11 ms·

I'm an MD, and most medical software is objectively terrible. I've worked in private hospitals, campus student health clinics, jails, juvenile detentions, VAs,

I'm an MD, and most medical software is objectively terrible. I've worked in private hospitals, campus student health clinics, jails, juvenile detentions, VAs, group homes, state hospitals (in the US) - and in clinics and hospitals in New Zealand. I have never used an electronic medical record that I would willingly inflict on another person. The reasons vary, and almost all of them have at least a couple of things that they do very well. But the bottom line is that this exactly the kind of "enterprise software" that is sold to people who will never have to actually use it. They are overwhelmingly sold as ways to increase reimbursement for services provided, as a part of the arms race of insurance companies refusing payment, and hospitals billing more and more. Even in public sector settings that aren't billing, the only viable options available are built with this problem in mind.

husarcik 6y ago
What is your opinion of Epic?
- phren0logy 6y ago
  It's among the least bad, but nobody would ever mistake it for software sold to general consumers in this century. I know it's complex and specialized, but so are IDEs, and those are (in my limited use and understanding of them) worlds better in their engineering. That said, I'm not crazy about how actively Epic appears have tried to keep medical records created in Epic locked in to Epic. The spirit, if not the letter, of the legislation requiring a move to electronic records was due to record portability. From where I stand, they have actively prevented that (or at a very minimum sandbagged) to expand their market share.
  - phobosanomaly 6y ago
    Another unintended consequence of this is that it makes it extremely difficult for doctors and nurses to pull data to do basic research or look at patient outcomes. For example, if you wanted to see what the outcomes of giving a specific drug at a specific dose to a specific group of patients at your hospital was, you're in for a real fun time manually copy-and-pasting thousands of entries from the EMR to a spreadsheet. Now more than ever it is important to look at data relating to patient outcomes with various COVID treatments that haven't been thoroughly vetted yet. But, guess why your local hospital isn't doing anything like that? Because what should be a simple 3-hour exploratory data analysis that can be breezed through IRB now has to involve a budget component of hiring a professional copy-paste person. Can't even use med students to do it anymore because they aren't allowed to hang around the hospital due to COVID, and you can't access those records remote due to HIPAA.
    - josephpmay 6y ago
      That’s just completely untrue. First of all, Epic has a built in tool called Slicer Dicer for clinicians to perform pretty complex population data analysis without having to do any database queries. Second, every healthcare organization extracts much of their patient data to a data warehouse where you can perform direct SQL calls on it.
      - phobosanomaly 6y ago
        Thank you very much for sharing that. I'll look into it more. The clinicians (head of trauma Evidence-Based Medicine as well as the head of the trauma department overall) I have talked to at my non-academic Level II trauma center do not have any clue this exists. They are currently exporting thousands of records by hand. Edit: Do you know offhand of a good guide to SlicerDicer I can share with them? I will google around, but if you had something you personally liked?
        josephpmay 6y ago
        I work at Epic, so the resources I have are all internal training/document. That being said, the best way to learn it is probably to have someone who’s an expert in it, ideally another doctor, walk them through it. If you want, I can see if I can find some specific customer-facing documents/training to link them to.
        owowow 6y ago
        Lack of public documentation has to be my #1 pain point with proprietary software over the years. Especially in the EMR space, putting up barriers to access basic documentation is quite unreasonable. Public documentation is not going to suddenly allow your competition to gain an advantage, while your own firm benefits from users being able to easily google and get authoritative answers from your own official documentation.
        deleted 6y ago
        [deleted]
  - nimish 6y ago
    Thankfully, TEFCA was implemented anyway, and is still on schedule. We'll see what it works out to in practice. But data sharing is definitely still possible, today, even with Epic (they are quite good actually). You are limited to certain reasons but they are pretty broad. Full disclosure: I work on this full time. It is a strange world, that works on its own standards and practices for good and bad reasons.
  - nradov 6y ago
    The latest version of Epic has fairly complete record portability. Is it missing anything specific? https://open.epic.com/ https://open.epic.com/ I think EHR vendors sometimes get unfairly blamed. The fault often lies with provider organizations who simply haven't turned on the available functionality.
