11 ms·

Why doctors hate their computers

157 points by greeneggs 8y ago

jatsign 8y ago
In the last few years, I've noticed that visiting my kids' pediatricians that the doctors spend most of the time during the visit poking at their computer. As a parent, it makes me feel that they're just filling out a form, not caring for my daughters.
- singingboyo 8y ago
  I suppose this is dependent on how much you trust the doctor(s) in question, but, in general, a specialist I trust 'filling out a form' is somewhat reassuring; there's nothing sufficiently bad that they're breaking routine. When programming, something that makes you think "yup, I'll do that as soon as there's time" is much better (for planning/PM) and more routine than "hmm, not sure, I'll try", right? I think the same applies to personal medicine - routine and boring forms are better than puzzled investigations.
  - brokenmachine 8y ago
    Unfortunately they need to fill out forms for puzzled investigations as well.
- gbustomtv5 8y ago
  They care about your daughters but they care about their children too. If they do not fill in electronic records they will have to stay after work. Many doctors have to work at home until 1-2AM to keep up with recordkeeping. On the other hand, healthcare administrators who demand doctors spend no more than 15 minutes per patient AND fill pages and pages with summaries of visits really do not care about your daughters even a tiny bit.
  - octorian 8y ago
    > They care about your daughters but they care about their children too. If they do not fill in electronic records they will have to stay after work. Many doctors have to work at home until 1-2AM to keep up with recordkeeping. I can certainly attest to this, from my own experiences growing up (in the 90's). My father is a doctor, and I distinctly remember him spending most of his evenings in his home office doing paperwork. I asked him why he didn't do it at the office, and he said that many of his colleagues did... But as a result, they didn't get home from work until much later. (and he was already getting home just barely in time for dinner)
- nradov 8y ago
  deleted
  - mrcu5 8y ago
    It did mention scribes. Even talked about virtual scribes in India.
    - nradov 8y ago
      Sorry I did a Ctrl+F search and it didn't find anything, my mistake.
beckler 8y ago
I used to work for a company that made EHR software. Doctors have very little patience for computer issues; most don't enjoy using them. My job at the time would involve me talking to most IT folks at hospitals, and they would have some crazy stories. My favorite was how this one doctor would call IT almost daily. He would complain that his computer was slow, so this IT guy would walk up to his office and do something random. Like unplug his Ethernet cord or mouse and plug it back in, or turn his screen off and back on. The doctor would evaluate if it was better, and always said "thanks, that fixed it".
- yhoneycomb 8y ago
  Your story makes it sound like he was dumb. He was probably being polite.
  - beckler 8y ago
    He called IT with the same complaint multiple times a week. The IT team realized that they just had to do something to make him happy when in reality they did nothing at all.
    - deleted 8y ago
      [deleted]
    - magicnubs 8y ago
      Like being given antibiotics for a viral infection.
  - rbanffy 8y ago
    He was given a placebo and reported an improvement. I can live with that explanation.
- expertentipp 8y ago
  That's how I'm oftentimes serviced when visiting the doctor.
- AnIdiotOnTheNet 8y ago
anitil 8y ago
The system designers are doomed though. - Legacy Systems - Complicated workflows - Enterprise software - Difficult compliance issues - Billing and coding Every moment I touch Jira feels like time I won't ever get back, and it is miles better than any medical software I've seen. Imagine if your whole work life was in a system like that. Misery.
- eropple 8y ago
  I'll cape up a little for Jira. You need to have it built and configured by somebody who actually, really cares about how people already work and has the Jira-specific knowledge to express it--and that can be hard when doing the right thing in Jira is as counter-intuitive as it is--but when done right it's really very powerful and can be made to be effective and user-friendly. (I volunteered to be the Jira admin at my new company because I do care and I do understand it well enough to do that stuff--and because I own enough of the other systems it'll have to hook into eventually, anyway.) On the other hand, I used to work on EHR software. Eff that.
  - anitil 8y ago
    I've heard that mentioned, so perhaps I just haven't had a good experience yet
  - wink 8y ago
    Can said person make the search return sensible results? I doubt it - it's not only configuration.
    - eropple 8y ago
      Search is, admittedly, the worst part of Jira. ;)
gbustomtv5 8y ago
Doctors hate their computers because of the growing volume of recordkeeping and patient communication required yet unpaid. Anyone told to stick around for 4 more hours after 8 hours of work to update records and answer emails would hate it too.
7402 8y ago
This was the part that absolutely stunned me: > Last fall, the night before daylight-saving time ended, an all-user e-mail alert went out. The system did not have a way to record information when the hour from 1 a.m. to 1:59 a.m. repeated in the night. This was, for the system, a surprise event. The only solution was to shut down the lab systems during the repeated hour. Any system like this that fails to store all times as UTC is broken. No one should make this mistake more than once. I made it once, and boy was it painful. And boy did I feel stupid to realize I had forgotten about daylight savings time. I just can't see how it was possible for the designers of this huge system to miss this.
- pm24601 8y ago
  You are making a bad assumption here: "Any system" ... Chances are we are talking about multiple systems created at different times and by different companies. I could easily see a case where the timestamp is stored as a string to interoperate across various computer SYSTEMS. Doing a wide scale fix for this problem is probably cost-prohibitive - assuming it is even possible.
  - roywiggins 8y ago
    From experience with an EHR system: these things are so big that interoperating between different pieces of big-ball-of-mud systems is a dicey matter and making any changes requires extensive manual tests, since there are approximately zero automated tests.
- nradov 8y ago
  It's not always necessary or desirable to store all times as UTC. What you actually need is a time plus offset from UTC. Storing times as UTC is essentially just a special case of that where the offset is always 0. Most lab data is communicated to other systems using HL7 V2.x messages. The standard does allow for including a time zone offset in all date/time fields. However, many older implementations fail to include the offset and just use local time. Obviously that's not a good idea.
  - 8y ago
clueless123 8y ago
For most people, (read spreadsheets, word processors, etc ) computers make their jobs easier or more productive. It is hard to say the same for medical software, mainly because it is not designed to help medical providers, but to help administrators.
- SketchySeaBeast 8y ago
  I wouldn't say that's correct - diagnostic imaging is entirely computerized these days and that's made life a lot more productive and efficient, but is also the source of huge frustration when these incredibly expensive machines have software glitches or network connectivity problems.
  - carbocation 8y ago
