6 ms·

As far as I can tell, there's no economic incentive for health care systems to undergo these transformations willingly. Remember, the digital transformation did

by fny 10y ago

As far as I can tell, there's no economic incentive for health care systems to undergo these transformations willingly. Remember, the digital transformation didn't occur until the HITECH act in 2009, which mandated the use of electronic health records. Why digitize your operations and worry about maintaining tech infrastructure when you can do everything on paper with a handful of secretaries? You could argue providing better data-driven healthcare to patients, but guess what--most health systems don't care because they make money every time you get sick.[0] With HITECH, the government forced them to transition to EHRs, and here's what hospital systems optimized for... 1. Reliability 2. Optimizing billing 3. Guaranteeing compliance with different protocols, particularly those related to billing Openess? Interoperability? They don't care. You're piling on more technical and administrative costs without the promise of future returns. > ensuring highly trained individuals have half decent tools would be a huge goal for society - but almost all healthcare software is still frankly, terrible. You know who hates EHRs the most? Doctors. Do you know who loves them? Hospital administrators. Guess who pays for the EHR? ;) [0]: An exception to this is Kaiser Permanente. They insure the patients for which they care, so they're incetivized to improve health to reduce costs over time.

JusticeJuice 10y ago
> As far as I can tell, there's no economic incentive for health care systems to undergo these transformations willingly Yes. Thing is, say you have shitty software and see 20 patients in one day. Say you have fantastic software - you'll probably still only see 20 patients a day. The cost of upgrading is usually not justified if it doesn't hit the bottom line. I'm trying to tackle this by making a system where improving it isn't a huge risk, or cost. For example, it has an extensible user interface - imagine something like atom text editor, or even browser extensions. Say you look at the immunization screen all day, and hate it. Find / build a small extension to arange it how you want, without changing any of the back-end system, and then share it to a registry for other people in your situation. Easy win. I'm actually designing this system within the context of primary care in New Zealand. We have a socialized healthcare system, which is honestly very effective. Everybody pays for it via tax, and resources are evenly distributed. We even bulk purchase generic drugs for the entire country. There isn't so much of an evil incentive to ensure all their 'customers' stay sick, but instead funding is a bit hard to come by. Funding happens regionally, and building national healthcare software systems is a huge task nobody but the government is willing to try. The market is so small (population of 4mill) that vendors can usually make more money elsewhere - so getting NZ tailored solutions is rare. This is why I think the opportunity is in making a crowdsourced system, as opposed to a 'product' to sell.
- fny 10y ago
  I have no idea what the market is like in New Zealand, so my insights there are limited, but a lot of EMR systems in the US have a similar notion of customizability built into the interface. Epic, the largest EHR vendor in the US, for example, doesn't sell a one size fits all solution. Hospitals develop their own GUIs and workflows within Epic, but again, hospital administrators make all the UX/UI decisions while optimizing for documentation that bolsters billing. Again, the doctors lose. For small practices, this might be a viable solution, but then again, they'd probably rather purchase a complete IT solution than something that handles medical records alone. Also, have you looked at OpenMRS?[0] They have a module system that allows you to develop extensions to the EHR.[1] If you're looking for your thesis to have a big impact, I'd really recommend getting in touch with an organization like OpenMRS or Partners Healthcare to see how you can extend their platforms. If you want an introduction, drop me a note: faraz dot yashar at the gmail. [0]: https://openmrs.org https://openmrs.org [1]: https://modules.openmrs.org/ https://modules.openmrs.org/
  - ryanSrich 10y ago
    The reason why so many EHRs are poorly designed is in part because they are so flexible. Don't under estimate the ego of a physician to think their way is superior to the way the doctor down the road does something. The EHR model will eventually lose because its one sided. Consumers and patients are completely left out of the picture and EHRs have no incentives right now to change. Beyond that companies like Epic are operating on outdated business models. The days of the black box of data that lives inside the four walls of the health system are numbered. Consumers won't deal with a dumpster fire of technology once they have the choice. Digital health will win once the barriers of compliance and interoperability are broken down.
    - iheartmemcache 10y ago
