6 ms·

See also https://gnuhealth.org https://gnuhealth.org, https://oscar-emr.com/ https://oscar-emr.com/ and https://hospitalrun.io/ https://hospitalrun.io/. As wit

See also https://gnuhealth.org https://gnuhealth.org, https://oscar-emr.com/ https://oscar-emr.com/ and https://hospitalrun.io/ https://hospitalrun.io/. As with anything in the b2b healthcare space, most of these systems suffer from quite a bit of legacy and at-best-average code quality. Despite that, many doctors, clinics and even small hospitals use them because the private solutions (think Epic [1], but smaller) aren't necessarily better code-wise (don't ask me how I know). I wish more FAANG-calibre devs would look into contributing to and evangelizing these platforms rather than writing yet another note-taking/"productivity management" app. It has a direct impact on the quality of care delivery in certain parts of the world and a positive impact on tool-related clinician burnout [2]. [1] https://news.ycombinator.com/item?id=18735023 https://news.ycombinator.com/item?id=18735023 [2] https://news.ycombinator.com/item?id=24336039 https://news.ycombinator.com/item?id=24336039

sidlls 6y ago
I hope like hell “FAANG caliber devs” never take an interest in this space. Or at least not until the culture changes substantially. There are just some things that “throw devs (of any quality) at it” just doesn’t work. The health care industry is one of them.
- boston_sre87 6y ago
  Believe it or not, there are some engineers that have worked at faang companies that are not sloppy and I work with a few of them.
  - sidlls 6y ago
    It’s not about being sloppy. It’s about ego and hubris. Just want to add: I work with (ex-)FAANG folks on a daily basis, too. Not all of them have egos bigger than their britches. But the ones who think “this industry just needs better software, and I can write it” sure as hell do.
    - boston_sre87 6y ago
      Yes, I absolutely agree that there is a problem with greed, ego and hubris in sillicon valley. Just wanted to point out that not all engineers fall in that category. I think that confidence in writing solid software when paired with humility can lead to good outcomes. To me, it seems like the ego and hubris issue can cause the most amount of problems when an individual (e.g. zuckerberg) takes on a savior and machiavellian complex. It seems like most of them actually believe that they are making the world better and they don't see the harm that their self interested blood thirsty capitalist side does at all.
    - throwaway894345 6y ago
      I work in the medical research space and we have to integrate with EMR systems to get our data. I don't think software is the root problem, but rather the root problem is "there aren't incentives for good CMSes"--namely, there's no incentive for systems that talk to each other because healthcare consumers don't think about this when choosing a hospital and hospitals don't have any incentive to make it easier for their customers to leave their system (and EMS vendors certainly don't have that incentive). Ultimately the question is "why do we believe EMSes are valuable, but no one can figure out how to make money from making them better?".
      - marcinzm 6y ago
        Hospitals are liable for data breaches and leaks, they have a direct incentive in making data as hard to access as possible.
        FireBeyond 6y ago
        Eh, as someone who deals with EPIC, ESO, and a few others... that's not the real motivation. Epic will _happily_ interconnect with other systems for data sharing. I mean Epic will happily _sell_ you interconnects with other systems, and will generally bill you on top a per patient, per export fee.
      - cryptochamorro 6y ago
        I used to work in Bioinformatics. Getting Epic and Cerner to flow into our i2b2 or REDCap was a mess. Epic was a real disappointment in terms of their willingness to implement simple features that would have truly helped researchers analyze more specific outcomes. But I guess you gotta make money some how.
- BadInformatics 6y ago
