13 ms·

I created the open source ClearHealth/HealthCloud EMR system, have managed hundreds of medical facilities large and small and am the author of "Hacking Healthca

I created the open source ClearHealth/HealthCloud EMR system, have managed hundreds of medical facilities large and small and am the author of "Hacking Healthcare". There are a lot of layers to this and competing concerns. This article is misguided at best. The quote "Doctors are among the most technology-avid people in society" is hilariously off the mark. The average age of doctors in the US is 51. Amongst many difficult problems related to this: -Medicare/Medicaid/Federal spending is half to 2/3 of all medical spending. They are insanely bureaucratic and simultaneously penny pinching. They require lots of things that make everyones jobs harder with no obvious benefit to anyone. They dictate in many ways how software must work in medical settings. -Doctors in most institutions are not given an adequate amount of time to accomplish all of the things that need to be accomplished to deliver quality care and also get properly paid for the interaction. This in part is financially driven but I would say it mostly occurs because there is little to no accountability for medical systems to operate well or efficiently. In many situations there are perverse incentives to operate inefficiently. -Doctors make an absolutely shocking amount of substantive errors, 25% of interactions or more. Preventable medical error is almost certainly in the top 5 causes of deaths in the united states. I could go on and on but cherry picking but I think I made my point that this article looks only at one perspective of one facet of disgruntled personnel involved in a single implementation.

