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I've read that doctors now spend as much as 50% of their time documenting their work. Companies such as Epic, which provide the software that hospitals use to b

I've read that doctors now spend as much as 50% of their time documenting their work. Companies such as Epic, which provide the software that hospitals use to build databases of patient data, have been big winners in the new world of hospitals-depending-on-software. But did the doctors become more productive? By almost any measure, they became less productive. People in tech keep thinking more tech will solve problems and they keep underestimating the flexibility of the old models. For instance, most large companies used to be run by armies of secretaries, and the senior secretaries functioned as what we would now call "project managers" -- they made calendars, oversaw who was working on what, followed up to keep track on whether work was being done, and kept a close eye on what money was being spent. The crucial thing about having humans overseeing such work is that humans can take a flexible approach to the rules: they know when to break them. By contrast, systems that are highly dependent on software tend to be more rigid. Software doesn't know when its rules should be broken. The flexibility of the old system is constantly underestimated, the rigidness of the new systems is often misunderstood. In his book "The Design Of Design" Fred Brooks talks about the power of trust, and he contrasts that situations where everything needs to be first negotiated and specified in a contract. High trust systems are flexible and fast, whereas a system where every detail needs to be specified in a contract is slow and rigid. We should stop and ask ourselves, our favorite Agile methodology resembles which of these? Are specifying things with needless detail?