      SQL has 'interoperability' re: an ANSI standard. Theoretically you should be able to get off all those old Oracle contracts right? Eventually there are little nuanced things that users end up building their workflow completely around. Even if you change no functionality and just slightly alter the GUI, you're going to have complaints that something is broken. Inertia is your #1 vendor lock in feature. EPIC is as golden as Oracle just due to resident incumbency. #2 is the whole risk aversion thing. Any platform migration is going to have political risk attached to it. Nike won't move away from Oracle even if Postgres can do everything it can line for line because paying the $200k maintenance fee each quarter is a cheap recurring cost compared to the political risk of a failed project. That's not even factoring in #3, the little features here and there which are value-adds to the platform and not part of the standard. I've inherited projects where my firm offers to support O&M for some poorly written ASP 1.1 Classic software. We'll go in, patch some business-logic bug, and get a phone-call later that afternoon asking to rollback our fix. Turns out their users had integrated bugs into their workflow such that when the software operates "properly" (i.e. 'to spec') it actually breaks things (i.e. stops operating in an expected fashion).
Spooky23 10y ago
I don't see why any physician implements an EMR. My family doctor, who was part of a midsize practice was punished hard by adopting a system. They did it in 2007 thinking they would save money... which didn't happen as they were only able to eliminate 1/4 clerk positions and had to pick up an IT guy and a consultant. Then they really got the shaft when the solution they chose wasn't meeting Medicare guidelines. They ended up getting another system that is worse. Now they got swallowed up by a regional medical system and have yet another EMR, plus they have 6 clerical staff versus 3 and whatever outsourcer handles IT for the hospital system. My other doctor friend is a ophamologist. It's a small practice with 3 full time and 1 part time doctor. They pay the fine every year for not having an EMR and use paper and have a standalone system for sending prescriptions. He is enormously happy with paper and feels that's it better in every way, including cost. I agree -- I see zero value in the EMR systems.
- nickpsecurity 10y ago
  I saw one system that seemed like a must have: apps that ensure you got the prescription right. Paper-loving doctors screwing up prescriptions harms a lot of patients. Especially when they insist on writing in cursive. Much of your post seems to be about bad tech, though. It could mostly be mitigated with a supplier that gave a shit.
  - Spooky23 10y ago
    Prescriptions ordered electronically seems to be the only thing that is an improvement. Everything else is not only bad IT, but ruins your interactions because the medicinal person is bent over a laptop.
  - gm-conspiracy 10y ago
    Also sounds like a shitty pharmacist and pharmacy tech.
    - nickpsecurity 10y ago
      I'm not going that far. What I read implied it was either a mental slip or illegible writing. Some of the drug names look similar when they're written in chicken scratch.
ryanSrich 10y ago
When patients are treated as consumers we'll see the wave of economic incentives. Value based care as part of the ACA is headed in the right direction.
- AethaPeterson 10y ago
  I can assure you, that no patient is a willing "customer" or "consumer" of healthcare. True 'consumers' or 'customers' have a choice to buy something or not. If you are a sick patient, there is no choice. As a physician and subspecialist I have invested 24+ years of education to achieve this title. Its degrading to our profession and patients to refer to us doctors as 'providers' and to patients as 'consumers'. This takeover of healthcare by MBA-speak is one of the most irksome trends, and rebranding patients as "consumers" is a patently false equivalence.
doctorpangloss 10y ago
> ...exception to this is Kaiser Permanente They are notorious in the medical community for valuing efficiency above all else. Kaiser also doesn't serve extremely difficult cases, uninsured patients or patients on Medicaid. Academic hospitals do. Kaiser can do a lot of things differently by virtue of being subsidized by the generosity of the state and the state's highly talented doctors. I don't know how much there is to learn from them. > they make money every time you get sick Nobody at an academic hospital makes money every time you get sick. Discharging patients is a high priority. Doctors are constantly trying to figure out how to do preventative care with the sorts of "frequent flyer" patients that tie up emergency rooms and hospital beds. To be more blunt, you're not really describing reality. You're describing a particularly cynical point of view, common among people who are unlucky enough to be (or to know someone) rich, sick and not getting better. It's doctor as antagonist, and it tends to emerge in some kind of economic rationalization. Here's reality: Mark Zuckerberg put his name on an academic hospital in San Francisco that has utterly dysfunctional EHR. Everyone in the system—especially the doctors, contrary to what you say—hates it and wishes the money would have been spent to improve it. Even the tech fantasy of magic money wand can't solve this problem. It isn't the fault of doctors ("you know who hates EHRs the most? Doctors"). No clever turn of the phrase or insight is going to provide the answer. Blah-blah-blahing about incentives isn't going to provide any solutions. It's a complex system. The original poster was saying as much. But then all the other commenters go on and start talking about economics, incentives, anecdotes, and assorted conspiracy theories. The guy is studying this! I think he's coming to the right answers.
- fny 10y ago