    - odyssey7 6y ago
      Why do I feel stressed out visiting this link on desktop? Perhaps someone who's good at UX could share a few thoughts?
      - hanklazard 6y ago
        Ha, exactly. UI/UX is precisely the area where Epic fails the most. I am not an expert in this area, but in my every day use, I can only describe the Epic style of UX as "vomit all information onto the screen at once."
        nradov 6y ago
        Given a choice, clinicians would usually rather have maximum information density to avoid clicking around for what they need.
        Shared404 6y ago
        Some better organization to the information would be nice though. Edit: Not a doctor/in health care. Just basing this on the link above.
        nradov 6y ago
        Better how?
        Shared404 6y ago
        Looking at the website right now, I see three different horizontal arrangements of links. Of these links, there are four duplicate pairs, at least. Two of these sets of pairs lead to indistinctly named pages (/Home/InteroperabilityGuide and /Home/Interoperate) I would start by having all of these links be at the top, and adding some descriptive text to each of the fields in the main body, as opposed to meaningless graphics/marketing numbers. Addendum: Also, I wouldn't want to do the split in thirds thing that occupies the majority of the page. Each of those can get a description of at least a paragraph, and go one after the other. If there's not enough info to fill a paragraph, then they probably need to be merged. Edit: ambiguously -> indistinctly
- VectorLock 6y ago
  I know a whole bunch of nurses who won't shut up about how much they hate Epic. I watched my doctor try to use it once when I was in for a visit and he didn't seem to be enjoying the experience much either based on his grumbling. It seemed like there was a LOT of UI cluttering going on so I can understand how it might not be very easy to use.
  - mv 6y ago
    At my hospital the nursing UI of Epic is absolutely horrid. It's cluttered and confusing with multiple places to document everything. Epic is completely customizable, but the people who make the decisions in nursing management aren't always the same people using the software. That and funding to make the changes. If you want to see really bad software take a look at Meditech it defaults 800x600 (!), and doesn't resize well at all.
    - throwaway4220 6y ago
      Ah yes, I am still forced to use Meditech's telnet interface today. I asked our IT guy if we can please change the font to a smoothed, non-raster font. I think it took all his willpower to not burst out laughing lol
  - somehnguy 6y ago
    Just a little personal anecdote but - A while back I had a week long stay in the hospital, after some small talk with one of my nurses she learned I write software. She told me a bunch of things they hated about Epic and gave me a quick tour of the interface they have to use. The main complaint seemed to be that things they need to do hundreds of times a day require way too many input actions. And it did indeed look incredibly cluttered. I love getting little tours of software I'll likely never use even though I'm not in a position to fix any of the problems. It's just interesting.
    - bena 6y ago
      You know why? Because every doctor, nurse, tech, etc has a goddamn opinion on what's important. They're of the opinion that everything needs to be "as few clicks" as possible. As if "number of clicks" was the only worthwhile message. Nobody would read a book where the keyboard was pressed as few times as possible. Sometimes, complex actions require complex input. We should be shooting for discoverability, not "number of clicks".
- euthymiclabs 6y ago
  All EHRs are bad, some are just worse than others. With the right build, Epic is one of the least bad. But the wrong build can really be soul-destroying.
- hanklazard 6y ago
  MD here. Epic is terrible, as are all other EMRs that I have used (with the exception of VA's older software). I use Epic every day and I am ready to jump ship from medicine altogether to help build an EMR that could actually work well for both health care providers and patients. There is no excuse for such poorly executed software, especially the UI/UX.
  - rscho 6y ago
    My bet is you won't succeed. UI is bad because of corporate and legal constraints, not because developers don't know better. Regardless, best of luck!
- caycep 6y ago
  Virtual basic running in some weird instance of something that you can only get through via citrix? "least bad" is not saying much, they're all pretty bad.
jseliger 6y ago
This reminds me of Blackboard and its competitor (I forget the name of it) in higher education: students hate it. Professors hate it. It's brutally hard to use. Professors can't easily adopt an alternative (as they can with by choosing Google Docs or Dropbox).
- greedo 6y ago
  Moodle?
  - bilegeek 6y ago
    There's also McGraw-Hill Connect and Brightspace.
  - jcrawfordor 6y ago
