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Why Doctors Hate Their Computers (2018)
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- mmaunder 6y agoI was startled back in 2015 when a world renowned oncologist got chatting with me about github and tinkering with code. I think it depends on one’s appetite for technology.
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- AnimalMuppet 6y agoTL;DR: Doctors don't hate computers. They hate medical software, because it's done badly. It gets in their way with pointless (to the doctors) bureaucratic trivia that the doctors shouldn't have to care about.
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- Spooky23 6y agoPlus they replaced paper systems that were better in most ways!
- idiot900 6y agoYep. EMRs are for billing first, clinical utility second. Committees composed of doctors know nothing about software design, so their advice to developers is not very useful. IMHO you need developers, who are also doctors or other providers actually doing the clinical work, to make decent medical software.
- Jtsummers 6y agoAnd, in the case of the software being discussed, eliminated or nearly eliminated the ability of office staff to handle those sorts of details. Additionally, it apparently failed to have reasonable defaults (active user isn't defaulted into the physician providing care; current date isn't defaulted into the date field for a note).
- gregmac 6y agoI'm going to take some guesses here but I'd love to hear a discussion about this from people with experience in medical software. Medical software seems like it is rife with mandated requirements, likely written by people with no regard to real-world usage implications. By this I mean decisions that are akin to attempting to increase security by password complexity and expiry requirements -- when the reality is that decreases security by making users write down and/or cycle through easily-predictable passwords. I would also guess the purchase cycle is very disconnected from its users. The people actually making the buying decisions never actually touch the software. This is probably also like a lot of enterprise software: very expensive, long contract/license lengths, high switching costs. A relatively minor point but there's also no dogfooding: The developers building the software are not medical professionals and thus never use it themselves. They don't get to see the daily pain. The result of all this would be very little incentive to build anything beyond "working" software -- spending time on UX or UI design just eats into profits. The type of developers/PMs/etc that excel at and advocate for this type of work are likely not going to stick around (or even work there in the first place), making improvements even less likely.
- motohagiography 6y agoHave spent decade more or less as health tech security and privacy consultant, checking in. Requirements come from the institutions that fund the solutions ("solutions," not products) and not the users themselves, so engagement with end users is limited. It's very waterfall, no product managers, just "business analysts," whose only leverage is their perceived relationship with "the client," who may or may not be represented by an actual user. I've thought a lot about how to disrupt healthcare, and the only viable way I can think of doing it is selling new products into emerging markets that don't yet have ensconced bureaucracies running health. The most successful grassroots medical product I am aware of is "Figure 1," but any product going into western world healthcare is going to be %95 enterprise solution and %5 health related. An "Uber for stitches" product would be illegal in most countries, but that's the only kind of innovation I can see driving change for most people.
- nikanj 6y agoKids who go to med school tend to be the ones who excel in math, chemistry, and similar ”logical thinking” subjects. They usually do reasonably well with computers. In my experience, the contrast is stark to another high-paid professional group: lawyers.
- whitepoplar 6y agoOh my god, agreed. I have known many lawyers, my father being one, and the amount of hubris and tech-derision is insane. You could give lawyers a computer that prints money and they would shrug and tell you to get it out of their office.
- brendawalsh 6y agoI don’t know how old your dad is, but I remember mine had an IBM XT and used WordPerfect, w DOS 3.3, I think. I remember WordPerfect being very popular in law offices, but also dictation machines, so who knows?
- ghaff 6y ago>I remember WordPerfect being very popular in law offices, but also dictation machines, so who knows? There was a period during which PCs (as well as other word processors) were coming in when computers were seen as being increasingly important (in law and elsewhere) but the management at many companies weren't sold on it being a good ROI for professionals, especially those billing by the hour, to use them directly. There was definitely a period of time in many places where there were computers but it was secretaries/paralegals/etc. who actually typed on them. And, remember, a lot of young professionals in the late 1980s had never really learned to type, even hunt and peck.
- nikanj 6y agoI swear some law offices still have those XTs and WordPerfects
- Chlorus 6y agoDo tech support for a hospital and this attitude will very quickly dissipate. >In my experience, the contrast is stark to another high-paid professional group: lawyers. Database systems like WestLaw & word processing systems in the 80s and 90s were killer apps for law offices, so if lawyers are tech illiterate it's a recent phenomenon.
- annoyingnoob 6y agoIs there any one-platform-to-rule-them-all solution, that will support 70K users across hundreds of sites, that doesn't look and work like a clunky piece of junk? Maybe the one-solution model isn't the best option.
- treis 6y agoThis is an extremely long article and admittedly I started skimming halfway through, but this statement: >But we think of this as a system for us and it’s not,” he said. “It is for the patients.” Is wrong. It's a misnomer to call them medical record systems. They are primarily billing systems. Sure, improving patient care or reducing paper records are nice. But the #1 thing is to document the care to allow them to bill insurance or the government.