happyjack 4y ago
I agree to a large extent with your comment. The "office" structure has changed a lot. Secretaries ran the show, and pretty much hand-held everyone in the office and kept the ship pointed in the right direction. Law firms and political offices still have this "outdated" model because if it ain't broken, don't fix it. Now, your company pays insane amounts of $ for software, systems, and data! You have to do your job, schedule your meetings, keep up with the ungodly amount of email, instant message, SLACK, enter the data in your CRM, talk on the phone, schedule the video meetings, etc. while also keeping track of your personal phone because your partner called or the school called and your dog is sick. There's just so much distraction now by not having "office hours" and having our whole lives in our pockets and constant reach that I think productivity has to go down. It's impossible to focus on anything for any amount of time anymore with how accessible we are expected to be.
Retric 4y ago
That documentation time is largely driven by the insurance industry which was really painful before these systems. It’s almost shocking how much more productive doctors are inside the VA.
- derbOac 4y ago
  Insurance is part of it, but not all of it. Government regulation is also a big part. EHR mandates under the Obama administration (? who I was generally supportive of, so not a criticism of his presidency in general) created a kind of "false pressure" to move to EHR immediately, rather than "naturally" adopt it at an organic pace, adopting whatever is most beneficial due to demand. I'm not anti EHR, but the way those systems were adopted were definitely forced onto providers top-down, rather than bottom-up like traditional hospital record systems. Hospitals scrambled to implement them in time for deadlines, and there was no room for pushback against poorly implemented structures that were pushed on hospitals essentially. More recently in my field I've seen additional layers of documentation requirements that have nothing to do with insurance, that are entirely state law. I have no doubt in my mind that if EHR rules didn't exist, they would have been adopted much more gradually, and selection would have been dictated by the ability of EHRs to supply features in demand. More competition would have existed and it would have cost less. Maybe some government regulation would have been needed in terms of interoperability standards but it could have been rolled out much much much better. I don't think people fully comprehend the cost overruns associated with adoption of EHRs under government mandates, or how big of a shift there was from records being in-house flexible, and provider and patient-driven, to out-of-house inflexible, and IT-corporation-driven.
  - supertrope 4y ago
    To play devil's advocate without the stick of Medicare funding being at stake, doctor's offices and hospitals will defer EHR upgrades until the heat death of the universe. HIPAA was passed in the 90s with a safe harbor for faxing and that's still the standard method to transfer a medical record.
    - 4y ago
sharadov 4y ago
Don't you worry, the next gen of block chain apps which are built on a bedrock of implicit trust, will make your concerns moot.
conductr 4y ago
I don’t think productivity was ever the goal of this software. It was to have a record that is standard, digital, transferable, etc. Doctors fought it as long as they could because they knew what it meant for them. I remember pretty early demos in early/mid 2000s when I was doing some clinical grunt work in college. I had written some software to make my department’s life easier so I was offered up as the hospital’s liaison for the software evaluation. This is when I formed my “never replace a terminal based app, with a GUI based app and expect productivity gains” theory. Everyone working in the hospital knew the terminal app, they type in some random 3 letter code and a screen would pop up. Then they would memorize how many tabs each field was apart from each other. Without a mouse, people could just hum along imputing data a blazing speed once some muscle memory was in place. Everyone had little cheat sheets printed out for the less frequently used commands/codes. When you replace this with a browser/desktop GUI with selectors and drop downs and reactive components of GUI, it tends to 1) require mouse usage for most people and 2) lose the ability to do this quick data entry I described. The pretty interface becomes a steady stream of speed bumps that reduce productivity. Since then I’ve witnessed it in banking and other industries too.
- FunnyBadger 4y ago
- yamtaddle 4y ago
  They also fought it because they didn't go to medical school and survive residency to fill out forms all damn day—and they didn't used to have to, they had staff for that. Then the computerized systems "replaced" that staff but all that really means is they cut the human time needed low enough that full-time workers weren't needed, but didn't eliminate it, so now that's another thing doctors have to do themselves. AFAI can tell, the effect of tech overall is to cut some jobs while making the remaining ones harder and more stressful, while increasing so-called context switching.
  - t-writescode 4y ago
    Sounds like modern startup devops-without-devops culture
Scoundreller 4y ago
> I've read that doctors now spend as much as 50% of their time documenting their work. Companies such as Epic, which provide the software that hospitals use to build databases of patient data, have been big winners in the new world of hospitals-depending-on-software. But did the doctors become more productive? By almost any measure, they became less productive. It’s less the software, and more the users, site-specific configuration and the environment they work in. Non-US Epic users spend 20-60% less time on various EHR activities than their US counterparts. One of the most dramatic differences is time spent on ordering, which you would think would be as optimized as it could be. Time spent documenting was 40 minutes/day for US users and 30 for non-US on average. Maybe some spend 50%, but that’s far from average. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2774129 https://jamanetwork.com/journals/jamainternalmedicine/fullar... Another study found US clinicians write 4x longer notes (cited in above). Now, does any of this improve clinical outcomes?
- dan_quixote 4y ago
  > Another study found US clinicians write 4x longer notes I wasn't aware of this, but as the spouse of a medical provider I know that most US providers are burdened with an ever-present worry about malpractice.
  - vanc_cefepime 4y ago
    This. So much this. In residency we are taught “document, document, document” and “this is a medical legal document” which leads to defensive medicine. Another point of why we spend more time documenting is billing. Coders/billers continue to come back and asking us to add more details about a diagnosis. More details = more charges to bill or up level. So the next progress note or office visit, I go back to add more. More time is spent fighting the notes. Terrible EMRs that destroy notes is one that leads to more time spent as well. Looking at you Allscripts (aka Allshits in my office). Overall it’s a sad state of medicine in the USA, which is terrible as when I was younger the whole point of medicine for me was to help people and focus on the patient and the issues that are ailing them. Now, patients are still important to me but it’s a race to the bottom trying to document while in seeing the patients so I can go home without paperwork and live my life. I got bills to pay, a 6 figure student loan that will take me another decade to pay off. At some point, it’s all going break down. Few of us are doing the concierge direct primary care model to avoid all this which will unfortunately lead to more health disparities and inequalities.
cm42 4y ago
"Just a billing platform with some patient stuff tacked on" https://www.youtube.com/watch?v=xB_tSFJsjsw https://www.youtube.com/watch?v=xB_tSFJsjsw
- FredPret 4y ago
  Zdogg, MD made my day!
bearjaws 4y ago
Are we sure the documentation isn't coming as required from the insurance companies? I know many Drs and especially nurses who CYA on all their documentation otherwise insurance will try to pin them on an adverse reaction.
- nradov 4y ago
  Payers in general (not just insurance companies) require high levels of documentation both to prevent fraud and to increase care quality. Most healthcare providers are highly ethical and only act in their patients' best interest. But there are always a minority of bad actors who will try to boost revenue by submitting claims for procedures that weren't medically necessary, or weren't performed at all. So the system needs checks for that in order to hold down costs for everyone, and prevent iatrogenic harm. You will also find many cases where even good providers let things slip through the cracks and fail to give some patients the appropriate level of care. For example, diabetics should generally receive annual foot exams, eye exams, and hemoglobin A1c tests. If the payer doesn't see evidence of those in the EHR then they can prompt the doctor to resolve that care quality gap.
warbler73 4y ago
There are huge productivity gains in private practices that eliminate web pages and email and switch to paper in filing cabinets only. This is also why fax machines still exist and are exclusively used by medical practices.
Mordisquitos 4y ago
> People in tech keep thinking more tech will solve problems and they keep underestimating the flexibility of the old models. Related to this, but in a completely different context, I have had similar thoughts lately when eating out at restaurants in Spain. It's incredibly frustrating from a customer's point of view when the waiter taking your group's order has to use a newfangled tablet or phone-like device and tap through each individual order, often depending on the peculiarities of the app's UI and how the designers expect the process to carry out: “Are you all having the set menu? No? OK, first I need to know how many of you are having it?" [taps count on screen] "Right, now I need the starters but ONLY for the set menu orders..." etcetera—you get the idea. Then, while going through this unnecessarily slow process, God forbid someone who ordered from the set menu wants to change their main while the waiter is already taking the à la carte orders. Meanwhile, in restaurants that haven't unnecessarily techified the procesz, the waiter can take the order in the way that's most practical given the circumstances and that best fits his way of taking notes. Ah, but then how does the order reach the kitchen without the tech? I have no idea, all I can say is that it worked fine before these things were put in place, and the manual system is by far the quickest and most flexible from a customer's point of view.
