

Why US Healthcare sucks and how I’m trying to change it - MIT_Hacker
http://delian.io/why-us-healthcare-sucks-and-how-im-trying-to-change-it

======
babesh
Totally wrong. The reason the US healthcare system sucks is that it's an
oligopoly. Medical schools limit enrollment to limit the supply of doctors
thus keeping salaries higher than they otherwise would be. Nurses unionize to
drive up their own wages. Insurance companies pile on the paperwork because
they can charge you for it. Doctors are incentivized to push more expensive
drugs and procedures because they make more money. Drug companies develop
drugs that will make them the most money and wine and dine pharmacists and
doctors to ply their drugs. Thus those that can pay end up paying more and
more. Those that cannot get no coverage at all. Oligopolistic capitalism at
its finest. Everyone in the system gets paid off a bit to not rock the boat.

~~~
mikeyouse

        Nurses unionize to drive up their own wages.
    

Ah that old canard. Fewer than 20% of RNs are in unions. Those in unions do
make more than their non-union counterparts (~$200 more per week [1]), but if
you think that's why nurses tend to unionize, you're fairly far from the mark.
Especially since real nurses wages haven't increased in the past 10 years.[2]

Imagine that being a programmer required a license from the state in order to
practice. Now imagine that if you make a significant error, you lose that
license, pretty much ensuring you could never make another dollar in salary as
a programmer. Say your work consists of doing week-long projects, with a team
of 4 other programmers. Your code must be released weekly and must be bug-
free. Now what happens when your boss realizes he could save 40% on costs if
he cuts your team from 5 to 3? Or to 2? How likely are you to release bug-free
code? That's the situation for nurses.

Adding to that, nursing is one of the most dangerous jobs in the country based
on the number of on-the-job injuries and missed-work.[3] Most of these
injuries are caused since hospital staffs are being cut, which leads to nurses
having to lift, turn, and dress patients without additional help.

Furthermore, nursing care levels are directly correlated with improved patient
outcomes, shorter hospital stays, lower mortality, and a number of other
positive indicators. [4]

So you have hospital management on one side, who's incentives are to cut pay,
cut hours, and cut staff (and frankly, to keep patients longer). And then you
have nurses / techs / etc. on the other side, who are more likely to injure
themselves, more likely to lose their licenses, and more likely to provide
substandard care with those cuts. Do you honestly think unionizing is a bad
idea?

[1] Barry Hirsch and David Macpherson, “Union Membership and Earnings Data
Book,” The Bureau of National Affairs. Bloomberg. 2012. [2]
[http://www.ananursespace.org/BlogsMain/BlogViewer/?BlogKey=c...](http://www.ananursespace.org/BlogsMain/BlogViewer/?BlogKey=c4f7cef5-bb71-4ddd-b5de-
dd97427418a0&ssopc=1) [3]
[http://www.bls.gov/news.release/osh2.nr0.htm](http://www.bls.gov/news.release/osh2.nr0.htm)
[4]
[http://www.nejm.org/doi/full/10.1056/NEJMsa012247](http://www.nejm.org/doi/full/10.1056/NEJMsa012247)

~~~
babesh
IMHO, unions are obviously a counterbalance against management but the truer
axiom would be that power corrupts. So just as unfettered power on
'management's side can corrupt so it can on the unions side.

------
hga
Go back one item in his posts, to [http://delian.io/an-apology-to-president-
reif-and-the-mit-co...](http://delian.io/an-apology-to-president-reif-and-the-
mit-community)

"..."

I can't imagine trusting this guy, or anyone willing to work with him, with
... anything, let alone implicit and explicit access to medical information,
until he presumably grows up a bit a decade or two from now.

~~~
Houshalter
That's pretty harsh. It seems like it was a relatively harmless prank that he
didn't even intend and immediately regretted. I don't understand why you judge
that so harshly or why you immediately dismiss his work based on it.

~~~
hga
Having learned more (see the additions to my reply to his reply), I wasn't
even vaguely harsh enough. He should have done some jail time (a few weeks, a
misdemeanor is enough), and if he reapplies to get back into MIT I hope the
Dean he has to talk to doesn't go softhearted absent a major attitude
adjustment that has yet to occur a solid half year later.