- nikisweeting 6y agoI don't think that's entirely accurate. It's true that billing is a core part of most EMRs, but out of the hundreds/thousands of features in a big platform like DrChrono or EPIC, a large portion of them are not billing related. There's tons of operational utilities like e-prescription, lab ordering, patient problem tracking, vital sign tracking, imaging and diagnostics tooling, etc. You could argue that all of those are somehow related to billing because they help doctors see more patients per day, but billing would still be possible without them, and they largely exist because doctors need them to work effectively and treat patients more efficiently, not because they directly serve the billing pipeline.
- conanbatt 6y agoIf you didn't have to bill insurance for the visit, you can document on a paper chart in a minute and that would be it.
- nikisweeting 6y agoGood luck using a piece of paper to e-prescribe a medication such that it's shipped to the patient's pharmacy before the patient even shows up. Ditto for lab orders, imaging analytical tools, custom vital tracking with automatic flagging, diagnostic hardware integration, etc. there is lots of stuff in modern doctors offices that would be significantly more difficult on paper. Not to mention all the issues of paper management and physical security once you have thousands of patient documents scattered around in filing cabinets.
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- scarier 6y agoPart of the problem: medical software isn't designed to facilitate efficient patient care. It's designed to facilitate billing.
- phren0logy 6y agoI'm an MD, and most medical software is objectively terrible. I've worked in private hospitals, campus student health clinics, jails, juvenile detentions, VAs, group homes, state hospitals (in the US) - and in clinics and hospitals in New Zealand. I have never used an electronic medical record that I would willingly inflict on another person. The reasons vary, and almost all of them have at least a couple of things that they do very well. But the bottom line is that this exactly the kind of "enterprise software" that is sold to people who will never have to actually use it. They are overwhelmingly sold as ways to increase reimbursement for services provided, as a part of the arms race of insurance companies refusing payment, and hospitals billing more and more. Even in public sector settings that aren't billing, the only viable options available are built with this problem in mind.
- husarcik 6y agoWhat is your opinion of Epic?
- phren0logy 6y agoIt's among the least bad, but nobody would ever mistake it for software sold to general consumers in this century. I know it's complex and specialized, but so are IDEs, and those are (in my limited use and understanding of them) worlds better in their engineering. That said, I'm not crazy about how actively Epic appears have tried to keep medical records created in Epic locked in to Epic. The spirit, if not the letter, of the legislation requiring a move to electronic records was due to record portability. From where I stand, they have actively prevented that (or at a very minimum sandbagged) to expand their market share.
- phobosanomaly 6y agoAnother unintended consequence of this is that it makes it extremely difficult for doctors and nurses to pull data to do basic research or look at patient outcomes. For example, if you wanted to see what the outcomes of giving a specific drug at a specific dose to a specific group of patients at your hospital was, you're in for a real fun time manually copy-and-pasting thousands of entries from the EMR to a spreadsheet. Now more than ever it is important to look at data relating to patient outcomes with various COVID treatments that haven't been thoroughly vetted yet. But, guess why your local hospital isn't doing anything like that? Because what should be a simple 3-hour exploratory data analysis that can be breezed through IRB now has to involve a budget component of hiring a professional copy-paste person. Can't even use med students to do it anymore because they aren't allowed to hang around the hospital due to COVID, and you can't access those records remote due to HIPAA.
- vedtopkar 6y agoHaving spoken to a lot of doctors during medical school, it really does feel like a generational thing. Physicians who were trained in the pre-EMR times have a really hard time transitioning. This is partially a UX design failure on the part of EMR companies. The newer crop of physicians have a much better time using EMRs. Don't get me wrong, they are acutely aware of the ridiculousness that is modern billing-centric medical records. But having been trained in that atmosphere, it definitely appears less painful to their day-to-day.
- euthymiclabs 6y agoPerhaps. The older generation has a lot of trouble with computerized systems in general. The younger generation of doctors (including me!) can handle them just fine but find them still to be an overwhelming waste of time. I'd love it if we just had a great API that workflows could be build upon. And I'd kill for a command line EHR!
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- vedtopkar 6y agoAbsolutely agree. The frustration with how much time is wasted is certainly universal. I would kill for a command line EHR, especially if I could edit notes in vim!
- chromatin 6y agoOMG I am in love with the thought of API and CLI based CPOE/documentation.
- josephpmay 6y agoA lot of Epic, at least on the technical side, is still accessible via the command line. I wonder if patient charts can be.