- whatshisface 4y ago
  Waiters put the bits of paper they're writing on on a rack in the kitchen. Other times, they shout out the orders and remember which table gets what.
  - Scoundreller 4y ago
    And shreds it all at the end of the day before the tax guy shows up. Though Quebec, Canada, had such a problem with “zappers” that would delete orders from the electronic system that every restaurant now must be online with the tax authority and every receipt has a tax authority response code on the top.
- maxrev17 4y ago
  That's just shitty software though. Good software gets out of the way and improves something. We could speculate on how to fix that scenario, but there's probably no incentive - in my experience there are fixations amongst tech people on profit-less ideas that end up getting squeezed awkwardly into applications such as bill splitting, digital ordering etc.
Eleison23 4y ago
The last good, independent physician I had was a fellow who played Chess on the weekends downtown. His practice moved about 5 times while I was a patient and he finally was snapped up by the VA. He habitually called me "friend" and was very frank about my insurance not paying for stuff I was asking about, which I appreciated. He also once profusely apologized to me for placing a computer in between us. He said the new requirements of his practice made it so he had to pay more attention to the computer than to me, and we were both sad about that. The doctors I got after that make no such apologies.
- ChrisMarshallNY 4y ago
  Reminds me of this anecdote: https://notalwaysright.com/trying-to-get-a-word-in-until-youre-blue-in-the-face/272921/ https://notalwaysright.com/trying-to-get-a-word-in-until-you... It may or may not be true (I suspect some of the stories on that site are made from whole cloth), but it speaks to your post.
Tsarbomb 4y ago
Having once worked in the EMR/EHR space, a big thing to consider is some companies come in with their own workflows, processes, and ideas that they want to push onto physicians while other companies are way more accommodating in building "bespoke" solutions to specific problems. The latter in my experience ends up providing better results to physicians as they have been employed as domain experts in building the software solution to their specific workflow. I've seen it done for in ophthalmology, specific disease/injury specific radiology, and diabetic specific checkup and appointments where I've seen as much as a 75% reduction in the amount of time the physician has to dedicate lookup up info, cross-referencing, and documenting.
- Scoundreller 4y ago
  > other companies are way more accommodating in building "bespoke" solutions to specific problems. Then you upgrade and everything breaks! But it’s an age old battle for and against standardization. I just walk around with several charging cables because each is “the best” for charging a small li-ion battery.
sebastianconcpt 4y ago
Brilliant observation. In a way, all might be a huge early optimization.
closeparen 4y ago
The big reason EMR is so overbearing is to optimize billing… as far as economic statistics, that should show up as positive even if less patient care is actually delivered.
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kewrkewm53 4y ago
I agree. Here in Finland the public healthcare organization in capital region and surrounding areas chose Epic as supplier of their new system. It has been a disaster, massive complaints from doctors about how unproductive it is to use, and also some issues that endanger patient safety. Apparently it's also programmed with MUMPS, which doesn't exactly sound a great idea in 21th century. I'm not sure whether this choice was a case of incompetence or corruption, but the end result is clearly a giant waste of money. Maybe it generates a lot of data, but efficiency would be way more important for an organization like this which is chronically underfunded and staffed.
throwaway894345 4y ago
> I've read that doctors now spend as much as 50% of their time documenting their work. Companies such as Epic, which provide the software that hospitals use to build databases of patient data, have been big winners in the new world of hospitals-depending-on-software. But did the doctors become more productive? By almost any measure, they became less productive. I don't think "by almost any measure" is right. I think in a very narrow sense they've become less productive (they see fewer patients), but by your own admission they're building databases of patient data, which you seem to suppose are only useful to the likes of Epic, but obviously Epic has customers--notably healthcare researchers use this data to improve patient care, develop new medicines, and to precisely identify which medicines are likely to help on a particular patient (and which medicines may even harm them!). This is stuff clearly benefits society, and doctors' role in this should be counted as "productive", although we can quibble about the relative value of facilitating healthcare research versus seeing more patients. Note that this isn't meant to vouch for Epic--I work for a company that consumes their data and anyone who has to integrate with them has nothing good to say about the software, but the role it plays is still incredibly important.
- VLM 4y ago
  Medical decisions are based primarily on financial profit, and patient outcome data is not required to determine which medicines are most profitable. The point of extensive documentation is shielding from the worst of malpractice lawsuits. The legal system is still of the legacy opinion that doctors have a responsibility to their patients as opposed to the more modern understanding of responsibility toward pharma company bottom lines, and all patients legally deserve the 100% successful participation trophy, so a documented decision with only 95% chance of success means insurance payouts about 5% of the time, unless its carefully documented it was all the patients fault or at least the MD could not have known the outcome in advance.
  - throwaway894345 4y ago
    > patient outcome data is not required to determine which medicines are most profitable This is blatantly false. Pharma spends tons of money to buy this data for their armies of researchers in order to determine outcomes. There's an entire very lucrative industry (that I work in) which exists to source this data from hospitals and refine it for researchers. If the point of documentation was CYA, then you wouldn't need complicated systems like Epic to standardize the documentation and make it available for electronic processing (you would just have some paralegal pour over the records of the individual patient).
theGnuMe 4y ago
Message passing was basically a solution for this in the tech world. Send messages to everyone and if they implement that message then they act.
scythe 4y ago
>Software doesn't know when its rules should be broken. Just to provide an example of this I ran into today: I'm doing a medical physics residency, and my supervisor was explaining that a new "fail-safe" incorporated into the software that reverted the collimator after every scan was now making the phototimer tests take twice as long, because we had to go back into the room and reset the collimator repeatedly. We tested a machine with the new system and one with the old system and it did in fact turn a 15-minute task into around 35 minutes.
nottorp 4y ago
Last time I had a blood test it took 2 minutes to take my blood and 15 to enter crap in various forms on the computer. And I'm not even in the US. There was a lot of clicking involved. To contrast, my first job was an accounting program. We spent weeks on making sure everything works via just the keyboard and some operations are as streamlined as possible. Because in some cases it was going to be used by people creating hundreds of invoices per day.
nonrandomstring 4y ago
Well said. Particularly on the value of trust within systems. In case it's of interest I wrote an article a couple of days ago on how "Digital Systems Fail Institutions" [1]. [1] https://techrights.org/2022/10/26/when-digital-systems-fail/ https://techrights.org/2022/10/26/when-digital-systems-fail/
ocbyc 4y ago
To get anything done, it seems I must speak to >=2 people on any customer support line.
danabrams 4y ago
We just had a baby this month, and I was shocked by how much time the medical staff was spending entering data into Epic. So much that they couldn’t actually fully concentrate on giving medical care. Everyone was very busy but it was very hard to get actual care.
lupire 4y ago
The article is about 2022 specifically, obviously pandemic related.
chaostheory 4y ago
You’re blaming tech for legal issues and requirements.
godelski 4y ago
> I've read that doctors now spend as much as 50% of their time documenting their work. Companies such as Epic, which provide the software that hospitals use to build databases of patient data, have been big winners in the new world of hospitals-depending-on-software. But did the doctors become more productive? By almost any measure, they became less productive. I'd ask another question: did lawsuits decrease? I'd imagine that a lot of this software is to avoid lawsuits. America is especially litigious and that's got to correlate strongly with the increase bureaucracy. I also suspect that a factor at play is that people are losing trust in the whole system. Most people now know that productivity has skyrocketed while salaries have remained relatively flat. With increasing economic disparity (not even just the West) it is no wonder that people become less productive. Who tries hard at a game that they believe is rigged against them? (doesn't matter if it is or isn't, just the belief) > People in tech keep thinking more tech will solve problems Because historically it has. But there are different types of tech. Tech enabled the modern world. It is the new medicines we have to cure illnesses that devastated populations. It is the chemicals that enable us to grow enough food to sustain our populations. It is everything from a wheel to the computers we use to make more efficient wheels that use less resources. But it is also naive to think that tech alone can solve every problem. It is also naive to think that tech can't create new problems. To create tech that solves problems we need to think long and hard about the intricate complexities involved and gather the expertise from relevant domains (an often missed, but essential, component). The other problem is that people hand wave away things like climate change saying "tech will solve it" rather than investing in said technology and waiting for it to magically appear. I do think tech is an important tool in solving many of the problems we face, but you're right that they are not all technology dependent (which is a continuous scale of weights, not a binary option). Also, we're a tech forum. Peoples' expertise here is in tech. So they see things through that lens and it is also very likely that the most we/they can contribute to solving these problems is, in fact, through technological means. The trick is to remember that tech isn't a cure-all and that the problems we face are exceedingly complex. Over simplifying is often harmful.