  That's imprecise shorthand on my part. s/"FANG Calibre"/"objectively talented and used to/capable of negotiating good compensation"/. There's a degree of Stockholm Syndrome in healthcare tech where people don't know what a well-developed product or codebase looks like. It's unlikely to change from the top, so getting more technical folks with higher leverage into the field is IMO the next-best option. And yes things are changing at a glacial pace, but they are changing. For example, my province is developing a new patient portal [1] out in the open. AFAICT, they seem to be doing everything aboveboard: CI, code quality standards, documentation and proper testing, etc. Yet if you look at another team in the same org (ministry of health), you'll find non-existent dev practices, oodles of VBA, or (even worse) some slow+buggy third party system put in place by one of the procurement vampires (IBM, CGI, Deloitte, you know the bunch). The biggest difference? The former project has a dedicated, US Digital Service-style team of skilled and hopefully better-compensated dev(ops) people who know how to deliver good software. [1] https://github.com/bcgov/healthgateway https://github.com/bcgov/healthgateway
  - sidlls 6y ago
    I think, in fact, you have it exactly backwards. You are very unlikely to find a decision making authority (person or committee) in a medical practice who gives the slightest bit of consideration for the development practices or code quality of software they're considering. These people have three things on their mind (in no particular order): 1) does this product meet this organization's requirements under our regulatory compliance policies; 2) does this product (including installation, maintenance, and training costs) fit within my budget; 3) is this product widely known and trusted by my peers at other medical practices. Notice something? The word "software" doesn't appear in that even once. They literally don't care. The result is that companies develop products (software) on the cheap, and that results in the quality issues that exist. Improving the quality of the code base and development practices is solving a problem the purse-holders (customers) don't have.
    - BadInformatics 6y ago
      I agree that all the factors you've listed are in play, but they are far from the only ones involved in decision making. Perhaps this is a regional thing, I've never experienced (and have no wish to) what the US EMR market is like. Some complaints/feedback I did receive from doctors and clinic admins while working for an EMR vendor: 1. Your system is buggy/unintuitive and we hate using it. 2. We're not upgrading or moving to your new system because of 1). 3. We're moving to competitor X because they have Y feature. 4. [conversely] We came from competitor X because their EMR is slow/buggy/lacks features. 5. We signed up because the docs/office assistants liked [hero feature] in the sales demo. So yes, 0 mentions of the word "software". However, all of these are directly related to the software itself. There's a reason flashy new companies can swoop in and steal some market share (at least where I am). Even more importantly, there are many tech-related reasons why some companies start floundering and drop out of the market: - bad foundations (most EMRs were created by doctors with limited dev experience) - rampant tech debt driven by feature-driven development - lack of knowledge about testing/CI These are not theoretical problems. More than once, we incurred regulatory fines and SLA penalties in excess of the "cost of doing business" threshold. After a pretty major patient data screw-up, upper management even relented and gave the dev(ops) team time/money to clean up their act. Regulatory and bureaucratic inertia may insulate health IT companies from software engineering issues, but there's a limit to everything and they can sure as hell bleed.
toomuchtodo 6y ago
> I wish more FAANG-calibre devs would look into contributing to and evangelizing these platforms rather than writing yet another note-taking/"productivity management" app. I would like to see the US Digital Service continue to task technologists with improving EMR systems at CMS (Centers for Medicare and Medicaid Services), but made free to use by all practitioners and citizens (and of course, open sourcing the resulting codebase). It seems sort of inefficient we keep reinventing the wheel (Epic and the like, which are crazy expensive, or self hosted solutions, when practitioners should not be spending time maintaining EMRs), when your records should be stored for your benefit by your government over the course of your life. This is where, imho, high calibre engineers provide the most leverage (one way ratchets on public goods at scale). [1] https://www.usds.gov/resources/USDS-Impact-Report-2020.pdf https://www.usds.gov/resources/USDS-Impact-Report-2020.pdf [2] https://www.va.gov/health-care/get-medical-records/ https://www.va.gov/health-care/get-medical-records/