    Instructure Canvas is probably the more popular alternative right now, Moodle having always struggled with usability and manageability issues (and taking a long time to get a "modern" looking UI). That said, during my student years I felt like Canvas was steadily converging on being as unusable as Blackboard, which maybe hints at some underlying pressures in that industry. I was involved peripherally in the decision-making process on a small university purchasing a new LMS, and the decision was amazingly political and driven by niche needs from vocal users, and I say this as someone who was pretty used to university politics at the time. It seems like the way to get an LMS contract is to throw every feature you can possibly think of into the bucket, usability and quality isn't something that really gets evaluated very well. This probably could be changed but I'm not sure how. For example, the university I was with performed student surveys related to the food service vendor and incorporated the results of those surveys as a performance standard in the contract. Nothing like this was done for the LMS purchasing, no student input was collected at either the purchasing or performance stages, and a combination of purchasing methods and institutional politics meant that faculty input was extremely limited (the vendor was basically chosen before the faculty were invited to provide feedback). I don't think higher-ed IT departments often have a user-focused culture but instead a cost-focused one.
    - 6y ago
osrec 6y ago
What top 3 things could be improved in medical software in your opinion? Is the UI a key problem or are there other bigger issues?
- Scoundreller 6y ago
  It seems like they never watched an end user use their product. Like, who re-invents the 'Page Next' function? Just put a blue underlined "Next Page" button at the bottom of the list like we've done for decades.
- tuatoru 6y ago
  A good text user interface, keyboards that can record and play back keystrokes for getting around the menus, customizable per user, and responsiveness. "Speed" (latency of response) has always been the number one user interface problem of all interactive software and it still is.
  - tuatoru 6y ago
    I forgot: the biggest improvement would be an amanuensis for every doctor and nurse.
bena 6y ago
It's one of those sectors where the people who are interested aren't good enough and the people who are good enough aren't interested. No one really wants to do EMR software. Or medical software in general. They do it until they can do something else. That and you have to work with doctors. And sorry to say, that is not exactly fun. You have people who think because they did a lot of school, that that makes them an expert in everything. And that their bikeshedding is the "real" important issue. When I last worked with it, databases were the hot new thing. And I don't mean databases were new tech. I mean medical software was just catching on to storing data in databases. I think one company was pushing a solution that was essentially a collection of Word templates. As if they had hit upon something not only novel, but that no one in history had thought to do. If you're a software developer, eventually you get tired of pissing up rope and get a better job.
chromatin 6y ago
Also an MD, also hate our EMR because it is hot garbage, and I love your username. My latest complaint is that the authors of our EMR, who I know to be legions of fresh out of college young twenty somethings (hardly anyone lasts long enough to be a senior engineer at this vendor, I am told), have not used any sort of helpful SDK for text input boxes, but instead have written their own, having inconsistent and wrong behavior with respect to keyboard based text selection, Ctl+backspace behavior and a variety of other well standardized functionalities. ...and they have written multiple different wrong implementations, as the text boxes behave differently in different parts of the EMR. Even the inconsistencies are inconsistent, like atrial fibrillation.
- fivre 6y ago
  To be fair to Epic engineers, I don't think many of them want the system to be that way either--they may not be super-experienced, but that shit's more a product of ossification from decades of refusing to change much of anything (the company seriously considered forking VB6 to avoid going to .NET). Individuals don't have much power to change an organizational culture riddled with NIH syndrome (the goddamn ticketing system, timekeeping system, and at some point in the dark past, the email system used internally were ALL written on top of the core EMR codebase) and cargo cult development (the people that /do/ stick around have a healthy share of people that couldn't easily get hired elsewhere on their merits, but do thrive in an environment where accumulating and regurgitating questionable tribal knowledge is crucial). The system is a testament to the inertia of enterprise software: you can muddle along with a product end users hate while making a damn good profit because the system does deliver on its promises to its actual customers, the hospital admins that are primarily charged with reducing costs and increasing revenue. The US medical system is so flush with cash and has such high barriers to entry that it doesn't really matter if software isn't great in some (important, but not important in a way that matters to decision makers) ways. The money keeps flowing, and continues concentrating power in the hands of major players. Something like the HITECH act /was/ needed, but lol if you think the people that bought a seat at the table to design it (but totally didn't--that would be corruption, and we don't have that in America!) didn't have a vested interest in pushing certain provisions. Save money by putting an EMR in place sooner, and accelerating vendor lock-in with the existing players? Sure, why not, everyone (for certain values of everyone) wins! https://www.motherjones.com/politics/2015/10/epic-systems-judith-faulkner-hitech-ehr-interoperability/ https://www.motherjones.com/politics/2015/10/epic-systems-ju...