- dogmatism 6y agoI'm older, and maybe this speaks to my age, but I also daily dream of a TUI EMR. Orders done using awk for text field processing, grepping for results, editing notes in vim with medical syntax highlighting and completion... Alas, I spend my days cursing as Cerner re-draws the unnecessary html and the focus refuses to follow the mouse, and that no one along any of multiple points took the time to write an interaction checker that didn't result in getting three popups to acknowledge that epi boluses given at separate times during a code (and now the patient is dead) don't interact.
- giantg2 6y agoThe big part of this issue is how lawyers and politicians make everything more complicated than it needs to be. Doctors can't access the data they need, require multiple forms and signatures for simple things (like transferring records), and are stuck in old school tech / jurisprudence (can I email a scan? Oh, it has to be fax). Don't even get me started on the format of VAERS data...
- Spivak 6y agoOf all the failings of our medical system I don’t think I would cite having safeguards for patient privacy that require explicit unambiguous consent in the form of a paper signature and mandates for secure communication channels. Yes it’s kinda silly that faxing is still allowed and grandfathered in but a lot of times the lowest common denominator since everybody can get a phone line. You actually can email that scan, your email provider just has to be part of DirectTrust.
- giantg2 6y agoI think it's the cost of the bureaucracy and systems that are a major failing, not privacy itself. The litigation involved is also expensive. I'm trying to get my kid's record transferred to primary care from two hospitals and it's a nightmare. I feel like most of the frustration could have been avoided if the personnel involved were properly trained. The costs of visits and treatments include this overhead. It doesn't matter if the signature is on paper since the files are digitized and thus exposed to attacks. Not to mention that fax isn't really more secure than email. I have yet to see a provider near me who will accept a scanned document through email, but maybe that's different in other areas. Medical files go for a high price on the black market, but they are still fairly prevalent. This is different than a hospital, but quite cheaper than a normal primary care visit ($200ish). https://www.bloomberg.com/news/articles/2019-12-13/pittsburgh-s-insurance-free-doctor-charges-35-per-visit https://www.bloomberg.com/news/articles/2019-12-13/pittsburg... Anyways, there are tons of problems and costs in the system.
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- canadaj 6y agoMy first "real" job out of college was database reporting at my local hospital that used Epic. I was young and starry-eyed, but I remember sitting at these Epic trainings and using the software. I knew something must have gotten lost in translation during development, because the software was absolutely a mess of confusing menus and screens. After all, I was a budding software developer with absolute computer literacy, if I didn't get it, who would?! I remember thinking that there was no way self respecting developers would allow this to happen, but I was so naive!
- bitxbit 6y agoHCIT is a sh*tshow. It’s mind boggling how nearly 7 years of billions in “investments” have yield minimal improvements. Tax dollars down the drain. And I‘ve seen enough to know that it’s all by design. The entire HC industry does everything within its power to keep the system as opaque as possible.
- jld 6y agoIt's like asking "Why do pilots hate airplane food?" It has nothing to do with why pilots are/aren't epicures, and a more to do with their bosses deciding to serve them crappy food.
- brundolf 6y agoRelevant: https://news.ycombinator.com/item?id=21224209 https://news.ycombinator.com/item?id=21224209
- jfkdkdnaahhdnd 6y agoI used to work for an EHR vendor. Users don't drive features, hospital administrators and CMIOs[1] do. In general, we give hospitals the ability to get better reimbursement from insurance companies by embedding more detailed billing information in the patient's chart and documents. We also help shield hospitals from liability by helping add more details demanded by their lawyers. Information about the patient from healthcare providers for other healthcare providers runs a distant third. If your old paper chart didn't get misfiled or fall behind the cabinet, almost everything in it was relevant to your care, because there wasn't enough hours in the day to record anything else. Now, it's a sea of compliance bullshit and autocompleted lies -- the unscrupulous practitioners insert multipage reports on tests that were never performed with just a few clicks. (I think the EHR vendors now also sell tools to detect that sort of fraud.) For users who ultimately want to provide care, dealing with electronic medical records is a nightmarish situation and it's leading to burnout at record rates. 1. Chief medical information officer --usually a doctor who became an expert EHR user and now decides what will work for doctors and what won't.
- brendawalsh 6y agoSo, HN doctors here, how ‘computer literate’ are your colleagues? I have worked with doctors of varying age groups, including family, and it really just depends. Age is not a factor, it seems some people are averse, and others passionate.
- testfoobar 6y agoHow are hospital records and billing managed in European countries?
- analog31 6y agoThis was a long time ago, but a relative of mine was hiking in Wales, and got injured. She made it to the next town and found a clinic, where she was treated. Then she asked how she should pay. They were like, pay? You don't pay for medical care. She told them that she wasn't from the UK and therefore wasn't covered by their system. But they said that they had no way of figuring out a price or generating a bill for her. So she went on her merry way.
