalate anyways. Ask your IT
department to contact the development company's staff. We want to hear any and
all feedback about specific workflows that are a struggle.

------
Farbklex
Just my 2 cents. I manage the IT for a doctor's office and the software they
use from a medium size company in Germany has a Word / Excel export that looks
like this:

1\. Software tries to open Excel / Word (it actually failed to open Excel on a
machine, but when I opened it manually, the export continued)

2\. It copies a row in the software

3\. It pastes the row into Word / Excel

4\. If more data is available, go back to 2.

This is for the export of a data integrity check report in that software
suite. It takes multiple minutes to export a report and you can watch live how
the copy / paste happens. I was amazed that somebody has the balls to sell
this and gets away with it.

------
peterwwillis
For the medical professionals here who hate their EHR systems: send the CEO,
CTO, President, VP, etc of the company some mail describing your problems, how
many people hate it, how much time it drains, one or two ideas on how to make
it better, and ask them to forward your mail to the product owners. One of
them will hopefully forward it down the chain and in a year maybe one of those
things will be less painful.

Also, a bunch of the people reading HN work for different vendors, so light up
the comments about specific problems with specific products and we can take
them directly to the people who can fix it.

------
scythe
This is probably the most trite argument on any software forum, but based on
my admittedly limited experience working in a hospital research environment,
Windows is a serious limiting factor for medical practitioners.

Not because it's a bad operating system, but because hospitals are constantly
out of money and computer upgrades are never a high priority. Microsoft does a
decent job of backwards compatibility with software, but the hardware
requirements keep piling up. Windows has no equivalent of LXDE; the computer
in the hallway takes 15 minutes to boot on Windows 7. It's a situation I run
into over and over: _the damn thing is slow_.

It doesn't help that, as others mention, medical software is rarely built with
the quality of software engineering we're accustomed to seeing. But it can't
help that the software tries to display all of the information graphically and
show as much as possible at once -- pictures I have to wait to load even if I
don't need to see them. This comes back, probably, to how it's sold: look at
this impressive flashy window with all these bells and whistles. Never mind
the system resources, and don't get me started on wasting screen real estate.
My workflow begins: turn on the computer, wait, log in, wait, open SNC
Patient, wait some more...

I don't know how many billable hours are spent waiting for computers to load,
but it can't be trivial.

------
dang
Discussed at the time:
[https://news.ycombinator.com/item?id=18381969](https://news.ycombinator.com/item?id=18381969)

------
gok
Paper medical records were great for doctors. They made it really hard to
switch providers. They were a great excuse for medical errors, or for
"accidentally" ordering expensive redundant tests from their buddies. EMR had
to be legally imposed on doctors because otherwise they would still be
gleefully killing people through bad handwriting.

~~~
lotsofpulp
I still don’t understand how society was OK with hundreds of dollars per
doctor visit just to get an illegible prescription for medicine that could
harm you if read incorrectly.

------
hollosi
Medical software is terrible, because healthcare is very expensive, and this
is the only effective cost control.

Since the payers (insurance companies and the government) want to avoid seen
making medical decisions, their only way to bring the cost down is to slow
down the providers.

Therefore, they do not allow automation in the EMR/Health software. This is
not a joke: for appropriate billing, the physician has to go through an
elaborate dance of clicks, and write and rewrite fields with the same content,
personally. In other words, if it was automated, or if the office staff filled
those out, then the billing would be much lower.

It's not true software vendors would not be able to automate a lot of this,
but they just can't, because the physicians are required to work in a manual
way for proper reimbursement.

It's a strange world, where a doctor who is a faster typist makes more
money...

It's very sad, but unfortunately it's working, at the cost of driving
physicians to the edge of insanity.

~~~
noisy_boy
I think in today's world, typing faster is a life-skill. I learned typing on
an actual Remington type-writer during my summer holidays eons ago because my
dad forced me to go to typing classes (he hoped with that I'll atleast be able
to secure a typist's job, if nothing else). That skill of touch typing has
paid for itself many times over since then.