    As a doctor, I agree with `clueless123. The imaging software is not what makes us frustrated: it's the EHR that is optimized for billing, not patients or doctors.
    - SketchySeaBeast 8y ago
      I'm just speaking from my experience with Rads and their technologists. I imagine billing is a nightmare as well.
      - carbocation 8y ago
        I actually don't think there is a real dichotomy - the system can be annoying to different groups for different reasons. The reasons it's annoying to MDs may be different from the reasons it's annoying to rads techs, etc. But you started by contradicting the parent post ("I wouldn't say that's correct"), which is why I felt inclined to chime in.
- draz 8y ago
  I was part of an implementation team for an EHR at a very large ambulatory unit (i.e., private practices of one of the largest hospitals in the US). Complaints for EHR by medical staff were as follows: 1) "I am spending time looking at the computer instead of making eye contact with the patient. Therefore, patient experience deteriorates." 2) "Pen and paper are much faster inputs than having to click around tabs and typing values" (especially for older doctors). This slows them down, which means they can see less patients (direct impact on revenue). 3) While there were government incentives to encourage practices to implement EHRs, doctors from more lucrative specialties (who are not involved in research) did not see value in having the data computerized. Imagine an ophthalmologist who can perform another Lasek procedure instead of record a patient's drinking status, and other things that may not affect the procedure.
dwd 8y ago
This was the telling statement of the whole article. "Previously, she sorted the patient records before clinic, drafted letters to patients, prepped routine prescriptions—all tasks that lightened the doctors’ load. None of this was possible anymore. The doctors had to do it all themselves." This is a huge fail and is not just a problem in medical - though the consequences are more serious and will result in patient deaths because doctors are spending more time on paperwork than diagnosing and treating patients. There was a recent article posted to HN on research going back decades highlighting this issue. https://news.ycombinator.com/item?id=18157885 https://news.ycombinator.com/item?id=18157885
- pm24601 8y ago
  Yeap. A relatively lower paid person should be able to help reduce the workload of the higher paid person. Makes good business sense. Welcome to rigid software not built for adaptability.
  - maxxxxx 8y ago
    "Welcome to rigid software not built for adaptability. " It's not the software it's the organization who cuts admin positions for short term gain. Instead of assistants who help you with that work you have a ton of VPs for diversity and whatever where nobody knows what they are actually doing.
- maxxxxx 8y ago
  That's a bad trend you see everywhere. Admin assistant positions are being reduced and now the specialists have to do everything themselves. In my company we used to have somebody who made all travel arrangements but now we have to do it ourselves which is a major pain and takes a lot of time if you use the system only once a year.
  - adolph 8y ago
    A term for this is "Shadow Work," unpaid labor in the form of self service. https://en.wikipedia.org/wiki/Shadow_work https://en.wikipedia.org/wiki/Shadow_work
naveen99 8y ago
This is why AI won’t replace doctors. Doctors aren’t even allowed to properly use computers their user interfaces are handicapped. No API to the medical record (hospital IT locks it out even if there is one from the vendor). If they give AI access to the full medical record with an API, they will have to give doctors access too.
- nradov 8y ago
  AI won't replace doctors, but it's not because of lack of API access to medical records. Medical records don't contain all of the data that an AI would need to make an accurate diagnosis and come up with an optimal treatment plan. In order for an AI to do that it would need to be able to see, touch, and converse with the patient. We're a long way from that capability.
  - Scoundreller 8y ago
    I give it 10 years before I’ll be pleading with the paramedics to take me to the AMZN or GOOG hospital instead of XYZ Health System.
- arbitel 8y ago
  Problem is education. There is prolly literally little to none courses about computers in medical school in most part of the world.
voltooid 8y ago
I am an engineer and I particularly relate to the problem that the doctor has with having to click multiple times to order medical tests where previously only one sufficed. Also, the problem of multiple links named with very similar, thus confusing names - "chart review", "result review" etc. I see this on a regular basis when using visual studio team services so much so that our team spends a large amount of our time dealing with the VSTS interface instead of making use of the system to do our planning quickly and efficiently. I deal with a computer all day every day and I don't find VSTS the least bit intuitive or helpful. The problem described in the article is not one that just doctors have to face.
- Chris2048 8y ago
  Didn't amazon patent one click orders?..
maxxxxx 8y ago
It's probably the same as me having to deal with our enterprise systems for documents and requirements. They are a major pain in the a.. and just add more burden instead of making my work easier. I hate them every second I have to use them and avoid as much as I can. I bet most medical record systems are built for administrators (who make the purchasing decisions) and not for doctors.
alxlaz 8y ago
I used to work on stuff that doctors use (and I miss it a great deal), so I've seen a lot of this first-hand. In my experience, a lot of the problems that medical software and devices have stem from a lack of understanding on the "other" side of the fence. Committees of people who don't really do much medicine anymore meet committees of people who don't write much software anymore and come up with specifications that are almost, but not quite, entirely unlike what the doctors really need. And then the implementation is outsourced to a team comprised of people who have to churn out software with minimal understanding about how it will be used. These folks will try to understand it at first, but there are so many project managers and customer satisfaction managers and NDAs between them and the people who need the system (and, of course, there's no documentation because that's the first thing that gets slashed out of the itemized billing when the customers see the price) that it takes weeks to get a straightforward answer to even the most trivial question. Not that it's easy to do things differently. When I was working on devices for the medical industry, I had not looked through an anatomy textbook since my teenage years; understanding the jargon alone was hard, let alone make meaningful design decisions. I was super fortunate to work for a company that had long learned these lessons and did things correctly. But doing things correctly and profitably takes a long time; most companies don't have that kind of patience so they don't really bother with it. People who possess substantial knowledge of both programming and medicine are extraordinarily rare and not too easy to keep on payroll, so these companies rarely manage to develop the kind of technical leadership required to successfully mentor new people and drive projects over a long time.
dmoy 8y ago