- beh9540 6y ago
  The VA sort-of does this, at least when I worked for them. The issue they had when I was there was depending on where you went, you may or may not have access to the record, because the VA didn't use a central system, it used many systems across the country, each with their own records(basically their own mainframe). We once added a hospital to our system, and had to have dual workstations because the systems couldn't be easily merged, and they had to look up patients in both systems. Also, with Veterans Choice, I don't know how much there was an effort to bring this data back. Same thing with the DoD, for a while there was an agreement to send medical records for active duty to the VA, but then that got pulled for a time. I believe there was a huge undertaking to consolidate these to fewer systems in the last few years, but Vista[0] (the VA's EMR) is pretty scary. I wouldn't wish it on anyone. https://en.wikipedia.org/wiki/VistA https://en.wikipedia.org/wiki/VistA
  - breck 6y ago
    The VA has something called BlueButton that looks really cool (https://www.va.gov/bluebutton/ https://www.va.gov/bluebutton/) and I think should be standard practice across all EMS systems (one click export of all a patient's data to a single text file). The file format itself seems like a bit tough to parse, but the concept I love.
safog 6y ago
I've worked in the space for a few years and I'd discourage anyone from trying to build a career as a software dev in the Healthcare IT / EMR space. It's extremely sales driven (devs aren't valued at all), code quality is terrible and the systems you write are mostly for the benefit of insurance companies / compliance than doctors or patients. I think there was a YC funded iPad EMR startup that tried to be cool / hip / provider first until they got smacked in the face by reality.
- erichurkman 6y ago
  You're thinking of https://www.drchrono.com/ https://www.drchrono.com/
  - xattt 6y ago
    All these hip, cool EMRs always show a glamour of a patient. I have yet to see a medical practice or health care facility that has a photo studio as a side business!
    - mhink 6y ago
      Maybe not a side business, but it's not as ridiculous as it sounds! A friend of mine was an in-house photographer and graphic designer (I think he had some sort of managerial role, too) for the local hospital network until he got laid off when COVID hit. Basically, in addition to being a good photographer, he had to be aware of the various patient-privacy regulations involved and also have a practical working knowledge of the hospital so he and his team wouldn't be getting in the way.
    - topkai22 6y ago
      I think most US hospitals have offer in house newborn photos. I know ours did :)
- BadInformatics 6y ago
  Not all healthcare systems are beholden to private insurance (my own country's included) and that shows in where these systems are deployed. Also, compliance doesn't fully explain why competitors are able to convince clinicians to switch systems. Word-of-mouth means that people will know your EMR is a flaming piece of garbage, but (as you noted) companies would much rather cut up-front prices so they can milk an extended contract than improving product quality. All that said, I think there's a bit of a chicken-and-egg thing going on here. Good people don't join the space because the culture sucks and the pay is bad, but those are because those with the talent and drive all self-selected out of it. I get it, health IT is a huge drag and not at all sexy. But just look at how often folks on HN ask about "doing social good" and how many complaints there are about healthcare delivery. Trying to run a "disruptive" VC-backed startup is IMO pretty crazy, but contributing to an OSS project is far less risky and more achievable.
breck 6y ago
I love this space—mostly because I loathe the absolutely awful American EMR systems— and intermittently have been working on some ideas with a few people (https://github.com/treenotation/pau https://github.com/treenotation/pau) (here are some fugly notes/links to EMS systems for anyone interested in the space: https://github.com/treenotation/pau/tree/master/paudb https://github.com/treenotation/pau/tree/master/paudb)