drewbeck 4y ago
I talk a lot about this flexibility gap in my day job in UX. Getting an organization onto a digital platform is great but a lot of them don’t recognize all the small ways that their current system’s flexibility is helping them. With big systems though I honestly think GUIs can only go so far, even at their very best, and any system that is required to be complex at some level will require expert knowledge of the system itself. That’s extra work and an extra burden for someone with the critical experience that an organization relies on. For doctors and the like it would make sense to try a system where the critical person/expert has an assistant who is a systems expert and does a lot of the needed data entry and the like. Doctor doesn’t have to worry about the system, they can talk to the assistant who manages all the extra work. If the system needs to change for any reason the assistant manages that and the doctor doesn’t have to worry about it. I think of this assistant role as the human API layer. It’s not far off from some social programs like insurance navigators, who help individuals find health insurance, including working through options and even—critically—filling out forms for folks. ETA: It’s a thing! I didn’t know: https://en.wikipedia.org/wiki/Medical_scribe https://en.wikipedia.org/wiki/Medical_scribe
insane_dreamer 4y ago
> I've read that doctors now spend as much as 50% of their time documenting their work. Companies such as Epic, which provide the software that hospitals use to build databases of patient data, have been big winners in the new world of hospitals-depending-on-software. My daughter works at Epic, and she explained that one (though not the only one) of the big reasons health care is so expensive is because Drs have so many record-keeping requirements, and one reason they have these is because of liability. It would greatly help if Americans weren't so lawsuit trigger-happy. The real winners are the lawyers (and insurance companies).
- mkbgw 4y ago
  Americans aren't actually don't sure that often, a topic addressed in The Myth of the Litigious Society by David Engel [c.f. https://blogs.lse.ac.uk/lsereviewofbooks/2017/02/01/book-review-the-myth-of-the-litigious-society-why-we-dont-sue-by-david-m-engel/ https://blogs.lse.ac.uk/lsereviewofbooks/2017/02/01/book-rev...].
  - insane_dreamer 4y ago
    It's the ease with which one can sue, and the damage it does even if it's baseless, that poses a continuous threat.
WheelsAtLarge 4y ago
Insightful... Figuring out the right amount of automation in business is hard. Too much automation makes the company too rigid to the point of breaking but too little reduces productivity. This is a dilemma that factories/companies have to constantly re-learn. We see it regularly. A new manager comes in and decides that a company can save a truck load of money by completely automating production. But soon finds out that there are too many variables in life and that total automation can't work. The goal should be to find the sweet spot that produces the maximum while being flexible to change. But I don't think this is why productivity is dropping. I suspect it's related to the reduction of reliance on foreign factories. The US wants to reduce the reliance on foreign manufacturing and bring all of that production back to the US. That will take time, capital and ability to learn how to do the work here. That will hit productivity hard. All than change won't happen cost free in terms of productivity and assets. The change started a few years ago. We are beginning to see the result.
P5fRxh5kUvp2th 4y ago
This resonates strongly and I'm surprised more people aren't talking about it. I recognized this problem in the 90's because I worked at a manufacturing plant where the software, even then, was getting in the way of workers needing to do something a bit non-standard (they developed workarounds over time). It's also why I'm a big fan of the 80% solution, I think there's a level of hubris involved in going for the 100% solution for everything. To your point about trust, it's something I've been thinking about recently. Not trust, but the authoritarian nature of software, which expresses itself and is purchased for the ability to distrust. You'll see this in things like debates about whether or not developers should be allowed to affect the deployment via yaml files or not. What makes it difficult is there is often a legitimate need for these sorts of systems, especially for regulatory compliance, but more often than not they just get in the way of actual work.
bigcat12345678 4y ago
> I've read that doctors now spend as much as 50% of their time documenting their work. What's the source?
epolanski 4y ago
I rarely go to my doctor but the few times i've done its more data insertion than medicine.
martindbp 4y ago
This has crept into schools as well. At many (most?) preschools around here have apps to document the kids' day, they send out almost daily emails and reminders about various things. If you have kids at preschool, regular school and after-school centers you're getting a constant deluge of information. Add to it that they all have different apps that don't work well (schedule, attendance etc), so of course they use email in addition. I love our current preschool precisely because they use very little technology: we actually talk to the teachers during drop-off and pick-up if needed, and get maybe one email a month. Their expressed philosphy is to be "present" with the kids and spend as little time as possible on other (administrative) things.
2c2c2c 4y ago
my experience at a healthtech startup is that any kind of cohesive product design gets perversed by nonsensical legal requirements and leadership pressures to check the boxes of comparable products because that's how the product they've used in the past did it
option 4y ago
is this really caused by tech or by more regulation and demands from insurance companies?
PointyFluff 4y ago
Hi. Medical professional here. You are high if you think we are better off with paper than an ePCR. Sometimes we have to default back to paper, some times the pt record system goes down. When that does happen, it's a literal fucking nightmare in the ER. We plan on it happening and we train for it happening, but ePCRs have made our lives so much fucking easier. Simple fucking fact. Have you ever had to read the pissed off notes in a hand-written chart from the last nurse who has been working 48 hours straight, taking care of 12 critical care pts? Huh? Give that a try sometime.
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radium3d 4y ago
I'm a web developer, and about 2 years ago my company implemented a new note taking policy that takes up a very large portion of my time, makes me feel like I'm untrusted and I just don't feel as happy as I did before. We are required to write a note of everything we do through the day with time spent and submit it by the end of the day. This is in addition to our project management system where we already track our time and write our detailed notes on what we do for each task. Prior to the policy I was able to finish work on time, now I dread the note portion of my day and I usually end up spending an hour or so at the end of the day to write up my "journal" of the day. I also have zero extra time which I used to use to learn new skills and techniques. It's an absolute waste of time and is destroying my urge to learn new skills that used to help improve the company's processes and efficiency.
- Eleison23 4y ago
  When I started my new role with my employer, I did this using a browser extension and a really neat time-tracker app. I forwarded every day's tracking data to my mentor and so he was able to see with a really fine grain what I was working on, and how long each task took me in a given day. Our apps security policy put the kibosh on that and I had to destroy my account once I realized it would not be feasible to keep it going forward. My employer is really conservative about allowing 3rd-party apps, which is great for security, and puts us in a veritable Stone Age of productivity.
fallingfrog 4y ago
Capitalism is trying to move to a model where everyone is atomically isolated, an independent contractor making anonymous sales in a marketplace. That means lawyers, contracts, and rigid rules and documentation. The more pure a market is, the more lawyers and rules you need to make it work. The goal is to eliminate the kind of fluid high trust social networks that characterized work life in the past. Partly because if everything is more rigid, it's easier to exert control, partly to prevent things like unions from forming. They want a perfectly abstracted workforce, free from the messy details that force you to treat your workforce as made up of people. Notice that we went from "personnel" to "human resources" to "human capital management". That's the Ayn Rand utopian dream made real. The idea is to turn people into units of production to be bought and sold, and you can't have a market for a commodity unless they are all the same. So, you must be made identical, so that the price of labor means something. Every criticism leveled against systems of control in the book "Seeing Like a State" apply to capitalism too. When people talk about a free market, remember that they're talking about a free market for labor more than anything else. You are the product in this scenario, not the customer. But even here, the purity of the labor market is hampered by rules designed to protect the laborer- osha rules, overtime rules, rules about how much a person can be controlled, and so forth. If you eliminate all those, and focus only on the making labor freely able to be bought and sold, you can begin to see what a completely pure free market for abstracted, commodity labor would look like. It is this: The most pure example of a free market for labor is a slave auction.
than3 4y ago
More correctly, fundamentally software can never know when its rules should be broken. Computers are just state machines, without determinism and a few other properties they do not perform work. Determinism means there is only one next possible state/action. Breaking rules would imply there are two or more possible states or actions, and that is a class of problems that computers cannot solve (they talk about this in compiler design courses). Most people subscribe to magical thinking because they don't know how computers work, or what they are even.

