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.
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.
> 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.
As an employer, my insurance brokers are able to show me very easy to compare tables listing premiums/deductibles/oop max/copays.
It’s all pretty comparable as long as you’re comparing within the same types of networks (HMO/PPO/EPO/etc), especially with metal levels.
If anything, HDHP PPO plans or Kaiser Permanente type HDHP HMO plans do have an incentive to keep costs down as they compete with each other for my business. I’ve been able to go to my health insurance website, and type in a healthcare procedure or exam and it will usually tell me the cost at various facilities. Nowhere near perfect, but a good start towards price transparency.
This all would work a lot better if everyone was forced to buy health insurance from healthcare.gov and employers were completely removed from the equation.
You’re totally right, and I love those charts. But let’s be clear about what they’re telling us: what we are buying for our employees. It provides no information about how those costs will increase or any “gotcha” features of the plan. While it provides information about a copay and percentage an employee pays and a deductible, I have no clue if plan 1 has negotiated 25% lower prices from the local hospital system vs its competitor. Likely, all the major plans have more or less the same negotiated rates with providers, but that opacity makes it even harder for anyone to drive efficiency.
Kaiser is a very interesting example actually. Because they own both sides of the business (provider AND payer) they have a big incentive to be efficient. They do pretty well! There’s a few issues: 1.) they are still part of a larger market, so they have to pay for doctors, which means they can’t be TOO far below market salaries. Many doctors are paid on both salary and based on how many and what procedures they do i.e. how much revenue they bring to the hospital. Your doctor in many cases is paid on commission. Kaiser doesn’t do this, which some docs like, but others don’t. 2.) they are regionally limited. You can’t get Kaiser in a lot of places in the US. I’m not sure why it hasn’t scaled nationally, I’d really love to know.
Oddly, I’m told by a friend who works there that Kaiser is run internally as two halves, the insurer and the provider, they then negotiate somewhat independently and keep each other accountable.
Anyway, my pet project is something like what you suggest, decoupling insurance for employment. As an employer (and by extension an employee) I pay no taxes on a health plan I buy. I pay with pre-tax $$. As an individual if I buy insurance I pay with post tax $$ unless it makes up a certain percentage of my income and that falls above some threshold and... I lost track it’s too complicated. It shouldn’t be, there should be a way to properly decouple employment and healthcare.
>But let’s be clear about what they’re telling us: what we are buying for our employees. It provides no information about how those costs will increase or any “gotcha” features of the plan.
You're definitely right about this, but in my experience, they're all the same negotiated pricing. And the insurance companies will conveniently group different doctors/healthcare facilities based on their costs into different tiers.
You can also be sure prices will keep going up, and I like to assume that I am liable for my out of pocket maximum since healthcare providers just bill willy nilly anyway, so I know I need to keep enough cash for 2 years worth of out of pocket expenses (in case something happens in Nov/Dec of one year and carries into next year). Hint: plan to have babies in April/May, so any complications all get stuffed into one plan year, and you hit out of pocket maximum sooner. Plus you avoid the new inexperienced resident doctors coming in during June.
>It shouldn’t be, there should be a way to properly decouple employment and healthcare.
It's really simple, remove the tax benefit from employers purchasing health insurance, and give it only to individuals purchasing on healthcare.gov. Ideally no one would have a tax benefit period, and everyone would be forced to go to healthcare.gov and employer plans and whatnot would be outlawed. Politically, big business will fight that though since price transparency helps people compare job offers properly and makes it easier for people to change jobs.
There's lots like that in the US, and to a much lesser extent in Europe as well. In the US I had a family member whose husband kept a not-great job because its insurance paid for her cancer treatment, whereas if he'd tried to switch jobs the other insurance might not have.
Even in Germany my (private) deductible is 3000 EUR so if I thought I might need "something done" I'd try to do it early in the year: if I spend 2999 in December the counter resets on January 1st. And I'm told I have a pretty sweet deal compared to America.
It's actually a poor hint. You want to choose to be pregnant just before you elect your coverage for the following year. Then you can buy the gold plated care with a tiny out of pocket maximum. Then you can go back to a lower quality plan until you're ready for baby #2
I hadn’t thought of that strategy! But my wife didn’t want to deal with brand new resident doctors, so avoiding the months of June onwards was important.
Also, I’m not sure if the out of pocket savings make up for the compounded investment earnings of a triple tax advantaged HSA contribution. However, it could work if both spouses get insurance from employer and they already have a kid, and the husband chooses an HDHP with HSA and puts one child under his insurance so he gets to contribute max amount to HSA, while wife chooses low deductible low out of pocket max plan and puts new baby under that.
But I wouldn’t waste my time figuring that out or doing that paperwork, it can’t be worth the different in out of pocket maximums and deductibles if you account for the headache of doing the paperwork.
>>It shouldn’t be, there should be a way to properly decouple employment and healthcare.
>It's really simple, remove the tax benefit from employers purchasing health insurance... and employer plans and whatnot would be outlawed.
How do you get from here to there without it turning into a boon for certain employers at the expense of their employees? That is, how do you ensure that the money currently paid in benefits is passed along to employees to purchase their own plans and not pocketed (partially or in total) by companies.
One way would be to allow companies to pay employee's healthcare premiums on the employee's behalf. That's almost like the current system, but still decoupled:
1. Employee buys their own plan from healthcare.gov.
2. Employee can choose to pay directly, using pre-tax dollars. Tax law is changed to that healthcare premiums are deducted from AGI for everyone who pays them.
3. Employee can choose to submit plan documentation to employer, who will pay some/all of the premium on the employee's behalf. In this case, employer gets the tax break. If only partially paid, employee pays the rest and gets to deduct that portion.
Financially, it's a wash either way. It gives the employee control over their health plan, and it changes the 'perk' status of employer-paid healthcare. It also gives time for employers to transition away from the "reduced salary + healthcare premium" model, because they'll be competing with employers who pay higher salary and no healthcare premium. Many employees will probably prefer the higher salary, because it's more flexible and feels better. That transition can occur over time without disadvantaging any employees, because the overall costs and tax implications are the same.
That will be forced to happen as people will need to purchase insurance and demand more pay.
If anything, people will have mobility to move to different jobs and the ability to actually see which job pays more or less, so employers will have to actually compete.
And half the people the US already don’t get health insurance from employers.
As an employee, I find those charts pretty much useless, because I don't really know what kind of health care I need. Not just that I can't predict the unknown future of my health, but that I don't even know what the difference will be between an HMO and a PPO if I need something other than routine medical care.
I've been fortunate to leave me with little need to deal with medical issues, and further fortunate that I don't have to optimize for price. But it means that every year I get shown a chart and tick off an entry more or less at random. Maybe on that day I'll guess that the more expensive plan would give me a better experience if I need it; maybe I'll decide that I might as well save money.
I assume that people who have to deal with health care systems have learned which kind of system fits their needs. I've been unable to figure it out from the charts. They make the prices clear enough, but the value is largely opaque.
> 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.
The "razor and blades model" is maybe not the best example here, as it's entirely voluntary for the consumer.
The ads convinced me to buy overpriced Mach 3 blades for 20 years, but at no time was I prevented from buying a safety razor and having cheap blades and a better shave. I could even buy one from Gillette if I really wanted to.
I'm not sure I'd want regulation protecting me from being a wasteful consumer, but I do think that something as important as a hospital shouldn't be allowed to run on whatever Ponzi scheme is momentarily profitable.
Perhaps we could regulate them more like we do banks? Something about maintaining certain critical capacity, or you lose your license to facelift?
Predatory pricing is related, but it relates to a business selling something so low it drives competitors out of business.
So I suppose if that applies where you live, and you had a business selling only the low-margin type of item, and your competitor was selling below cost, then you'd have standing for action. I'm not sure if consumers ever get a say though outside of regulatory agencies like the ACCC.
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.
> 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.
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.
If there is margin on the service, it isn't really a subsidy, it's capacity utilization (building a hospital that can do 100 surgeries a year instead of a hospital that can do 45 knee surgeries a year and filling the slots with other services).
I guess you can probably re-frame your argument using some other similar measure though.