ryukafalz 6y ago
By any chance have you used GNU Health[0] at all? I'm guessing no since it's uncommon in the US/NZ, but figured I'd ask just in case. Curious what your impression of it would be as an MD. [0] https://en.wikibooks.org/wiki/GNU_Health https://en.wikibooks.org/wiki/GNU_Health
- kube-system 6y ago
  Does anyone in high-income countries use something like that? It is worth nothing that the software product itself is only a tiny part of implementing most enterprise software projects.
  - ryukafalz 6y ago
    Maybe not, but if the EHR systems used in high-income countries are as universally awful as I've heard from doctors, and if GNU Health is at all better... I'd ask why not then!
    - Shared404 6y ago
      > why not then! Because people stand to lose profit if GNU Health is used.
    - owowow 6y ago
      Billing and marketing is likely the reason. There is no one responding to RFPs advocating for GNU Health, and it likely is not up to scratch for medical billing/automated overbilling of insurance providers. EHRs in the USA, Germany and other countries with numerous health insurance providers are primarily there to ensure every service and tools used is billed fully (or overbilled).
    - kube-system 6y ago
      Everyone hates all enterprise software because it is designed to meet the needs of everyone, not the needs of any particular user.
    - dragonwriter 6y ago
gonzo41 6y ago
Lets not talk about the craven insurance industry or security or American healthcare for a moment. Lets let ourselves dream. Most medical records don't capture enough information about a person longitudinally over time. I worked in a bank that had fantastic customer relationship management software that captured every interaction between the bank and customer and acted as a integration layer ontop of all services the bank provided. It was a stack based model where recent interactions went ontop and nothing could be deleted. You could find old scans of documents, letters the bank had sent and replies. The interaction between bank and customer over internet banking were all captured. I saw my own records from when I got my own account as a child and could see everything from then till now. I've had a bunch of touch points with medical professionals relating to an eye injury in the last few years. From Emergency to Surgeons and specialists. A lot of information had to be repeated by my wife along the way whilst I a sat there blind. I don't think special form support or really even business process support would be that useful. I just think having a single pile of client information that's in chronological order would really help doctors be able to stay on top of the issues at hand and then creating a culture of active documentation of actions by all staff so that patient records such as whats on the chart at the end of my bed get's onto my medical record by the end of shift or earlier each day. This seems like a good place for an ISO standard.
- michaelrpeskin 6y ago
  25 years ago when I was an intern, I worked for a healthcare software company on the interface team. Our job was to get records out of a hospital’s system and into a home care provider’s system. We were an early proponent of the HL7 standard and our customers were thrilled with not having to repeat information like you experienced. But as you saw (pun intended), it hasn’t gone far. Every time I see my doctor I have to fill out the same forms and repeat the same information. Too bad my work didn’t go far.
  - epmaybe 6y ago
    Your doctor shouldn't be having you fill out the exact same information. Review of systems (like if you have a cough, etc) is fine, but all of your past history? It should just be what has changed or been added to your problem list since the last time they saw you.
matheusmoreira 6y ago
I remember one system whose idea of a backup was to make a copy of the MySQL database directory to another location on the same machine. Another system would transmit everything I wrote to the backend via HTTP with zero encryption. Lawyers tell me to record everything that happens yet all systems I've used don't let me add any information after the consult is finished, exposing me to legal liability. I wish I had the time to make my own software... At this point I'd be most happy with just a text area where I can write anything I want. I'd love IDE-style features such as autocompletion for medications and tests. An inference engine for simple calculations would also be great. For example, if I write the patient's height and weight, the software should notice that it has enough information to derive the BMI and just do it.