  I work at an academic hospital, and I've seen how the incentives drive policy. Frankly, it's terrifying. > Nobody at an academic hospital makes money every time you get sick. Of course they do! Every time you go in for treatment, they make money, and there only incentives for preventative care come from government/Medicare mandates (e.g. hospital readmissions, ACOs.) Let me color the picture a bit more vividly. At a public pitch competition within the university, a department head--and judge of the competition--laughed at an ML start up: "you do realize we make money from the procedures you're trying to prevent." > Discharging patients is a high priority. Hospitals are often penalized for long stays by insurance. > Doctors are constantly trying to figure out how to do preventative care with the sorts of "frequent flyer" patients that tie up emergency rooms and hospital beds. Aside from tying up resources, high-utilizers can't afford to pay for services and the hospitals treat them at a massive loss. Naturally, a hospital would like to free up these resources for patients who can pay. > It's doctor as antagonist. I never said this, and nor do I believe this. Doctors are victims of this system. I even made the point that doctors hate the EHR because it's been warped by hospital administrators into a billing-centric machine with umpteen documentation requirements at every turn. For this reason, many who went into medicine for altruistic reasons end up disenchanted with the health system that's been wrecked by those running the business.
fredsmith42 10y ago
Um, what? I've spent 20 years implementing EHRs. You seem to be implying that hospitals were using paper until 2009. I've implemented lab systems with electronic charts in VMS. The systems weren't, and aren't, interoperable, but they were definitely recognizable as EMRs.
- acveilleux 10y ago
  He's probably limiting the definition to the kind of overarching EMR that fully replaces paper charts for all departments and provide a single view of the patients. I've also done migrations (I'm in radiology systems, PACS and RIS) where clients had reports going back to the early 1980s. Not very common mind you, especially in private practices (which we get a lot of) and rural hospitals (the kind of places with CPSI/Evident or, god forbid, Healthland.)
ThomPete 10y ago
I agree with everything you say besides the claim there is no economic incentive. Just a few 1) Getting patients to pay their bills. 2) Spending less time on each patient. 3) Reducing errors. All these have economic incentives. But yes it's still a hard sell.
- deleted 10y ago
  [deleted]
nradov 10y ago
It's no longer necessarily true that providers make money every time you get sick. Insurers have shifted risk to providers in some areas in the form of accountable care organizations (ACOs) which receive a flat fee per patient. So in theory the ACOs have a financial incentive to prevent you from getting sick. Kaiser Permanente uses the same Epic EMR software as many other large provider organizations.
- gmarx 10y ago
  In fact they were essentially the first and the reason it has become a near monolopoly
  - fny 10y ago
    Kaiser was, however, one the first systems to start (2000) and finish (2010) their electronic transition. Their decision had nothing to do with the government mandate in 2009, precisely because their business depended on it. Also, don't forget that EHRs don't come with a data governance model, so the entire onus of maintaining clean, available, interoperable data falls on the institution. Again, since Kaiser depends on clean, available, interoperable data, they made that a priority both internally and in their contracts with Epic.
- fny 10y ago
  And I have seen shifts that ACOs have caused first hand! Unfortunately, the only insurer running ACOs is Medicare which is an example of a political solution to the problem. While we have yet to see what the financial implications of ACOs are, I can say that I've seen admins work hard to develop data-oriented preventative care. However, these advances are still only limited to the ACO population, which gets back to my point. Hospitals aren't going to fund patient risk analysis until the economic incentives are in place, and for that reason, I fear that the issue of bad interoperability will exist for as long as we live in a "fee-for-service" world. As for Kaiser adopting Epic, remember I noted that hospitals can customize the EHR to their needs in detail--it does however require troves of cash. Since Kaiser heavily relies on data-driven preventative care as part of their business model, they pay to have a lot of data systems in place to facilitate their operations. Hell, Kaiser even had an Open API since 2013!![0] Good luck finding that anywhere else! [0]: http://interchange.kp.org/ http://interchange.kp.org/
deleted 10y ago
[deleted]
organsnyder 10y ago
There is absolutely an incentive for healthcare systems to do these transformations. But it requires leadership that is willing and able to see the long-term benefits. Of course, that can be challenging, and is probably only feasible in larger nonprofits (for-profits need to please shareholders, and smaller organizations simply can't afford it), but the future payoff is there. I think we're in the turd-age (opposite of golden age) of EMRs right now. Everyone has adopted them—many unwillingly—but user interfaces are still terrible, and interoperability is spotty at best. There are signs of this changing (lots of vendors are touting/promising UX improvements, and FHIR is hot right now), but it will still take time.