sidlls 6y ago

I hope like hell “FAANG caliber devs” never take an interest in this space. Or at least not until the culture changes substantially. There are just some things that “throw devs (of any quality) at it” just doesn’t work. The health care industry is one of them.

boston_sre87 6y ago
Believe it or not, there are some engineers that have worked at faang companies that are not sloppy and I work with a few of them.
- sidlls 6y ago
  It’s not about being sloppy. It’s about ego and hubris. Just want to add: I work with (ex-)FAANG folks on a daily basis, too. Not all of them have egos bigger than their britches. But the ones who think “this industry just needs better software, and I can write it” sure as hell do.
  - boston_sre87 6y ago
    Yes, I absolutely agree that there is a problem with greed, ego and hubris in sillicon valley. Just wanted to point out that not all engineers fall in that category. I think that confidence in writing solid software when paired with humility can lead to good outcomes. To me, it seems like the ego and hubris issue can cause the most amount of problems when an individual (e.g. zuckerberg) takes on a savior and machiavellian complex. It seems like most of them actually believe that they are making the world better and they don't see the harm that their self interested blood thirsty capitalist side does at all.
  - throwaway894345 6y ago
    I work in the medical research space and we have to integrate with EMR systems to get our data. I don't think software is the root problem, but rather the root problem is "there aren't incentives for good CMSes"--namely, there's no incentive for systems that talk to each other because healthcare consumers don't think about this when choosing a hospital and hospitals don't have any incentive to make it easier for their customers to leave their system (and EMS vendors certainly don't have that incentive). Ultimately the question is "why do we believe EMSes are valuable, but no one can figure out how to make money from making them better?".
    - marcinzm 6y ago
      Hospitals are liable for data breaches and leaks, they have a direct incentive in making data as hard to access as possible.
      - FireBeyond 6y ago
        Eh, as someone who deals with EPIC, ESO, and a few others... that's not the real motivation. Epic will _happily_ interconnect with other systems for data sharing. I mean Epic will happily _sell_ you interconnects with other systems, and will generally bill you on top a per patient, per export fee.
    - cryptochamorro 6y ago
      I used to work in Bioinformatics. Getting Epic and Cerner to flow into our i2b2 or REDCap was a mess. Epic was a real disappointment in terms of their willingness to implement simple features that would have truly helped researchers analyze more specific outcomes. But I guess you gotta make money some how.
BadInformatics 6y ago
That's imprecise shorthand on my part. s/"FANG Calibre"/"objectively talented and used to/capable of negotiating good compensation"/. There's a degree of Stockholm Syndrome in healthcare tech where people don't know what a well-developed product or codebase looks like. It's unlikely to change from the top, so getting more technical folks with higher leverage into the field is IMO the next-best option. And yes things are changing at a glacial pace, but they are changing. For example, my province is developing a new patient portal [1] out in the open. AFAICT, they seem to be doing everything aboveboard: CI, code quality standards, documentation and proper testing, etc. Yet if you look at another team in the same org (ministry of health), you'll find non-existent dev practices, oodles of VBA, or (even worse) some slow+buggy third party system put in place by one of the procurement vampires (IBM, CGI, Deloitte, you know the bunch). The biggest difference? The former project has a dedicated, US Digital Service-style team of skilled and hopefully better-compensated dev(ops) people who know how to deliver good software. [1] https://github.com/bcgov/healthgateway https://github.com/bcgov/healthgateway
- sidlls 6y ago
  I think, in fact, you have it exactly backwards. You are very unlikely to find a decision making authority (person or committee) in a medical practice who gives the slightest bit of consideration for the development practices or code quality of software they're considering. These people have three things on their mind (in no particular order): 1) does this product meet this organization's requirements under our regulatory compliance policies; 2) does this product (including installation, maintenance, and training costs) fit within my budget; 3) is this product widely known and trusted by my peers at other medical practices. Notice something? The word "software" doesn't appear in that even once. They literally don't care. The result is that companies develop products (software) on the cheap, and that results in the quality issues that exist. Improving the quality of the code base and development practices is solving a problem the purse-holders (customers) don't have.
  - BadInformatics 6y ago
    I agree that all the factors you've listed are in play, but they are far from the only ones involved in decision making. Perhaps this is a regional thing, I've never experienced (and have no wish to) what the US EMR market is like. Some complaints/feedback I did receive from doctors and clinic admins while working for an EMR vendor: 1. Your system is buggy/unintuitive and we hate using it. 2. We're not upgrading or moving to your new system because of 1). 3. We're moving to competitor X because they have Y feature. 4. [conversely] We came from competitor X because their EMR is slow/buggy/lacks features. 5. We signed up because the docs/office assistants liked [hero feature] in the sales demo. So yes, 0 mentions of the word "software". However, all of these are directly related to the software itself. There's a reason flashy new companies can swoop in and steal some market share (at least where I am). Even more importantly, there are many tech-related reasons why some companies start floundering and drop out of the market: - bad foundations (most EMRs were created by doctors with limited dev experience) - rampant tech debt driven by feature-driven development - lack of knowledge about testing/CI These are not theoretical problems. More than once, we incurred regulatory fines and SLA penalties in excess of the "cost of doing business" threshold. After a pretty major patient data screw-up, upper management even relented and gave the dev(ops) team time/money to clean up their act. Regulatory and bureaucratic inertia may insulate health IT companies from software engineering issues, but there's a limit to everything and they can sure as hell bleed.