husarcik 6y ago

What is your opinion of Epic?

phren0logy 6y ago
It's among the least bad, but nobody would ever mistake it for software sold to general consumers in this century. I know it's complex and specialized, but so are IDEs, and those are (in my limited use and understanding of them) worlds better in their engineering. That said, I'm not crazy about how actively Epic appears have tried to keep medical records created in Epic locked in to Epic. The spirit, if not the letter, of the legislation requiring a move to electronic records was due to record portability. From where I stand, they have actively prevented that (or at a very minimum sandbagged) to expand their market share.
- phobosanomaly 6y ago
  Another unintended consequence of this is that it makes it extremely difficult for doctors and nurses to pull data to do basic research or look at patient outcomes. For example, if you wanted to see what the outcomes of giving a specific drug at a specific dose to a specific group of patients at your hospital was, you're in for a real fun time manually copy-and-pasting thousands of entries from the EMR to a spreadsheet. Now more than ever it is important to look at data relating to patient outcomes with various COVID treatments that haven't been thoroughly vetted yet. But, guess why your local hospital isn't doing anything like that? Because what should be a simple 3-hour exploratory data analysis that can be breezed through IRB now has to involve a budget component of hiring a professional copy-paste person. Can't even use med students to do it anymore because they aren't allowed to hang around the hospital due to COVID, and you can't access those records remote due to HIPAA.
  - josephpmay 6y ago
    That’s just completely untrue. First of all, Epic has a built in tool called Slicer Dicer for clinicians to perform pretty complex population data analysis without having to do any database queries. Second, every healthcare organization extracts much of their patient data to a data warehouse where you can perform direct SQL calls on it.
    - phobosanomaly 6y ago
      Thank you very much for sharing that. I'll look into it more. The clinicians (head of trauma Evidence-Based Medicine as well as the head of the trauma department overall) I have talked to at my non-academic Level II trauma center do not have any clue this exists. They are currently exporting thousands of records by hand. Edit: Do you know offhand of a good guide to SlicerDicer I can share with them? I will google around, but if you had something you personally liked?
      - josephpmay 6y ago
        I work at Epic, so the resources I have are all internal training/document. That being said, the best way to learn it is probably to have someone who’s an expert in it, ideally another doctor, walk them through it. If you want, I can see if I can find some specific customer-facing documents/training to link them to.
        owowow 6y ago
        Lack of public documentation has to be my #1 pain point with proprietary software over the years. Especially in the EMR space, putting up barriers to access basic documentation is quite unreasonable. Public documentation is not going to suddenly allow your competition to gain an advantage, while your own firm benefits from users being able to easily google and get authoritative answers from your own official documentation.
        deleted 6y ago
        [deleted]
- nimish 6y ago
  Thankfully, TEFCA was implemented anyway, and is still on schedule. We'll see what it works out to in practice. But data sharing is definitely still possible, today, even with Epic (they are quite good actually). You are limited to certain reasons but they are pretty broad. Full disclosure: I work on this full time. It is a strange world, that works on its own standards and practices for good and bad reasons.
- nradov 6y ago
  The latest version of Epic has fairly complete record portability. Is it missing anything specific? https://open.epic.com/ https://open.epic.com/ I think EHR vendors sometimes get unfairly blamed. The fault often lies with provider organizations who simply haven't turned on the available functionality.
  - odyssey7 6y ago
    Why do I feel stressed out visiting this link on desktop? Perhaps someone who's good at UX could share a few thoughts?
    - hanklazard 6y ago
