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Secondary to the question, but I live right by the Epic campus and use the Epic MyChart platform to communicate with the University of Wisconsin health system.

Secondary to the question, but I live right by the Epic campus and use the Epic MyChart platform to communicate with the University of Wisconsin health system. It is phenomenal as a patient; I can handle all billing, message any doctor I've seen, view test results as soon as they're uploaded, etc. Recently I saw the results of some bloodwork in the ER before the nurses had time to come and tell me about it. (The UI/UX is awful, though.) I look at the screens of the medical staff when I'm in the office and I can see why they don't like Epic; bad UI/UX and they definitely reorder and rearrange common menus when there's a big update. For overworked medical staff it's got to be a nightmare. There must be a middle ground. I never want to go back to a healthcare system where I don't have something like Epic, but also it would be nice to have a platform with a more stable, simple design philosophy.

etiam 4y ago
Now proceed to imagine that software being shoehorned into a healthcare system where many aspects of the US healthcare system are impossible to fill out at the care provider side, because they don't exist in the society model. (Let's be honest, you guys have opted for a model which have several very distinctive features in an international comparison). And I'd be surprised if the Norwegians didn't already have the positive aspect on the patient side in whatever this is now supposed to replace.
- quijoteuniv 4y ago
  yes, the patient side already exist here as far as I know. Helseplatform use their endpoints. The integration is mostly for the hospital, pre-ER and city health services. The pre-ER or LegeVakt (Scandinavian system you call/go if you need assistance but is not life threatning) has been using it for a few months and service level is now so bad that they have apologised in the newspapers. The city that has been sold this system had a wishful thought that all the doctors practices (and all Norway) was also going to use it. This is simply not going to happen now. However the "city" used so much money on this that they refuse to hear the health personel and insist on going further with the project without improving the system. Apparently Epic selling points was something like "It is not going to happen what happened in Denmark" Maybe some Danish people can iluminate on what happened there.
- semi-extrinsic 4y ago
  There are a couple of use cases that the new platform is solving, that were not straight-forward in the old system. Primarily the fact that your GP/family doctor and the hospital system did not have access to a common set of health records, they had to send specific requests for copies back and forth. As an example, when you're pregnant you get this special paper booklet where all your information gets recorded by GP/ultrasound/midwife/etc., and when you go to give birth you have to bring this booklet and give it to the midwife so they can see your pregnancy-related health records. But we have had for a long time a website called "Helsenorge" where you can log in and access most of your health records. For example during covid this was used to give you PCR test results and that worked flawlessly, you get an SMS notification when you have updates to see. So a big part of the "why on earth are they using this Epic software" sentiment is the feeling that we would be much better off by extending the Helsenorge system to do what we need. Especially since it's only a small part of the country going with the Epic system, and other parts will run other systems - a legacy of the previous privatisation-trigger-happy government. There are also a lot of obviously broken things on the end-user side in Epic Mycharts. For one, you cannot change the language in the app, it is tied to your phone system language. So if you're Norwegian but prefer to use Android/iOS in English, you're stuck with poor translations to English that you have to guess-translate back again to Norwegian. The app needs a new login after 10 minutes of inactivity, and this login is using a semi-complicated Norway-specific MFA called BankID that is run by the banking sector, so the login flow takes about a minute to complete. This means you can't actually get push notifications from the app, since it's never logged in while running in the background. So you get SMS and/or email notifications instead. There is a lot of cruft related to insurance and billing stuff you have to scroll through in the menus that will never be useful to anyone in this country, and nobody understands why they can't just hide those buttons. There are three different types of messages you can send - Letter, Question and Message - nobody knows what is the difference and one of them redirects you to the other when you start