- Silhouette 6y agoWe're not quite as generous in the UK as this makes us sound. Anyone interested in more details might find this informative: https://www.gov.uk/guidance/nhs-entitlements-migrant-health-guide https://www.gov.uk/guidance/nhs-entitlements-migrant-health-... The short version is that primary care services like consulting with a GP, visiting a walk-in centre, or emergency treatment in a hospital accident and emergency department are generally free to all, as are various other specific types of care. Most secondary care services such as other hospital treatment are only free to people ordinarily resident in the UK, which roughly means anyone who is an EEA citizen or who has the immigration status of indefinite leave to remain, again with lots of other special cases. Some services, such as dental work and buying prescribed medication, are generally chargeable by default for everyone, though even then the NHS may set standard prices and there are various provisions to help those of limited means or in certain vulnerable groups. But yes, if you have a nasty accident and need to go to hospital as a result, no-one is going to be asking for your credit card number here before sending the ambulance, and if you only need treatment in A&E and don't need to be admitted as an in-patient, you probably would get most or all of your treatment for free even though the equivalent in certain other places would cost a fortune if you didn't have insurance to cover it. There are a lot of reasons we are proud of our NHS here, and this is one of them. Just in case anyone reads this later, let me add a final note that if you're coming here, please check the details for exactly where you're planning to visit. A lot of health policy is devolved, meaning policies can be different in England from in Wales, for example.
- bigtones 6y agoEpic was a medical records system built up since the 1970's in Verona Wisconsin, first developed to turn paper based medical records into a database computer system. A good 8 minute YouTube video from January this year on the sole female founder and the quirky company culture is at: https://www.youtube.com/watch?v=8lPMYk09nUg https://www.youtube.com/watch?v=8lPMYk09nUg
- chromatin 6y agoIt’s too bad they spend their billions on Harry Potter Hogwarts themed campus instead of UI/UX studies
- goda90 6y agoEpic does do UI/UX studies. It's got a lot of legacy code to plow through, combined with regulatory and customization demands that lead to best UX practices having to be bypassed sometimes. Striking a balance between too much information and having a clinician miss critical information because it was hidden behind a click or hover bubble is always a concern. Regarding the campus, the theming is actually quite cheap. The bigger expenses come from employee QOL stuff like roomy underground parking to keep cars out of the snow.
- tuna-piano 6y agoEpic's founder, Judy Faulkner, is the fourth richest self made woman in the US. She's the CEO of one of the largest companies in the health tech industry, and almost no one has heard of her. https://en.wikipedia.org/wiki/Judith_Faulkner https://en.wikipedia.org/wiki/Judith_Faulkner https://www.forbes.com/self-made-women/#68196cf36d96 https://www.forbes.com/self-made-women/#68196cf36d96
- dang 6y agoDiscussed at the time: https://news.ycombinator.com/item?id=18381969 https://news.ycombinator.com/item?id=18381969
- dctoedt 6y agoThe author, Dr. Atul Gawande, is more than a bit of a rock star. He's a Rhodes Scholar and MacArthur Fellow "genius grant" recipient. He wrote, among other things, The Checklist Manifesto, having headed up (IIRC) a World Health Organization project to implement short, bang-for-the-buck preincision checklists for surgeries, which apparently improved outcomes dramatically. https://en.wikipedia.org/wiki/Atul_Gawande https://en.wikipedia.org/wiki/Atul_Gawande
- epmaybe 6y agoMy six degrees of kevin bacon story: I met his neighbor once, they love him.
- anitil 6y agoThis article is what led me to read The Checklist Manifesto. What I loved about that book is that it works through all the traps around how these checklists can be implemented. An example - Administrators typically want _everything_ on a list, because everything is important, right? However these lists need to be concise enough to be useful otherwise people just ignore them.
- jungletime 6y agoI hate my dentist's computer. She's looking at my xrays on the computer, touching the mouse then my mouth. Should I freak out? What are the odds she autoclaves the mouse between patients.
- Something1234 6y agoI hate watching the nurses typing on the keyboards that they wheel around from room to room, and touching patients after touching the keyboards. Especially considering that those keyboards are not easy to clean, and just standard dell keyboards. It's absolutely disgusting.
- Aeolun 6y agoConsidering what’s just floating around in a hospital, or what is on a doorknob, I wonder how much effect this actually has.