NPR has done a couple series on how dollar stores (Dollar General/Dollar Tree/Family Dollar, just search "NPR dollar general" to see the content) can setup shop directly next door to a traditional grocery store and erode the traditional grocery store out of business. Reason being - dollar stores sell only the high margin items for low prices, whereas the grocery store has the expectation that they will provide all the staples people need, even the super low-margin items like lettuce. Once a grocery store loses the competition on the high margin items, they can no longer subsidize selling the low margin items and go out of business. A real (and growing) problem in many communities.
From what you can tell, is there any real and sensible reason for having health insurance paid by employers? Is it just an artifact of the past? I honestly can't see a single benefit from this system.
Nationalised health systems work very hard on cost control. There is a lot of FUD spread about e.g. the UK's NHS but the actual numbers show that it provides an excellent healthcare service to everyone for the same amount as Medicare+Medicade+health insurance for federal and state employees (in total via these channels half the people in the US have their healthcare paid for by the US taxpayer). I.e. the NHS is nearly twice as efficient as the US system.
Sadly they've added a billing system for 'health tourism'. Before that they didn't ask too many questions just treated people. I guess the billing system pays for itself? Not sure.
Presumably the billers spend a lot of time trying to get money out of insurance companies? We don't have those either..
[We do have private healthcare provides but even they seem much cheaper than the US system]
Edit: Any time the US healthcare system is described on HN it all sounds rather bureaucratic and stressful - as if being sick wasn't bad enough already!
Doctors like to think they are among the most technology-avid people in society.
In fact, my experience with doctors (coming from a place where I worked closely with them specifically on IT matters) is that doctors believe that because they're good at medicine that they are good at everything, specifically making good business decisions and understanding and correctly using technology.
Damn near every time a subject that isn't software that I have good personal knowledge of comes up there's I notice a few big grayed out walls of well thought out and nuanced text.
The worst cases seem to be when there's an article (seems like it's always on Medium) about some complicated multi-part technical thing going wrong, a top level comment slings blame around as if they know exactly where to sling it and uses a PopSci understanding of the subject matter to justify it. Then someone who actually knows the relevant industry says "well actually it's a little more nuanced", proceeds to explain and then gets down-voted and flagged for it. Seems like a great way to send the message that technical knowledge and experience is not welcome here if it's going to go against whatever the convenient narrative is. What it definitely doesn't do is instill trust in comments about things I am less familiar in.
Nobody wants to hear from the guy who admits he doesn't know everything. They want the opinion from the guy who is still on mount stupid and knows just enough to think he know everything about the subject.
I like to think I've gotten over myself pretty fast and will now freely admit that I know nothing and suck at everything.
Tongue-in-cheek of course, there's no need to downplay your own abilities and knowledge. But if anything, I'm no longer feeling like I'm missing out in the rat race. I'm missing out on the whole AI / machine learning thing but that's all right because it just doesn't pique my interest.
Not exactly related, is it that perhaps doctors are one of the major professions where there is not much of an audit or continuous review of outcomes once they are appointed?
Perhaps there needs to be some type of continuous formal evaluation system as is applied to airline pilots.
Doctors are encouraged to communicate with certainty. Breeds? Selects? For arrogance. Other professions apperciate and display uncertainty. Most scientists speak of confidence intervals.
The most pretentious people I ever met are scientists. Mathematicians, specifically.
You are being unfair. Show offs are found everywhere, and all in all docs are not particularly worse than many others such as scientists, economists, CEOs, whatever...
I don't know, I think we are all smart. Every single one of us. There are a few exceptions, but nearly all human beings on this planet are truly "smart" compared to all other known, non-human beings.
Unless this is one of those "everything's weird and 'normal' is particularly weird" arguments.
If so I agree that "everything's stupid and therefore it's especially stupid to think anything could be 'smart'"
> nearly all human beings on this planet are truly "smart" compared to all other known, non-human beings.
This is like telling someone in poverty "well you're actually in the top 1% of worldwide income, and the top 0.1% of all-time worldwide income, so things are pretty great!"
People are smart. What they don't always have is good information or the ability to know what they don't know.
I'm very weary of "people are dumb" arguments because they seem to lead to "and that's why we should dumb down our product, remove their freedom and treat them like crap" with an alarming regularity.
- polymathy, don't specialize too much, it's good to walk in other fields
- listen, being able to discuss, see the situation from all parties POV, exchange well
It's indeed rare to find this, also, I tried being less stuck up and listen but you quickly get stomped on by less knowledgeable but more dominant minds, it's tiresome.
> Analyzing medical death rate data over an eight-year period, Johns Hopkins patient safety experts have calculated that more than 250,000 deaths per year are due to medical error in the U.S.
I’ve mentioned it here before but the book “Black Box Thinking” by Matthew Syed is an interesting read in this regard. It really highlights how important it is to design a system that’s focused on error reduction (like aviation) rather than focused on allocating blame (like medicine).
IIRC there’s a chapter in the book about patient safety correlating with how “friendly” the OR nurses perceive a surgeon. The implication being that if someone makes a mistake they’re more likely to fess up a nicer surgeon (who will then have the opportunity to correct the error) and more likely to cover it up or ignore if they might get chewed out for bringing it up.
> It really highlights how important it is to design a system that’s focused on error reduction (like aviation) rather than focused on allocating blame (like medicine).
How can we change this culture though? For some reason doctors attract insane lawsuits seeking hundreds of thousands of dollars in damages. People don't seem to be so litigious when they're against rich corporations with lots of lawyers at their disposal.
If this continues, the only possible result is defensive medicine since doctors will need every bit of proof and documentation in order to prove their innocence in the event of a lawsuit.
Doing things like making sure medical staff arent forced to work while sleep deprived would go a long way to avoiding errors in the first place. Policy changes that walk the walk and substantively prioritize safety over profit can help create safety culture from the top down. Having more staff available in general can also make redundancy checks more feasible.
It is my understanding that the error rates skyrocket when patients are handed off between medical staff. Longer shifts reduce the number of hand-offs and thereby reduce the number of errors overall, despite sleep deprivation being a source of errors in itself.
Considering error rates due to sleep deprivation must rise at some point and the hand off error rate is probably quite constant there may be an optimal hand off.
However that doesn't mean this is the global optimum. There are probably ways to reduce hand off errors, e.g. by introducing hand off check lists. Sleep deprivation errors on the other hand can only be reduced by reducing sleep deprivation, giving crystal meth to the doctor (probably unethical and unsustainable) and by general poka yoke style changes that will have benefits even when not sleep deprived.
So the global optimum can probably be shifted to somewhere where the doctor is not sleep deprived and the hand off is organized. Which is also more humane towards the doctor.
Overlapping shifts could just be seen as a better hand-off. However I think the hand-off issues are probably the same that you have in any project. There's a lot of implicit knowledge. E.g. you've noticed patient X was breathing heavily, but you weren't sure if it meant something, if you see that again 10h later you might investigate, while for the other doctor if he started after 8h he might notice it for the first time, and have a similar wait and see approach.
In this case one procedural way to make this better would be to teach doctors to write up anything unusual they notice during the day, and read this list of unusual events during hand-off to the next doctor.
That's a good idea, but I was suggesting something slightly different: try to minimize the number of hand-offs by overlapping shifts and stopping the acceptance of new cases for the outgoing personnel.
Technically a day is not a hard constraint in the short term. Maybe if you do one 36h shift, however unlikely, produces fewer errors than a 12h shift with 2 hand-offs. Long term we know about adverse health effects of inconsistent sleeping patterns, so those would factor in as well.
There are articles on how the early aviation had too much pilot egos and cowboy attitude, and how the aviation industry was able to change that and reduce human errors. And how medicine should learn from them, and maybe already is.
I wonder how doable it is to make medicine more like aviation?
Medicine is for a large part trial and error (try this medicine and come and in one week to see if it helped), under high time pressure (general practitioners in the netherlands have 10 minutes to see a patient, including reading up on previous visits, and following up with hospital research results, etc).
Even if you'd try to determine learnings from every error, and put these in protocols to instruct healthcare people to avoid same mistakes next time, would they be able to effectively use this knowledge within the 10 minutes allocated?
> In many situations there are perverse incentives to operate inefficiently.
Would you mind taking the time elaborate on this? Inefficiency in the US healthcare system is something everyone talks about but concrete examples are few and far in between. I would love to get an insiders perspective on this!
