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I wrote Hacking Healthcare for O'Reilly Media, created ClearHealth/HealthCloud, WebVista, yada yada... There are several factors that collide to make everythin

I wrote Hacking Healthcare for O'Reilly Media, created ClearHealth/HealthCloud, WebVista, yada yada... There are several factors that collide to make everything in software associated with health exponentially more difficult than in other areas. First, people's lives are actually on the line, the stakes are very high. Second, government regulation plays a significant role in how things can and cannot be done, this is a double edged sword in preventing some abuses but also making iteration and innovation more difficult. The other most signifcant point is that there are often very large gaps in vision between different layers of a very large and complex human system. The needs of keeping the lights on and billing are often in direct tension to the needs of optimal care, this often manifests in software as a chimera that pleases no one. One other tidbit I will add is well covered in my book's chapter "The incredible bandwidth of paper". When you actually sit in a room and see how fast and how complex the information recorded by a group of medical professionals with nothing but pen and paper form is, it is daunting to actually deliver that level of performance and reliability with any technology that exists today.

flerovium 5y ago
Then why isn't more of it done on an electronic paper? If it served in the old world, why can't the software equivalent work?
- duffpkg 5y ago
  Is there any electronic paper that works well and is reasonably priced?
- PeterisP 5y ago
  Because various processes still need to extract structured information out of it to send to other organizations (insurance, billing) and that part doesn't work automatically without someone converting the scribbles on e-paper to verified entries in a specific form.
  - flerovium 5y ago
    How did the system work before? My sense is that doctors spend more time on administrative work now than they did before. How is the new system better?
robbiep 5y ago
I like the concept of 'paper bandwith'. That rings so true with my experience. I've lived through a number of transitions from paper to Cerner. At one hospital, they were going live across the entire 600 bed facility in a 2 week period. It was also the start of the new interns - I was there as a surgical registrar. We went from having our 4 person team (Senior Registrar, myself, 2 Juniors) pushing the cart with the files around, taking 4 minutes per patient, Juniors carefully watching and observing the examination, writing useful shorthand, to a situation where both Juniors were pushing dual-screen COWs frantically trying to keep up with reported findings and plans. Later in that transition period I was on nights and called to review a patient with SOB. They had been in for 10 days - typical chest that could be APO/could be Pneumonia. The last time the chest findings were documented in Powerchart was 10 days ago on ED admission!! Of course, poor documentation is part of the problem but every day that patient had had their chest examined, there just wasn't a useful way to document it in a shorthand way and the juniors were totally overwhelmed, requiring 2 of them to do the job of half of one of them previously
mikewarot 5y ago
A friend used to work ER, any time the computers went down, the backlog in the waiting room would get cleared up. Paper works so much better when you're just trying to save someone's life, and don't know which of the hundreds of different forms you'll eventually have to fill out in the computer.
- flerovium 5y ago
  Wow. This is eye-opening. I'm surprised this isn't at the top. Is paper better? Why do hospitals use electronic records then?
  - calvano915 5y ago
    Because paper record absolutely sucks to retrieve/interpret later, and billing/coding would be even more arduous from paper than it already is with EMRs.
  - duffpkg 5y ago
    A LOT of money is tied up in reporting that is all but impossible to do without comprehesive electronic versions of medical record information.
Areading314 5y ago
Thanks for writing this fantastic book. I think it is a must read for any software PM or engineer looking to "disrupt" healthcare. That chapter about paper-based workflows was really eye opening for me as someone who has never worked in that kind of environment. I think another big area here is that regulations concerning medical software (such as the design controls needed for FDA Software-as-a-medical-device) are simply outdated and do not reflect software development best practices. Instead of things like testing, fast deploys, monitoring, redundancy, scalability, etc the regulations strongly push people to emphasize up-front specification and documentation, which takes an incredible amount of time and energy out of a project.

flerovium 5y ago

Then why isn't more of it done on an electronic paper? If it served in the old world, why can't the software equivalent work?

duffpkg 5y ago
Is there any electronic paper that works well and is reasonably priced?
PeterisP 5y ago
Because various processes still need to extract structured information out of it to send to other organizations (insurance, billing) and that part doesn't work automatically without someone converting the scribbles on e-paper to verified entries in a specific form.
- flerovium 5y ago
  How did the system work before? My sense is that doctors spend more time on administrative work now than they did before. How is the new system better?

robbiep 5y ago

I like the concept of 'paper bandwith'. That rings so true with my experience. I've lived through a number of transitions from paper to Cerner. At one hospital, they were going live across the entire 600 bed facility in a 2 week period. It was also the start of the new interns - I was there as a surgical registrar. We went from having our 4 person team (Senior Registrar, myself, 2 Juniors) pushing the cart with the files around, taking 4 minutes per patient, Juniors carefully watching and observing the examination, writing useful shorthand, to a situation where both Juniors were pushing dual-screen COWs frantically trying to keep up with reported findings and plans. Later in that transition period I was on nights and called to review a patient with SOB. They had been in for 10 days - typical chest that could be APO/could be Pneumonia. The last time the chest findings were documented in Powerchart was 10 days ago on ED admission!! Of course, poor documentation is part of the problem but every day that patient had had their chest examined, there just wasn't a useful way to document it in a shorthand way and the juniors were totally overwhelmed, requiring 2 of them to do the job of half of one of them previously

mikewarot 5y ago

A friend used to work ER, any time the computers went down, the backlog in the waiting room would get cleared up. Paper works so much better when you're just trying to save someone's life, and don't know which of the hundreds of different forms you'll eventually have to fill out in the computer.

flerovium 5y ago
Wow. This is eye-opening. I'm surprised this isn't at the top. Is paper better? Why do hospitals use electronic records then?
- calvano915 5y ago
  Because paper record absolutely sucks to retrieve/interpret later, and billing/coding would be even more arduous from paper than it already is with EMRs.
- duffpkg 5y ago
  A LOT of money is tied up in reporting that is all but impossible to do without comprehesive electronic versions of medical record information.

Areading314 5y ago

Thanks for writing this fantastic book. I think it is a must read for any software PM or engineer looking to "disrupt" healthcare. That chapter about paper-based workflows was really eye opening for me as someone who has never worked in that kind of environment. I think another big area here is that regulations concerning medical software (such as the design controls needed for FDA Software-as-a-medical-device) are simply outdated and do not reflect software development best practices. Instead of things like testing, fast deploys, monitoring, redundancy, scalability, etc the regulations strongly push people to emphasize up-front specification and documentation, which takes an incredible amount of time and energy out of a project.