- amelius 6y agohttps://news.ycombinator.com/item?id=23802761 https://news.ycombinator.com/item?id=23802761
- sabujp 6y agotldr; information overload, reduced actual time with patients and increased time entering bunch of information into computers, summary from https://autosummarizer.com/ https://autosummarizer.com/ : My hospital had, over the years, computerized many records and processes, but the new system would give us one platform for doing almost everything health professionals needed—recording and communicating our medical observations, sending prescriptions to a patient’s pharmacy, ordering tests and scans, viewing results, scheduling surgery, sending insurance bills. But three years later I’ve come to feel that a system that promised to increase my mastery over my work has, instead, increased my work’s mastery over me. A 2016 study found that physicians spent about two hours doing computer work for every hour spent face to face with a patient—whatever the brand of medical software. My hospital had to hire hundreds of moonlighting residents and pharmacists to double-check the medication list for every patient while technicians worked to fix the data-transfer problem. “Now I come to look at a patient, I pull up the problem list, and it means nothing. I have to go read through their past notes, especially if I’m doing urgent care,” where she’s usually meeting someone for the first time. Many scientists complained to Spencer in the way that doctors do—they were spending so much time on the requirements of the software that they were losing time for actual research. In 2014, fifty-four per cent of physicians reported at least one of the three symptoms of burnout, compared with forty-six per cent in 2011. Only a third agreed that their work schedule “leaves me enough time for my personal/family life,” compared with almost two-thirds of other workers. There are messages from patients, messages containing lab and radiology results, messages from colleagues, messages from administrators, automated messages about not responding to previous messages. Previously, she sorted the patient records before clinic, drafted letters to patients, prepped routine prescriptions—all tasks that lightened the doctors’ load. She called it “a ‘stay in your lane’ thing.” She couldn’t even help the doctors navigate and streamline their computer systems: office assistants have different screens and are not trained or authorized to use the ones doctors have.
- tus88 6y agoA lot of in-house medical "software" is Access databases so no wonder really.
- cs702 6y agoDoctors hate their computers because the software they are forced to use sucks. And it sucks for the same reason that most enterprise software sucks: because the people who budget for it, choose it, and pay for it are not the people who use it. For more on this, see this now-classic Twitter thread by Princeton CS Prof Arvind Narayanan: "Why Enterprise Software Sucks" https://twitter.com/random_walker/status/1182635589604171776 https://twitter.com/random_walker/status/1182635589604171776
- kube-system 6y agoTo be fair, the people who use enterprise software typically only understand a single-digit percentage of what the software needs to do, at best. If you asked them to design it, you wouldn't get a better result. To properly architect enterprise software, you need to capture the competing needs and goals of hundreds of different roles in different departments. You will uncover underlying political and organizational issues that you will need leadership to sort out before you can ever start to determine the business-logic. To be successful, you have to be an expert at playing politics, business analysis, and mediating conflict. I wouldn't say "enterprise software sucks"... more like, the lack of cooperation in many organizations sucks, and enterprise software puts a big spotlight on it.
- dragonwriter 6y ago> To be fair, the people who use enterprise software typically only understand a single-digit percentage of what the software needs to do, at best. If you asked them to design it, you wouldn't get a better result. Sure, users don't know what a system needs to do to meet their needs, but if you had modestly competent business analysts work with them to specify the system, you'd have good results.
- tuatoru 6y agoExactly. The role of systems analyst (nowadays confusingly called business analyst) seesm to have largely vanished in the beliefs that either COTS enterprise software would be used as it came, or that users know what they need (as opposed to what they want) and can rationally set priorities and tradeoffs. Turns out neither of those beliefs was true, and systems analysts are needed. With the passage of time the role has largely been forgotten.
- peterwwillis 6y agoFor the medical professionals here who hate their EHR systems: send the CEO, CTO, President, VP, etc of the company some mail describing your problems, how many people hate it, how much time it drains, one or two ideas on how to make it better, and ask them to forward your mail to the product owners. One of them will hopefully forward it down the chain and in a year maybe one of those things will be less painful. Also, a bunch of the people reading HN work for different vendors, so light up the comments about specific problems with specific products and we can take them directly to the people who can fix it.
- nitwit005 6y agoI wonder how often people are pissed at the software companies, when the real villain in this story is their hospital. They're actually upset at customizations the hospital insisted on. At my last job I tried to get some fields in our bug tracking system made optional. You could run reports showing they were garbage most of the time. Naturally, I failed, and those fields are still required to this day. I started putting "supercalifragilisticexpialidocious" as a value in some of them. No one ever commented on it.
- duffpkg 6y agoI created the open source ClearHealth/HealthCloud EMR system, have managed hundreds of medical facilities large and small and am the author of "Hacking Healthcare". There are a lot of layers to this and competing concerns. This article is misguided at best. The quote "Doctors are among the most technology-avid people in society" is hilariously off the mark. The average age of doctors in the US is 51. Amongst many difficult problems related to this: -Medicare/Medicaid/Federal spending is half to 2/3 of all medical spending. They are insanely bureaucratic and simultaneously penny pinching. They require lots of things that make everyones jobs harder with no obvious benefit to anyone. They dictate in many ways how software must work in medical settings. -Doctors in most institutions are not given an adequate amount of time to accomplish all of the things that need to be accomplished to deliver quality care and also get properly paid for the interaction. This in part is financially driven but I would say it mostly occurs because there is little to no accountability for medical systems to operate well or efficiently. In many situations there are perverse incentives to operate inefficiently. -Doctors make an absolutely shocking amount of substantive errors, 25% of interactions or more. Preventable medical error is almost certainly in the top 5 causes of deaths in the united states. I could go on and on but cherry picking but I think I made my point that this article looks only at one perspective of one facet of disgruntled personnel involved in a single implementation.