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 ago
  I’ve mentioned it here before but the book “Black Box Thinking” by Matthew Syed is an interesting read in this regard. It really highlights how important it is to design a system that’s focused on error reduction (like aviation) rather than focused on allocating blame (like medicine). IIRC there’s a chapter in the book about patient safety correlating with how “friendly” the OR nurses perceive a surgeon. The implication being that if someone makes a mistake they’re more likely to fess up a nicer surgeon (who will then have the opportunity to correct the error) and more likely to cover it up or ignore if they might get chewed out for bringing it up.
  - matheusmoreira 6y ago
    > It really highlights how important it is to design a system that’s focused on error reduction (like aviation) rather than focused on allocating blame (like medicine). How can we change this culture though? For some reason doctors attract insane lawsuits seeking hundreds of thousands of dollars in damages. People don't seem to be so litigious when they're against rich corporations with lots of lawyers at their disposal. If this continues, the only possible result is defensive medicine since doctors will need every bit of proof and documentation in order to prove their innocence in the event of a lawsuit.
    - deleted 6y ago
      [deleted]
    - yummypaint 6y ago
      Doing things like making sure medical staff arent forced to work while sleep deprived would go a long way to avoiding errors in the first place. Policy changes that walk the walk and substantively prioritize safety over profit can help create safety culture from the top down. Having more staff available in general can also make redundancy checks more feasible.
      - adrianN 6y ago
        It is my understanding that the error rates skyrocket when patients are handed off between medical staff. Longer shifts reduce the number of hand-offs and thereby reduce the number of errors overall, despite sleep deprivation being a source of errors in itself.
        carlmr 6y ago
        Considering error rates due to sleep deprivation must rise at some point and the hand off error rate is probably quite constant there may be an optimal hand off. However that doesn't mean this is the global optimum. There are probably ways to reduce hand off errors, e.g. by introducing hand off check lists. Sleep deprivation errors on the other hand can only be reduced by reducing sleep deprivation, giving crystal meth to the doctor (probably unethical and unsustainable) and by general poka yoke style changes that will have benefits even when not sleep deprived. So the global optimum can probably be shifted to somewhere where the doctor is not sleep deprived and the hand off is organized. Which is also more humane towards the doctor.
- TheButlerian 6y ago
  Covid-19 cannot get to 200 000 still and it will be one and done. Absolutely baffling that people are not outraged by the doctors killings...I guess not enough media drumming up of the number? Time to have counters on every news media with the murders?
cik2e 6y ago
> In many situations there are perverse incentives to operate inefficiently. Would you mind taking the time elaborate on this? Inefficiency in the US healthcare system is something everyone talks about but concrete examples are few and far in between. I would love to get an insiders perspective on this!
- AmericanChopper 6y ago
  The 80/20 rule in the ACA has to be one of the most perverse incentives out there. It states 80% of premiums have to go to providing care, and all admin costs and profits have to come out of the remaining 20%. It’s obvious why this might sound like a good idea, but only slightly less obvious why it’s a terrible one. It means that the primary mechanism available to increase profits is to drive up care spending as much as possible. Because if the 80% is a bigger number, the 20% will be too.
  - freeone3000 6y ago
    Sounds like a 100/0 rule might be better, then.
    - eru 6y ago
      How do you propose to pay for admin costs, then?
  - deleted 6y ago
    [deleted]
  - lotsofpulp 6y ago
    Hence employers need to be removed from the equation so everyone ends up on healthcare.gov and there can be a whole bunch of insurance companies competing to keep premiums down so people purchase from them, just like car insurance.
    - AmericanChopper 6y ago
      Price transparency wouldn't really do much do change this. One of the key ways that prices are jacked up so high is through unnecessary treatments: https://www.npr.org/sections/health-shots/2018/02/01/582216198/unnecessary-medical-care-more-common-than-you-might-imagine https://www.npr.org/sections/health-shots/2018/02/01/5822161... and especially through unnecessary (and very, very expensive) tests: https://www.npr.org/sections/health-shots/2019/12/23/787403509/for-her-head-cold-insurer-coughed-up-25-865 https://www.npr.org/sections/health-shots/2019/12/23/7874035... The people who decide what treatments and tests are necessary are the doctors, so the marketing for this would have to be "buy our cheap insurance, we deny coverage to more testing and treatments than the other insurers do". Which is obviously not a winning strategy. If you combine that with the increase in insurer owned clinics and hospitals (which unsurprisingly saw a sharp uptick around the time the ACA came into effect), then the insurance company gets to profit more twice. Once when they jack up the premiums, and a second time when those expenses show up as revenue in their other businesses. https://www.beckershospitalreview.com/hospital-management-administration/the-quiet-takeover-insurers-buying-physicians-and-hospitals.html https://www.beckershospitalreview.com/hospital-management-ad... I'm all for giving more power to consumers, but when you have a regulation that creates such a strong incentive for raising premiums, layering more haphazard regulation on top of it isn't going to help.
derefr 6y ago
> They dictate in many ways how software must work in medical settings. Would it be possible for an EMR software vendor to ship both a "canonical" client interface that meets all the specs/requirements; and then a separate, secondary client interface, for the same backend, which isn't included in the "package" of EMR software sold to the clinic/hospital/etc., but rather is instead a "bottom-up adoption" play, with download links to it being passed around under-the-table between doctors? If there's any potential for doctors being liable for such-and-such if they were found to not be "using" the primary client, then said secondary interface could be implemented as macro+screen-scraping software, that operates the primary client-interface underneath—much like Mint used to do before banks supported OFX export. Then just get it classified as accessibility software, like a screen reader, and let those doctors claim a need for it :)
- jkingsman 6y ago
  As someone who as only barely dipped their development toes into the waters of EMR/EHR systems, medical arenas are not the place for workarounds, under the table systems, or creative re-routings. There are two reasons for this: one, medical terminals are super, hilariously locked down. The medical systems I've worked on are ultra-hostile instances that are often centered around detecting and eradicating non-explicitly-authorized applications, even to the point of kneecapping actually-needed software. Second and more practically, malpractice suits are vicious wars of discovery and bitter, knock-down-drag-out compliance fights. As with so many things, the legal fiction of accessibility software sounds nice but would not stand up to the scouring scrutiny of legal counsel and defendants with critical reasoning skills and powers of discussion (and deduction) above that of policy and compliance controls. I don't mean to belittle your idea at all, but much like the doctrine of Sovereign Citizens, all is well and good until you actually encounter a judge or human with reasoning skills and the ability to trivially perceive what's /actually/ going on, and then it all falls apart.
  - derefr 6y ago
    > all is well and good until you actually encounter a judge or human with reasoning skills and the ability to trivially perceive what's /actually/ going on, and then it all falls apart. Not disagreeing at all! My suggestion was predicated on the idea that this particular medical regulation might be a "Type II" law. To explain — I feel like there are two types of law: • Type I: law that has a logical "spirit" behind it (usually because it was drafted all-at-once by a small number of authors) where judges will interpret the law and violations against it as reasonable human beings do; • Type II: law (usually more "regulation", but let's call it all "law" here) that is effectively the output of a continuously-iterating bureaucratic process; or law with a "spirit" that is obviously contravened by newer laws, but which still stands because no case has yet come to knock it down; or where there's no "spirit" to the law at all, just an infinite stream of under-the-table negotiated compromises, encoded as a huge book of requirements and exceptions. Type II law includes, for examples: tariffs; statutory crimes; and created-by-fiat licensing schemes. Judges can't think like humans when deciding whether someone has violated a Type II law, because there's no human-legible rationale behind why the law exists. They have to just plug in the formula specified in the legal code, and see what happens. I suspect that much of medical regulation is Type II law. Insofar as that's true, you could get away with a lot as long as you still adhere to the precise wording of the relevant requirements. This particular case (EMR software) may indeed fall more under the provision of a Type I law/regulation, though.