------
mitchbob
Keep reading this excellent article, and you'll get to what for me was the
best part, about the power of co-design:

> Some people are pushing back. Neil R. Malhotra is a boyish, energetic,
> forty-three-year-old neurosurgeon who has made his mark at the University of
> Pennsylvania as something of a tinkerer...Soon, he and his fellow-tinkerers
> were removing useless functions and adding useful ones. Before long, they
> had built a faster, more intuitive interface...Malhotra’s innovations showed
> that there were ways for users to take at least some control of their
> technology—to become, with surprising ease, creators.

------
nikanj
Kids who go to med school tend to be the ones who excel in math, chemistry,
and similar ”logical thinking” subjects. They usually do reasonably well with
computers.

In my experience, the contrast is stark to another high-paid professional
group: lawyers.

~~~
whitepoplar
Oh my god, agreed. I have known many lawyers, my father being one, and the
amount of hubris and tech-derision is insane. You could give lawyers a
computer that prints money and they would shrug and tell you to get it out of
their office.

~~~
brendawalsh
I don’t know how old your dad is, but I remember mine had an IBM XT and used
WordPerfect, w DOS 3.3, I think.

I remember WordPerfect being very popular in law offices, but also dictation
machines, so who knows?

~~~
ghaff
>I remember WordPerfect being very popular in law offices, but also dictation
machines, so who knows?

There was a period during which PCs (as well as other word processors) were
coming in when computers were seen as being increasingly important (in law and
elsewhere) but the management at many companies weren't sold on it being a
good ROI for professionals, especially those billing by the hour, to use them
directly.

There was definitely a period of time in many places where there were
computers but it was secretaries/paralegals/etc. who actually typed on them.
And, remember, a lot of young professionals in the late 1980s had never really
learned to type, even hunt and peck.

------
brendawalsh
So, HN doctors here, how ‘computer literate’ are your colleagues?

I have worked with doctors of varying age groups, including family, and it
really just depends. Age is not a factor, it seems some people are averse, and
others passionate.

------
annoyingnoob
Is there any one-platform-to-rule-them-all solution, that will support 70K
users across hundreds of sites, that doesn't look and work like a clunky piece
of junk?

Maybe the one-solution model isn't the best option.

~~~
idiot900
I'm curious how Epic compares to SAP, having been subjected to the former for
years but never having used the latter.

~~~
iagovar
SAP is actually decent if you don't mess a lot with customizations, at leas in
my field, IDK in medical.

------
viraptor
This is also an amazing space for shadow IT and customisations. Probably the
best ROI software I wrote were AutoIT scripts for medical software. Plug them
into StreamDeck and they're saving amazing amount of time. On a single case
it's just a few tens of seconds, but it really adds up over time. (Think one
button specialist referral which clicks through / fills out 4 windows)

Then there's mass-edit scripting. Have you ever told someone that you updated
200 records and added $4k income, while saving 4h of manual error-prone
clicking?

------
LoSboccacc
the epidemic has been a boon for the digital transformation of doctors here in
Italy.

turns out you can do take appointment at the gp, it wasn't impossible

turns out you can request exams trough email, it wasn't impossible

turns out you can have a pre-screening via photo and messaging apps, it wasn't
impossible

turns out you can safely deliver prescription trough digital channels to both
the person and the pharmacist so that you can just show up with your
healthcare number and take the drugs home

it has been dragging medics and other professionals around then into the
present kicking and screaming

------
testfoobar
How are hospital records and billing managed in European countries?

~~~
analog31
This was a long time ago, but a relative of mine was hiking in Wales, and got
injured. She made it to the next town and found a clinic, where she was
treated. Then she asked how she should pay. They were like, pay? You don't
_pay_ for medical care.