toomuchtodo 6y ago

> I wish more FAANG-calibre devs would look into contributing to and evangelizing these platforms rather than writing yet another note-taking/"productivity management" app. I would like to see the US Digital Service continue to task technologists with improving EMR systems at CMS (Centers for Medicare and Medicaid Services), but made free to use by all practitioners and citizens (and of course, open sourcing the resulting codebase). It seems sort of inefficient we keep reinventing the wheel (Epic and the like, which are crazy expensive, or self hosted solutions, when practitioners should not be spending time maintaining EMRs), when your records should be stored for your benefit by your government over the course of your life. This is where, imho, high calibre engineers provide the most leverage (one way ratchets on public goods at scale). [1] https://www.usds.gov/resources/USDS-Impact-Report-2020.pdf https://www.usds.gov/resources/USDS-Impact-Report-2020.pdf [2] https://www.va.gov/health-care/get-medical-records/ https://www.va.gov/health-care/get-medical-records/

beh9540 6y ago
The VA sort-of does this, at least when I worked for them. The issue they had when I was there was depending on where you went, you may or may not have access to the record, because the VA didn't use a central system, it used many systems across the country, each with their own records(basically their own mainframe). We once added a hospital to our system, and had to have dual workstations because the systems couldn't be easily merged, and they had to look up patients in both systems. Also, with Veterans Choice, I don't know how much there was an effort to bring this data back. Same thing with the DoD, for a while there was an agreement to send medical records for active duty to the VA, but then that got pulled for a time. I believe there was a huge undertaking to consolidate these to fewer systems in the last few years, but Vista[0] (the VA's EMR) is pretty scary. I wouldn't wish it on anyone. https://en.wikipedia.org/wiki/VistA https://en.wikipedia.org/wiki/VistA
- breck 6y ago
  The VA has something called BlueButton that looks really cool (https://www.va.gov/bluebutton/ https://www.va.gov/bluebutton/) and I think should be standard practice across all EMS systems (one click export of all a patient's data to a single text file). The file format itself seems like a bit tough to parse, but the concept I love.

safog 6y ago

I've worked in the space for a few years and I'd discourage anyone from trying to build a career as a software dev in the Healthcare IT / EMR space. It's extremely sales driven (devs aren't valued at all), code quality is terrible and the systems you write are mostly for the benefit of insurance companies / compliance than doctors or patients. I think there was a YC funded iPad EMR startup that tried to be cool / hip / provider first until they got smacked in the face by reality.

erichurkman 6y ago
You're thinking of https://www.drchrono.com/ https://www.drchrono.com/
- xattt 6y ago
  All these hip, cool EMRs always show a glamour of a patient. I have yet to see a medical practice or health care facility that has a photo studio as a side business!
  - mhink 6y ago
    Maybe not a side business, but it's not as ridiculous as it sounds! A friend of mine was an in-house photographer and graphic designer (I think he had some sort of managerial role, too) for the local hospital network until he got laid off when COVID hit. Basically, in addition to being a good photographer, he had to be aware of the various patient-privacy regulations involved and also have a practical working knowledge of the hospital so he and his team wouldn't be getting in the way.
  - topkai22 6y ago
    I think most US hospitals have offer in house newborn photos. I know ours did :)
BadInformatics 6y ago
Not all healthcare systems are beholden to private insurance (my own country's included) and that shows in where these systems are deployed. Also, compliance doesn't fully explain why competitors are able to convince clinicians to switch systems. Word-of-mouth means that people will know your EMR is a flaming piece of garbage, but (as you noted) companies would much rather cut up-front prices so they can milk an extended contract than improving product quality. All that said, I think there's a bit of a chicken-and-egg thing going on here. Good people don't join the space because the culture sucks and the pay is bad, but those are because those with the talent and drive all self-selected out of it. I get it, health IT is a huge drag and not at all sexy. But just look at how often folks on HN ask about "doing social good" and how many complaints there are about healthcare delivery. Trying to run a "disruptive" VC-backed startup is IMO pretty crazy, but contributing to an OSS project is far less risky and more achievable.

breck 6y ago

I love this space—mostly because I loathe the absolutely awful American EMR systems— and intermittently have been working on some ideas with a few people (https://github.com/treenotation/pau https://github.com/treenotation/pau) (here are some fugly notes/links to EMS systems for anyone interested in the space: https://github.com/treenotation/pau/tree/master/paudb https://github.com/treenotation/pau/tree/master/paudb)