I went to the doctor for a routine vaccination a couple weeks ago. As I sat in the room I had a perfect view of the computer that the doctor was using to fill out the requisite form. It was a pretty bog standard form with a gazillion fields. But one thing that stood out is that at least twice when the doctor clicked on a drop-down, tbe computer selected a different option that wasn't even visible in the ~8 item scroll drop-down. The second time it happened the doctor turned around to me with a confused look and I said, "Yup, I totally saw that too, I dunno". I was unclear if this was just native software (kinda looked like it), or just a really old fashioned website. Doesn't instill a lot of confidence in me about the safety of my medical data...
skarras 8y ago
In the past I was a developer working on a EHR system. I was laughing when I read "There was a column of thirteen tabs on the left side of my screen". This is a really sad truth. Not only for physicians but also for other workers who have to work with an ERP system. At least here in Greece I have not seen until now any EHR/ERP that has good UI/UX. Most of the time we was just building copies of physical forms or simply expose most of the fields of a huge entity in openEHR. Without automating anything. I think that a big factor thats data entry process takes longer is because instead of hand writing something, now they have to type it or search for a check box to check. At least here in Greece I don't know any physician who can type as fast as he/she writes by hand.
- ad-hominem 8y ago
  Cerner millenium (a common and widespread EMR) looks like a 90s visual basic application. Hell, it probably IS a 90s VB application under the hood.
mhd 8y ago
Medical software still has huge rooms for improvement. Combining complexity with bureaucracy will just result in issues, never mind that in hospitals the sheer volume of porting things is a recipe for keeping legacy systems alive and plenty of technical debt. Good luck getting rid of you MUMPS system. Or dot matrix printers (AFAIK still required in Germany, as some forms require a literal carbon copy). On the other hang, as with travel agents, it might be that the old mainframe-based legacy system is better than the Windows/Web-based replacement, UI-wise. And never mind the software, against the ever-changing requirements of the state and insurance companies, the IT gods themselves struggle in vain.
jcowdy 8y ago
The problem with this article is that Dr Gawande is too quick to point the finger at the EHR vendors for increasing the amount of non-clinical work that physicians are responsible for today. The EHR has become the face for arcane and archaic billing, regulatory, and compliance requirements which, when enforced through the software of the EHR, cause additional work to be shifted to the physician. Those questions that you get when you place a radiology order have typically not been added by the EHR vendor. More than likely they were added at the advice of legal / compliance. Unfortunately the problem isn't as simple as getting more competent EHR designers and developers (although that certainly wouldn't hurt), but rather a deeper look into each aspect of increased work for physicians and analysis of why it is in the workflow (5 whys application would be great). At that point, organizations and physicians will better understand the reason work is on the physicians' plate and have a chance to weigh the pros and cons of either removing that work or shifting it to another person. The other side of this that most don't see is that EHR vendors are also being held back by these same billing and compliance pressures. Here's a secret - EHR vendors actually want to help physicians be as efficient as possible and would love to automate work off of their plate. Unfortunately the environment created by compliance departments who are afraid of being sued and hospitals who would like to get paid has handcuffed the more innovative development from EHR vendors. If a system reviews incoming medication refill requests from patients, evaluates protocols, and determines that a refill should be approved who does is listed as the authorizing provider for the purpose of the pharmacy and the patient's insurance?
- jcowdy 8y ago
  EHR vendors and clinicians need to find a way to come together to both design software that will make clinicians lives easier, but also to change any billing/legal/compliance hurdles that are in the way of putting this technology in clinics. If someone can put all of these pieces together we could see some powerful changes. Perhaps Dr Gawande's new venture with Amazon, Berkshire Hathaway and JPMorgan will give him a chance to control both sizes of this puzzle and create a better environment for clinicians and patients.
- danans 8y ago
  > If a system reviews incoming medication refill requests from patients, evaluates protocols, and determines that a refill should be approved who does is listed as the authorizing provider for the purpose of the pharmacy and the patient's insurance? If this system has really done all this work that presumably would have otherwise been done by a provider, what's the harm in presenting the recommendation to a doctor or pharmacist for final approval? I'd think that it's important to get a trained professional to apply their experience to the final decision, which is perhaps why there is an "authorizing provider" field in the first place.
sonnyblarney 8y ago
UX centric design is the future, companies need to understand that. Particularly buyers who are making decisions of of 'feature checklists'.
- octorian 8y ago
  This is only possible when the customer isn't completely disconnected from the user, there is real competition, and that competition is based on the product itself... Not the contract to buy/develop said product. These reasons are also why so much defense-industry software is also a completely unusable mess. (that's an industry I used to work in) The software is written to satisfy a requirements checklist, nothing more, nothing less.
  - sonnyblarney 8y ago
    I worked in defence as well, and the requirements are not just a 'checklist'. You're talking about safety, consistency. Lives - and geopoltical situations are at stake. Do you know what it means if a guided missile goes wayward and crosses international borders? Or the rescue helicoptor's GPS is unreliable? Totally agree it's bogged down in bureaucracy ... But those requirements are real. You want complicated: work in 'manned space flight' probably the highest safety tolerances of anything. My god I don't even know how we get someone in space these days. We use the Russian system because it's old school, probably less complicated and reliable.
- Scoundreller 8y ago
  Ethnographic analysis is becoming more common. E.g. throw a user in front of 5 different systems and do the same task. What is the actual experience? Error rate? How long did it actually take? Number of clicks doesn’t matter: that’s the equivalent of buying art by the pound.
throwaway5752 8y ago
Because Cerner and Epic are awful and the rest are too.
CaptSpify 8y ago
This isn't isolated to doctors sadly. You see this in any medium to large organization: schools, cities, companies, etc. The problem, the way I see it, is that management is the one really being sold to. The actual people who do the day to day work have no real say in which software systems they use. Only management has any real say, so sales people tailor their pitch towards management. Unfortunately, managers only have a high-level overview of what the people below them actually do, and no understanding of software, so they have no idea what they need their software to do. And situations like this are where sales people shine brightest. Sure, the new "cloud-based, totally-super-secure, widget producer 9000" won't actual be useful at anything, but it sure looks cool to management. Look at companies like Oracle, and Microsoft for good examples: Their actual products are awful, but that doesn't matter. What matters is that their sales team can sell a shit product.