Damorian 6y ago
As an EHR developer, this is the most correct comment I've read on the internet, maybe ever.
- duffpkg 6y ago
  thank you
- tonyhb 6y ago
  +1 unfortunately. This isn't the place for that but... Really. This is reality.
- sumtechguy 6y ago
  As a former EHR dev many of our costs come from these very same systems too. Procedures auto added to people just for walking into a building. Usually I tell people to review the bill make sure all the procedures were actually done. Many are skipped. Because they are not really needed but are still billed for. My exp is before the big conglomerates. Doctors when I did this were crazy cheap on what they would spend money on. This has sort of moved over to the cost center now and the doctors are the ones who get shorted along with everyone else. These systems also create a sense of not knowing what is going on. They create a system to disincentive people for looking at ways to make it better. Only the bean counters and shareholders look into that. So you end up with very strange cost cutting initiatives. Then we added mega insurance into the mix. Which has seemed to found out it is just dandy to pass the bill onto everyone while the costs go up and up. They were supposed to keep a lid on the prices. But they didn't. I do not hold out any hope for a 'medicare for all' system doing any better. The insurance companies have a good incentive to do better. The gov not so much.
forbiddenvoid 6y ago
Doctors like to think they are among the most technology-avid people in society. In fact, my experience with doctors (coming from a place where I worked closely with them specifically on IT matters) is that doctors believe that because they're good at medicine that they are good at everything, specifically making good business decisions and understanding and correctly using technology.
- rscho 6y ago
  This is the same with lots of professions. Software developers are also like that, and this can be verified every day on this very forum.
  - deleted 6y ago
    [deleted]
  - risyachka 6y ago
    True, I am a software developer and I am just like that! But I am trying to fight it really hard.
  - Cthulhu_ 6y ago
    I like to think I've gotten over myself pretty fast and will now freely admit that I know nothing and suck at everything. Tongue-in-cheek of course, there's no need to downplay your own abilities and knowledge. But if anything, I'm no longer feeling like I'm missing out in the rat race. I'm missing out on the whole AI / machine learning thing but that's all right because it just doesn't pique my interest.
  - throwaway0a5e 6y ago
    Damn near every time a subject that isn't software that I have good personal knowledge of comes up there's I notice a few big grayed out walls of well thought out and nuanced text. The worst cases seem to be when there's an article (seems like it's always on Medium) about some complicated multi-part technical thing going wrong, a top level comment slings blame around as if they know exactly where to sling it and uses a PopSci understanding of the subject matter to justify it. Then someone who actually knows the relevant industry says "well actually it's a little more nuanced", proceeds to explain and then gets down-voted and flagged for it. Seems like a great way to send the message that technical knowledge and experience is not welcome here if it's going to go against whatever the convenient narrative is. What it definitely doesn't do is instill trust in comments about things I am less familiar in.
entee 6y ago
First of all thanks for the book, it was a formative read for me as I started out in healthcare data and programming. Second of all, I can’t just upvote, this is so so accurate. The thing to remember in US healthcare is there’s actually not a single entity that has an incentive to be efficient. There are some incentives scattered through the system to pay less or to not get sued, those are not the same. To a first approximation nobody spends money in healthcare except insurers and the government. The government just says what they’ll pay, and where they can’t, they have limited negotiating ability. You’d think an insurer would care about paying less, but they actually don’t. They care about predictability. How much are costs going to rise next year? If you’re right, you make money. If you’re wrong you lose money. That’s not really an incentive to reduce costs in the absolute because the people who pay for insurance are not patients but employers. As an employer I care about my health insurance plan’s cost. BUT I also have no clue about what one plan vs another really means or how they’re maybe gonna save me money long term. I simply don’t have the time to understand that, and I’m probably more informed than most on the subject having worked in the sector. I too care about predictability more than cost. Crazy part of the pandemic, during a historic health crisis many medical systems were facing bankruptcy. Why? Most of the money being paid with a good profit margin into these systems is for “elective” care. This includes cancer treatment, because surgery can take place today or a week from now and it doesn’t matter that much. Contrast to a heart attack, which is non-elective. When a pandemic rolls around, all elective care gets shut down, so hospitals lose money despite being needed more than ever. The whole system is a zombie with none of the right incentives, no clear way to even measure the right outcomes, and worse: nobody is driving the ship.
- lotsofpulp 6y ago
  > As an employer I care about my health insurance plan’s cost. BUT I also have no clue about what one plan vs another really means or how they’re maybe gonna save me money long term. I simply don’t have the time to understand that, and I’m probably more informed than most on the subject having worked in the sector. I too care about predictability more than cost. As an employer, my insurance brokers are able to show me very easy to compare tables listing premiums/deductibles/oop max/copays. It’s all pretty comparable as long as you’re comparing within the same types of networks (HMO/PPO/EPO/etc), especially with metal levels. If anything, HDHP PPO plans or Kaiser Permanente type HDHP HMO plans do have an incentive to keep costs down as they compete with each other for my business. I’ve been able to go to my health insurance website, and type in a healthcare procedure or exam and it will usually tell me the cost at various facilities. Nowhere near perfect, but a good start towards price transparency. This all would work a lot better if everyone was forced to buy health insurance from healthcare.gov and employers were completely removed from the equation.
biotech 6y ago
> Preventable medical error is almost certainly in the top 5 causes of deaths in the united states. This is untrue, a very common myth based on a questionable study out of Johns Hopkins, which included known complications of medical procedures in the classification of "medical error." https://sciencebasedmedicine.org/are-medical-errors-really-the-third-most-common-cause-of-death-in-the-u-s-2019-edition/ https://sciencebasedmedicine.org/are-medical-errors-really-t...
guuggye 6y ago
@duffpkg will you be updating or releasing a second edition of Hacking Healthcare anytime soon?
fizixer 6y ago
Doctors are not tech-savvy, there is not doubt about that. But the Micro$hit Window$ kludges I've seen in pretty much every doctor's office, with many instances of the doctor entering their credentials for login, and then waiting an ungodly amount of time to get in and to the medical s/w interface, is not helping either.
iso947 6y ago
> The average age of doctors in the US is 51. So windows 95 came out the year they left medical school, and had just finished residency when the internet became particular popular and broadband started being normal.
agumonkey 6y ago
I find that insane somehow the system drives itself to the ground. I just left a govt agency clerk job. I couldn't resist making automation scripts. Due to politics I didn't talk about it. But on my last day I showed it to a tech-saavy dude saying this might help you going faster or at least give them a case to show the hierarchy things can be improved. I wonder if this insider hack is the only way to push things around ..
victor106 6y ago
Your book is awesome. But it’s 9 years old. Are you planning to release an updated version? Or you think most topics are still up to date.
deleted 6y ago
[deleted]