to compose something. When you go to view your health records summary, there is a big text box at the top which says "Take care, the results here might be displayed in a mixture of Norwegian and American formats" - they have obviously not learned the lessons of the Mars Climate Orbiter failure. For instance it says "Marital status: Gift" on my summary. To access my children's health records I had to send Proxy Data Requests for each one, which went through a rather complicated login flow every time. Then after three weeks I got a message from some random person saying I have access, apparently there are some poor souls sitting somewhere and manually verifying that yes, this person is the child of that person, even though that information is already in the Helsenorge database. All in all it seems that either the Epic system is such a horrible pile of fragile spaghetti code that nobody dares to touch it and adapt it to our use case, or we are simply such a small customer that they can't be arsed to fix our woes. It kinda feels like when you are using any product from Google or Microsoft, only in this case you're paying Microsoft a couple hundred million to adapt the software to your organization and still have that feeling.
kelnos 4y ago
Yeah, UCSF here also uses MyChart, and I agree that it's great from the perspective of the power and flexibility it offers me, even if the UX isn't fantastic (frankly, I think it's fine, though could be better). But, like you, I've also observed medical staff inputting my data during a visit, and it looks terrible, and I've also noticed significant UI changes on occasion. (I've gone in once a month for the past two years for an allergy immunotherapy injection, so I get to see it regularly, and over time.) I've only heard the nurses complain once or twice, but I can kinda tell how they occasionally stumble with the UI, and it all just seems completely unavoidably bad. A little user research would go a long way, but I imagine the cost of switching to another system (if there even are that many good options) is so high that a hospital might ignore staff complaints anyway, so the company is not incentivized to spend time and money to make things better.
closeparen 4y ago
>message any doctor I've seen Doctors especially hate this part, since they don't get reimbursed for fielding these messages and (unlike scheduled appointments) there's no limit to how many there can be or how quickly they can come.
- matheusmoreira 4y ago
  Yeah. These messaging services essentially place doctors on call at zero extra compensation.
  - jakear 4y ago
    “On call” has a precise, intuitive, definition that “receives messages and can respond to them at-will” does not fit.
    - matheusmoreira 4y ago
      Can respond at will? Yeah, about that. I have no doubt the patients using the doctor messaging feature will expect a prompt if not immediate answer. The system is definitely imposing an unpredictable work schedule on doctors with no compensation. If you're expected to respond to patient messages, you can't go do something else with your life.
      - squeaky-clean 4y ago
        I'm sure there are folks who don't read disclaimers but that's on them. Before I can send any messages I get the disclaimer > Please use this for non-urgent medical questions. Replies may take 2-3 business days. If you need immediate assistance, you will need to contact the practice. > If this is a medical emergency, call 911. > Please note, this is not a text message and should be used to ask questions directly related to your medical care. Some requests for medical advice may require an office visit. I've only used it to send 2 messages but I think they were fair. One was telling my doctor that I had gotten a lab appointment for an exam they referred me for on a certain date. The second messages was today, I got some scan results back, my cardiologist commented things looked good, so I sent a message asking if I could start jogging again. I don't mind if he takes 5 days to respond or even says "we're not sure", but Id rather not wait for my next appointment in 3 months to ask that.
colinmhayes 4y ago
I have some doctors in my family and they told me that when their system switched to Epic, Epic sent a consultant to sit in their office for months and answer questions because every new user complains about UX.
electriccatblan 4y ago
Disclaimer: My Epic experience is around a decade old. I never saw a riot, but I definitely saw providers who hated Epic when it was installed. As in people literally screaming at the top of their lungs at IT nerds. I saw a few contributing factors: 1. Epic supports making all the technically-mandatory-but-not-mandatory-if-you're-in-a-hurry data actually mandatory, so providers have more typing and less ability to just get stuff done when needed (which minimizes agency). 2. Related to above, Epic will make the updates for any new regulation, which increases the amount of data providers need to collect. 3. The customizability of the Epic UI and workflows for each type of visit was completely insane; many permutations of steps in a visit had to be supported which meant a huge maintenance surface with ok coverage rather than an opinionated workflow for each visit that could be optimized and improved over time.