by fny 10y ago

JusticeJuice 10y ago

> As far as I can tell, there's no economic incentive for health care systems to undergo these transformations willingly Yes. Thing is, say you have shitty software and see 20 patients in one day. Say you have fantastic software - you'll probably still only see 20 patients a day. The cost of upgrading is usually not justified if it doesn't hit the bottom line. I'm trying to tackle this by making a system where improving it isn't a huge risk, or cost. For example, it has an extensible user interface - imagine something like atom text editor, or even browser extensions. Say you look at the immunization screen all day, and hate it. Find / build a small extension to arange it how you want, without changing any of the back-end system, and then share it to a registry for other people in your situation. Easy win. I'm actually designing this system within the context of primary care in New Zealand. We have a socialized healthcare system, which is honestly very effective. Everybody pays for it via tax, and resources are evenly distributed. We even bulk purchase generic drugs for the entire country. There isn't so much of an evil incentive to ensure all their 'customers' stay sick, but instead funding is a bit hard to come by. Funding happens regionally, and building national healthcare software systems is a huge task nobody but the government is willing to try. The market is so small (population of 4mill) that vendors can usually make more money elsewhere - so getting NZ tailored solutions is rare. This is why I think the opportunity is in making a crowdsourced system, as opposed to a 'product' to sell.

fny 10y ago
I have no idea what the market is like in New Zealand, so my insights there are limited, but a lot of EMR systems in the US have a similar notion of customizability built into the interface. Epic, the largest EHR vendor in the US, for example, doesn't sell a one size fits all solution. Hospitals develop their own GUIs and workflows within Epic, but again, hospital administrators make all the UX/UI decisions while optimizing for documentation that bolsters billing. Again, the doctors lose. For small practices, this might be a viable solution, but then again, they'd probably rather purchase a complete IT solution than something that handles medical records alone. Also, have you looked at OpenMRS?[0] They have a module system that allows you to develop extensions to the EHR.[1] If you're looking for your thesis to have a big impact, I'd really recommend getting in touch with an organization like OpenMRS or Partners Healthcare to see how you can extend their platforms. If you want an introduction, drop me a note: faraz dot yashar at the gmail. [0]: https://openmrs.org https://openmrs.org [1]: https://modules.openmrs.org/ https://modules.openmrs.org/
- ryanSrich 10y ago
  The reason why so many EHRs are poorly designed is in part because they are so flexible. Don't under estimate the ego of a physician to think their way is superior to the way the doctor down the road does something. The EHR model will eventually lose because its one sided. Consumers and patients are completely left out of the picture and EHRs have no incentives right now to change. Beyond that companies like Epic are operating on outdated business models. The days of the black box of data that lives inside the four walls of the health system are numbered. Consumers won't deal with a dumpster fire of technology once they have the choice. Digital health will win once the barriers of compliance and interoperability are broken down.
  - iheartmemcache 10y ago
    SQL has 'interoperability' re: an ANSI standard. Theoretically you should be able to get off all those old Oracle contracts right? Eventually there are little nuanced things that users end up building their workflow completely around. Even if you change no functionality and just slightly alter the GUI, you're going to have complaints that something is broken. Inertia is your #1 vendor lock in feature. EPIC is as golden as Oracle just due to resident incumbency. #2 is the whole risk aversion thing. Any platform migration is going to have political risk attached to it. Nike won't move away from Oracle even if Postgres can do everything it can line for line because paying the $200k maintenance fee each quarter is a cheap recurring cost compared to the political risk of a failed project. That's not even factoring in #3, the little features here and there which are value-adds to the platform and not part of the standard. I've inherited projects where my firm offers to support O&M for some poorly written ASP 1.1 Classic software. We'll go in, patch some business-logic bug, and get a phone-call later that afternoon asking to rollback our fix. Turns out their users had integrated bugs into their workflow such that when the software operates "properly" (i.e. 'to spec') it actually breaks things (i.e. stops operating in an expected fashion).