- goalieca 6y ago> Analyzing medical death rate data over an eight-year period, Johns Hopkins patient safety experts have calculated that more than 250,000 deaths per year are due to medical error in the U.S. https://hub.jhu.edu/2016/05/03/medical-errors-third-leading-cause-of-death/ https://hub.jhu.edu/2016/05/03/medical-errors-third-leading-...
- elliekelly 6y agoI’ve mentioned it here before but the book “Black Box Thinking” by Matthew Syed is an interesting read in this regard. It really highlights how important it is to design a system that’s focused on error reduction (like aviation) rather than focused on allocating blame (like medicine). IIRC there’s a chapter in the book about patient safety correlating with how “friendly” the OR nurses perceive a surgeon. The implication being that if someone makes a mistake they’re more likely to fess up a nicer surgeon (who will then have the opportunity to correct the error) and more likely to cover it up or ignore if they might get chewed out for bringing it up.
- viraptor 6y agoThis is also an amazing space for shadow IT and customisations. Probably the best ROI software I wrote were AutoIT scripts for medical software. Plug them into StreamDeck and they're saving amazing amount of time. On a single case it's just a few tens of seconds, but it really adds up over time. (Think one button specialist referral which clicks through / fills out 4 windows) Then there's mass-edit scripting. Have you ever told someone that you updated 200 records and added $4k income, while saving 4h of manual error-prone clicking?
- fullstackmd 6y agoI'm an MD/Dev at one of the only major academic centers in US that still maintains a home-built EHR. Atul Gawande is definitely a giant in healthcare process improvement and a great writer. Many of us were eagerly anticipating what he would do with the Amazon/JP Morgan/Berkshire Hathaway healthcare initiative and disappointed when he stepped down (https://www.geekwire.com/2020/atul-gawande-steps-ceo-haven-healthcare-joint-venture/ https://www.geekwire.com/2020/atul-gawande-steps-ceo-haven-h...). Unfortunately, there are too few of us that understand both the challenges of caring for patients and the barriers of writing (and maintaining!) good software. Our EHR is far from perfect, but the basic HTML interface has aged remarkably well into the era of smartphones. Our approach is to extend functionality of our EHR with APIs and an ecosystem of add-ons. Always looking for people with a passion for healthcare and flexible skills. Mumps/Cache, API design, JS (vanilla, JQuery, React), mobile (Swift, Java, React Native, Kony), and ML (computer vision and NLP).
- abhisuri97 6y agoHoping to be an MD/Dev of sorts depending on this med school app cycle :) what institution is this? Most of the ones I know are gobbled up by Epic.
- fullstackmd 6y agoGood luck! Long road ahead, but it's worth it. I'm at BIDMC. Reach out (email in profile) if you need advice or want an interesting project to work on.
- hollosi 6y agoMedical software is terrible, because healthcare is very expensive, and this is the only effective cost control. Since the payers (insurance companies and the government) want to avoid seen making medical decisions, their only way to bring the cost down is to slow down the providers. Therefore, they do not allow automation in the EMR/Health software. This is not a joke: for appropriate billing, the physician has to go through an elaborate dance of clicks, and write and rewrite fields with the same content, personally. In other words, if it was automated, or if the office staff filled those out, then the billing would be much lower. It's not true software vendors would not be able to automate a lot of this, but they just can't, because the physicians are required to work in a manual way for proper reimbursement. It's a strange world, where a doctor who is a faster typist makes more money... It's very sad, but unfortunately it's working, at the cost of driving physicians to the edge of insanity.
- noisy_boy 6y agoI think in today's world, typing faster is a life-skill. I learned typing on an actual Remington type-writer during my summer holidays eons ago because my dad forced me to go to typing classes (he hoped with that I'll atleast be able to secure a typist's job, if nothing else). That skill of touch typing has paid for itself many times over since then.
- Peepers 6y agoMedical professionals in this thread, I encourage you to reach out to the people at your organization making the decisions for your EMR. Escalate, or the development company will never hear about the issues that are hurting you daily. I'm a developer at one of these companies, and we truly do want to make your experience better. If there's a workflow that you do for every patient that takes 3 clicks instead of 1, escalate. There's a good chance there's build that could help you out. If there's not, escalate anyways. Ask your IT department to contact the development company's staff. We want to hear any and all feedback about specific workflows that are a struggle.