happyjack 4y ago

I agree to a large extent with your comment. The "office" structure has changed a lot. Secretaries ran the show, and pretty much hand-held everyone in the office and kept the ship pointed in the right direction. Law firms and political offices still have this "outdated" model because if it ain't broken, don't fix it. Now, your company pays insane amounts of $ for software, systems, and data! You have to do your job, schedule your meetings, keep up with the ungodly amount of email, instant message, SLACK, enter the data in your CRM, talk on the phone, schedule the video meetings, etc. while also keeping track of your personal phone because your partner called or the school called and your dog is sick. There's just so much distraction now by not having "office hours" and having our whole lives in our pockets and constant reach that I think productivity has to go down. It's impossible to focus on anything for any amount of time anymore with how accessible we are expected to be.

Retric 4y ago

That documentation time is largely driven by the insurance industry which was really painful before these systems. It’s almost shocking how much more productive doctors are inside the VA.

derbOac 4y ago
Insurance is part of it, but not all of it. Government regulation is also a big part. EHR mandates under the Obama administration (? who I was generally supportive of, so not a criticism of his presidency in general) created a kind of "false pressure" to move to EHR immediately, rather than "naturally" adopt it at an organic pace, adopting whatever is most beneficial due to demand. I'm not anti EHR, but the way those systems were adopted were definitely forced onto providers top-down, rather than bottom-up like traditional hospital record systems. Hospitals scrambled to implement them in time for deadlines, and there was no room for pushback against poorly implemented structures that were pushed on hospitals essentially. More recently in my field I've seen additional layers of documentation requirements that have nothing to do with insurance, that are entirely state law. I have no doubt in my mind that if EHR rules didn't exist, they would have been adopted much more gradually, and selection would have been dictated by the ability of EHRs to supply features in demand. More competition would have existed and it would have cost less. Maybe some government regulation would have been needed in terms of interoperability standards but it could have been rolled out much much much better. I don't think people fully comprehend the cost overruns associated with adoption of EHRs under government mandates, or how big of a shift there was from records being in-house flexible, and provider and patient-driven, to out-of-house inflexible, and IT-corporation-driven.
- supertrope 4y ago
  To play devil's advocate without the stick of Medicare funding being at stake, doctor's offices and hospitals will defer EHR upgrades until the heat death of the universe. HIPAA was passed in the 90s with a safe harbor for faxing and that's still the standard method to transfer a medical record.
  - 4y ago

sharadov 4y ago

Don't you worry, the next gen of block chain apps which are built on a bedrock of implicit trust, will make your concerns moot.

conductr 4y ago

I don’t think productivity was ever the goal of this software. It was to have a record that is standard, digital, transferable, etc. Doctors fought it as long as they could because they knew what it meant for them. I remember pretty early demos in early/mid 2000s when I was doing some clinical grunt work in college. I had written some software to make my department’s life easier so I was offered up as the hospital’s liaison for the software evaluation. This is when I formed my “never replace a terminal based app, with a GUI based app and expect productivity gains” theory. Everyone working in the hospital knew the terminal app, they type in some random 3 letter code and a screen would pop up. Then they would memorize how many tabs each field was apart from each other. Without a mouse, people could just hum along imputing data a blazing speed once some muscle memory was in place. Everyone had little cheat sheets printed out for the less frequently used commands/codes. When you replace this with a browser/desktop GUI with selectors and drop downs and reactive components of GUI, it tends to 1) require mouse usage for most people and 2) lose the ability to do this quick data entry I described. The pretty interface becomes a steady stream of speed bumps that reduce productivity. Since then I’ve witnessed it in banking and other industries too.