- pimmen 8y ago
  I whole heartedly agree, and if newer computer programmers don't believe that's how the sausage is made they could either start working as a consultant or ask their consultant friends about the inevitably awful software they use to log their hours. The reason it's awful is because at no point has a consultant's work flow ever been considered during development. At no point has a consultant ever been present while the software was sold. The consultant isn't the customer, or even the end user in mind, it's the financial departments who get to turn all those hours logged into nifty charts. Imagine that's not a consultant anymore but a doctor, and he or she is not entering hours worked but medical stats. Sleep well tonight.
- threatofrain 8y ago
  I feel that companies selling B2B think of high-level executives as having incentives to deliver "something that wins", but they won't be around years later when it stinks. The company structures themselves accordingly by delivering fast productivity now, but skeleton crew later.
- analog31 8y ago
  This was once described to me as the Law of Enterprise Sofware: All enterprise software sucks, because it's sold to administrators, not to users. The managers see the purpose of software as improving their own workflow (tracking, data gathering, compliance) as well as controlling the users, not (gasp) empowering them. Compounding the problem of enterprise software is customization. A person who works at an EHR vendor told me that every clinic system wants to develop their own bespoke workflow, in search of slightly higher efficiency, and so the thing that the user actually sees is not a well engineered system, but a hodgepodge of screens and forms that were designed at the last minute. My friend said that the user experience is a lot better at sites where the customer uses the off-the-shelf implementation with little or no customization.
kapauldo 8y ago
This is an absurd complaint by a millionaire who is too important to document his work. Boo hoo.
amelius 8y ago
To the IT people who are making others click ads: perhaps it's time to fix some real problems ...
- SmellyGeekBoy 8y ago
  Ads in medical software! I like your thinking.
  - hotzenplotz 8y ago
    European doctor here. We have ads in our medical software!
Areading314 8y ago
Sounds like jira
classichasclass 8y ago
So here's my story about this. I'm a physician primarily working in an administrative capacity for a large local government (though I also have a background in enterprise computing and did that for several years both full-time and as a consultant). I'd lived through the horrors of the EHR transition at the large HMO I used to work for and was determined not to have that happen again. We were selecting an EHR product and had it narrowed down to three main products which I won't name here but they're all major players and are still in the market. I was representing the clinicians, so I selected the product "A" I felt had the best clinical support, the best clinical workflow and the easiest UI slope. So did the nurses who were selecting for nursing staff (we didn't coordinate our choices; we each legitimately felt this was the best product for our respective scopes of practice). The billers selected the product "B" that had the best reporting and financials. So, we on the clinical side were asked, can you live with "B"? Well, yeah, sure, I guess? We can make it work, but it's clearly less flexible, the workflow is clunkier, the decision support is less comprehensive and we felt would be more difficult for the physicians. The billers said adamantly that "A" was too much work to deal with the reporting and they wanted something out of the box. They were not willing to compromise despite our concerns on the clinical side, even though we'd have more facetime with the product than they would, and there would be less to bill if the physicians couldn't figure out how. So the clinicians got overruled by the billers and "B" was selected. I understand that the billers must have a say, but the billers are dealing with a small portion of the product. The billers managed to convince administration that their concerns were more valuable because their work translated into dollars. As if the clinicians' work didn't? How does that work? And yet I see this occur again and again in other clinical systems. As a postscript, the local government's rollout of "B" went aground and we ended up with a cheap vanilla install of "D", which wasn't part of the original three and ended up pleasing no one, and is ironically the same EHR I still have PTSD from all those years ago.
- Scoundreller 8y ago
  Could it be that the “B” product was a lot cheaper? The “best” EHR vendors know they are, and charge accordingly. The underdogs know that they can win on price if they can’t on usability
shanecleveland 8y ago
There are many factors at play. I work for a US manufacturer in the medical industry, and our customers definitely lag behind in technology. Some of the things I see: Much of the workforce is older and adoption of new technology is avoided by many. Large organizations move slowly and health care workers don't tend to be among early adopters of technology. While working individually, face-to-face with a patient, pen and paper can actually be the best option. A younger workforce, more understanding patient population and new environments centered around technology first will occur eventually.
- phren0logy 8y ago
  I'm a (relatively) young and tech-savvy doctor. The electronic medical records I have used (around 5 or 6) are all truly terrible. As the medical director of a group of clinics, I explored replacing our terrible system, and every other system I looked that was a reasonable fit for our needs was, at best, marginally better. While there are other factors at play, the main one is that electronic medical record software is really, really bad.
  - shanecleveland 8y ago
    No doubt. I didn't mean to minimize this aspect. I think it will take a new generation of professionals like yourself involved in building not only the software systems, but also the hardware used, the clinic environment and entire patient experience. As it is, these terrible systems, designed by non-medical professionals, are dropped in the laps of practitioners who are not comfortable with technology in settings not designed around the use of technology.
stmw 8y ago
Great article -- it's a big problem that needs urgent nnovation. BTW, if you are reading this and are interested in helping build better software for doctors, drop us a line. We are a stealth startup working to fix the software doctors use. As the article explains, if you have seen what physicians have to put up with, it's a bad version of the 90s, and makes medical care worse and more expensive for everyone. Please email jobs@commure.com and mention "[whydoctorshatetheircomputers]" in the subject line.
noddy1w 8y ago
Medtech is annoying because of the primary focus being documentation. I spend much of my day writing stuff that noone cares about for people who will never read it. Doing this on paper is slow. Doing it on a computer is even slower. Finding a terminal and filling in structured forms is a pain in the ass when I want to be seeing patients, doing procedures etc. Using things like google glass and offsite scribes is a good way to do this.