I work in a university affiliated cancer center lab, inside of the largest hospital in my area. Due to a weird contract signed many moons ago, we are very restricted in the lab tests we are allowed to run for the cancer center physicians (employed by the university). the dumbest example is this: the total/direct bilirubin ratio. Total bilirubin is one test that we run on almost every patient as part of the comprehensive metabolic panel. Direct bilirubin is less common, but we do run a fair few of them. The calculation for the ratio is simple division. But when the ratio is ordered as a standalone test, it must be sent to another lab in the hospital megacampus. But not the gigantic lab in the main building, the lab in the children's hospital. Nobody has a good explanation for why I must send this test off into the wild blue yonder instead of simply doing some arithmetic, and I'm beginning to doubt that there is one at all.
Are there significant costs with sending the test to a far away land? I know some people that work in the medical field, and they've told me about tests being thrown into the request pile most likely for the sake of revenue.
I have one example that I think a lot of healthcare consumers deal with - ridiculous prices for the uninsured.
The history is fascinating - in order to promote more transparency in the cost of healthcare, the gov't passed a law that defines "usual, customary and reasonable (UCR)" prices. This was because insurers used to just pay the bill, no questions asked (50+ years ago). Then they realized that the price for the same procedure varied a lot. So the law said that one could only charge the "usual and customary" price.
Sounds good right? Who wouldn't want to know the typical price?
Well, a part of that law was that the UCR price was the maximum that could be charged. There was no law about charging less.
So insurers start to negotiate discounts. Some insurers would get a discount, otherwise they pay UCR. That creates a huge incentive to push UCR as high as you can, otherwise you're potentially leaving money on the table if you get a random insurer willing to pay UCR.
So fast forward a few decades and the UCR prices have undergone astronomical inflation. No insurer pays U&C any more. In fact, they might pay 20-30% of U&C. It's nowhere close to "usual, customary and reasonable".
It wouldn't be a disaster if everyone had insurance because nobody pays it. But we do have uninsured and that's the price they're quoted now. $15,000 for an MRI that an insurer would pay $1500.
As they say, the road to hell is paved with good intentions.
The problem here seems to be that UCR prices are not correctly calculated, as the net prices that are actually paid, not label price. If UCR would be defined as the median of net prices charged in the last 24 months, inflation would halt. As for the correct way to infer net prices, it's a problem related to transfer pricing, for which good accounting practices exist, that would take into consideration exotic arrangements for paying back the discount, in stock, other contracts etc.
If UCR would be defined as the median of net prices charged in the last 24 months, inflation would halt.
They do something similar with drug prices for Medicare called Average Selling Price (ASP). That system gets gamed as well. In fact, it actually causes prices to rise.
Medicare requires hospitals to report pricing, so they have a decent sense as to what actual costs are. You could create a law saying you have to be within 20% of that price. It wouldn’t be perfect, but it might help.
Thanks for the specifics. The drug prices problem has a quite direct solution for single buyer systems: competitive tenders for generics, and QALY price ceilings for patent drugs. If a producer asks for a too high price compared to the health outcome of their drug, the total budget is reassigned among existing drugs, thus forcing all pharmaceutic companies to compete to deliver the best overall healthcare outcome for a given budget.
Too bad the politics in USA prevent this and dismiss it as "death panels", and people are led to believe the hard trade-offs in healthcare can somehow magically go away.
The 80/20 rule in the ACA has to be one of the most perverse incentives out there. It states 80% of premiums have to go to providing care, and all admin costs and profits have to come out of the remaining 20%.
It’s obvious why this might sound like a good idea, but only slightly less obvious why it’s a terrible one. It means that the primary mechanism available to increase profits is to drive up care spending as much as possible. Because if the 80% is a bigger number, the 20% will be too.
One small (but major) nuance: the 80/20 rule applies specifically to the _insurance_ business.
So what's another way to increase profits in addition to letting care spending keep creeping up? Add non-insurance lines of business to the company, i.e. vertically integrate by acquiring some of the middle men you're paying.
Insurers snatching up PBMs[1] (or in some cases, PBMs snatching up insurers) is one insidious example. For those unfamiliar, PBMs are the companies that manage your prescription benefits. Insurers negotiate a predictable rate card with the PBM for the drugs on their formulary, insulating the insurer from market and regional pricing volatility. The PBM then negotiates with all the various pharmacies on actual prices. So when you purchase a prescription:
1. You pay your share (a fixed copay for many plans)
2. If the price the PBM negotiated was more than your copay, the PBM pays the pharmacy the difference
3. The insurer then pays the PBM whatever pre-negotiated rate they have for that prescription
With the PBM deriving their revenue/profit from the spread they're able to generate in the process[2]. But when the insurer and PBM are one-in-the-same, that spread is really just an inter-company accounting transfer that ultimately rolls up to the same P&L. But it's a _magical_ inter-company transfer, as the insurer side of the books count it as a medical cost (part of the 80% spending requirement) and the PBM side of the books (that show it as revenue) aren't subject to the 80/20 requirements. And best of all, the insurers spent so many years letting cost inflation run rampant[3] that such egregious slight-of-hand easily passes the arms length test for transfer pricing[4].
[2] They also have other revenue streams, such as squeezing rebates out of drug manufacturers as well. But the simplified scenario above covers the gist of things, and illustrates the primary conflict of interest involved.
[3] As [1] mentioned with the CVS/Aetna example, PBMs can be far more profitable than insurers. CVS generated 2.5x more profit than Aetna when they merged.
Unclear why the downvotes - the system dynamics the parent is describing are valid. Insurers win over time if total costs go up in a predictable way. (Note: Not true for self-insured companies, such which includes essentially all large employers.)
Hence employers need to be removed from the equation so everyone ends up on healthcare.gov and there can be a whole bunch of insurance companies competing to keep premiums down so people purchase from them, just like car insurance.
The people who decide what treatments and tests are necessary are the doctors, so the marketing for this would have to be "buy our cheap insurance, we deny coverage to more testing and treatments than the other insurers do". Which is obviously not a winning strategy.
If you combine that with the increase in insurer owned clinics and hospitals (which unsurprisingly saw a sharp uptick around the time the ACA came into effect), then the insurance company gets to profit more twice. Once when they jack up the premiums, and a second time when those expenses show up as revenue in their other businesses.
I'm all for giving more power to consumers, but when you have a regulation that creates such a strong incentive for raising premiums, layering more haphazard regulation on top of it isn't going to help.
This works if there are multiple insurance companies competing for business, which would require everyone to be forced to healthcare.gov so there is a simple marketplace with sufficient number of insurance customers so that bad actors have competition.
And from my experience, the best healthcare is provided by Kaiser Permanente, which offers health insurance and healthcare under one company.
Pricing in medicine is jacked up because of low supply of workers (the grunt work is undesireable and doctors take a long time to license as well as residency funding restrictions), and infinite liability and legal costs that have to be priced in. On top of that, medicine is very complex, so you have to pay two or more very highly qualified people to double and triple check things.
Also, healthcare cost increases have slowed drastically since introduction of ACA:
It's a deep topic but I can cherry pick three big reasons for you in no particular order.
-Most hospitals and larger primary care installations are monopolies. There is not and cannot be for practical, zoning and regulatory reasons any sort of meaningful "competition". As a result most regulation and enforcement is toothless because no one wants the resulting problems of closing, even temporarily, a facility that is the only care for tens of thousands of people.
When there are no consequences for bad behaviors things tends toward a lowest common denominator. There are many examples but MLK Harbor Hospital strikes me as a particularly horrific one. It operated as one of the worst facilities in the US, by many objective and subjective measures, for 35+ years before it was finally closed.
-Healthcare, at it's base, is a resource allocation problem. When I last calculated what it would cost to provide every american with all of the healthcare they might reasonably consume which was 2019, that number was ~92 trillion dollars a year. We actually spend ~4 trillion. How do we decide who doesn't get the thing they should get at the time they should get it? We employ a pseudo-random system and as a result it is incredibly inefficient. Without getting into the deep dive that is healthcare costs I will just point out that the US has by far the largest number of acute care, ICU and trauma center services per capita anywhere in the world. For example we have seven times the number per capita that a country we are commonly compare to does, England. This is astronomically expensive. Without ultimately capping in some way the total resource expenditure per person this will continue. Is it a worthwhile use of resources to expend hundreds of thousands of dollars to extend someones life for 2 weeks? Maybe it depends on the someone, an 85 year old? An 8 year old? It's a very difficult set of questions that mostly just gets avoided.