- PubliusMI 4y ago
  >technically-mandatory-but-not-mandatory-if-you're-in-a-hurry :/
  - meandthewallaby 4y ago
    In my experience, the software development profession could spend a long, long time doing some self-reflection about this one. It's eloquently stated, and something a lot of developers could learn. Too many times, I've seen overly restrictive inputs cause users to hate and distrust the software. Ironically, overly restrictive inputs cause users to think that the software doesn't properly understand the domain, which is the root of mistrust. We should be very liberal with accepted inputs. I call them "Fuck It Buttons." There are lots of cases where you want a "Fuck It" button to just go around all the data entry and get an answer or move on with minimum info. Warn that the data isn't complete and we're using defaults, and don't just make output look the same as a complete workflow, but let them go through, nonetheless. Health care is just one example, but "Fuck It" comes up in every industry. This is the UI/UX equivalent of knowing which hills to die on.
    - emmelaich 4y ago
alchemist1e9 4y ago
Totally agree. Even better is doctors from different providers can likely see your records from each other. It isn’t fool proof but it’s getting pretty good. If a provider doesn’t use Epic then I’ll be looking for a different provider at this point.
an1sotropy 4y ago
I agree that my healthcare interactions have been improved by Epic. But Epic has no motivation to keep improving, because they control most [1] of the US medical records, and once a hospital is a client, its practically impossible for the hospital to also try a competitor's record management system (medical records are not unique in the enormous cost of switching between systems). So even while we can be glad for mychart we will suffer the increasing downsides of Epic's practical monopoly, without even knowing how much better it could be. [1] https://www.forbes.com/sites/katiejennings/2021/04/08/billionaire-judy-faulkner-epic-systems/?sh=559f5024575a https://www.forbes.com/sites/katiejennings/2021/04/08/billio...
actually_a_dog 4y ago
Medical staff don't like Epic because it's the kind of software that's sold to administrators, but used by providers. Guess who has the most sway in things like what features are included and how much effort gets invested into making the UX good?
- bearjaws 4y ago
  Bingo, Epic has probably the most in depth sales team, they know everything about your organization and YOU before even starting the call. They will smooch, take to dinner, do whatever it takes to bribe the head of office staff. Then once they're in the door they convince you to hire 5-10 of their 'Epic Engineers' and charge you $500+ an hour for the honor. Soon you discover that you can never really get rid of those engineers and need to hire your own on staff team... Which you probably could have done with literally any other EMR if you wanted to customize it. 2 years in the medical staff hate life and the front of house staff have costed their business 50-100M in fees. Alberta found this out the hard way after spending 5 years and 450M+ on Epic. Roughly $100 per person in the province was required to get Epic 'running'. (I am not sure if its been rolled out to all of Alberta?)
  - pythko 4y ago
    I don’t think Epic’s install costs are secret or a “gotcha”. Any administrator interested in Epic can look at 20 years of installs and see that an Epic implementation is routinely a multi year, $100 million+ project for large organizations. I’m also not sure what these “Epic Engineers” you’re referring to are, but I know that IT staffing is a conversation that happens early on in the sales process and it is not a surprise to anyone who’s looked around at existing Epic sites. Whatever Epic’s flaws may be, I don’t think “public boondoggle” is a fair portrayal of how they do business.
permo-w 4y ago
I don’t mean this to sound passive aggressive; I’m genuinely unsure: are you using “UI/UX” correctly here? if you’re getting exactly what you want from it, is that not good UX?
- Bedon292 4y ago
  Its definitely possible for something to work and still suck to use. Just because you can get there eventually doesn't mean the experience of clicking through a dozen menus to find where a button has been moved with this update is a good one.
- quacked 4y ago
  Maybe? I think that the system is poorly designed, but I can still do everything I want to do with a medium level of difficulty in achieving it. MyChart is way better than nothing, but it's not as good as "a good version of MyChart".