      Ha, exactly. UI/UX is precisely the area where Epic fails the most. I am not an expert in this area, but in my every day use, I can only describe the Epic style of UX as "vomit all information onto the screen at once."
      - nradov 6y ago
        Given a choice, clinicians would usually rather have maximum information density to avoid clicking around for what they need.
        Shared404 6y ago
        Some better organization to the information would be nice though. Edit: Not a doctor/in health care. Just basing this on the link above.
        nradov 6y ago
        Better how?
        Shared404 6y ago
        Looking at the website right now, I see three different horizontal arrangements of links. Of these links, there are four duplicate pairs, at least. Two of these sets of pairs lead to indistinctly named pages (/Home/InteroperabilityGuide and /Home/Interoperate) I would start by having all of these links be at the top, and adding some descriptive text to each of the fields in the main body, as opposed to meaningless graphics/marketing numbers. Addendum: Also, I wouldn't want to do the split in thirds thing that occupies the majority of the page. Each of those can get a description of at least a paragraph, and go one after the other. If there's not enough info to fill a paragraph, then they probably need to be merged. Edit: ambiguously -> indistinctly
VectorLock 6y ago
I know a whole bunch of nurses who won't shut up about how much they hate Epic. I watched my doctor try to use it once when I was in for a visit and he didn't seem to be enjoying the experience much either based on his grumbling. It seemed like there was a LOT of UI cluttering going on so I can understand how it might not be very easy to use.
- mv 6y ago
  At my hospital the nursing UI of Epic is absolutely horrid. It's cluttered and confusing with multiple places to document everything. Epic is completely customizable, but the people who make the decisions in nursing management aren't always the same people using the software. That and funding to make the changes. If you want to see really bad software take a look at Meditech it defaults 800x600 (!), and doesn't resize well at all.
  - throwaway4220 6y ago
    Ah yes, I am still forced to use Meditech's telnet interface today. I asked our IT guy if we can please change the font to a smoothed, non-raster font. I think it took all his willpower to not burst out laughing lol
- somehnguy 6y ago
  Just a little personal anecdote but - A while back I had a week long stay in the hospital, after some small talk with one of my nurses she learned I write software. She told me a bunch of things they hated about Epic and gave me a quick tour of the interface they have to use. The main complaint seemed to be that things they need to do hundreds of times a day require way too many input actions. And it did indeed look incredibly cluttered. I love getting little tours of software I'll likely never use even though I'm not in a position to fix any of the problems. It's just interesting.
  - bena 6y ago
    You know why? Because every doctor, nurse, tech, etc has a goddamn opinion on what's important. They're of the opinion that everything needs to be "as few clicks" as possible. As if "number of clicks" was the only worthwhile message. Nobody would read a book where the keyboard was pressed as few times as possible. Sometimes, complex actions require complex input. We should be shooting for discoverability, not "number of clicks".
euthymiclabs 6y ago
All EHRs are bad, some are just worse than others. With the right build, Epic is one of the least bad. But the wrong build can really be soul-destroying.
hanklazard 6y ago
MD here. Epic is terrible, as are all other EMRs that I have used (with the exception of VA's older software). I use Epic every day and I am ready to jump ship from medicine altogether to help build an EMR that could actually work well for both health care providers and patients. There is no excuse for such poorly executed software, especially the UI/UX.
- rscho 6y ago
  My bet is you won't succeed. UI is bad because of corporate and legal constraints, not because developers don't know better. Regardless, best of luck!
caycep 6y ago
Virtual basic running in some weird instance of something that you can only get through via citrix? "least bad" is not saying much, they're all pretty bad.