-Patients do not have a rational sense of value when it comes to healthcare services. The US has very low taxes compared to much of the world and when you take that into account it has relatively low healthcare insurance premiums. I'm not saying they are low to people on an individual basis but it's a complex thing. Take canada. Every canadian individual including children is paying, at a minimum, ~$600 a month for healthcare in taxes. They don't think of it that way because it is lumped in to the tax bill. Many people in the US pay much less than this.
I have a friend who was recently complaining to me about a $700 ambulance bill. They were doing this as they were holding a brand new $1,000 iphone in their hand. I sat down with them and in a "napkin" spreadsheet created a fictitious ambulance service. They walked away thinking $600 was a pretty good deal. The inefficiency is patients put off a lot of things that are small due to cost. Those things dramatically exacerbate inefficiencies. See points 1 & 2.
> They [Canadians] don't think of it that way because it is lumped in to the tax bill. Many people in the US pay much less than this.
There’s a good chance that most Americans are paying less toward gov health expenditures than the average Canadian due to income inequality. But in aggregate, it is more per person.
> Most hospitals and larger primary care installations are monopolies. There is not and cannot be for practical, zoning and regulatory reasons any sort of meaningful "competition".
This, by itself, realistically rules out any sort of "free market" healthcare system.
American (income) taxes are not as low as people think they are, and if you consider that health insurance plans are a form of tax, then it can be higher in places like California or maybe a couple of % points less in other states with income tax.
As a former EHR dev many of our costs come from these very same systems too. Procedures auto added to people just for walking into a building. Usually I tell people to review the bill make sure all the procedures were actually done. Many are skipped. Because they are not really needed but are still billed for.
My exp is before the big conglomerates. Doctors when I did this were crazy cheap on what they would spend money on. This has sort of moved over to the cost center now and the doctors are the ones who get shorted along with everyone else.
These systems also create a sense of not knowing what is going on. They create a system to disincentive people for looking at ways to make it better. Only the bean counters and shareholders look into that. So you end up with very strange cost cutting initiatives.
Then we added mega insurance into the mix. Which has seemed to found out it is just dandy to pass the bill onto everyone while the costs go up and up. They were supposed to keep a lid on the prices. But they didn't. I do not hold out any hope for a 'medicare for all' system doing any better. The insurance companies have a good incentive to do better. The gov not so much.
I find that insane somehow the system drives itself to the ground.
I just left a govt agency clerk job. I couldn't resist making automation scripts. Due to politics I didn't talk about it. But on my last day I showed it to a tech-saavy dude saying this might help you going faster or at least give them a case to show the hierarchy things can be improved.
I wonder if this insider hack is the only way to push things around ..
> They dictate in many ways how software must work in medical settings.
Would it be possible for an EMR software vendor to ship both a "canonical" client interface that meets all the specs/requirements; and then a separate, secondary client interface, for the same backend, which isn't included in the "package" of EMR software sold to the clinic/hospital/etc., but rather is instead a "bottom-up adoption" play, with download links to it being passed around under-the-table between doctors?
If there's any potential for doctors being liable for such-and-such if they were found to not be "using" the primary client, then said secondary interface could be implemented as macro+screen-scraping software, that operates the primary client-interface underneath—much like Mint used to do before banks supported OFX export. Then just get it classified as accessibility software, like a screen reader, and let those doctors claim a need for it :)
As someone who as only barely dipped their development toes into the waters of EMR/EHR systems, medical arenas are not the place for workarounds, under the table systems, or creative re-routings.
There are two reasons for this: one, medical terminals are super, hilariously locked down. The medical systems I've worked on are ultra-hostile instances that are often centered around detecting and eradicating non-explicitly-authorized applications, even to the point of kneecapping actually-needed software.
Second and more practically, malpractice suits are vicious wars of discovery and bitter, knock-down-drag-out compliance fights. As with so many things, the legal fiction of accessibility software sounds nice but would not stand up to the scouring scrutiny of legal counsel and defendants with critical reasoning skills and powers of discussion (and deduction) above that of policy and compliance controls. I don't mean to belittle your idea at all, but much like the doctrine of Sovereign Citizens, all is well and good until you actually encounter a judge or human with reasoning skills and the ability to trivially perceive what's /actually/ going on, and then it all falls apart.
> all is well and good until you actually encounter a judge or human with reasoning skills and the ability to trivially perceive what's /actually/ going on, and then it all falls apart.
Not disagreeing at all! My suggestion was predicated on the idea that this particular medical regulation might be a "Type II" law. To explain — I feel like there are two types of law:
• Type I: law that has a logical "spirit" behind it (usually because it was drafted all-at-once by a small number of authors) where judges will interpret the law and violations against it as reasonable human beings do;
• Type II: law (usually more "regulation", but let's call it all "law" here) that is effectively the output of a continuously-iterating bureaucratic process; or law with a "spirit" that is obviously contravened by newer laws, but which still stands because no case has yet come to knock it down; or where there's no "spirit" to the law at all, just an infinite stream of under-the-table negotiated compromises, encoded as a huge book of requirements and exceptions.
Type II law includes, for examples: tariffs; statutory crimes; and created-by-fiat licensing schemes. Judges can't think like humans when deciding whether someone has violated a Type II law, because there's no human-legible rationale behind why the law exists. They have to just plug in the formula specified in the legal code, and see what happens.
I suspect that much of medical regulation is Type II law. Insofar as that's true, you could get away with a lot as long as you still adhere to the precise wording of the relevant requirements.
This particular case (EMR software) may indeed fall more under the provision of a Type I law/regulation, though.
A lot of the current situation came about because of the Hi-Tech act. This was piles of "free" government money for healthcare facilities to use software that met voluminous requirements that are ultimately vetted by off-shore contractors hired by "beltway bandit" type organizations far removed from medicine, patients, etc. The vetting costs in the neighborhood of $100k. This creates a powerful incentive for people making software to make software that is the easiest to push through the gauntlet of vetting. It also immediately ended meaningful innovation because once you have something approved you are not going to rock the boat trying new things the require another approval cycle.
Doctors are not tech-savvy, there is not doubt about that.
But the Micro$hit Window$ kludges I've seen in pretty much every doctor's office, with many instances of the doctor entering their credentials for login, and then waiting an ungodly amount of time to get in and to the medical s/w interface, is not helping either.
So windows 95 came out the year they left medical school, and had just finished residency when the internet became particular popular and broadband started being normal.
> Preventable medical error is almost certainly in the top 5 causes of deaths in the united states.
This is untrue, a very common myth based on a questionable study out of Johns Hopkins, which included known complications of medical procedures in the classification of "medical error."
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.
Also an MD, also hate our EMR because it is hot garbage, and I love your username.
My latest complaint is that the authors of our EMR, who I know to be legions of fresh out of college young twenty somethings (hardly anyone lasts long enough to be a senior engineer at this vendor, I am told), have not used any sort of helpful SDK for text input boxes, but instead have written their own, having inconsistent and wrong behavior with respect to keyboard based text selection, Ctl+backspace behavior and a variety of other well standardized functionalities.
...and they have written multiple different wrong implementations, as the text boxes behave differently in different parts of the EMR. Even the inconsistencies are inconsistent, like atrial fibrillation.
To be fair to Epic engineers, I don't think many of them want the system to be that way either--they may not be super-experienced, but that shit's more a product of ossification from decades of refusing to change much of anything (the company seriously considered forking VB6 to avoid going to .NET).
Individuals don't have much power to change an organizational culture riddled with NIH syndrome (the goddamn ticketing system, timekeeping system, and at some point in the dark past, the email system used internally were ALL written on top of the core EMR codebase) and cargo cult development (the people that /do/ stick around have a healthy share of people that couldn't easily get hired elsewhere on their merits, but do thrive in an environment where accumulating and regurgitating questionable tribal knowledge is crucial).
The system is a testament to the inertia of enterprise software: you can muddle along with a product end users hate while making a damn good profit because the system does deliver on its promises to its actual customers, the hospital admins that are primarily charged with reducing costs and increasing revenue.
The US medical system is so flush with cash and has such high barriers to entry that it doesn't really matter if software isn't great in some (important, but not important in a way that matters to decision makers) ways. The money keeps flowing, and continues concentrating power in the hands of major players. Something like the HITECH act /was/ needed, but lol if you think the people that bought a seat at the table to design it (but totally didn't--that would be corruption, and we don't have that in America!) didn't have a vested interest in pushing certain provisions. Save money by putting an EMR in place sooner, and accelerating vendor lock-in with the existing players? Sure, why not, everyone (for certain values of everyone) wins!