157 points by greeneggs 8y ago

In the last few years, I've noticed that visiting my kids' pediatricians that the doctors spend most of the time during the visit poking at their computer. As a parent, it makes me feel that they're just filling out a form, not caring for my daughters.

singingboyo 8y ago
I suppose this is dependent on how much you trust the doctor(s) in question, but, in general, a specialist I trust 'filling out a form' is somewhat reassuring; there's nothing sufficiently bad that they're breaking routine. When programming, something that makes you think "yup, I'll do that as soon as there's time" is much better (for planning/PM) and more routine than "hmm, not sure, I'll try", right? I think the same applies to personal medicine - routine and boring forms are better than puzzled investigations.
- brokenmachine 8y ago
  Unfortunately they need to fill out forms for puzzled investigations as well.
gbustomtv5 8y ago
They care about your daughters but they care about their children too. If they do not fill in electronic records they will have to stay after work. Many doctors have to work at home until 1-2AM to keep up with recordkeeping. On the other hand, healthcare administrators who demand doctors spend no more than 15 minutes per patient AND fill pages and pages with summaries of visits really do not care about your daughters even a tiny bit.
- octorian 8y ago
  > They care about your daughters but they care about their children too. If they do not fill in electronic records they will have to stay after work. Many doctors have to work at home until 1-2AM to keep up with recordkeeping. I can certainly attest to this, from my own experiences growing up (in the 90's). My father is a doctor, and I distinctly remember him spending most of his evenings in his home office doing paperwork. I asked him why he didn't do it at the office, and he said that many of his colleagues did... But as a result, they didn't get home from work until much later. (and he was already getting home just barely in time for dinner)
nradov 8y ago
deleted
- mrcu5 8y ago
  It did mention scribes. Even talked about virtual scribes in India.
  - nradov 8y ago
    Sorry I did a Ctrl+F search and it didn't find anything, my mistake.

beckler 8y ago

I used to work for a company that made EHR software. Doctors have very little patience for computer issues; most don't enjoy using them. My job at the time would involve me talking to most IT folks at hospitals, and they would have some crazy stories. My favorite was how this one doctor would call IT almost daily. He would complain that his computer was slow, so this IT guy would walk up to his office and do something random. Like unplug his Ethernet cord or mouse and plug it back in, or turn his screen off and back on. The doctor would evaluate if it was better, and always said "thanks, that fixed it".

yhoneycomb 8y ago
Your story makes it sound like he was dumb. He was probably being polite.
- beckler 8y ago
  He called IT with the same complaint multiple times a week. The IT team realized that they just had to do something to make him happy when in reality they did nothing at all.
  - deleted 8y ago
    [deleted]
  - magicnubs 8y ago
    Like being given antibiotics for a viral infection.
- rbanffy 8y ago
  He was given a placebo and reported an improvement. I can live with that explanation.
expertentipp 8y ago
That's how I'm oftentimes serviced when visiting the doctor.
AnIdiotOnTheNet 8y ago

anitil 8y ago

The system designers are doomed though. - Legacy Systems - Complicated workflows - Enterprise software - Difficult compliance issues - Billing and coding Every moment I touch Jira feels like time I won't ever get back, and it is miles better than any medical software I've seen. Imagine if your whole work life was in a system like that. Misery.

eropple 8y ago
I'll cape up a little for Jira. You need to have it built and configured by somebody who actually, really cares about how people already work and has the Jira-specific knowledge to express it--and that can be hard when doing the right thing in Jira is as counter-intuitive as it is--but when done right it's really very powerful and can be made to be effective and user-friendly. (I volunteered to be the Jira admin at my new company because I do care and I do understand it well enough to do that stuff--and because I own enough of the other systems it'll have to hook into eventually, anyway.) On the other hand, I used to work on EHR software. Eff that.
- anitil 8y ago
  I've heard that mentioned, so perhaps I just haven't had a good experience yet
- wink 8y ago
  Can said person make the search return sensible results? I doubt it - it's not only configuration.
  - eropple 8y ago
    Search is, admittedly, the worst part of Jira. ;)

gbustomtv5 8y ago

Doctors hate their computers because of the growing volume of recordkeeping and patient communication required yet unpaid. Anyone told to stick around for 4 more hours after 8 hours of work to update records and answer emails would hate it too.

7402 8y ago

This was the part that absolutely stunned me: > Last fall, the night before daylight-saving time ended, an all-user e-mail alert went out. The system did not have a way to record information when the hour from 1 a.m. to 1:59 a.m. repeated in the night. This was, for the system, a surprise event. The only solution was to shut down the lab systems during the repeated hour. Any system like this that fails to store all times as UTC is broken. No one should make this mistake more than once. I made it once, and boy was it painful. And boy did I feel stupid to realize I had forgotten about daylight savings time. I just can't see how it was possible for the designers of this huge system to miss this.

pm24601 8y ago
You are making a bad assumption here: "Any system" ... Chances are we are talking about multiple systems created at different times and by different companies. I could easily see a case where the timestamp is stored as a string to interoperate across various computer SYSTEMS. Doing a wide scale fix for this problem is probably cost-prohibitive - assuming it is even possible.
- roywiggins 8y ago
  From experience with an EHR system: these things are so big that interoperating between different pieces of big-ball-of-mud systems is a dicey matter and making any changes requires extensive manual tests, since there are approximately zero automated tests.
nradov 8y ago
It's not always necessary or desirable to store all times as UTC. What you actually need is a time plus offset from UTC. Storing times as UTC is essentially just a special case of that where the offset is always 0. Most lab data is communicated to other systems using HL7 V2.x messages. The standard does allow for including a time zone offset in all date/time fields. However, many older implementations fail to include the offset and just use local time. Obviously that's not a good idea.
- 8y ago

clueless123 8y ago

For most people, (read spreadsheets, word processors, etc ) computers make their jobs easier or more productive. It is hard to say the same for medical software, mainly because it is not designed to help medical providers, but to help administrators.