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 ago
I’ve mentioned it here before but the book “Black Box Thinking” by Matthew Syed is an interesting read in this regard. It really highlights how important it is to design a system that’s focused on error reduction (like aviation) rather than focused on allocating blame (like medicine). IIRC there’s a chapter in the book about patient safety correlating with how “friendly” the OR nurses perceive a surgeon. The implication being that if someone makes a mistake they’re more likely to fess up a nicer surgeon (who will then have the opportunity to correct the error) and more likely to cover it up or ignore if they might get chewed out for bringing it up.
- matheusmoreira 6y ago
  > It really highlights how important it is to design a system that’s focused on error reduction (like aviation) rather than focused on allocating blame (like medicine). How can we change this culture though? For some reason doctors attract insane lawsuits seeking hundreds of thousands of dollars in damages. People don't seem to be so litigious when they're against rich corporations with lots of lawyers at their disposal. If this continues, the only possible result is defensive medicine since doctors will need every bit of proof and documentation in order to prove their innocence in the event of a lawsuit.
  - deleted 6y ago
    [deleted]
  - yummypaint 6y ago
    Doing things like making sure medical staff arent forced to work while sleep deprived would go a long way to avoiding errors in the first place. Policy changes that walk the walk and substantively prioritize safety over profit can help create safety culture from the top down. Having more staff available in general can also make redundancy checks more feasible.
    - adrianN 6y ago
      It is my understanding that the error rates skyrocket when patients are handed off between medical staff. Longer shifts reduce the number of hand-offs and thereby reduce the number of errors overall, despite sleep deprivation being a source of errors in itself.
      - carlmr 6y ago
        Considering error rates due to sleep deprivation must rise at some point and the hand off error rate is probably quite constant there may be an optimal hand off. However that doesn't mean this is the global optimum. There are probably ways to reduce hand off errors, e.g. by introducing hand off check lists. Sleep deprivation errors on the other hand can only be reduced by reducing sleep deprivation, giving crystal meth to the doctor (probably unethical and unsustainable) and by general poka yoke style changes that will have benefits even when not sleep deprived. So the global optimum can probably be shifted to somewhere where the doctor is not sleep deprived and the hand off is organized. Which is also more humane towards the doctor.
TheButlerian 6y ago
Covid-19 cannot get to 200 000 still and it will be one and done. Absolutely baffling that people are not outraged by the doctors killings...I guess not enough media drumming up of the number? Time to have counters on every news media with the murders?