Thanks for posting this -- I didn't know this was the system we bought (am Danish).
The back story (for Denmark) is that we have been building our very own system since the 1990's at massive cost without getting very far, so by now the biggest commercial offering probably looks like a safe heaven.
Reasons the "in-house" systems never got far are a good story.
First, there is the normal insanity of hiring consultancies on cost-plus contracts to design and build a system that is "spec'd" by collecting wish lists from everywhere.
Despite this, things might have worked: A lot of my friends from uni started work at these consultancies and the story is that there was not much naked greed and cynicism, and that people really tried to come up with good systems.
The real killer was that Denmark, despite being a completely homogeneous country of 5m people with state-funded healthcare, did not opt to build a single system!? Healthcare is provided by the "regions", and the regions could not agree on buying a single system. Since Danes expect their medical records available across regions, the ministry of health then had to step in and provide a data interchange standard. Picture an insane XML-schema for every conceivable piece of medical information, coupled with granular access controls and origin metadata. And then mapping this schema faithfully to 5 different alternative representations...
We have the regions in Sweden too, and they too do their own thing. I think it might be better in 5 to 10 years, because the national parliament decided to integrate the software.
Lets not talk about the craven insurance industry or security or American healthcare for a moment. Lets let ourselves dream.
Most medical records don't capture enough information about a person longitudinally over time. I worked in a bank that had fantastic customer relationship management software that captured every interaction between the bank and customer and acted as a integration layer ontop of all services the bank provided. It was a stack based model where recent interactions went ontop and nothing could be deleted. You could find old scans of documents, letters the bank had sent and replies. The interaction between bank and customer over internet banking were all captured. I saw my own records from when I got my own account as a child and could see everything from then till now.
I've had a bunch of touch points with medical professionals relating to an eye injury in the last few years. From Emergency to Surgeons and specialists. A lot of information had to be repeated by my wife along the way whilst I a sat there blind.
I don't think special form support or really even business process support would be that useful. I just think having a single pile of client information that's in chronological order would really help doctors be able to stay on top of the issues at hand and then creating a culture of active documentation of actions by all staff so that patient records such as whats on the chart at the end of my bed get's onto my medical record by the end of shift or earlier each day.
I now keep a copy of the photos of my retina on a USB stick. It never fails - either I move and get a new ophthalmologist or they change systems and my old photos are lost/inaccessible. Having a history can be a big help to them in tracking my age-related vision issues, and so far every system is able to export a PNG/TIFF/JPG image.
Microsoft Health Vault was supposed to do something like this. The promotional materials said it was going to be a system that you and your medical professional could securely access, and be a central repository of your medical records, so you wouldn't have EMR vendor lock-in. It did OK for tracking immunizations (but I have a yellow WHO booklet for that..)
There have been several attempts at creating a personal health record system like Microsoft Health Vault. All have failed because providers have no incentive to cooperate. However it appears the Apple Health app is getting some traction and they have built interfaces to quite a few providers.
It’s the Carte Jaune (Yellow Card) which has a function of being a record of immunisations that is sometimes useful when travelling to or from regions with specific disease outbreaks (yellow fever, measles, polio etc). The US Government printing office may still print a version of this. https://en.m.wikipedia.org/wiki/Carte_Jaune
I told a doctor I'd received a few vaccinations but forgotten to bring the card, and they just added them with no other questions. I'm pretty sure that was true, but it's definitely not a very bulletproof set of credentials.
25 years ago when I was an intern, I worked for a healthcare software company on the interface team. Our job was to get records out of a hospital’s system and into a home care provider’s system. We were an early proponent of the HL7 standard and our customers were thrilled with not having to repeat information like you experienced.
But as you saw (pun intended), it hasn’t gone far. Every time I see my doctor I have to fill out the same forms and repeat the same information. Too bad my work didn’t go far.
Your doctor shouldn't be having you fill out the exact same information. Review of systems (like if you have a cough, etc) is fine, but all of your past history? It should just be what has changed or been added to your problem list since the last time they saw you.
It's like that in some places. Typically, the consequence is that you'll get a phonebook-sized file in no time, with so much cruft accumulated from prior encounters that the file will be next to useless.
This is a great point. As someone who receives a lot of medical records from various exports, I can just say that hundreds of pages for a healthy 11 YO only makes it easier to miss the important parts.
This just seems like lazy doctoring compounded by busy schedules. If you can't summarize what's going on succinctly, what was the point of all that training? God forbid you spend a little more time on patients.
It's one of those sectors where the people who are interested aren't good enough and the people who are good enough aren't interested.
No one really wants to do EMR software. Or medical software in general. They do it until they can do something else.
That and you have to work with doctors. And sorry to say, that is not exactly fun. You have people who think because they did a lot of school, that that makes them an expert in everything. And that their bikeshedding is the "real" important issue.
When I last worked with it, databases were the hot new thing. And I don't mean databases were new tech. I mean medical software was just catching on to storing data in databases.
I think one company was pushing a solution that was essentially a collection of Word templates. As if they had hit upon something not only novel, but that no one in history had thought to do.
If you're a software developer, eventually you get tired of pissing up rope and get a better job.
This reminds me of Blackboard and its competitor (I forget the name of it) in higher education: students hate it. Professors hate it. It's brutally hard to use. Professors can't easily adopt an alternative (as they can with by choosing Google Docs or Dropbox).
Desire2Learn appears to be the big competitor now (the university i worked at was completing the migration from Blackboard to D2L when i started. and the Uni System of Georgia followed suit.
Instructure Canvas is probably the more popular alternative right now, Moodle having always struggled with usability and manageability issues (and taking a long time to get a "modern" looking UI).
That said, during my student years I felt like Canvas was steadily converging on being as unusable as Blackboard, which maybe hints at some underlying pressures in that industry. I was involved peripherally in the decision-making process on a small university purchasing a new LMS, and the decision was amazingly political and driven by niche needs from vocal users, and I say this as someone who was pretty used to university politics at the time.
It seems like the way to get an LMS contract is to throw every feature you can possibly think of into the bucket, usability and quality isn't something that really gets evaluated very well. This probably could be changed but I'm not sure how. For example, the university I was with performed student surveys related to the food service vendor and incorporated the results of those surveys as a performance standard in the contract. Nothing like this was done for the LMS purchasing, no student input was collected at either the purchasing or performance stages, and a combination of purchasing methods and institutional politics meant that faculty input was extremely limited (the vendor was basically chosen before the faculty were invited to provide feedback). I don't think higher-ed IT departments often have a user-focused culture but instead a cost-focused one.
It's interesting, I've used four or five LMS' over my time as a student (Canvas, Blackboard, some k-12 ones, touched Moodle once). Canvas has been the only one I really liked. It works amazingly well at managing coursework, isn't slow, doesn't have a weird paradigm around groups vs courses vs sections. It's not confusing to use either, and they leave a graphiql client there on the hosted version if you want to pull your data yourself (and the API is great). I don't understand why people use Blackboard anymore if they can help it (although maybe it's better now?).
Canvas is free software, Instructure's main value add is a 24/7 support desk, operational expertise (not needed for small scale users) and custom software development.
Compared to Pearson's crummy web learning platform and the mess of perl that constituted my college's homegrown infrastructure, Canvas was the bright spot where when things went wrong you could get ahold of someone technically competent and helpful at 11pm the night before your test on Saturday.
Moodle is more or less fine, we use it quite successfully at the University of Geneva. It helped us a lot to organize remote classes during the pandemic. There were some quirks, but nothing on “enterprise-grade horror worthy of TheDailyWTF page” scale.
I remember one system whose idea of a backup was to make a copy of the MySQL database directory to another location on the same machine. Another system would transmit everything I wrote to the backend via HTTP with zero encryption. Lawyers tell me to record everything that happens yet all systems I've used don't let me add any information after the consult is finished, exposing me to legal liability.
I wish I had the time to make my own software... At this point I'd be most happy with just a text area where I can write anything I want. I'd love IDE-style features such as autocompletion for medications and tests. An inference engine for simple calculations would also be great. For example, if I write the patient's height and weight, the software should notice that it has enough information to derive the BMI and just do it.