etiam 4y ago

Now proceed to imagine that software being shoehorned into a healthcare system where many aspects of the US healthcare system are impossible to fill out at the care provider side, because they don't exist in the society model. (Let's be honest, you guys have opted for a model which have several very distinctive features in an international comparison). And I'd be surprised if the Norwegians didn't already have the positive aspect on the patient side in whatever this is now supposed to replace.

quijoteuniv 4y ago
yes, the patient side already exist here as far as I know. Helseplatform use their endpoints. The integration is mostly for the hospital, pre-ER and city health services. The pre-ER or LegeVakt (Scandinavian system you call/go if you need assistance but is not life threatning) has been using it for a few months and service level is now so bad that they have apologised in the newspapers. The city that has been sold this system had a wishful thought that all the doctors practices (and all Norway) was also going to use it. This is simply not going to happen now. However the "city" used so much money on this that they refuse to hear the health personel and insist on going further with the project without improving the system. Apparently Epic selling points was something like "It is not going to happen what happened in Denmark" Maybe some Danish people can iluminate on what happened there.
semi-extrinsic 4y ago
There are a couple of use cases that the new platform is solving, that were not straight-forward in the old system. Primarily the fact that your GP/family doctor and the hospital system did not have access to a common set of health records, they had to send specific requests for copies back and forth. As an example, when you're pregnant you get this special paper booklet where all your information gets recorded by GP/ultrasound/midwife/etc., and when you go to give birth you have to bring this booklet and give it to the midwife so they can see your pregnancy-related health records. But we have had for a long time a website called "Helsenorge" where you can log in and access most of your health records. For example during covid this was used to give you PCR test results and that worked flawlessly, you get an SMS notification when you have updates to see. So a big part of the "why on earth are they using this Epic software" sentiment is the feeling that we would be much better off by extending the Helsenorge system to do what we need. Especially since it's only a small part of the country going with the Epic system, and other parts will run other systems - a legacy of the previous privatisation-trigger-happy government. There are also a lot of obviously broken things on the end-user side in Epic Mycharts. For one, you cannot change the language in the app, it is tied to your phone system language. So if you're Norwegian but prefer to use Android/iOS in English, you're stuck with poor translations to English that you have to guess-translate back again to Norwegian. The app needs a new login after 10 minutes of inactivity, and this login is using a semi-complicated Norway-specific MFA called BankID that is run by the banking sector, so the login flow takes about a minute to complete. This means you can't actually get push notifications from the app, since it's never logged in while running in the background. So you get SMS and/or email notifications instead. There is a lot of cruft related to insurance and billing stuff you have to scroll through in the menus that will never be useful to anyone in this country, and nobody understands why they can't just hide those buttons. There are three different types of messages you can send - Letter, Question and Message - nobody knows what is the difference and one of them redirects you to the other when you start to compose something. When you go to view your health records summary, there is a big text box at the top which says "Take care, the results here might be displayed in a mixture of Norwegian and American formats" - they have obviously not learned the lessons of the Mars Climate Orbiter failure. For instance it says "Marital status: Gift" on my summary. To access my children's health records I had to send Proxy Data Requests for each one, which went through a rather complicated login flow every time. Then after three weeks I got a message from some random person saying I have access, apparently there are some poor souls sitting somewhere and manually verifying that yes, this person is the child of that person, even though that information is already in the Helsenorge database. All in all it seems that either the Epic system is such a horrible pile of fragile spaghetti code that nobody dares to touch it and adapt it to our use case, or we are simply such a small customer that they can't be arsed to fix our woes. It kinda feels like when you are using any product from Google or Microsoft, only in this case you're paying Microsoft a couple hundred million to adapt the software to your organization and still have that feeling.

kelnos 4y ago

Yeah, UCSF here also uses MyChart, and I agree that it's great from the perspective of the power and flexibility it offers me, even if the UX isn't fantastic (frankly, I think it's fine, though could be better). But, like you, I've also observed medical staff inputting my data during a visit, and it looks terrible, and I've also noticed significant UI changes on occasion. (I've gone in once a month for the past two years for an allergy immunotherapy injection, so I get to see it regularly, and over time.) I've only heard the nurses complain once or twice, but I can kinda tell how they occasionally stumble with the UI, and it all just seems completely unavoidably bad. A little user research would go a long way, but I imagine the cost of switching to another system (if there even are that many good options) is so high that a hospital might ignore staff complaints anyway, so the company is not incentivized to spend time and money to make things better.

closeparen 4y ago

>message any doctor I've seen Doctors especially hate this part, since they don't get reimbursed for fielding these messages and (unlike scheduled appointments) there's no limit to how many there can be or how quickly they can come.

matheusmoreira 4y ago
Yeah. These messaging services essentially place doctors on call at zero extra compensation.
- jakear 4y ago
  “On call” has a precise, intuitive, definition that “receives messages and can respond to them at-will” does not fit.
  - matheusmoreira 4y ago
    Can respond at will? Yeah, about that. I have no doubt the patients using the doctor messaging feature will expect a prompt if not immediate answer. The system is definitely imposing an unpredictable work schedule on doctors with no compensation. If you're expected to respond to patient messages, you can't go do something else with your life.
    - squeaky-clean 4y ago
      I'm sure there are folks who don't read disclaimers but that's on them. Before I can send any messages I get the disclaimer > Please use this for non-urgent medical questions. Replies may take 2-3 business days. If you need immediate assistance, you will need to contact the practice. > If this is a medical emergency, call 911. > Please note, this is not a text message and should be used to ask questions directly related to your medical care. Some requests for medical advice may require an office visit. I've only used it to send 2 messages but I think they were fair. One was telling my doctor that I had gotten a lab appointment for an exam they referred me for on a certain date. The second messages was today, I got some scan results back, my cardiologist commented things looked good, so I sent a message asking if I could start jogging again. I don't mind if he takes 5 days to respond or even says "we're not sure", but Id rather not wait for my next appointment in 3 months to ask that.

colinmhayes 4y ago

I have some doctors in my family and they told me that when their system switched to Epic, Epic sent a consultant to sit in their office for months and answer questions because every new user complains about UX.

electriccatblan 4y ago

Disclaimer: My Epic experience is around a decade old. I never saw a riot, but I definitely saw providers who hated Epic when it was installed. As in people literally screaming at the top of their lungs at IT nerds. I saw a few contributing factors: 1. Epic supports making all the technically-mandatory-but-not-mandatory-if-you're-in-a-hurry data actually mandatory, so providers have more typing and less ability to just get stuff done when needed (which minimizes agency). 2. Related to above, Epic will make the updates for any new regulation, which increases the amount of data providers need to collect. 3. The customizability of the Epic UI and workflows for each type of visit was completely insane; many permutations of steps in a visit had to be supported which meant a huge maintenance surface with ok coverage rather than an opinionated workflow for each visit that could be optimized and improved over time.