cik2e 6y ago

> In many situations there are perverse incentives to operate inefficiently. Would you mind taking the time elaborate on this? Inefficiency in the US healthcare system is something everyone talks about but concrete examples are few and far in between. I would love to get an insiders perspective on this!

AmericanChopper 6y ago
The 80/20 rule in the ACA has to be one of the most perverse incentives out there. It states 80% of premiums have to go to providing care, and all admin costs and profits have to come out of the remaining 20%. It’s obvious why this might sound like a good idea, but only slightly less obvious why it’s a terrible one. It means that the primary mechanism available to increase profits is to drive up care spending as much as possible. Because if the 80% is a bigger number, the 20% will be too.
- freeone3000 6y ago
  Sounds like a 100/0 rule might be better, then.
  - eru 6y ago
    How do you propose to pay for admin costs, then?
- deleted 6y ago
  [deleted]
- lotsofpulp 6y ago
  Hence employers need to be removed from the equation so everyone ends up on healthcare.gov and there can be a whole bunch of insurance companies competing to keep premiums down so people purchase from them, just like car insurance.
  - AmericanChopper 6y ago
    Price transparency wouldn't really do much do change this. One of the key ways that prices are jacked up so high is through unnecessary treatments: https://www.npr.org/sections/health-shots/2018/02/01/582216198/unnecessary-medical-care-more-common-than-you-might-imagine https://www.npr.org/sections/health-shots/2018/02/01/5822161... and especially through unnecessary (and very, very expensive) tests: https://www.npr.org/sections/health-shots/2019/12/23/787403509/for-her-head-cold-insurer-coughed-up-25-865 https://www.npr.org/sections/health-shots/2019/12/23/7874035... The people who decide what treatments and tests are necessary are the doctors, so the marketing for this would have to be "buy our cheap insurance, we deny coverage to more testing and treatments than the other insurers do". Which is obviously not a winning strategy. If you combine that with the increase in insurer owned clinics and hospitals (which unsurprisingly saw a sharp uptick around the time the ACA came into effect), then the insurance company gets to profit more twice. Once when they jack up the premiums, and a second time when those expenses show up as revenue in their other businesses. https://www.beckershospitalreview.com/hospital-management-administration/the-quiet-takeover-insurers-buying-physicians-and-hospitals.html https://www.beckershospitalreview.com/hospital-management-ad... I'm all for giving more power to consumers, but when you have a regulation that creates such a strong incentive for raising premiums, layering more haphazard regulation on top of it isn't going to help.

derefr 6y ago

> They dictate in many ways how software must work in medical settings. Would it be possible for an EMR software vendor to ship both a "canonical" client interface that meets all the specs/requirements; and then a separate, secondary client interface, for the same backend, which isn't included in the "package" of EMR software sold to the clinic/hospital/etc., but rather is instead a "bottom-up adoption" play, with download links to it being passed around under-the-table between doctors? If there's any potential for doctors being liable for such-and-such if they were found to not be "using" the primary client, then said secondary interface could be implemented as macro+screen-scraping software, that operates the primary client-interface underneath—much like Mint used to do before banks supported OFX export. Then just get it classified as accessibility software, like a screen reader, and let those doctors claim a need for it :)