Of course, I'm also one of those members of the MIT community who believe
Aaron Swartz should have done some serious time in Club Fed (> a year, i.e.
felony), am not in the least swayed by his exit from a mess entirely of his
own making ("If you aren't willing to do the time, don't do the crime.",
incalculably stupid for someone who suffered from depression), and am rather
perturbed by all those taking the side of a criminal again MIT to the point of
committing even more crimes against the community, like this one.

To answer the rest of your points, it comes down to character, and his actions
and most especially his responses afterwords conclusively demonstrate he isn't
worthy of the trust which is required for this sort of access to people's
health information.

I don't "dismiss his work" so much as "don't trust him or anyone of such poor
judgement to work with him" with a service handling sensitive stuff.

------
Justin_K
I've worked in the Health IT space for 15 years and agree with you that it's a
mess. But your POC site doesn't really show anything or explain how you're
going to solve the problems you described. How is this information shared with
physicians? How is it made available when a patient shows up to the Emergency
Dept? All of the information you displayed should be condensed to one page.
What is the point of knowing if a patient missed their meds three weeks ago?
You can't berate a 75 year old for missing their meds. What you're recording
isn't as useful as you think.

The problem population today is elderly patients with chronic conditions,
either landing them in the hospital constantly or requiring regular visits to
specialists, labs and pharmacies. This population does not use smart phones.
So the burden is on the physicians and hospitals to track the information and
coordinate care.

The whole idea of Accountable Care Organizations (What you described as "The
New Model") is to coordinate care. ACOs are pilot projects, most just barely
starting up. So the reality is only a fraction of the population in the US
will be affected by these organizations. The big workflow change is really for
the nurses who gather the information, not the physicians. The goal of ACOs is
to improve outcomes. ACOs receive bonuses if the can improve outcomes for the
same cost or less that is being paid for the same population today.

Also as a FYI, everything you described as Obamacare (ACOs / EHRs) was
actually developed and funded in 2009 by ARRA, not last year in the ACA /
Obamacare.

------
andreipop
Delian - love the initiative!

There are a few basic assumptions underlying your vision that may be useful to
flush out further (I can tell you that, from similar experience, what you are
going to bump in to is a fundamental lack of desire from the majority of the
system to see change).

1\. You are betting that Obamacare will actually drive the system towards
"accountable" care -- we are a long way off from this unfortunately. I won't
rehash it all here, but many ACOs are turning back from the model:
[http://www.hhnmag.com/hhnmag/HHNDaily/HHNDailyDisplay.dhtml?...](http://www.hhnmag.com/hhnmag/HHNDaily/HHNDailyDisplay.dhtml?id=7540007960)

2\. You are betting that patient engagement in their own health will be high,
particularly for the high cost, at risk patients. This has been historically
proven not to be the case. High touch intervention + technology works (i.e.
take a look at the Diabetes Prevention Programs now being run digitally by
organizations such as Omada) but technology by itself has had a pretty low hit
rate with driving meaningful patient engagement for the at risk populations.
For some reading on the challenges of adherence, check out:
[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1661624/](http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1661624/)

I really do think we need more people working on these problems, so keep at
it, and if I can help at all please let me know!

(drop me a line at andrei@humanapi.co)

~~~
DanBC
> You are betting that patient engagement in their own health will be high,
> particularly for the high cost, at risk patients. This has been historically
> proven not to be the case.

The commonest reason for transplanted organ failure is that the patient isn't
compliant with medication.

This happens in UK (free surgery, free meds) and US (expensive surgery,
expensive meds).

It's weird.

------
rpedela
Although I agree that EHRs largely suck, it is not the elephant in the room.
From a technology perspective, if you really want to fundamentally change
healthcare then you have to tackle diagnosis. For the majority of illness and
disease, we still do not have a good set of technologies that diagnose
accurately, quickly, and cheaply. Instead a physician makes an educated guess
based on symptoms and sometimes on tests. Tests which give clues but rarely a
definitive answer.

I don't know what the answer is, but I know that the sooner we take the "art"
out of medicine, the sooner healthcare will get a lot better.

~~~
laCour
For those that haven't seen or read Paul Graham's bit on ongoing diagnosis:
[http://www.paulgraham.com/ambitious.html](http://www.paulgraham.com/ambitious.html)
(#7)

Or if you prefer to watch it from 2012's PyCon:
[https://www.youtube.com/watch?v=R9ITLdmfdLI#t=1587](https://www.youtube.com/watch?v=R9ITLdmfdLI#t=1587)

------
markolschesky
Interestingly enough, the picture you showed is of VISTA used in the VA
hospitals, which is generally considered to be the most usable EHR by
clinicians. An ignominious honor, perhaps, but it's worth consideration. 60%
of doctors know how to use it, since most doctors do some type of rounds
through a VA hospital since it's the largest medical system in the United
States.