SketchySeaBeast 8y ago
I wouldn't say that's correct - diagnostic imaging is entirely computerized these days and that's made life a lot more productive and efficient, but is also the source of huge frustration when these incredibly expensive machines have software glitches or network connectivity problems.
- carbocation 8y ago
  As a doctor, I agree with `clueless123. The imaging software is not what makes us frustrated: it's the EHR that is optimized for billing, not patients or doctors.
  - SketchySeaBeast 8y ago
    I'm just speaking from my experience with Rads and their technologists. I imagine billing is a nightmare as well.
    - carbocation 8y ago
      I actually don't think there is a real dichotomy - the system can be annoying to different groups for different reasons. The reasons it's annoying to MDs may be different from the reasons it's annoying to rads techs, etc. But you started by contradicting the parent post ("I wouldn't say that's correct"), which is why I felt inclined to chime in.
draz 8y ago
I was part of an implementation team for an EHR at a very large ambulatory unit (i.e., private practices of one of the largest hospitals in the US). Complaints for EHR by medical staff were as follows: 1) "I am spending time looking at the computer instead of making eye contact with the patient. Therefore, patient experience deteriorates." 2) "Pen and paper are much faster inputs than having to click around tabs and typing values" (especially for older doctors). This slows them down, which means they can see less patients (direct impact on revenue). 3) While there were government incentives to encourage practices to implement EHRs, doctors from more lucrative specialties (who are not involved in research) did not see value in having the data computerized. Imagine an ophthalmologist who can perform another Lasek procedure instead of record a patient's drinking status, and other things that may not affect the procedure.

dwd 8y ago

This was the telling statement of the whole article. "Previously, she sorted the patient records before clinic, drafted letters to patients, prepped routine prescriptions—all tasks that lightened the doctors’ load. None of this was possible anymore. The doctors had to do it all themselves." This is a huge fail and is not just a problem in medical - though the consequences are more serious and will result in patient deaths because doctors are spending more time on paperwork than diagnosing and treating patients. There was a recent article posted to HN on research going back decades highlighting this issue. https://news.ycombinator.com/item?id=18157885 https://news.ycombinator.com/item?id=18157885

pm24601 8y ago
Yeap. A relatively lower paid person should be able to help reduce the workload of the higher paid person. Makes good business sense. Welcome to rigid software not built for adaptability.
- maxxxxx 8y ago
  "Welcome to rigid software not built for adaptability. " It's not the software it's the organization who cuts admin positions for short term gain. Instead of assistants who help you with that work you have a ton of VPs for diversity and whatever where nobody knows what they are actually doing.
maxxxxx 8y ago
That's a bad trend you see everywhere. Admin assistant positions are being reduced and now the specialists have to do everything themselves. In my company we used to have somebody who made all travel arrangements but now we have to do it ourselves which is a major pain and takes a lot of time if you use the system only once a year.
- adolph 8y ago
  A term for this is "Shadow Work," unpaid labor in the form of self service. https://en.wikipedia.org/wiki/Shadow_work https://en.wikipedia.org/wiki/Shadow_work

naveen99 8y ago

This is why AI won’t replace doctors. Doctors aren’t even allowed to properly use computers their user interfaces are handicapped. No API to the medical record (hospital IT locks it out even if there is one from the vendor). If they give AI access to the full medical record with an API, they will have to give doctors access too.

nradov 8y ago
AI won't replace doctors, but it's not because of lack of API access to medical records. Medical records don't contain all of the data that an AI would need to make an accurate diagnosis and come up with an optimal treatment plan. In order for an AI to do that it would need to be able to see, touch, and converse with the patient. We're a long way from that capability.
- Scoundreller 8y ago
  I give it 10 years before I’ll be pleading with the paramedics to take me to the AMZN or GOOG hospital instead of XYZ Health System.
arbitel 8y ago
Problem is education. There is prolly literally little to none courses about computers in medical school in most part of the world.

voltooid 8y ago

I am an engineer and I particularly relate to the problem that the doctor has with having to click multiple times to order medical tests where previously only one sufficed. Also, the problem of multiple links named with very similar, thus confusing names - "chart review", "result review" etc. I see this on a regular basis when using visual studio team services so much so that our team spends a large amount of our time dealing with the VSTS interface instead of making use of the system to do our planning quickly and efficiently. I deal with a computer all day every day and I don't find VSTS the least bit intuitive or helpful. The problem described in the article is not one that just doctors have to face.

Chris2048 8y ago
Didn't amazon patent one click orders?..

maxxxxx 8y ago

It's probably the same as me having to deal with our enterprise systems for documents and requirements. They are a major pain in the a.. and just add more burden instead of making my work easier. I hate them every second I have to use them and avoid as much as I can. I bet most medical record systems are built for administrators (who make the purchasing decisions) and not for doctors.

alxlaz 8y ago

I used to work on stuff that doctors use (and I miss it a great deal), so I've seen a lot of this first-hand. In my experience, a lot of the problems that medical software and devices have stem from a lack of understanding on the "other" side of the fence. Committees of people who don't really do much medicine anymore meet committees of people who don't write much software anymore and come up with specifications that are almost, but not quite, entirely unlike what the doctors really need. And then the implementation is outsourced to a team comprised of people who have to churn out software with minimal understanding about how it will be used. These folks will try to understand it at first, but there are so many project managers and customer satisfaction managers and NDAs between them and the people who need the system (and, of course, there's no documentation because that's the first thing that gets slashed out of the itemized billing when the customers see the price) that it takes weeks to get a straightforward answer to even the most trivial question. Not that it's easy to do things differently. When I was working on devices for the medical industry, I had not looked through an anatomy textbook since my teenage years; understanding the jargon alone was hard, let alone make meaningful design decisions. I was super fortunate to work for a company that had long learned these lessons and did things correctly. But doing things correctly and profitably takes a long time; most companies don't have that kind of patience so they don't really bother with it. People who possess substantial knowledge of both programming and medicine are extraordinarily rare and not too easy to keep on payroll, so these companies rarely manage to develop the kind of technical leadership required to successfully mentor new people and drive projects over a long time.