jseliger 6y ago

This reminds me of Blackboard and its competitor (I forget the name of it) in higher education: students hate it. Professors hate it. It's brutally hard to use. Professors can't easily adopt an alternative (as they can with by choosing Google Docs or Dropbox).

greedo 6y ago
Moodle?
- bilegeek 6y ago
  There's also McGraw-Hill Connect and Brightspace.
- jcrawfordor 6y ago
  Instructure Canvas is probably the more popular alternative right now, Moodle having always struggled with usability and manageability issues (and taking a long time to get a "modern" looking UI). That said, during my student years I felt like Canvas was steadily converging on being as unusable as Blackboard, which maybe hints at some underlying pressures in that industry. I was involved peripherally in the decision-making process on a small university purchasing a new LMS, and the decision was amazingly political and driven by niche needs from vocal users, and I say this as someone who was pretty used to university politics at the time. It seems like the way to get an LMS contract is to throw every feature you can possibly think of into the bucket, usability and quality isn't something that really gets evaluated very well. This probably could be changed but I'm not sure how. For example, the university I was with performed student surveys related to the food service vendor and incorporated the results of those surveys as a performance standard in the contract. Nothing like this was done for the LMS purchasing, no student input was collected at either the purchasing or performance stages, and a combination of purchasing methods and institutional politics meant that faculty input was extremely limited (the vendor was basically chosen before the faculty were invited to provide feedback). I don't think higher-ed IT departments often have a user-focused culture but instead a cost-focused one.
  - 6y ago

osrec 6y ago

What top 3 things could be improved in medical software in your opinion? Is the UI a key problem or are there other bigger issues?

Scoundreller 6y ago
It seems like they never watched an end user use their product. Like, who re-invents the 'Page Next' function? Just put a blue underlined "Next Page" button at the bottom of the list like we've done for decades.
tuatoru 6y ago
A good text user interface, keyboards that can record and play back keystrokes for getting around the menus, customizable per user, and responsiveness. "Speed" (latency of response) has always been the number one user interface problem of all interactive software and it still is.
- tuatoru 6y ago
  I forgot: the biggest improvement would be an amanuensis for every doctor and nurse.

bena 6y ago

It's one of those sectors where the people who are interested aren't good enough and the people who are good enough aren't interested. No one really wants to do EMR software. Or medical software in general. They do it until they can do something else. That and you have to work with doctors. And sorry to say, that is not exactly fun. You have people who think because they did a lot of school, that that makes them an expert in everything. And that their bikeshedding is the "real" important issue. When I last worked with it, databases were the hot new thing. And I don't mean databases were new tech. I mean medical software was just catching on to storing data in databases. I think one company was pushing a solution that was essentially a collection of Word templates. As if they had hit upon something not only novel, but that no one in history had thought to do. If you're a software developer, eventually you get tired of pissing up rope and get a better job.

chromatin 6y ago

Also an MD, also hate our EMR because it is hot garbage, and I love your username. My latest complaint is that the authors of our EMR, who I know to be legions of fresh out of college young twenty somethings (hardly anyone lasts long enough to be a senior engineer at this vendor, I am told), have not used any sort of helpful SDK for text input boxes, but instead have written their own, having inconsistent and wrong behavior with respect to keyboard based text selection, Ctl+backspace behavior and a variety of other well standardized functionalities. ...and they have written multiple different wrong implementations, as the text boxes behave differently in different parts of the EMR. Even the inconsistencies are inconsistent, like atrial fibrillation.

fivre 6y ago
To be fair to Epic engineers, I don't think many of them want the system to be that way either--they may not be super-experienced, but that shit's more a product of ossification from decades of refusing to change much of anything (the company seriously considered forking VB6 to avoid going to .NET). Individuals don't have much power to change an organizational culture riddled with NIH syndrome (the goddamn ticketing system, timekeeping system, and at some point in the dark past, the email system used internally were ALL written on top of the core EMR codebase) and cargo cult development (the people that /do/ stick around have a healthy share of people that couldn't easily get hired elsewhere on their merits, but do thrive in an environment where accumulating and regurgitating questionable tribal knowledge is crucial). The system is a testament to the inertia of enterprise software: you can muddle along with a product end users hate while making a damn good profit because the system does deliver on its promises to its actual customers, the hospital admins that are primarily charged with reducing costs and increasing revenue. The US medical system is so flush with cash and has such high barriers to entry that it doesn't really matter if software isn't great in some (important, but not important in a way that matters to decision makers) ways. The money keeps flowing, and continues concentrating power in the hands of major players. Something like the HITECH act /was/ needed, but lol if you think the people that bought a seat at the table to design it (but totally didn't--that would be corruption, and we don't have that in America!) didn't have a vested interest in pushing certain provisions. Save money by putting an EMR in place sooner, and accelerating vendor lock-in with the existing players? Sure, why not, everyone (for certain values of everyone) wins! https://www.motherjones.com/politics/2015/10/epic-systems-judith-faulkner-hitech-ehr-interoperability/ https://www.motherjones.com/politics/2015/10/epic-systems-ju...