You're right, most EHR UI is bad and it's built upon old technology. It
entirely pre-dates the "design era". But, part of the reason for this is that
healthcare was one of the first major industries to use IT heavily. What these
systems lack in modern design principles, they often make up for in stability
and ability to support system flows for larger organizations.

I admire your spirit and I hope that you do make an impact on healthcare. But,
it might be wise to try and glean some lessons from the past vs. writing
everything off as something that "fucking sucks". You might learn something
along the way on your path to making health delivery better.

~~~
Fishkins
Thanks for the note about the picture. I knew it didn't look like any remotely
recent screen in Epic. I worked for Epic for a couple years circa 2008, and
even then it would have looked outdated. Also, at least in Epic, I know
there's a huge focus on usability. That doesn't mean they always succeed, but
it's not for lack of trying.

------
dundu
This guy is a huge jackass.

[http://delian.io/an-apology-to-president-reif-and-the-mit-
co...](http://delian.io/an-apology-to-president-reif-and-the-mit-community)

I wouldn't have anything to do with him or his company.

~~~
ikt
Not only that but he obviously hasn't heard of begging the question when he
says:

3\. Jim is released but doesn’t improve his habits and has another heart
attack

------
nathan_long
>> I want to one day build a clinic run without an EHR. All of the personal
health data of a patient will be stored on their phone. Each time they come
into the office, they’ll give OAuth access to one of our physicians...

I like this idea, but patients vary wildly in responsibility. You'd have to
have a plan for those who can't or won't keep track of anything.

~~~
keithg
I agree. It's the first thing I thought when I read it.

This is a stunningly huge point of failure with a very high probability that
any one patient will either: forget their phone, break their phone, not have a
phone, have the wrong phone, have no charge on their phone, not know how to
use their phone, have an out-dated phone, etc. I think you get the idea.

------
mollyisgreen
Something to keep in mind is that many people with the worst health
prospects/problems (e.g. Medicare/Medicaid patients) are the least tech-
saavy/have the worst access to tech-enabled solutions to addressing their
health problems. These patients make up a non-trivial portion of any
provider's patient list.

Kudos!

------
Shivetya
One correction, or whatever.

The fines did not force more doctors to look at EHRs, it forced many like my
Doctor and those in his office complex to sell their practices to big Medical
conglomerates. So from a complex of multiple independent practices, many
decades old, they all sold. Now they are employees of these conglomerates and
there is now staff who deals with EHR, they just ask for print outs and fill
out forms.

As for Doctors suddenly becoming responsible for managing their customers
care, well that will lead to less individual practices as they won't be able
to afford those patients who cannot be managed.

Your now a number to be managed. Fortunately for me my Doctor remembers his
long term patients. He will be here till they finally force him out.

~~~
toomuchtodo
Your doctor could always get [http://drchrono.com](http://drchrono.com). Its
practice management/EHRs for ~$100-500/month.

Not affiliated, just a huge fan.

------
uslic001
He is spot on about how bad EHR UI's are. We really need some people who know
something about user friendly UI's to release a good EHR.

------
Marazan
What happens if you are brought in unconscious?

Every so often people come up with this idea of the patients holding their
medical information rather than the institutions but they tend to suffer
greatly in emergency situations and/or have tortuously complicated hierarchies
of trust and security.

~~~
toomuchtodo
Agreed.

EHRs should be centralized, but with extremely tight controls, either managed
by a non-profit GSE or a government agency with an extremely high level of
accountability.

If you go to any healthcare provider, they can request access using your
government ID number (driver's license, etc). If you're conscious, you can
approve this request using a two-factor auth notification on your phone (SMS,
push, whatever). If you're at the ER and unable to approve the request, they
can override the request, but its flagged and its going to need to be
justified.

The answer, as always, is complete transparency and accountability.

------
kat
How do you stop patient's from deleting health information they deem 'not
important' or 'too embarrassing'? I think it is important that health
professionals keep their own records of patient health.

Although, I do agree software in hospitals is NOT user friendly!

------
7Figures2Commas
It's going to be hard to effect the "change" so many are seeking when folks
continue to confuse and conflate "health", "healthcare", "the healthcare
system" and "health insurance."