dmoy 8y ago

I went to the doctor for a routine vaccination a couple weeks ago. As I sat in the room I had a perfect view of the computer that the doctor was using to fill out the requisite form. It was a pretty bog standard form with a gazillion fields. But one thing that stood out is that at least twice when the doctor clicked on a drop-down, tbe computer selected a different option that wasn't even visible in the ~8 item scroll drop-down. The second time it happened the doctor turned around to me with a confused look and I said, "Yup, I totally saw that too, I dunno". I was unclear if this was just native software (kinda looked like it), or just a really old fashioned website. Doesn't instill a lot of confidence in me about the safety of my medical data...

skarras 8y ago

In the past I was a developer working on a EHR system. I was laughing when I read "There was a column of thirteen tabs on the left side of my screen". This is a really sad truth. Not only for physicians but also for other workers who have to work with an ERP system. At least here in Greece I have not seen until now any EHR/ERP that has good UI/UX. Most of the time we was just building copies of physical forms or simply expose most of the fields of a huge entity in openEHR. Without automating anything. I think that a big factor thats data entry process takes longer is because instead of hand writing something, now they have to type it or search for a check box to check. At least here in Greece I don't know any physician who can type as fast as he/she writes by hand.

ad-hominem 8y ago
Cerner millenium (a common and widespread EMR) looks like a 90s visual basic application. Hell, it probably IS a 90s VB application under the hood.

mhd 8y ago

Medical software still has huge rooms for improvement. Combining complexity with bureaucracy will just result in issues, never mind that in hospitals the sheer volume of porting things is a recipe for keeping legacy systems alive and plenty of technical debt. Good luck getting rid of you MUMPS system. Or dot matrix printers (AFAIK still required in Germany, as some forms require a literal carbon copy). On the other hang, as with travel agents, it might be that the old mainframe-based legacy system is better than the Windows/Web-based replacement, UI-wise. And never mind the software, against the ever-changing requirements of the state and insurance companies, the IT gods themselves struggle in vain.

jcowdy 8y ago

The problem with this article is that Dr Gawande is too quick to point the finger at the EHR vendors for increasing the amount of non-clinical work that physicians are responsible for today. The EHR has become the face for arcane and archaic billing, regulatory, and compliance requirements which, when enforced through the software of the EHR, cause additional work to be shifted to the physician. Those questions that you get when you place a radiology order have typically not been added by the EHR vendor. More than likely they were added at the advice of legal / compliance. Unfortunately the problem isn't as simple as getting more competent EHR designers and developers (although that certainly wouldn't hurt), but rather a deeper look into each aspect of increased work for physicians and analysis of why it is in the workflow (5 whys application would be great). At that point, organizations and physicians will better understand the reason work is on the physicians' plate and have a chance to weigh the pros and cons of either removing that work or shifting it to another person. The other side of this that most don't see is that EHR vendors are also being held back by these same billing and compliance pressures. Here's a secret - EHR vendors actually want to help physicians be as efficient as possible and would love to automate work off of their plate. Unfortunately the environment created by compliance departments who are afraid of being sued and hospitals who would like to get paid has handcuffed the more innovative development from EHR vendors. If a system reviews incoming medication refill requests from patients, evaluates protocols, and determines that a refill should be approved who does is listed as the authorizing provider for the purpose of the pharmacy and the patient's insurance?

jcowdy 8y ago
EHR vendors and clinicians need to find a way to come together to both design software that will make clinicians lives easier, but also to change any billing/legal/compliance hurdles that are in the way of putting this technology in clinics. If someone can put all of these pieces together we could see some powerful changes. Perhaps Dr Gawande's new venture with Amazon, Berkshire Hathaway and JPMorgan will give him a chance to control both sizes of this puzzle and create a better environment for clinicians and patients.
danans 8y ago
> If a system reviews incoming medication refill requests from patients, evaluates protocols, and determines that a refill should be approved who does is listed as the authorizing provider for the purpose of the pharmacy and the patient's insurance? If this system has really done all this work that presumably would have otherwise been done by a provider, what's the harm in presenting the recommendation to a doctor or pharmacist for final approval? I'd think that it's important to get a trained professional to apply their experience to the final decision, which is perhaps why there is an "authorizing provider" field in the first place.

sonnyblarney 8y ago

UX centric design is the future, companies need to understand that. Particularly buyers who are making decisions of of 'feature checklists'.

octorian 8y ago
This is only possible when the customer isn't completely disconnected from the user, there is real competition, and that competition is based on the product itself... Not the contract to buy/develop said product. These reasons are also why so much defense-industry software is also a completely unusable mess. (that's an industry I used to work in) The software is written to satisfy a requirements checklist, nothing more, nothing less.
- sonnyblarney 8y ago
  I worked in defence as well, and the requirements are not just a 'checklist'. You're talking about safety, consistency. Lives - and geopoltical situations are at stake. Do you know what it means if a guided missile goes wayward and crosses international borders? Or the rescue helicoptor's GPS is unreliable? Totally agree it's bogged down in bureaucracy ... But those requirements are real. You want complicated: work in 'manned space flight' probably the highest safety tolerances of anything. My god I don't even know how we get someone in space these days. We use the Russian system because it's old school, probably less complicated and reliable.
Scoundreller 8y ago
Ethnographic analysis is becoming more common. E.g. throw a user in front of 5 different systems and do the same task. What is the actual experience? Error rate? How long did it actually take? Number of clicks doesn’t matter: that’s the equivalent of buying art by the pound.

throwaway5752 8y ago

Because Cerner and Epic are awful and the rest are too.