FunnyBadger 4y ago
yamtaddle 4y ago
They also fought it because they didn't go to medical school and survive residency to fill out forms all damn day—and they didn't used to have to, they had staff for that. Then the computerized systems "replaced" that staff but all that really means is they cut the human time needed low enough that full-time workers weren't needed, but didn't eliminate it, so now that's another thing doctors have to do themselves. AFAI can tell, the effect of tech overall is to cut some jobs while making the remaining ones harder and more stressful, while increasing so-called context switching.
- t-writescode 4y ago
  Sounds like modern startup devops-without-devops culture

Scoundreller 4y ago

dan_quixote 4y ago
> Another study found US clinicians write 4x longer notes I wasn't aware of this, but as the spouse of a medical provider I know that most US providers are burdened with an ever-present worry about malpractice.
- vanc_cefepime 4y ago
  This. So much this. In residency we are taught “document, document, document” and “this is a medical legal document” which leads to defensive medicine. Another point of why we spend more time documenting is billing. Coders/billers continue to come back and asking us to add more details about a diagnosis. More details = more charges to bill or up level. So the next progress note or office visit, I go back to add more. More time is spent fighting the notes. Terrible EMRs that destroy notes is one that leads to more time spent as well. Looking at you Allscripts (aka Allshits in my office). Overall it’s a sad state of medicine in the USA, which is terrible as when I was younger the whole point of medicine for me was to help people and focus on the patient and the issues that are ailing them. Now, patients are still important to me but it’s a race to the bottom trying to document while in seeing the patients so I can go home without paperwork and live my life. I got bills to pay, a 6 figure student loan that will take me another decade to pay off. At some point, it’s all going break down. Few of us are doing the concierge direct primary care model to avoid all this which will unfortunately lead to more health disparities and inequalities.

cm42 4y ago

"Just a billing platform with some patient stuff tacked on" https://www.youtube.com/watch?v=xB_tSFJsjsw https://www.youtube.com/watch?v=xB_tSFJsjsw

FredPret 4y ago
Zdogg, MD made my day!

bearjaws 4y ago

Are we sure the documentation isn't coming as required from the insurance companies? I know many Drs and especially nurses who CYA on all their documentation otherwise insurance will try to pin them on an adverse reaction.

nradov 4y ago
Payers in general (not just insurance companies) require high levels of documentation both to prevent fraud and to increase care quality. Most healthcare providers are highly ethical and only act in their patients' best interest. But there are always a minority of bad actors who will try to boost revenue by submitting claims for procedures that weren't medically necessary, or weren't performed at all. So the system needs checks for that in order to hold down costs for everyone, and prevent iatrogenic harm. You will also find many cases where even good providers let things slip through the cracks and fail to give some patients the appropriate level of care. For example, diabetics should generally receive annual foot exams, eye exams, and hemoglobin A1c tests. If the payer doesn't see evidence of those in the EHR then they can prompt the doctor to resolve that care quality gap.

warbler73 4y ago

There are huge productivity gains in private practices that eliminate web pages and email and switch to paper in filing cabinets only. This is also why fax machines still exist and are exclusively used by medical practices.

Mordisquitos 4y ago

> People in tech keep thinking more tech will solve problems and they keep underestimating the flexibility of the old models. Related to this, but in a completely different context, I have had similar thoughts lately when eating out at restaurants in Spain. It's incredibly frustrating from a customer's point of view when the waiter taking your group's order has to use a newfangled tablet or phone-like device and tap through each individual order, often depending on the peculiarities of the app's UI and how the designers expect the process to carry out: “Are you all having the set menu? No? OK, first I need to know how many of you are having it?" [taps count on screen] "Right, now I need the starters but ONLY for the set menu orders..." etcetera—you get the idea. Then, while going through this unnecessarily slow process, God forbid someone who ordered from the set menu wants to change their main while the waiter is already taking the à la carte orders. Meanwhile, in restaurants that haven't unnecessarily techified the procesz, the waiter can take the order in the way that's most practical given the circumstances and that best fits his way of taking notes. Ah, but then how does the order reach the kitchen without the tech? I have no idea, all I can say is that it worked fine before these things were put in place, and the manual system is by far the quickest and most flexible from a customer's point of view.

whatshisface 4y ago
Waiters put the bits of paper they're writing on on a rack in the kitchen. Other times, they shout out the orders and remember which table gets what.
- Scoundreller 4y ago
  And shreds it all at the end of the day before the tax guy shows up. Though Quebec, Canada, had such a problem with “zappers” that would delete orders from the electronic system that every restaurant now must be online with the tax authority and every receipt has a tax authority response code on the top.
maxrev17 4y ago
That's just shitty software though. Good software gets out of the way and improves something. We could speculate on how to fix that scenario, but there's probably no incentive - in my experience there are fixations amongst tech people on profit-less ideas that end up getting squeezed awkwardly into applications such as bill splitting, digital ordering etc.

Eleison23 4y ago

The last good, independent physician I had was a fellow who played Chess on the weekends downtown. His practice moved about 5 times while I was a patient and he finally was snapped up by the VA. He habitually called me "friend" and was very frank about my insurance not paying for stuff I was asking about, which I appreciated. He also once profusely apologized to me for placing a computer in between us. He said the new requirements of his practice made it so he had to pay more attention to the computer than to me, and we were both sad about that. The doctors I got after that make no such apologies.

ChrisMarshallNY 4y ago
Reminds me of this anecdote: https://notalwaysright.com/trying-to-get-a-word-in-until-youre-blue-in-the-face/272921/ https://notalwaysright.com/trying-to-get-a-word-in-until-you... It may or may not be true (I suspect some of the stories on that site are made from whole cloth), but it speaks to your post.

Tsarbomb 4y ago

Having once worked in the EMR/EHR space, a big thing to consider is some companies come in with their own workflows, processes, and ideas that they want to push onto physicians while other companies are way more accommodating in building "bespoke" solutions to specific problems. The latter in my experience ends up providing better results to physicians as they have been employed as domain experts in building the software solution to their specific workflow. I've seen it done for in ophthalmology, specific disease/injury specific radiology, and diabetic specific checkup and appointments where I've seen as much as a 75% reduction in the amount of time the physician has to dedicate lookup up info, cross-referencing, and documenting.

Scoundreller 4y ago
> other companies are way more accommodating in building "bespoke" solutions to specific problems. Then you upgrade and everything breaks! But it’s an age old battle for and against standardization. I just walk around with several charging cables because each is “the best” for charging a small li-ion battery.

sebastianconcpt 4y ago

Brilliant observation. In a way, all might be a huge early optimization.

closeparen 4y ago

The big reason EMR is so overbearing is to optimize billing… as far as economic statistics, that should show up as positive even if less patient care is actually delivered.