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.
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.
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.
MD here too. I encourage you to stop and think about your defensive reaction to a tool you know well that's designed for exactly the purpose the client is looking for. OP, who I wager uses Epic every weekday for 5+ hours, has no idea about this tool and probably wishes existed (I'm guessing). It's probably not included in their software contract, or there are unnecessary HIPAA issues, or the IT person is not competent. Just some of the many issues.
On the radiology side, I know there are extensions and tools for PACS that the vendors can't be bothered to come explain/train, even though the company sold it to the hospital. It's like pulling teeth.
Valid point. My defensiveness was less directed towards OP's specific scenario but rather to the blanket statement that EHRs are broken in this way, when there are specific and high-quality tools designed specifically for data analysis. A lot of people, including myself, tend to put a lot of faith in HN comments about industries that we are not personally familiar with, and someone reading OP's comment would likely get the wrong impression about the state of the medical records industry.
There are certainly a million reasons why a doctor may not have access to or be able to use tools like Slicer Dicer, but most of those come down mainly to hospital policy. Amount and quality of training is certainly the biggest differentiation between clinician who are satisfied with Epic and those that hate it.
You are correct, I made a blanket statement based on what was apparently incorrect information. But, I'm glad I made it on HN, because I went from having an incorrect assumption to having a solution!
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?
There's still likely some good reason to do that work manually. The quality of data entry into EMRs is often poor, especially when it comes to event or time data that's not just numeric bloodwork. Imagine that at a random physicals date your patient was suddenly was 155kg and 65cm tall. Or for another example, having someone be inaccurately be diagnosed as having new onset diabetes after transplant, despite them having DM for several years prior. People switch up entry fields, inaccurately assess or diagnose patients all the time--generally because of the sheer variety of ways in which data can be screwed up, only a person can notice those oddities (or write a little script to fix them).
At population levels I could concede that these errors may well be inconsequential though.
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.
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.
> and you can't access those records remote due to HIPAA.
The person who told you that is misinformed. I have personally worked on products that allow physicians and staff to access patient records remotely in a safe and fully HIPAA compliant manner. It's incredibly common.
I think EHR vendors sometimes get unfairly blamed. The fault often lies with provider organizations who simply haven't turned on the available functionality.
Ha, exactly. UI/UX is precisely the area where Epic fails the most. I am not an expert in this area, but in my every day use, I can only describe the Epic style of UX as "vomit all information onto the screen at once."
Looking at the website right now, I see three different horizontal arrangements of links.
Of these links, there are four duplicate pairs, at least. Two of these sets of pairs lead to indistinctly named pages (/Home/InteroperabilityGuide and /Home/Interoperate)
I would start by having all of these links be at the top, and adding some descriptive text to each of the fields in the main body, as opposed to meaningless graphics/marketing numbers.
Addendum: Also, I wouldn't want to do the split in thirds thing that occupies the majority of the page. Each of those can get a description of at least a paragraph, and go one after the other. If there's not enough info to fill a paragraph, then they probably need to be merged.
This one isn't entirely their fault--it's legitimately a customer demand they've acquiesced to, and while they bear some blame for doing so, they're not the root of the issue there, users are.
There's a legitimate case for high-density, specialized interfaces that aren't focused on usability in the sense that you might find in more consumer-targeted software: the end users of these systems don't necessarily need something that's easy to learn or that presents only important info up front. Arguably they need the opposite: something that packs a lot of complex functionality and dense information into a small space is _good_ when your users are highly-specialized and frequently run through similar complex workflows. It's akin to a phone camera interface and a camera designed for professional photographers: the former eschews having ALL THE THINGS for accessibility, whereas the latter eschews accessibility for high info density and rapid access to tools because its users are okay putting in the time to learn something complex when getting over the learning curve will afford them a high degree of control and quick feedback.
Where things break down is customizability: expert tools, and especially expert software tools, suffer from "the user knows best, they can design their own UX" syndrome: this is true to a degree, but in the case of shared tools oft turns into one user (team lead X, who's been doing this shit for years! they know their shit!) designing something that works for them, or that replicates an existing workflow from elsewhere (just make it EXACTLY like the old paper charts! why would you do anything else? what do you mean the design considerations for a paper system might not perfectly transfer to a computer system?) in total ignorance of things they fail to do well. Computer systems, I think as an artifact of their relative novelty, lead users to believe they're experts in UX design by virtue of having (a) experience in the field the system serves and (b) having used a computer interface at some point in the past (and, in America, (c), broader cultural hubris about individual competency across disciplines based on competency in some unrelated highly-skilled field). Designing a truly good interface requires a dialog between user and designer, but we too often tend towards a "skilled user must be right, they're good at SOMETHING and therefore good at EVERYTHING" mindset. Enterprise software design provides customizability to a fault--we hear users want it, don't have enough time to actually sit down and try workflows with them, and they say they're skilled enough to do it themselves independently, so let em have at it.
I sometimes wonder what it'd be like in a world where "cars" were sold to ENTERPRISE DRIVING CABALS, full of VERY SKILLED DRIVERS, where the "car" in question ended up being a pile of sheet metal and control surfaces, a collection of engine and power train components, a big tub of asphalt, and a rough map of places people need to go, entrusted to a multitude of very experienced horse carriage drivers who each sought out to build their own bespoke personal vehicles and interstate highway system as they saw fit based on their own intuition and cunning, with nary a notion of needing to design something that worked for anyone else or wanting to take advantage of the new tech's more novel features. I doubt it would be a good one, but it would probably be hilarious to look at having driven on a somewhat saner system in a more thoughtfully designed vehicle.
Certainly that's an issue, but again you can't really blame the vendors if providers make extensive customizations to EHRs and then refuse to commit IT resources toward rolling out version upgrades.
Good luck actually using that, most deployments have the open-operability stuff specifically disabled, and it required many layers of bureaucracy to get it enabled and have keys issued.
Thankfully, TEFCA was implemented anyway, and is still on schedule.
We'll see what it works out to in practice. But data sharing is definitely still possible, today, even with Epic (they are quite good actually). You are limited to certain reasons but they are pretty broad.
Full disclosure: I work on this full time. It is a strange world, that works on its own standards and practices for good and bad reasons.
I know a whole bunch of nurses who won't shut up about how much they hate Epic. I watched my doctor try to use it once when I was in for a visit and he didn't seem to be enjoying the experience much either based on his grumbling. It seemed like there was a LOT of UI cluttering going on so I can understand how it might not be very easy to use.
Just a little personal anecdote but - A while back I had a week long stay in the hospital, after some small talk with one of my nurses she learned I write software. She told me a bunch of things they hated about Epic and gave me a quick tour of the interface they have to use. The main complaint seemed to be that things they need to do hundreds of times a day require way too many input actions. And it did indeed look incredibly cluttered.
I love getting little tours of software I'll likely never use even though I'm not in a position to fix any of the problems. It's just interesting.
Epic just unveiled a new user interface for nurses trying to address this exact issue. The problem, and another commenter pointed out, becomes everybody has a different idea of what they need quickest access to, and many hospitals want to customize to fit their existing workflows, even when that’s not ideal for speed of use.
Sure. Discoverability is great for new users to software. After the initial learning period I care far more about ease of performing repetitive actions. Discoverability is useless to me when I've already established a workflow and just want to perform known actions.
I was specifically talking about things they do hundreds of times a day (at least) like dispensing medication, requesting medication, inputting vitals, taking notes, etc. Those things shouldn't require 10-15 clicks and 4 different modals/menus each time. They're extremely common use cases that a nurse will likely be performing a number of times in every single room they enter.
And why shouldn't they have an opinion on what is important? They're the ones using the software all day!
> After the initial learning period I care far more about ease of performing repetitive actions. Discoverability is useless to me when I've already established a workflow and just want to perform known actions.
I once got in trouble for using autohotkey for something like this. Like, wow were they upset with me.
In a clinic or hospital setting, there's always going to be someone on an initial learning period. So while discoverability may be "useless" to you, it's not useless to everyone.
The issue is also what's important for one use is not important for another. The person dispensing medication may not be the same person taking vitals, etc.
And it might be the common use case for that nurse, but another nurse may have a different workflow. What works for cardiovascular doesn't work for ophthalmology.
And all these people think they're equally important. They all want the same priority.
Not to mention, most people are bad at UX design. So while they should have opinions, they should not be the only consideration.