She told them that she wasn't from the UK and therefore wasn't covered by
their system. But they said that they had no way of figuring out a price or
generating a bill for her. So she went on her merry way.

~~~
Silhouette
We're not quite as generous in the UK as this makes us sound. Anyone
interested in more details might find this informative:

[https://www.gov.uk/guidance/nhs-entitlements-migrant-
health-...](https://www.gov.uk/guidance/nhs-entitlements-migrant-health-guide)

The short version is that primary care services like consulting with a GP,
visiting a walk-in centre, or emergency treatment in a hospital accident and
emergency department are generally free to all, as are various other specific
types of care.

Most secondary care services such as other hospital treatment are only free to
people ordinarily resident in the UK, which roughly means anyone who is an EEA
citizen or who has the immigration status of indefinite leave to remain, again
with lots of other special cases.

Some services, such as dental work and buying prescribed medication, are
generally chargeable by default for everyone, though even then the NHS may set
standard prices and there are various provisions to help those of limited
means or in certain vulnerable groups.

But yes, if you have a nasty accident and need to go to hospital as a result,
no-one is going to be asking for your credit card number here before sending
the ambulance, and if you only need treatment in A&E and don't need to be
admitted as an in-patient, you probably would get most or all of your
treatment for free even though the equivalent in certain other places would
cost a fortune if you didn't have insurance to cover it. There are a lot of
reasons we are proud of our NHS here, and this is one of them.

Just in case anyone reads this later, let me add a final note that if you're
coming here, please check the details for exactly where you're planning to
visit. A lot of health policy is devolved, meaning policies can be different
in England from in Wales, for example.

------
AnimalMuppet
TL;DR: Doctors don't hate computers. They hate medical software, because it's
done badly. It gets in their way with pointless (to the doctors) bureaucratic
trivia that the doctors shouldn't have to care about.

~~~
idiot900
Yep. EMRs are for billing first, clinical utility second.

Committees composed of doctors know nothing about software design, so their
advice to developers is not very useful.

IMHO you need developers, who are also doctors or other providers actually
doing the clinical work, to make decent medical software.

~~~
xxpor
Good luck at ever convincing Judy Faulkner she needs software developers
that'll cost $700k+ a year.

------
mmaunder
I was startled back in 2015 when a world renowned oncologist got chatting with
me about github and tinkering with code. I think it depends on one’s appetite
for technology.

------
jbj
I tried a "EPIC similator" at a medical museum, it was a bunch of drop down
menus combined with slow loading pages I could navigate between.

I get an impression that hospitals are wasting many expensive workhours from
highly trained professionals to operate these types of systems. I really
wonder if it could make economic sense to let MDs have personal assistants for
these purposes.

~~~
Hammershaft
You should read further in the article, it discusses just that, including an
initiative to offshore medical scribing to India.

------
giantg2
The big part of this issue is how lawyers and politicians make everything more
complicated than it needs to be. Doctors can't access the data they need,
require multiple forms and signatures for simple things (like transferring
records), and are stuck in old school tech / jurisprudence (can I email a
scan? Oh, it has to be fax).

Don't even get me started on the format of VAERS data...

~~~
Spivak
Of all the failings of our medical system I don’t think I would cite having
safeguards for patient privacy that require explicit unambiguous consent in
the form of a paper signature and mandates for secure communication channels.
Yes it’s kinda silly that faxing is still allowed and grandfathered in but a
lot of times the lowest common denominator since everybody can get a phone
line.

You actually can email that scan, your email provider just has to be part of
DirectTrust.

~~~
giantg2
I think it's the cost of the bureaucracy and systems that are a major failing,
not privacy itself. The litigation involved is also expensive. I'm trying to
get my kid's record transferred to primary care from two hospitals and it's a
nightmare. I feel like most of the frustration could have been avoided if the
personnel involved were properly trained. The costs of visits and treatments
include this overhead.

It doesn't matter if the signature is on paper since the files are digitized
and thus exposed to attacks. Not to mention that fax isn't really more secure
than email. I have yet to see a provider near me who will accept a scanned
document through email, but maybe that's different in other areas. Medical
files go for a high price on the black market, but they are still fairly
prevalent.