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kewrkewm53 4y ago

I agree. Here in Finland the public healthcare organization in capital region and surrounding areas chose Epic as supplier of their new system. It has been a disaster, massive complaints from doctors about how unproductive it is to use, and also some issues that endanger patient safety. Apparently it's also programmed with MUMPS, which doesn't exactly sound a great idea in 21th century. I'm not sure whether this choice was a case of incompetence or corruption, but the end result is clearly a giant waste of money. Maybe it generates a lot of data, but efficiency would be way more important for an organization like this which is chronically underfunded and staffed.

throwaway894345 4y ago

VLM 4y ago
Medical decisions are based primarily on financial profit, and patient outcome data is not required to determine which medicines are most profitable. The point of extensive documentation is shielding from the worst of malpractice lawsuits. The legal system is still of the legacy opinion that doctors have a responsibility to their patients as opposed to the more modern understanding of responsibility toward pharma company bottom lines, and all patients legally deserve the 100% successful participation trophy, so a documented decision with only 95% chance of success means insurance payouts about 5% of the time, unless its carefully documented it was all the patients fault or at least the MD could not have known the outcome in advance.
- throwaway894345 4y ago
  > patient outcome data is not required to determine which medicines are most profitable This is blatantly false. Pharma spends tons of money to buy this data for their armies of researchers in order to determine outcomes. There's an entire very lucrative industry (that I work in) which exists to source this data from hospitals and refine it for researchers. If the point of documentation was CYA, then you wouldn't need complicated systems like Epic to standardize the documentation and make it available for electronic processing (you would just have some paralegal pour over the records of the individual patient).

theGnuMe 4y ago

Message passing was basically a solution for this in the tech world. Send messages to everyone and if they implement that message then they act.

scythe 4y ago

>Software doesn't know when its rules should be broken. Just to provide an example of this I ran into today: I'm doing a medical physics residency, and my supervisor was explaining that a new "fail-safe" incorporated into the software that reverted the collimator after every scan was now making the phototimer tests take twice as long, because we had to go back into the room and reset the collimator repeatedly. We tested a machine with the new system and one with the old system and it did in fact turn a 15-minute task into around 35 minutes.

nottorp 4y ago

Last time I had a blood test it took 2 minutes to take my blood and 15 to enter crap in various forms on the computer. And I'm not even in the US. There was a lot of clicking involved. To contrast, my first job was an accounting program. We spent weeks on making sure everything works via just the keyboard and some operations are as streamlined as possible. Because in some cases it was going to be used by people creating hundreds of invoices per day.

nonrandomstring 4y ago

Well said. Particularly on the value of trust within systems. In case it's of interest I wrote an article a couple of days ago on how "Digital Systems Fail Institutions" [1]. [1] https://techrights.org/2022/10/26/when-digital-systems-fail/ https://techrights.org/2022/10/26/when-digital-systems-fail/

ocbyc 4y ago

To get anything done, it seems I must speak to >=2 people on any customer support line.

danabrams 4y ago

We just had a baby this month, and I was shocked by how much time the medical staff was spending entering data into Epic. So much that they couldn’t actually fully concentrate on giving medical care. Everyone was very busy but it was very hard to get actual care.

lupire 4y ago

The article is about 2022 specifically, obviously pandemic related.

chaostheory 4y ago

You’re blaming tech for legal issues and requirements.

godelski 4y ago

> I've read that doctors now spend as much as 50% of their time documenting their work. Companies such as Epic, which provide the software that hospitals use to build databases of patient data, have been big winners in the new world of hospitals-depending-on-software. But did the doctors become more productive? By almost any measure, they became less productive. I'd ask another question: did lawsuits decrease? I'd imagine that a lot of this software is to avoid lawsuits. America is especially litigious and that's got to correlate strongly with the increase bureaucracy. I also suspect that a factor at play is that people are losing trust in the whole system. Most people now know that productivity has skyrocketed while salaries have remained relatively flat. With increasing economic disparity (not even just the West) it is no wonder that people become less productive. Who tries hard at a game that they believe is rigged against them? (doesn't matter if it is or isn't, just the belief) > People in tech keep thinking more tech will solve problems Because historically it has. But there are different types of tech. Tech enabled the modern world. It is the new medicines we have to cure illnesses that devastated populations. It is the chemicals that enable us to grow enough food to sustain our populations. It is everything from a wheel to the computers we use to make more efficient wheels that use less resources. But it is also naive to think that tech alone can solve every problem. It is also naive to think that tech can't create new problems. To create tech that solves problems we need to think long and hard about the intricate complexities involved and gather the expertise from relevant domains (an often missed, but essential, component). The other problem is that people hand wave away things like climate change saying "tech will solve it" rather than investing in said technology and waiting for it to magically appear. I do think tech is an important tool in solving many of the problems we face, but you're right that they are not all technology dependent (which is a continuous scale of weights, not a binary option). Also, we're a tech forum. Peoples' expertise here is in tech. So they see things through that lens and it is also very likely that the most we/they can contribute to solving these problems is, in fact, through technological means. The trick is to remember that tech isn't a cure-all and that the problems we face are exceedingly complex. Over simplifying is often harmful.

drewbeck 4y ago

I talk a lot about this flexibility gap in my day job in UX. Getting an organization onto a digital platform is great but a lot of them don’t recognize all the small ways that their current system’s flexibility is helping them. With big systems though I honestly think GUIs can only go so far, even at their very best, and any system that is required to be complex at some level will require expert knowledge of the system itself. That’s extra work and an extra burden for someone with the critical experience that an organization relies on. For doctors and the like it would make sense to try a system where the critical person/expert has an assistant who is a systems expert and does a lot of the needed data entry and the like. Doctor doesn’t have to worry about the system, they can talk to the assistant who manages all the extra work. If the system needs to change for any reason the assistant manages that and the doctor doesn’t have to worry about it. I think of this assistant role as the human API layer. It’s not far off from some social programs like insurance navigators, who help individuals find health insurance, including working through options and even—critically—filling out forms for folks. ETA: It’s a thing! I didn’t know: https://en.wikipedia.org/wiki/Medical_scribe https://en.wikipedia.org/wiki/Medical_scribe

insane_dreamer 4y ago

mkbgw 4y ago
Americans aren't actually don't sure that often, a topic addressed in The Myth of the Litigious Society by David Engel [c.f. https://blogs.lse.ac.uk/lsereviewofbooks/2017/02/01/book-review-the-myth-of-the-litigious-society-why-we-dont-sue-by-david-m-engel/ https://blogs.lse.ac.uk/lsereviewofbooks/2017/02/01/book-rev...].
- insane_dreamer 4y ago
  It's the ease with which one can sue, and the damage it does even if it's baseless, that poses a continuous threat.