jkingsman 6y ago
As someone who as only barely dipped their development toes into the waters of EMR/EHR systems, medical arenas are not the place for workarounds, under the table systems, or creative re-routings. There are two reasons for this: one, medical terminals are super, hilariously locked down. The medical systems I've worked on are ultra-hostile instances that are often centered around detecting and eradicating non-explicitly-authorized applications, even to the point of kneecapping actually-needed software. Second and more practically, malpractice suits are vicious wars of discovery and bitter, knock-down-drag-out compliance fights. As with so many things, the legal fiction of accessibility software sounds nice but would not stand up to the scouring scrutiny of legal counsel and defendants with critical reasoning skills and powers of discussion (and deduction) above that of policy and compliance controls. I don't mean to belittle your idea at all, but much like the doctrine of Sovereign Citizens, all is well and good until you actually encounter a judge or human with reasoning skills and the ability to trivially perceive what's /actually/ going on, and then it all falls apart.
- derefr 6y ago
  > all is well and good until you actually encounter a judge or human with reasoning skills and the ability to trivially perceive what's /actually/ going on, and then it all falls apart. Not disagreeing at all! My suggestion was predicated on the idea that this particular medical regulation might be a "Type II" law. To explain — I feel like there are two types of law: • Type I: law that has a logical "spirit" behind it (usually because it was drafted all-at-once by a small number of authors) where judges will interpret the law and violations against it as reasonable human beings do; • Type II: law (usually more "regulation", but let's call it all "law" here) that is effectively the output of a continuously-iterating bureaucratic process; or law with a "spirit" that is obviously contravened by newer laws, but which still stands because no case has yet come to knock it down; or where there's no "spirit" to the law at all, just an infinite stream of under-the-table negotiated compromises, encoded as a huge book of requirements and exceptions. Type II law includes, for examples: tariffs; statutory crimes; and created-by-fiat licensing schemes. Judges can't think like humans when deciding whether someone has violated a Type II law, because there's no human-legible rationale behind why the law exists. They have to just plug in the formula specified in the legal code, and see what happens. I suspect that much of medical regulation is Type II law. Insofar as that's true, you could get away with a lot as long as you still adhere to the precise wording of the relevant requirements. This particular case (EMR software) may indeed fall more under the provision of a Type I law/regulation, though.

Damorian 6y ago

As an EHR developer, this is the most correct comment I've read on the internet, maybe ever.

duffpkg 6y ago
thank you
tonyhb 6y ago
+1 unfortunately. This isn't the place for that but... Really. This is reality.
sumtechguy 6y ago
As a former EHR dev many of our costs come from these very same systems too. Procedures auto added to people just for walking into a building. Usually I tell people to review the bill make sure all the procedures were actually done. Many are skipped. Because they are not really needed but are still billed for. My exp is before the big conglomerates. Doctors when I did this were crazy cheap on what they would spend money on. This has sort of moved over to the cost center now and the doctors are the ones who get shorted along with everyone else. These systems also create a sense of not knowing what is going on. They create a system to disincentive people for looking at ways to make it better. Only the bean counters and shareholders look into that. So you end up with very strange cost cutting initiatives. Then we added mega insurance into the mix. Which has seemed to found out it is just dandy to pass the bill onto everyone while the costs go up and up. They were supposed to keep a lid on the prices. But they didn't. I do not hold out any hope for a 'medicare for all' system doing any better. The insurance companies have a good incentive to do better. The gov not so much.

forbiddenvoid 6y ago

Doctors like to think they are among the most technology-avid people in society. In fact, my experience with doctors (coming from a place where I worked closely with them specifically on IT matters) is that doctors believe that because they're good at medicine that they are good at everything, specifically making good business decisions and understanding and correctly using technology.

rscho 6y ago
This is the same with lots of professions. Software developers are also like that, and this can be verified every day on this very forum.
- deleted 6y ago
  [deleted]
- risyachka 6y ago
  True, I am a software developer and I am just like that! But I am trying to fight it really hard.
- Cthulhu_ 6y ago
  I like to think I've gotten over myself pretty fast and will now freely admit that I know nothing and suck at everything. Tongue-in-cheek of course, there's no need to downplay your own abilities and knowledge. But if anything, I'm no longer feeling like I'm missing out in the rat race. I'm missing out on the whole AI / machine learning thing but that's all right because it just doesn't pique my interest.
- throwaway0a5e 6y ago
  Damn near every time a subject that isn't software that I have good personal knowledge of comes up there's I notice a few big grayed out walls of well thought out and nuanced text. The worst cases seem to be when there's an article (seems like it's always on Medium) about some complicated multi-part technical thing going wrong, a top level comment slings blame around as if they know exactly where to sling it and uses a PopSci understanding of the subject matter to justify it. Then someone who actually knows the relevant industry says "well actually it's a little more nuanced", proceeds to explain and then gets down-voted and flagged for it. Seems like a great way to send the message that technical knowledge and experience is not welcome here if it's going to go against whatever the convenient narrative is. What it definitely doesn't do is instill trust in comments about things I am less familiar in.