ryukafalz 6y ago

By any chance have you used GNU Health[0] at all? I'm guessing no since it's uncommon in the US/NZ, but figured I'd ask just in case. Curious what your impression of it would be as an MD. [0] https://en.wikibooks.org/wiki/GNU_Health https://en.wikibooks.org/wiki/GNU_Health

kube-system 6y ago
Does anyone in high-income countries use something like that? It is worth nothing that the software product itself is only a tiny part of implementing most enterprise software projects.
- ryukafalz 6y ago
  Maybe not, but if the EHR systems used in high-income countries are as universally awful as I've heard from doctors, and if GNU Health is at all better... I'd ask why not then!
  - Shared404 6y ago
    > why not then! Because people stand to lose profit if GNU Health is used.
  - owowow 6y ago
    Billing and marketing is likely the reason. There is no one responding to RFPs advocating for GNU Health, and it likely is not up to scratch for medical billing/automated overbilling of insurance providers. EHRs in the USA, Germany and other countries with numerous health insurance providers are primarily there to ensure every service and tools used is billed fully (or overbilled).
  - kube-system 6y ago
    Everyone hates all enterprise software because it is designed to meet the needs of everyone, not the needs of any particular user.
  - dragonwriter 6y ago

gonzo41 6y ago

Lets not talk about the craven insurance industry or security or American healthcare for a moment. Lets let ourselves dream. Most medical records don't capture enough information about a person longitudinally over time. I worked in a bank that had fantastic customer relationship management software that captured every interaction between the bank and customer and acted as a integration layer ontop of all services the bank provided. It was a stack based model where recent interactions went ontop and nothing could be deleted. You could find old scans of documents, letters the bank had sent and replies. The interaction between bank and customer over internet banking were all captured. I saw my own records from when I got my own account as a child and could see everything from then till now. I've had a bunch of touch points with medical professionals relating to an eye injury in the last few years. From Emergency to Surgeons and specialists. A lot of information had to be repeated by my wife along the way whilst I a sat there blind. I don't think special form support or really even business process support would be that useful. I just think having a single pile of client information that's in chronological order would really help doctors be able to stay on top of the issues at hand and then creating a culture of active documentation of actions by all staff so that patient records such as whats on the chart at the end of my bed get's onto my medical record by the end of shift or earlier each day. This seems like a good place for an ISO standard.

michaelrpeskin 6y ago
25 years ago when I was an intern, I worked for a healthcare software company on the interface team. Our job was to get records out of a hospital’s system and into a home care provider’s system. We were an early proponent of the HL7 standard and our customers were thrilled with not having to repeat information like you experienced. But as you saw (pun intended), it hasn’t gone far. Every time I see my doctor I have to fill out the same forms and repeat the same information. Too bad my work didn’t go far.
- epmaybe 6y ago
  Your doctor shouldn't be having you fill out the exact same information. Review of systems (like if you have a cough, etc) is fine, but all of your past history? It should just be what has changed or been added to your problem list since the last time they saw you.

matheusmoreira 6y ago

I remember one system whose idea of a backup was to make a copy of the MySQL database directory to another location on the same machine. Another system would transmit everything I wrote to the backend via HTTP with zero encryption. Lawyers tell me to record everything that happens yet all systems I've used don't let me add any information after the consult is finished, exposing me to legal liability. I wish I had the time to make my own software... At this point I'd be most happy with just a text area where I can write anything I want. I'd love IDE-style features such as autocompletion for medications and tests. An inference engine for simple calculations would also be great. For example, if I write the patient's height and weight, the software should notice that it has enough information to derive the BMI and just do it.