1, 2, 15, 100, the number of clicks doesn't really matter.
It's like measuring code quality by line count.
It's Spinal Tap. "But it's one less click, innit?" If it takes you 10 seconds to find the one place to click or requires such heavy front-loading that it slows down the system on every click, you've already failed. Doing more of the thing that caused you to fail is a hole with no bottom.
Second, the engineers and UX designers aren't the people really driving the design process. That's a problem. The people driving the design process don't know what they're doing. Because everyone things UX design is easy. It's not. It's hard. People think they know what they want, but the don't really. What they know is what they want to do. But they get it wrapped up in their mind that what and how are interchangeable. So "I want to prescribe medicine easy." becomes "Prescriptions need to be one click".
Maybe they don't really. Maybe to make them easier to do, they need to be in a context menu or something else. I don't know either. I'm not a UX designer by trade. Because I know it's hard.
I don't think it is, at all. And counting clicks isn't a fools game - it's a direct metric for how buried simple tasks are. Do you need 15 clicks to restart the process you're debugging? No, it's one click on the debug window. This is no different.
>"But it's one less click, innit?" If it takes you 10 seconds to find the one place to click or requires such heavy front-loading that it slows down the system on every click, you've already failed. Doing more of the thing that caused you to fail is a hole with no bottom.
Why would it take the nurse 10 seconds to find a button or place to click for an action they've performed thousands of times?
We've already established that new nurses have a training program to get familiar with the system. You don't think they are just hired and then thrown into 'go take care of this hallway by yourself' do you? And whats better - front loading so they can select a patient as they enter the room and let it all load up while getting ready to treat (confirm name, start gathering data, etc), or waiting 5 seconds every single time they click anything? Oops, clicked the wrong thing there - thats 10 seconds to let it load, back out, then select the right thing.
You can argue discoverability all you want - but go stay a week in a hospital and observe the people actually using the software. Watch how 3/4 of the time they're in your room they're fighting with the computer to perform simple tasks. Tasks they know how to do, but take way too long because of the clutter and poor design of the system. Watch them click 15 times through 4 different windows to dispense a medication - which they'll do 8 times a day just for you. Multiply by that by all the patients they're responsible for. Do you see the problem yet?
It feels like I'm saying 'make it easier to use for the people who use it' and you're saying 'no make it shinier so anyone off the street can use it' lol. Maybe we're actually saying similar things - just not aligning thoughts well?
> We've already established that new nurses have a training program to get familiar with the system
You've made the claim. But really, that's just washing your hands of the problem. I've been part of that training. I'd call it a joke, but there's nothing funny about it. You aren't going to get familiar with these systems in an afternoon seminar with the vendor's representatives.
You say this:
> You can argue discoverability all you want -
Then just make my argument for me.
> because of the clutter and poor design of the system
Reducing clutter would make things more discoverable. Making things discoverable is part of good desing.
I'm not saying "make it shinier". That's a poor inference on your part.
I'm saying the metrics by which we are using to design these systems are just flat out wrong. They are confusing the what with the how. And I'm not even getting into how sometimes you actually want things to be complex or hard to reach because you want the action to be deliberate.
Counting clicks is wrong. And anyone who advocates for it is also wrong. Discoverablity makes things easier to use. For the people who use it. You have this platonic ideal of a user who always knows the software in and out. That user does not exist. Any given user will only really use about 20% of the software, but every user will use a different 20%. So that other 80% needs to be discoverable. You shouldn't need to memorize or hunt down on a screen of options for it.
And since that 80% is different for all users, it logically follows that the entire system needs to be discoverable.
And that's not to say you can't implement shortcuts and hotkeys and what not. But really, any software shouldn't be making people think to much about how they're doing something so they can focus on what they're doing.
Your whole argument basically boils down to 'I somehow know better than the people who use the software for hours nearly every day and will disregard their usability complaints'. I think that is pretty arrogant and dismissive towards the users. I don't see us making any ground in this conversation so I'm going to leave it.
Not myself. But someone. Some people make it their job to figure this stuff out. UX design is a skill. A skill you have to train and study.
The idea that users themselves know how to make something usable is just as misguided as what you're accusing me of. It's like assuming that most people are good chefs because they have a lot of experience eating.
They can tell us whether something is bad or not, but they can't tell us how to make it good. Don't confuse the former for the latter.
They aren't exclusive. Something that is easily discovered gives you an efficiency of thought.
But "number of clicks" isn't a measure of efficiency.
What's the time from thought to action? That should be our main concern. If that takes one click, five clicks, ten thousand click, it doesn't matter. Thought to action.
At the end of the day, it's a simple record of the patient, not an IDE. Nurses need to see stuff, MDs need to see stuff.
FWIW, my goddamn opinion: Epic is probably the best EMR I've used, but I can still see some random dude's dog in Bolivia on FB faster than I can pull up a patient's critical lab values during a procedure. Not too worried about missing out on "Now your EMR comes with customizable colors! [dismiss]"
Batch loads are usually faster. Regardless, no it's not a different problem. It's THE problem. Clinicians need to go fast, and EMRs slow them down. If everything is a single click away from the landing page, they'll go much faster and in their eyes it's the only thing that matters even if it goes against any kind of common sense.
At my hospital the nursing UI of Epic is absolutely horrid. It's cluttered and confusing with multiple places to document everything.
Epic is completely customizable, but the people who make the decisions in nursing management aren't always the same people using the software. That and funding to make the changes.
If you want to see really bad software take a look at Meditech it defaults 800x600 (!), and doesn't resize well at all.
Ah yes, I am still forced to use Meditech's telnet interface today. I asked our IT guy if we can please change the font to a smoothed, non-raster font. I think it took all his willpower to not burst out laughing lol
MD here. Epic is terrible, as are all other EMRs that I have used (with the exception of VA's older software). I use Epic every day and I am ready to jump ship from medicine altogether to help build an EMR that could actually work well for both health care providers and patients. There is no excuse for such poorly executed software, especially the UI/UX.
All EHRs are bad, some are just worse than others. With the right build, Epic is one of the least bad. But the wrong build can really be soul-destroying.
By any chance have you used GNU Health[0] at all? I'm guessing no since it's uncommon in the US/NZ, but figured I'd ask just in case. Curious what your impression of it would be as an MD.
Does anyone in high-income countries use something like that? It is worth nothing that the software product itself is only a tiny part of implementing most enterprise software projects.
Maybe not, but if the EHR systems used in high-income countries are as universally awful as I've heard from doctors, and if GNU Health is at all better... I'd ask why not then!
Billing and marketing is likely the reason. There is no one responding to RFPs advocating for GNU Health, and it likely is not up to scratch for medical billing/automated overbilling of insurance providers.
EHRs in the USA, Germany and other countries with numerous health insurance providers are primarily there to ensure every service and tools used is billed fully (or overbilled).
Because the EHR system is not itself an independent system, but part of a broader complex that also includes handling of financial transactions, and financial transactions are what moves money.
GNU Health’s support for the whole set of pre-authorization, billing, payment, and related transactions seems to be...generating manual invoices.
A good text user interface, keyboards that can record and play back keystrokes for getting around the menus, customizable per user, and responsiveness.
"Speed" (latency of response) has always been the number one user interface problem of all interactive software and it still is.
It seems like they never watched an end user use their product. Like, who re-invents the 'Page Next' function? Just put a blue underlined "Next Page" button at the bottom of the list like we've done for decades.
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:
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.
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.
To be fair, the people who use enterprise software typically only understand a single-digit percentage of what the software needs to do, at best. If you asked them to design it, you wouldn't get a better result.
To properly architect enterprise software, you need to capture the competing needs and goals of hundreds of different roles in different departments. You will uncover underlying political and organizational issues that you will need leadership to sort out before you can ever start to determine the business-logic. To be successful, you have to be an expert at playing politics, business analysis, and mediating conflict.
I wouldn't say "enterprise software sucks"... more like, the lack of cooperation in many organizations sucks, and enterprise software puts a big spotlight on it.
> To be fair, the people who use enterprise software typically only understand a single-digit percentage of what the software needs to do, at best. If you asked them to design it, you wouldn't get a better result.
Sure, users don't know what a system needs to do to meet their needs, but if you had modestly competent business analysts work with them to specify the system, you'd have good results.