WheelsAtLarge 4y ago

Insightful... Figuring out the right amount of automation in business is hard. Too much automation makes the company too rigid to the point of breaking but too little reduces productivity. This is a dilemma that factories/companies have to constantly re-learn. We see it regularly. A new manager comes in and decides that a company can save a truck load of money by completely automating production. But soon finds out that there are too many variables in life and that total automation can't work. The goal should be to find the sweet spot that produces the maximum while being flexible to change. But I don't think this is why productivity is dropping. I suspect it's related to the reduction of reliance on foreign factories. The US wants to reduce the reliance on foreign manufacturing and bring all of that production back to the US. That will take time, capital and ability to learn how to do the work here. That will hit productivity hard. All than change won't happen cost free in terms of productivity and assets. The change started a few years ago. We are beginning to see the result.

P5fRxh5kUvp2th 4y ago

This resonates strongly and I'm surprised more people aren't talking about it. I recognized this problem in the 90's because I worked at a manufacturing plant where the software, even then, was getting in the way of workers needing to do something a bit non-standard (they developed workarounds over time). It's also why I'm a big fan of the 80% solution, I think there's a level of hubris involved in going for the 100% solution for everything. To your point about trust, it's something I've been thinking about recently. Not trust, but the authoritarian nature of software, which expresses itself and is purchased for the ability to distrust. You'll see this in things like debates about whether or not developers should be allowed to affect the deployment via yaml files or not. What makes it difficult is there is often a legitimate need for these sorts of systems, especially for regulatory compliance, but more often than not they just get in the way of actual work.

bigcat12345678 4y ago

> I've read that doctors now spend as much as 50% of their time documenting their work. What's the source?

epolanski 4y ago

I rarely go to my doctor but the few times i've done its more data insertion than medicine.

martindbp 4y ago

This has crept into schools as well. At many (most?) preschools around here have apps to document the kids' day, they send out almost daily emails and reminders about various things. If you have kids at preschool, regular school and after-school centers you're getting a constant deluge of information. Add to it that they all have different apps that don't work well (schedule, attendance etc), so of course they use email in addition. I love our current preschool precisely because they use very little technology: we actually talk to the teachers during drop-off and pick-up if needed, and get maybe one email a month. Their expressed philosphy is to be "present" with the kids and spend as little time as possible on other (administrative) things.

2c2c2c 4y ago

my experience at a healthtech startup is that any kind of cohesive product design gets perversed by nonsensical legal requirements and leadership pressures to check the boxes of comparable products because that's how the product they've used in the past did it

option 4y ago

is this really caused by tech or by more regulation and demands from insurance companies?

PointyFluff 4y ago

Hi. Medical professional here. You are high if you think we are better off with paper than an ePCR. Sometimes we have to default back to paper, some times the pt record system goes down. When that does happen, it's a literal fucking nightmare in the ER. We plan on it happening and we train for it happening, but ePCRs have made our lives so much fucking easier. Simple fucking fact. Have you ever had to read the pissed off notes in a hand-written chart from the last nurse who has been working 48 hours straight, taking care of 12 critical care pts? Huh? Give that a try sometime.

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radium3d 4y ago

I'm a web developer, and about 2 years ago my company implemented a new note taking policy that takes up a very large portion of my time, makes me feel like I'm untrusted and I just don't feel as happy as I did before. We are required to write a note of everything we do through the day with time spent and submit it by the end of the day. This is in addition to our project management system where we already track our time and write our detailed notes on what we do for each task. Prior to the policy I was able to finish work on time, now I dread the note portion of my day and I usually end up spending an hour or so at the end of the day to write up my "journal" of the day. I also have zero extra time which I used to use to learn new skills and techniques. It's an absolute waste of time and is destroying my urge to learn new skills that used to help improve the company's processes and efficiency.

Eleison23 4y ago
When I started my new role with my employer, I did this using a browser extension and a really neat time-tracker app. I forwarded every day's tracking data to my mentor and so he was able to see with a really fine grain what I was working on, and how long each task took me in a given day. Our apps security policy put the kibosh on that and I had to destroy my account once I realized it would not be feasible to keep it going forward. My employer is really conservative about allowing 3rd-party apps, which is great for security, and puts us in a veritable Stone Age of productivity.

fallingfrog 4y ago

Capitalism is trying to move to a model where everyone is atomically isolated, an independent contractor making anonymous sales in a marketplace. That means lawyers, contracts, and rigid rules and documentation. The more pure a market is, the more lawyers and rules you need to make it work. The goal is to eliminate the kind of fluid high trust social networks that characterized work life in the past. Partly because if everything is more rigid, it's easier to exert control, partly to prevent things like unions from forming. They want a perfectly abstracted workforce, free from the messy details that force you to treat your workforce as made up of people. Notice that we went from "personnel" to "human resources" to "human capital management". That's the Ayn Rand utopian dream made real. The idea is to turn people into units of production to be bought and sold, and you can't have a market for a commodity unless they are all the same. So, you must be made identical, so that the price of labor means something. Every criticism leveled against systems of control in the book "Seeing Like a State" apply to capitalism too. When people talk about a free market, remember that they're talking about a free market for labor more than anything else. You are the product in this scenario, not the customer. But even here, the purity of the labor market is hampered by rules designed to protect the laborer- osha rules, overtime rules, rules about how much a person can be controlled, and so forth. If you eliminate all those, and focus only on the making labor freely able to be bought and sold, you can begin to see what a completely pure free market for abstracted, commodity labor would look like. It is this: The most pure example of a free market for labor is a slave auction.

than3 4y ago

More correctly, fundamentally software can never know when its rules should be broken. Computers are just state machines, without determinism and a few other properties they do not perform work. Determinism means there is only one next possible state/action. Breaking rules would imply there are two or more possible states or actions, and that is a class of problems that computers cannot solve (they talk about this in compiler design courses). Most people subscribe to magical thinking because they don't know how computers work, or what they are even.