This is different than a hospital, but quite cheaper than a normal primary
care visit ($200ish).
[https://www.bloomberg.com/news/articles/2019-12-13/pittsburg...](https://www.bloomberg.com/news/articles/2019-12-13/pittsburgh-
s-insurance-free-doctor-charges-35-per-visit)

Anyways, there are tons of problems and costs in the system.

~~~
Spivak
> It doesn't matter if the signature is on paper…

I’m not saying that having them on paper makes them more secure or anything,
just that signing hard copies is the best way to make sure the signer actually
understands what they’re doing and the gravity of it. For you I realize this
is not such a great feature but for a system that has to work for absolutely
everyone pen and paper works really well. But yeah I’m sorry you had such a
painful experience with it. It’s supposed to be one request, you fill out the
sheet with the doctor’s info and it shows up at their office.

My bad, of course _you_ can’t email documents to your doctors. The issue is
that Gmail isn’t set up to process your medical data. Doctors can email other
doctors though with that system. I agree that faxing isn’t exactly the panacea
of information-theoretic security but it’s pretty good in terms of policy-
security. You’re not going to accidentally have your faxes processed for
marketing data and anyone who tries risks big-time jail. Plus faxing these
days is all digital and encrypted beyond the last mile. Not super dissimilar
to the evolution of email having to bolt on security features after years and
years. Unless you’re using a literal physical fax machine it’s very likely
that your fax was encrypted the whole way.

I’m surprised your office doesn’t have a patient portal of some sort with an
document uploader.

~~~
giantg2
The primary doesn't have a portal. The hospital does, but apparently I had to
sign up while there (no one told me). Portals cost money, which raises prices
and increases attack surface - not something I particularly like.

I swear we signed a release at the primary that they can request the record
from anywhere, but so far it seems to be a big fiasco. I strongly question the
training and professionalism that our doctors recieved. My kid suffered an SVT
48 hours after recieving 4 vaccines. While I acknowledge vaccines as generally
safe and a great modern accomplishment, the staff seems to be brainwashed into
thinking they are infallible. Everyone said it can't possibly be associated.
Show me the VAERS and PubMed data then? Looks like I have to submit to VAERS
and do the data analysis myself. Who knows, maybe I will be published in a
journal if I find some strong correlation. No one else will try.

------
caycep
Saying as someone who has to run several different EMRS from 10 different
hospitals in a weird hellstew of citrix and VMWare Horizon clents...I would
kill for someone to write a stripped down front end that runs natively in
iOS/Mac OS or the web (assuming a good recent web app library)..

------
Aeolun
One of the things I think would still be super interesting to try and set up
is private single payer health insurance in the US.

If we cannot get the government to do it, we should just do it ourselves.

The only issue is the absolutely massive upfront investment necessary :/

~~~
nradov
Every health insurer is a private single payer for all their members.

~~~
Aeolun
Fair point. I guess the bigger thing is to trash all the things that make the
US system so insane.

------
rukuu001
Looks like doctors (or most of them) didn't get a look at this until it was
done?

In a field as technical and regulation-laden as medicine it's hard enough as
is. Without relentlessly validating it with users it could only go in one
direction.

------
moonbug
Hey America, get yourself some healthcare infrastructure.

------
brundolf
Relevant:
[https://news.ycombinator.com/item?id=21224209](https://news.ycombinator.com/item?id=21224209)

------
desmap
It's not about medical software but about how big the lock-in is (which is
always higher with B2B). The higher the lock-in the worse the overall UX.

------
acd
I think that Parkinsons law applies to all form of administration tasks
including doctors and hospitals. "Parkinson's law is the adage that "work
expands so as to fill the time available for its completion". It is sometimes
applied to the growth of bureaucracy in an organization."