- xyst 6y agoI am not surprised at all. When I was a college student on the medical school track, there was a unique opportunity to work alongside doctors in a hospital setting. The job was to be the doctor's "scribe" and input all of the doctors findings, patient history, and document the care provided by the physician (eg, suture repairs, intubations, and other procedures). It didn't make sense why this job existed until I actually started training on the system. The system is absolutely god awful in terms of UX experience, but after awhile (1-2 months) you get acclimated to it and could complete a chart in <5 minutes. Some or most of the doctors I worked with absolutely hated the system itself. On many occasions, I have observed doctors input the wrong orders which if they were performed would have had severe consequences. Fortunately, 99.9% of the time the error was caught by the physician or the nurse assigned to the patient. The one instance where it wasn't caught was actually due to human error - nurse gave patient anti-hypertensive med instead of the ordered calcium channel blocker (Cardene vs Cardizem?). On the worst occasion, one doctor I worked with struggled on a daily basis to input orders into the system. I think it would take 5-6 minutes just to input some basic orders. Someone ended up teaching him how to input the orders in free form text and the nurse(s) would just write up new orders based on that (eg, doctor would write a single order as "cbc,cmp,ua r/o uti, drug screen, CXR 1v r/o pneumonia" and the assigned nurse would recreate the orders in the system in a line-item fashion). Kind of sucks for the nurse, but I think it ended up working out better for both parties. I ended up dropping out of the doctor career path due to this unique and eye-opening experience as a scribe (not because of the EHR software itself but figured the "doctor life" was not meant for me).
- cknight 6y agoThat medical software is simply bad is also my experience, having been an IT Manager for a clinic management company for a few years now. In Australia at least, 85%+ of medical practices run one of two practice management systems. Both of these systems were originally developed by the same guy, and both have their centre of operations in the same small regional town in Queensland. I don't think it's a surprise that top-tier developers are unlikely to be willing to move to the middle of nowhere. My experience with the version we use is that its UX is unpleasant, the platform isn't reliable, and it doesn't perform well at scale for larger clinics like ours. I completely understand that the monolithic design of the software is mandated by too many competing interests (and regulations) for it to be simple. But I am sure it could be better.
- longtimegoogler 6y agoDoesn't everyone hate their computer? I know I have a love hate relationship with them.
- gok 6y agoPaper medical records were great for doctors. They made it really hard to switch providers. They were a great excuse for medical errors, or for "accidentally" ordering expensive redundant tests from their buddies. EMR had to be legally imposed on doctors because otherwise they would still be gleefully killing people through bad handwriting.
- lotsofpulp 6y agoI still don’t understand how society was OK with hundreds of dollars per doctor visit just to get an illegible prescription for medicine that could harm you if read incorrectly.
- caycep 6y agoSaying as someone who has to run several different EMRS from 10 different hospitals in a weird hellstew of citrix and VMWare Horizon clents...I would kill for someone to write a stripped down front end that runs natively in iOS/Mac OS or the web (assuming a good recent web app library)..
- LoSboccacc 6y agothe epidemic has been a boon for the digital transformation of doctors here in Italy. turns out you can do take appointment at the gp, it wasn't impossible turns out you can request exams trough email, it wasn't impossible turns out you can have a pre-screening via photo and messaging apps, it wasn't impossible turns out you can safely deliver prescription trough digital channels to both the person and the pharmacist so that you can just show up with your healthcare number and take the drugs home it has been dragging medics and other professionals around then into the present kicking and screaming
- scythe 6y agoThis is probably the most trite argument on any software forum, but based on my admittedly limited experience working in a hospital research environment, Windows is a serious limiting factor for medical practitioners. Not because it's a bad operating system, but because hospitals are constantly out of money and computer upgrades are never a high priority. Microsoft does a decent job of backwards compatibility with software, but the hardware requirements keep piling up. Windows has no equivalent of LXDE; the computer in the hallway takes 15 minutes to boot on Windows 7. It's a situation I run into over and over: the damn thing is slow. It doesn't help that, as others mention, medical software is rarely built with the quality of software engineering we're accustomed to seeing. But it can't help that the software tries to display all of the information graphically and show as much as possible at once -- pictures I have to wait to load even if I don't need to see them. This comes back, probably, to how it's sold: look at this impressive flashy window with all these bells and whistles. Never mind the system resources, and don't get me started on wasting screen real estate. My workflow begins: turn on the computer, wait, log in, wait, open SNC Patient, wait some more... I don't know how many billable hours are spent waiting for computers to load, but it can't be trivial.
- rukuu001 6y agoLooks like doctors (or most of them) didn't get a look at this until it was done? In a field as technical and regulation-laden as medicine it's hard enough as is. Without relentlessly validating it with users it could only go in one direction.