Spooky23 10y ago

I don't see why any physician implements an EMR. My family doctor, who was part of a midsize practice was punished hard by adopting a system. They did it in 2007 thinking they would save money... which didn't happen as they were only able to eliminate 1/4 clerk positions and had to pick up an IT guy and a consultant. Then they really got the shaft when the solution they chose wasn't meeting Medicare guidelines. They ended up getting another system that is worse. Now they got swallowed up by a regional medical system and have yet another EMR, plus they have 6 clerical staff versus 3 and whatever outsourcer handles IT for the hospital system. My other doctor friend is a ophamologist. It's a small practice with 3 full time and 1 part time doctor. They pay the fine every year for not having an EMR and use paper and have a standalone system for sending prescriptions. He is enormously happy with paper and feels that's it better in every way, including cost. I agree -- I see zero value in the EMR systems.

nickpsecurity 10y ago
I saw one system that seemed like a must have: apps that ensure you got the prescription right. Paper-loving doctors screwing up prescriptions harms a lot of patients. Especially when they insist on writing in cursive. Much of your post seems to be about bad tech, though. It could mostly be mitigated with a supplier that gave a shit.
- Spooky23 10y ago
  Prescriptions ordered electronically seems to be the only thing that is an improvement. Everything else is not only bad IT, but ruins your interactions because the medicinal person is bent over a laptop.
- gm-conspiracy 10y ago
  Also sounds like a shitty pharmacist and pharmacy tech.
  - nickpsecurity 10y ago
    I'm not going that far. What I read implied it was either a mental slip or illegible writing. Some of the drug names look similar when they're written in chicken scratch.

ryanSrich 10y ago

When patients are treated as consumers we'll see the wave of economic incentives. Value based care as part of the ACA is headed in the right direction.

AethaPeterson 10y ago
I can assure you, that no patient is a willing "customer" or "consumer" of healthcare. True 'consumers' or 'customers' have a choice to buy something or not. If you are a sick patient, there is no choice. As a physician and subspecialist I have invested 24+ years of education to achieve this title. Its degrading to our profession and patients to refer to us doctors as 'providers' and to patients as 'consumers'. This takeover of healthcare by MBA-speak is one of the most irksome trends, and rebranding patients as "consumers" is a patently false equivalence.

doctorpangloss 10y ago

> ...exception to this is Kaiser Permanente They are notorious in the medical community for valuing efficiency above all else. Kaiser also doesn't serve extremely difficult cases, uninsured patients or patients on Medicaid. Academic hospitals do. Kaiser can do a lot of things differently by virtue of being subsidized by the generosity of the state and the state's highly talented doctors. I don't know how much there is to learn from them. > they make money every time you get sick Nobody at an academic hospital makes money every time you get sick. Discharging patients is a high priority. Doctors are constantly trying to figure out how to do preventative care with the sorts of "frequent flyer" patients that tie up emergency rooms and hospital beds. To be more blunt, you're not really describing reality. You're describing a particularly cynical point of view, common among people who are unlucky enough to be (or to know someone) rich, sick and not getting better. It's doctor as antagonist, and it tends to emerge in some kind of economic rationalization. Here's reality: Mark Zuckerberg put his name on an academic hospital in San Francisco that has utterly dysfunctional EHR. Everyone in the system—especially the doctors, contrary to what you say—hates it and wishes the money would have been spent to improve it. Even the tech fantasy of magic money wand can't solve this problem. It isn't the fault of doctors ("you know who hates EHRs the most? Doctors"). No clever turn of the phrase or insight is going to provide the answer. Blah-blah-blahing about incentives isn't going to provide any solutions. It's a complex system. The original poster was saying as much. But then all the other commenters go on and start talking about economics, incentives, anecdotes, and assorted conspiracy theories. The guy is studying this! I think he's coming to the right answers.