CaptSpify 8y ago

This isn't isolated to doctors sadly. You see this in any medium to large organization: schools, cities, companies, etc. The problem, the way I see it, is that management is the one really being sold to. The actual people who do the day to day work have no real say in which software systems they use. Only management has any real say, so sales people tailor their pitch towards management. Unfortunately, managers only have a high-level overview of what the people below them actually do, and no understanding of software, so they have no idea what they need their software to do. And situations like this are where sales people shine brightest. Sure, the new "cloud-based, totally-super-secure, widget producer 9000" won't actual be useful at anything, but it sure looks cool to management. Look at companies like Oracle, and Microsoft for good examples: Their actual products are awful, but that doesn't matter. What matters is that their sales team can sell a shit product.

pimmen 8y ago
I whole heartedly agree, and if newer computer programmers don't believe that's how the sausage is made they could either start working as a consultant or ask their consultant friends about the inevitably awful software they use to log their hours. The reason it's awful is because at no point has a consultant's work flow ever been considered during development. At no point has a consultant ever been present while the software was sold. The consultant isn't the customer, or even the end user in mind, it's the financial departments who get to turn all those hours logged into nifty charts. Imagine that's not a consultant anymore but a doctor, and he or she is not entering hours worked but medical stats. Sleep well tonight.
threatofrain 8y ago
I feel that companies selling B2B think of high-level executives as having incentives to deliver "something that wins", but they won't be around years later when it stinks. The company structures themselves accordingly by delivering fast productivity now, but skeleton crew later.
analog31 8y ago
This was once described to me as the Law of Enterprise Sofware: All enterprise software sucks, because it's sold to administrators, not to users. The managers see the purpose of software as improving their own workflow (tracking, data gathering, compliance) as well as controlling the users, not (gasp) empowering them. Compounding the problem of enterprise software is customization. A person who works at an EHR vendor told me that every clinic system wants to develop their own bespoke workflow, in search of slightly higher efficiency, and so the thing that the user actually sees is not a well engineered system, but a hodgepodge of screens and forms that were designed at the last minute. My friend said that the user experience is a lot better at sites where the customer uses the off-the-shelf implementation with little or no customization.

kapauldo 8y ago

This is an absurd complaint by a millionaire who is too important to document his work. Boo hoo.

amelius 8y ago

To the IT people who are making others click ads: perhaps it's time to fix some real problems ...

SmellyGeekBoy 8y ago
Ads in medical software! I like your thinking.
- hotzenplotz 8y ago
  European doctor here. We have ads in our medical software!

Areading314 8y ago

Sounds like jira

classichasclass 8y ago

So here's my story about this. I'm a physician primarily working in an administrative capacity for a large local government (though I also have a background in enterprise computing and did that for several years both full-time and as a consultant). I'd lived through the horrors of the EHR transition at the large HMO I used to work for and was determined not to have that happen again. We were selecting an EHR product and had it narrowed down to three main products which I won't name here but they're all major players and are still in the market. I was representing the clinicians, so I selected the product "A" I felt had the best clinical support, the best clinical workflow and the easiest UI slope. So did the nurses who were selecting for nursing staff (we didn't coordinate our choices; we each legitimately felt this was the best product for our respective scopes of practice). The billers selected the product "B" that had the best reporting and financials. So, we on the clinical side were asked, can you live with "B"? Well, yeah, sure, I guess? We can make it work, but it's clearly less flexible, the workflow is clunkier, the decision support is less comprehensive and we felt would be more difficult for the physicians. The billers said adamantly that "A" was too much work to deal with the reporting and they wanted something out of the box. They were not willing to compromise despite our concerns on the clinical side, even though we'd have more facetime with the product than they would, and there would be less to bill if the physicians couldn't figure out how. So the clinicians got overruled by the billers and "B" was selected. I understand that the billers must have a say, but the billers are dealing with a small portion of the product. The billers managed to convince administration that their concerns were more valuable because their work translated into dollars. As if the clinicians' work didn't? How does that work? And yet I see this occur again and again in other clinical systems. As a postscript, the local government's rollout of "B" went aground and we ended up with a cheap vanilla install of "D", which wasn't part of the original three and ended up pleasing no one, and is ironically the same EHR I still have PTSD from all those years ago.

Scoundreller 8y ago
Could it be that the “B” product was a lot cheaper? The “best” EHR vendors know they are, and charge accordingly. The underdogs know that they can win on price if they can’t on usability

shanecleveland 8y ago

There are many factors at play. I work for a US manufacturer in the medical industry, and our customers definitely lag behind in technology. Some of the things I see: Much of the workforce is older and adoption of new technology is avoided by many. Large organizations move slowly and health care workers don't tend to be among early adopters of technology. While working individually, face-to-face with a patient, pen and paper can actually be the best option. A younger workforce, more understanding patient population and new environments centered around technology first will occur eventually.

phren0logy 8y ago
I'm a (relatively) young and tech-savvy doctor. The electronic medical records I have used (around 5 or 6) are all truly terrible. As the medical director of a group of clinics, I explored replacing our terrible system, and every other system I looked that was a reasonable fit for our needs was, at best, marginally better. While there are other factors at play, the main one is that electronic medical record software is really, really bad.
- shanecleveland 8y ago
  No doubt. I didn't mean to minimize this aspect. I think it will take a new generation of professionals like yourself involved in building not only the software systems, but also the hardware used, the clinic environment and entire patient experience. As it is, these terrible systems, designed by non-medical professionals, are dropped in the laps of practitioners who are not comfortable with technology in settings not designed around the use of technology.

stmw 8y ago

Great article -- it's a big problem that needs urgent nnovation. BTW, if you are reading this and are interested in helping build better software for doctors, drop us a line. We are a stealth startup working to fix the software doctors use. As the article explains, if you have seen what physicians have to put up with, it's a bad version of the 90s, and makes medical care worse and more expensive for everyone. Please email jobs@commure.com and mention "[whydoctorshatetheircomputers]" in the subject line.

noddy1w 8y ago

Medtech is annoying because of the primary focus being documentation. I spend much of my day writing stuff that noone cares about for people who will never read it. Doing this on paper is slow. Doing it on a computer is even slower. Finding a terminal and filling in structured forms is a pain in the ass when I want to be seeing patients, doing procedures etc. Using things like google glass and offsite scribes is a good way to do this.