Parkinson noticed that the English ship fleet was decreasing in numbers but
the number of administrators administrating the fleet was increasing. This
rule can be generalized and said to adhere to all kind of public work. If we
do not keep Parkinsons law in check doctors will spend more time at computers
fulfilling rules administrators invented instead of doing real critical work
helping sick patients. Our tax burden will also increase since the efficiency
of the system goes down over time, more tax money needs to be allocated to
serve the rules and laws the administrators have invented. Is critical that we
limit the number of rules and laws administrators can invent so that we have
efficient system that serves there original purpose.

Parkinson's law is the adage that "work expands so as to fill the time
available for its completion"

Key take away passage from Parkinsons law: "The accompanying table is derived
from Admiralty statistics for 1914 and 1928. The criticism voiced at the time
centered on the comparison between the sharp fall in numbers of those
available for fighting and the sharp rise in those available only for
administration, the creation, it was said, of "a magnificent Navy on land."
But that comparison is not to the present purpose. What we have to note is
that the 2,000 Admiralty officials of 1914 had become the 3,569 of 1928; and
that this growth was unrelated to any possible increase in their work. The
Navy during that period had diminished, in point of fact, by a third in men
and two-thirds in ships. Nor, from 1922 onwards, was its strength even
expected to increase, for its total of ships (unlike its total of officials)
was limited by the Washington Naval Agreement of that year. Yet in these
circumstances we had a 78.45 percent increase in Admiralty officials over a
period of fourteen years; an average increase of 5.6 percent a year on the
earlier total"

[https://www.economist.com/news/1955/11/19/parkinsons-
law](https://www.economist.com/news/1955/11/19/parkinsons-law)
[http://www.berglas.org/Articles/parkinsons_law.pdf](http://www.berglas.org/Articles/parkinsons_law.pdf)
[https://en.wikipedia.org/wiki/Parkinson%27s_law](https://en.wikipedia.org/wiki/Parkinson%27s_law)

------
longtimegoogler
Doesn't everyone hate their computer? I know I have a love hate relationship
with them.

------
tus88
A lot of in-house medical "software" is Access databases so no wonder really.

------
xchip
Could anyone post the answer? I am sure it can be stated in three sentences.

------
sabujp
tldr; information overload, reduced actual time with patients and increased
time entering bunch of information into computers, summary from
[https://autosummarizer.com/](https://autosummarizer.com/) :

My hospital had, over the years, computerized many records and processes, but
the new system would give us one platform for doing almost everything health
professionals needed—recording and communicating our medical observations,
sending prescriptions to a patient’s pharmacy, ordering tests and scans,
viewing results, scheduling surgery, sending insurance bills.

But three years later I’ve come to feel that a system that promised to
increase my mastery over my work has, instead, increased my work’s mastery
over me.

A 2016 study found that physicians spent about two hours doing computer work
for every hour spent face to face with a patient—whatever the brand of medical
software.

My hospital had to hire hundreds of moonlighting residents and pharmacists to
double-check the medication list for every patient while technicians worked to
fix the data-transfer problem.

“Now I come to look at a patient, I pull up the problem list, and it means
nothing. I have to go read through their past notes, especially if I’m doing
urgent care,” where she’s usually meeting someone for the first time.

Many scientists complained to Spencer in the way that doctors do—they were
spending so much time on the requirements of the software that they were
losing time for actual research.

In 2014, fifty-four per cent of physicians reported at least one of the three
symptoms of burnout, compared with forty-six per cent in 2011. Only a third
agreed that their work schedule “leaves me enough time for my personal/family
life,” compared with almost two-thirds of other workers.

There are messages from patients, messages containing lab and radiology
results, messages from colleagues, messages from administrators, automated
messages about not responding to previous messages.

Previously, she sorted the patient records before clinic, drafted letters to
patients, prepped routine prescriptions—all tasks that lightened the doctors’
load.

She called it “a ‘stay in your lane’ thing.” She couldn’t even help the
doctors navigate and streamline their computer systems: office assistants have
different screens and are not trained or authorized to use the ones doctors
have.