entee 6y ago

First of all thanks for the book, it was a formative read for me as I started out in healthcare data and programming. Second of all, I can’t just upvote, this is so so accurate. The thing to remember in US healthcare is there’s actually not a single entity that has an incentive to be efficient. There are some incentives scattered through the system to pay less or to not get sued, those are not the same. To a first approximation nobody spends money in healthcare except insurers and the government. The government just says what they’ll pay, and where they can’t, they have limited negotiating ability. You’d think an insurer would care about paying less, but they actually don’t. They care about predictability. How much are costs going to rise next year? If you’re right, you make money. If you’re wrong you lose money. That’s not really an incentive to reduce costs in the absolute because the people who pay for insurance are not patients but employers. As an employer I care about my health insurance plan’s cost. BUT I also have no clue about what one plan vs another really means or how they’re maybe gonna save me money long term. I simply don’t have the time to understand that, and I’m probably more informed than most on the subject having worked in the sector. I too care about predictability more than cost. Crazy part of the pandemic, during a historic health crisis many medical systems were facing bankruptcy. Why? Most of the money being paid with a good profit margin into these systems is for “elective” care. This includes cancer treatment, because surgery can take place today or a week from now and it doesn’t matter that much. Contrast to a heart attack, which is non-elective. When a pandemic rolls around, all elective care gets shut down, so hospitals lose money despite being needed more than ever. The whole system is a zombie with none of the right incentives, no clear way to even measure the right outcomes, and worse: nobody is driving the ship.

lotsofpulp 6y ago
> As an employer I care about my health insurance plan’s cost. BUT I also have no clue about what one plan vs another really means or how they’re maybe gonna save me money long term. I simply don’t have the time to understand that, and I’m probably more informed than most on the subject having worked in the sector. I too care about predictability more than cost. As an employer, my insurance brokers are able to show me very easy to compare tables listing premiums/deductibles/oop max/copays. It’s all pretty comparable as long as you’re comparing within the same types of networks (HMO/PPO/EPO/etc), especially with metal levels. If anything, HDHP PPO plans or Kaiser Permanente type HDHP HMO plans do have an incentive to keep costs down as they compete with each other for my business. I’ve been able to go to my health insurance website, and type in a healthcare procedure or exam and it will usually tell me the cost at various facilities. Nowhere near perfect, but a good start towards price transparency. This all would work a lot better if everyone was forced to buy health insurance from healthcare.gov and employers were completely removed from the equation.

biotech 6y ago

> Preventable medical error is almost certainly in the top 5 causes of deaths in the united states. This is untrue, a very common myth based on a questionable study out of Johns Hopkins, which included known complications of medical procedures in the classification of "medical error." https://sciencebasedmedicine.org/are-medical-errors-really-the-third-most-common-cause-of-death-in-the-u-s-2019-edition/ https://sciencebasedmedicine.org/are-medical-errors-really-t...

guuggye 6y ago

@duffpkg will you be updating or releasing a second edition of Hacking Healthcare anytime soon?

fizixer 6y ago

Doctors are not tech-savvy, there is not doubt about that. But the Micro$hit Window$ kludges I've seen in pretty much every doctor's office, with many instances of the doctor entering their credentials for login, and then waiting an ungodly amount of time to get in and to the medical s/w interface, is not helping either.

iso947 6y ago

> The average age of doctors in the US is 51. So windows 95 came out the year they left medical school, and had just finished residency when the internet became particular popular and broadband started being normal.

agumonkey 6y ago

I find that insane somehow the system drives itself to the ground. I just left a govt agency clerk job. I couldn't resist making automation scripts. Due to politics I didn't talk about it. But on my last day I showed it to a tech-saavy dude saying this might help you going faster or at least give them a case to show the hierarchy things can be improved. I wonder if this insider hack is the only way to push things around ..

victor106 6y ago

Your book is awesome. But it’s 9 years old. Are you planning to release an updated version? Or you think most topics are still up to date.

deleted 6y ago

[deleted]