The role of systems analyst (nowadays confusingly called business analyst) seesm to have largely vanished in the beliefs that either COTS enterprise software would be used as it came, or that users know what they need (as opposed to what they want) and can rationally set priorities and tradeoffs.
Turns out neither of those beliefs was true, and systems analysts are needed. With the passage of time the role has largely been forgotten.
> The role of systems analyst (nowadays confusingly called business analyst)
Classical systems analysts were, as I understand it, usually the more experienced programmers on a project, and had a role that combined the more recent technical architect and business analyst roles, so they aren't interchangeable with BAs, who often are nonprogrammers, and in any case are viewed as less technical than developers.
> seesm to have largely vanished in the beliefs that either COTS enterprise software would be used as it came, or that users know what they need (as opposed to what they want) and can rationally set priorities and tradeoffs.
In theory, the kind of requirement that is the role of a system or business analyst in other development methodologies seems to be largely shoveled into the responsibilities of the omnicompetent development team in Agile methodologies, though some of it also seems to fall into the product owner bucket in methodologies with that role.
I do think that that the requirements elicitation and analysis skills that go with that role have become undervalued because there is an idea that incremental iteration means you never need to look at requirements in a structured way. I don't think this is even approximately correct, but it seems to be the thinking.
That'll get you part way there -- but for a truly enterprise-wide deployment you also need analysts with deep cross-divisional understanding and some degree of cross-divisional political capital.
Often, organizations that try to do this internally have their business analysts inherently shackled to a specific department or division by nature of the org chart. It is the interdepartmental conflicts that are the hardest to mitigate.
This is one of the lesser-spoken reasons that higher-ups call in consultants -- they have a better ability to short-circuit the org chart and haven't been around long enough to piss off that one director, Karen.
Also the devs who write the software never actually need to use it. Developer tools such as editors and compilers are of high quality (relatively, of course) because developers use these tools while working on said tools. Many developers doing enterprise software don't even have a rudimentary idea of the work flow around the app that they're developing. Consequently, they are unable to design an effective and efficient app.
Yes and no. People can force software on your office computer but not on your private laptop, tablet and raspis. And even on windows computers you will find ways to install software without admin rights (e.g. Putty doesn't need any admin rights). Therefore I would argue the main thing missing is a desire to conquer the computer as a tool, a tool that might save hours of work time, that might help analyse problems more efficiently than a human brain can, that can help outperform one's colleagues.
With a desire to conquer the computer, open source, and exchanging knowledge online, actually many private enthusiasts who can't afford medical care or won't get the right one can already help themselves. And they have not studied as long or hard as most medical people do. I.e. a doctor with the right spirit should be able to achieve a lot more than such hobby enthusiasts.
And with that passion and knowledge the medical community as a whole would slowly also force better software into their work environments. They know how to hold conferences and argue with facts.
It's hard to blame others if you belong to one of the smartest tribes on the planet.
That's not really true. There are open-sourced EHMR's, consumer-facing emrs and in-house built EMRs. They all suck, and there are many reasons for it which are not this one.
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.
Having worked for a company producing software like this, the EHR and Practice Management/Billing components were essentially separate products. Analytics was separate as well. Those were the three big tentpoles, and they would all talk to or depend on each other, but shared very little code and were of course doing completely different things.
You're kind of right though in that it never felt like we did anything because it's what patients or providers wanted. We didn't do things if we were afraid providers wouldn't like it, but a lot of work seemed to be mostly driven by regulatory requirements (meaningful use, icd10, etc.).
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.
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.
It's a more generic problem than that. It's that the purchase requirements of the system are not controlled by the users. There are billing requirements, sure, but also regulatory requirements and hospital administrator requirements etc.
The result is that the number of companies offering a system that meets all the bureaucratic requirements is small, because doing so is arduous and expensive and disheartening. So the few that exist don't have a lot of competition and people still use their product even if it's miserable. People not using their product would have been their incentive to make it better to use, and the disincentive that making it better costs money is still there, so they don't.
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.
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.
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.
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!
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.
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.
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!
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.
Partly generational, partly how ingrained habits/preferences are.
I had to switch from my primary care about a year ago. (He was getting out of doing primary care work because, he said, he had a small practice and just couldn't deal with the paperwork.) From the beginning, he really resisted the computerized systems and probably complained about them pretty much every time I was in for a physical.
My new primary care, in the same hospital system, and not that much younger at least gives the appearance of encouraging things like tele-medicine, using the medical portal, and so forth.
On the contrary. Young docs hate EMRs with unrivaled passion. I am personally convinced that EMRs are a frequent indirect cause of suicide among young docs.
> 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.
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:
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.
Epic's founder, Judy Faulkner, is the fourth richest self made woman in the US. She's the CEO of one of the largest companies in the health tech industry, and almost no one has heard of her.
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.
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.
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.
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...).
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).
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.
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).
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Do tech support for a hospital and this attitude will very quickly dissipate.
>In my experience, the contrast is stark to another high-paid professional group: lawyers.
Database systems like WestLaw & word processing systems in the 80s and 90s were killer apps for law offices, so if lawyers are tech illiterate it's a recent phenomenon.
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.
>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.
Anecdotally, I disagree with this, for both lawyers and doctors.
I know several doctors my age and younger that cannot stand using any computer or laptop, while my best friend’s father, a surgeon, had one of the first HP color flatbed scanners (SCSI) and the only person I knew to have an ISDN line.
My cousin is about a decade older than me, and I remember spending the night at his house with his TRS-80 and Apple II computers. He is an attorney.
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.
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.
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.
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?
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
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.
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.
I'm sure it depends on the country. Denmark currently have five different systems for hospital records, which communicates poorly or not at all. So records from on region has to be manually send to hospitals in other regions. I the future I believe we'll be down to two or three systems, one of which is Epic and the other is developed by a Danish company.
As for pay, pretty much as in the US, each visit to a doctor as a value, but the bill is handled by the local region. Denmark has five Regions, each responsible for the healthcare in that geographic area. The regions are given a sum of money by the state each year, to cover the cost of operating the healthcare system and pay for doctors, hospitals, ambulances and so on.
It's a little complicated, but for instant: I need to see my doctor tomorrow, he'll be paid a fixed amount for that consultation. A consultation is defined as 12 minutes. That's 12 minutes to say "Hi", diagnose, write a prescription (if needed), talk to me about treatment and document everything.
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.
I'm going to take some guesses here but I'd love to hear a discussion about this from people with experience in medical software.
Medical software seems like it is rife with mandated requirements, likely written by people with no regard to real-world usage implications. By this I mean decisions that are akin to attempting to increase security by password complexity and expiry requirements -- when the reality is that decreases security by making users write down and/or cycle through easily-predictable passwords.
I would also guess the purchase cycle is very disconnected from its users. The people actually making the buying decisions never actually touch the software. This is probably also like a lot of enterprise software: very expensive, long contract/license lengths, high switching costs.
A relatively minor point but there's also no dogfooding: The developers building the software are not medical professionals and thus never use it themselves. They don't get to see the daily pain.
The result of all this would be very little incentive to build anything beyond "working" software -- spending time on UX or UI design just eats into profits. The type of developers/PMs/etc that excel at and advocate for this type of work are likely not going to stick around (or even work there in the first place), making improvements even less likely.
Have spent decade more or less as health tech security and privacy consultant, checking in.
Requirements come from the institutions that fund the solutions ("solutions," not products) and not the users themselves, so engagement with end users is limited. It's very waterfall, no product managers, just "business analysts," whose only leverage is their perceived relationship with "the client," who may or may not be represented by an actual user.
I've thought a lot about how to disrupt healthcare, and the only viable way I can think of doing it is selling new products into emerging markets that don't yet have ensconced bureaucracies running health. The most successful grassroots medical product I am aware of is "Figure 1," but any product going into western world healthcare is going to be %95 enterprise solution and %5 health related.
An "Uber for stitches" product would be illegal in most countries, but that's the only kind of innovation I can see driving change for most people.
And, in the case of the software being discussed, eliminated or nearly eliminated the ability of office staff to handle those sorts of details. Additionally, it apparently failed to have reasonable defaults (active user isn't defaulted into the physician providing care; current date isn't defaulted into the date field for a note).
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.
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...
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.
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.
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.
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.
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.
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)..
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.
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"
tldr; information overload, reduced actual time with patients and increased time entering bunch of information into computers, summary from 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.
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.