fny 10y ago
I work at an academic hospital, and I've seen how the incentives drive policy. Frankly, it's terrifying. > Nobody at an academic hospital makes money every time you get sick. Of course they do! Every time you go in for treatment, they make money, and there only incentives for preventative care come from government/Medicare mandates (e.g. hospital readmissions, ACOs.) Let me color the picture a bit more vividly. At a public pitch competition within the university, a department head--and judge of the competition--laughed at an ML start up: "you do realize we make money from the procedures you're trying to prevent." > Discharging patients is a high priority. Hospitals are often penalized for long stays by insurance. > Doctors are constantly trying to figure out how to do preventative care with the sorts of "frequent flyer" patients that tie up emergency rooms and hospital beds. Aside from tying up resources, high-utilizers can't afford to pay for services and the hospitals treat them at a massive loss. Naturally, a hospital would like to free up these resources for patients who can pay. > It's doctor as antagonist. I never said this, and nor do I believe this. Doctors are victims of this system. I even made the point that doctors hate the EHR because it's been warped by hospital administrators into a billing-centric machine with umpteen documentation requirements at every turn. For this reason, many who went into medicine for altruistic reasons end up disenchanted with the health system that's been wrecked by those running the business.

fredsmith42 10y ago

Um, what? I've spent 20 years implementing EHRs. You seem to be implying that hospitals were using paper until 2009. I've implemented lab systems with electronic charts in VMS. The systems weren't, and aren't, interoperable, but they were definitely recognizable as EMRs.

acveilleux 10y ago
He's probably limiting the definition to the kind of overarching EMR that fully replaces paper charts for all departments and provide a single view of the patients. I've also done migrations (I'm in radiology systems, PACS and RIS) where clients had reports going back to the early 1980s. Not very common mind you, especially in private practices (which we get a lot of) and rural hospitals (the kind of places with CPSI/Evident or, god forbid, Healthland.)

ThomPete 10y ago

I agree with everything you say besides the claim there is no economic incentive. Just a few 1) Getting patients to pay their bills. 2) Spending less time on each patient. 3) Reducing errors. All these have economic incentives. But yes it's still a hard sell.

deleted 10y ago
[deleted]

nradov 10y ago

It's no longer necessarily true that providers make money every time you get sick. Insurers have shifted risk to providers in some areas in the form of accountable care organizations (ACOs) which receive a flat fee per patient. So in theory the ACOs have a financial incentive to prevent you from getting sick. Kaiser Permanente uses the same Epic EMR software as many other large provider organizations.

gmarx 10y ago
In fact they were essentially the first and the reason it has become a near monolopoly
- fny 10y ago
  Kaiser was, however, one the first systems to start (2000) and finish (2010) their electronic transition. Their decision had nothing to do with the government mandate in 2009, precisely because their business depended on it. Also, don't forget that EHRs don't come with a data governance model, so the entire onus of maintaining clean, available, interoperable data falls on the institution. Again, since Kaiser depends on clean, available, interoperable data, they made that a priority both internally and in their contracts with Epic.
fny 10y ago
And I have seen shifts that ACOs have caused first hand! Unfortunately, the only insurer running ACOs is Medicare which is an example of a political solution to the problem. While we have yet to see what the financial implications of ACOs are, I can say that I've seen admins work hard to develop data-oriented preventative care. However, these advances are still only limited to the ACO population, which gets back to my point. Hospitals aren't going to fund patient risk analysis until the economic incentives are in place, and for that reason, I fear that the issue of bad interoperability will exist for as long as we live in a "fee-for-service" world. As for Kaiser adopting Epic, remember I noted that hospitals can customize the EHR to their needs in detail--it does however require troves of cash. Since Kaiser heavily relies on data-driven preventative care as part of their business model, they pay to have a lot of data systems in place to facilitate their operations. Hell, Kaiser even had an Open API since 2013!![0] Good luck finding that anywhere else! [0]: http://interchange.kp.org/ http://interchange.kp.org/

deleted 10y ago

[deleted]

organsnyder 10y ago

There is absolutely an incentive for healthcare systems to do these transformations. But it requires leadership that is willing and able to see the long-term benefits. Of course, that can be challenging, and is probably only feasible in larger nonprofits (for-profits need to please shareholders, and smaller organizations simply can't afford it), but the future payoff is there. I think we're in the turd-age (opposite of golden age) of EMRs right now. Everyone has adopted them—many unwillingly—but user interfaces are still terrible, and interoperability is spotty at best. There are signs of this changing (lots of vendors are touting/promising UX improvements, and FHIR is hot right now), but it will still take time.