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- acd 6y agoI think that Parkinsons law applies to all form of administration tasks including doctors and hospitals. "Parkinson's law is the adage that "work expands so as to fill the time available for its completion". It is sometimes applied to the growth of bureaucracy in an organization." Parkinson noticed that the English ship fleet was decreasing in numbers but the number of administrators administrating the fleet was increasing. This rule can be generalized and said to adhere to all kind of public work. If we do not keep Parkinsons law in check doctors will spend more time at computers fulfilling rules administrators invented instead of doing real critical work helping sick patients. Our tax burden will also increase since the efficiency of the system goes down over time, more tax money needs to be allocated to serve the rules and laws the administrators have invented. Is critical that we limit the number of rules and laws administrators can invent so that we have efficient system that serves there original purpose. Parkinson's law is the adage that "work expands so as to fill the time available for its completion" Key take away passage from Parkinsons law: "The accompanying table is derived from Admiralty statistics for 1914 and 1928. The criticism voiced at the time centered on the comparison between the sharp fall in numbers of those available for fighting and the sharp rise in those available only for administration, the creation, it was said, of "a magnificent Navy on land." But that comparison is not to the present purpose. What we have to note is that the 2,000 Admiralty officials of 1914 had become the 3,569 of 1928; and that this growth was unrelated to any possible increase in their work. The Navy during that period had diminished, in point of fact, by a third in men and two-thirds in ships. Nor, from 1922 onwards, was its strength even expected to increase, for its total of ships (unlike its total of officials) was limited by the Washington Naval Agreement of that year. Yet in these circumstances we had a 78.45 percent increase in Admiralty officials over a period of fourteen years; an average increase of 5.6 percent a year on the earlier total" https://www.economist.com/news/1955/11/19/parkinsons-law https://www.economist.com/news/1955/11/19/parkinsons-law http://www.berglas.org/Articles/parkinsons_law.pdf http://www.berglas.org/Articles/parkinsons_law.pdf https://en.wikipedia.org/wiki/Parkinson%27s_law https://en.wikipedia.org/wiki/Parkinson%27s_law
- prerok 6y ago> the design choices were more political than technical: administrative staff and doctors had different views about what should be included. I worked at a company that designed such a system. I was not involved with the project but when the system came out there was a lot of heat in the press quoting medical professionals about how bad the system was. Suddenly, with the new system, the workarounds used in the previous one stopped working. The problem, of course, was not in the "programming" part, even if the press portrayed it so. The problem was the requirements and the insanity of the medical management to force the users to stick to the exact documented work process. The article addresses this as well later on and describes how solutions are then added by workgroups for specific fields. Just another example how you should design such a system along with the users and not by encoding work process some administrative entity proscribed.
- xchip 6y agoCould anyone post the answer? I am sure it can be stated in three sentences.
- moonbug 6y agoHey America, get yourself some healthcare infrastructure.
- desmap 6y agoIt's not about medical software but about how big the lock-in is (which is always higher with B2B). The higher the lock-in the worse the overall UX.
- jbj 6y agoI tried a "EPIC similator" at a medical museum, it was a bunch of drop down menus combined with slow loading pages I could navigate between. I get an impression that hospitals are wasting many expensive workhours from highly trained professionals to operate these types of systems. I really wonder if it could make economic sense to let MDs have personal assistants for these purposes.
- Hammershaft 6y agoYou should read further in the article, it discusses just that, including an initiative to offshore medical scribing to India.
- Aeolun 6y agoOne of the things I think would still be super interesting to try and set up is private single payer health insurance in the US. If we cannot get the government to do it, we should just do it ourselves. The only issue is the absolutely massive upfront investment necessary :/
- Farbklex 6y agoJust my 2 cents. I manage the IT for a doctor's office and the software they use from a medium size company in Germany has a Word / Excel export that looks like this: 1. Software tries to open Excel / Word (it actually failed to open Excel on a machine, but when I opened it manually, the export continued) 2. It copies a row in the software 3. It pastes the row into Word / Excel 4. If more data is available, go back to 2. This is for the export of a data integrity check report in that software suite. It takes multiple minutes to export a report and you can watch live how the copy / paste happens. I was amazed that somebody has the balls to sell this and gets away with it.
- mitchbob 6y agoKeep reading this excellent article, and you'll get to what for me was the best part, about the power of co-design: > Some people are pushing back. Neil R. Malhotra is a boyish, energetic, forty-three-year-old neurosurgeon who has made his mark at the University of Pennsylvania as something of a tinkerer...Soon, he and his fellow-tinkerers were removing useless functions and adding useful ones. Before long, they had built a faster, more intuitive interface...Malhotra’s innovations showed that there were ways for users to take at least some control of their technology—to become, with surprising ease, creators.