PubliusMI 4y ago
>technically-mandatory-but-not-mandatory-if-you're-in-a-hurry :/
- meandthewallaby 4y ago
  In my experience, the software development profession could spend a long, long time doing some self-reflection about this one. It's eloquently stated, and something a lot of developers could learn. Too many times, I've seen overly restrictive inputs cause users to hate and distrust the software. Ironically, overly restrictive inputs cause users to think that the software doesn't properly understand the domain, which is the root of mistrust. We should be very liberal with accepted inputs. I call them "Fuck It Buttons." There are lots of cases where you want a "Fuck It" button to just go around all the data entry and get an answer or move on with minimum info. Warn that the data isn't complete and we're using defaults, and don't just make output look the same as a complete workflow, but let them go through, nonetheless. Health care is just one example, but "Fuck It" comes up in every industry. This is the UI/UX equivalent of knowing which hills to die on.
  - emmelaich 4y ago

alchemist1e9 4y ago

Totally agree. Even better is doctors from different providers can likely see your records from each other. It isn’t fool proof but it’s getting pretty good. If a provider doesn’t use Epic then I’ll be looking for a different provider at this point.

an1sotropy 4y ago

I agree that my healthcare interactions have been improved by Epic. But Epic has no motivation to keep improving, because they control most [1] of the US medical records, and once a hospital is a client, its practically impossible for the hospital to also try a competitor's record management system (medical records are not unique in the enormous cost of switching between systems). So even while we can be glad for mychart we will suffer the increasing downsides of Epic's practical monopoly, without even knowing how much better it could be. [1] https://www.forbes.com/sites/katiejennings/2021/04/08/billionaire-judy-faulkner-epic-systems/?sh=559f5024575a https://www.forbes.com/sites/katiejennings/2021/04/08/billio...

actually_a_dog 4y ago

Medical staff don't like Epic because it's the kind of software that's sold to administrators, but used by providers. Guess who has the most sway in things like what features are included and how much effort gets invested into making the UX good?

bearjaws 4y ago
Bingo, Epic has probably the most in depth sales team, they know everything about your organization and YOU before even starting the call. They will smooch, take to dinner, do whatever it takes to bribe the head of office staff. Then once they're in the door they convince you to hire 5-10 of their 'Epic Engineers' and charge you $500+ an hour for the honor. Soon you discover that you can never really get rid of those engineers and need to hire your own on staff team... Which you probably could have done with literally any other EMR if you wanted to customize it. 2 years in the medical staff hate life and the front of house staff have costed their business 50-100M in fees. Alberta found this out the hard way after spending 5 years and 450M+ on Epic. Roughly $100 per person in the province was required to get Epic 'running'. (I am not sure if its been rolled out to all of Alberta?)
- pythko 4y ago
  I don’t think Epic’s install costs are secret or a “gotcha”. Any administrator interested in Epic can look at 20 years of installs and see that an Epic implementation is routinely a multi year, $100 million+ project for large organizations. I’m also not sure what these “Epic Engineers” you’re referring to are, but I know that IT staffing is a conversation that happens early on in the sales process and it is not a surprise to anyone who’s looked around at existing Epic sites. Whatever Epic’s flaws may be, I don’t think “public boondoggle” is a fair portrayal of how they do business.

permo-w 4y ago

I don’t mean this to sound passive aggressive; I’m genuinely unsure: are you using “UI/UX” correctly here? if you’re getting exactly what you want from it, is that not good UX?

Bedon292 4y ago
Its definitely possible for something to work and still suck to use. Just because you can get there eventually doesn't mean the experience of clicking through a dozen menus to find where a button has been moved with this update is a good one.
quacked 4y ago
Maybe? I think that the system is poorly designed, but I can still do everything I want to do with a medium level of difficulty in achieving it. MyChart is way better than nothing, but it's not as good as "a good version of MyChart".