19 ms·

Everyone hates the electronic medical record

• justina20 3y ago
  [dead]
• analog31 3y ago
  My mom would just bring a briefcase full of printed medical records to every appointment.
  • rkagerer 3y ago
    You may jest but I wouldn't mind this model. i.e. Records are under a digital lock to which I hold the key, and can grant access to a medical professional service provider for a period of time with set access expiry. Written records at least provided some physical locality that made me feel less at risk, and it was also easy for me to ask for a photocopy for my own records (I'm surprised how many people just entrust this to their institutions).
    • hashishen 3y ago
      the issue arises when you are unconcious and there are certain risks to treating you the staff needs to know about. Maybe your throat closes for benedryl but you're showing obvious signs of an allergy? Maybe you have a pre-existing condition which gives you symptoms that signal a stroke? the risk is always going to be there
      • balderdash 3y ago
        Isn’t this the case with most emergency situations? My guess is that if that I end up in the ER unconscious they’ll have no records on me…
        • lostlogin 3y ago
          What if we all get microchipped? Maybe have duplicates so that the time you cut your arm off doesn’t mean your record gets left behind.
      • rkagerer 3y ago
        They don't need my full medical history for that. Just a highlights or "in case of emergency" summary. Humans dealt with these issues just fine before records were centralized. And still do e.g. when I travel to another jurisdiction. Being an engaged and proactive actor in my recordkeeping actually improves my posture. I deal with the same issues when it comes to estate planning (e.g. what happens if I become unable to make decisions for myself). There are tactics and contingencies available (like trusted individuals, powers of attorney, etc) and I don't need my full financial background to be openly available to thousands of participants in the system to accommodate. Society and the concept of trust did not evolve over millions of years to end up becoming nothing more than an individual and a computer somewhere in the cloud.
  • mindslight 3y ago
    How does this work out in practice, given that doctors generally only give you 10 or maybe 15 minutes before they start pushing you out the door?
• jackvalentine 3y ago
  Disclaimer - I work for a health service that isn't in the USA and has a very extensive EMR. I don't disagree. I started my career dealing with paper folders of records that were fastidiously organised by a team that made sense of them. Now everything is electronic and fucking _everywhere_. The work didn't go away - but giving everyone a computer made it everyone's problem and nobody's job. A really good EMR (or other records project) makes the 'work doers' jobs easier and is intuitive. We often severely miss that mark or only do half the job required.
  • j16sdiz 3y ago
    Clinic can't organise their file in their own way is a big time waster. Each clinic have their own speciality and therefore their own way of filing stuffs
    • rtpg 3y ago
      is there any good research or information on various clinic's organizational style? I feel like there are plenty of places where digitalization took its time to get there. I feel like in general there's gotta be a lot of good sociological research on how stuff is kept straight. I only see stuff regarding DX work, but organizing was a problem even before computers, right?
  • wharvle 3y ago
    This is everywhere. We made everyone their own secretary but gave them crappy tools and no training. Also they’re never gonna be doing it more than very part-time, so will always tend to be bad at it and find it a distraction from the work they’re actually good at. I’m skeptical computerization has even been a net benefit for productivity for most jobs, for that and other reasons. I think it’s been such a huge boost in a few areas that it looks productive overall, but actually it’s been a step back in most jobs. The high of eliminating positions and of centralized command-economy-style technocratic visibility into everything keeps management hooked on it anyway.
    • whatshisface 3y ago
• JusticeJuice 3y ago
  I wrote a thesis on EHR's 7 years ago. They really haven't seemed to improve much. I personally think a big part of the issue is actually scope, these systems are expected to do everything - medical notes, script ordering, appointment management, billing of course, and 3000 other things. This weirdly leads to a distribution problem, you can't be a serious competitor in just one area, you have to do everything. Only the monolith can shift the monolith. Then combined with the risk (or perceived risk) of working with medical data, and you're left with something that just never improves. If your curious, here's where I discuss these points in the thesis https://barnett.surge.sh/welcome/complexity.html https://barnett.surge.sh/welcome/complexity.html
  • sixothree 3y ago
    Yea. But in that time there has been an absolute revolution in what can be done with that data. FHIR specifically has completely changed the landscape.
    • nradov 3y ago
      FHIR is great for interoperability but it doesn't really do anything for the EHR user experience.
      • ahoka 3y ago
        Decoupling the EHR from the client can pave the way for better user experience.
    • JusticeJuice 3y ago
      Yes. FHIR was pretty well established when I was writing the thesis, but I am very pleased to see it get more and more usage since then. Apart from interoperability the opportunities to do much better data mining from free-text medical notes with AI, are huge now. Back when patient prescription lists ot structured, so many new drug interactions were found, now there's the chance to do similar stuff from open medical records. Patient-accessible medical systems are more common now too, which is great. EHealth got way more common. At the end of the day though, what your doctor is clicking on still sucks, which is the sad part.
• deleted 3y ago
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• KennyBlanken 3y ago
  > Patient R was in a hurry. I signed into my computer—or tried to. Recently, IT had us update to a new 14-digit password. Once in, I signed (different password) into the electronic medical record That's IT infrastructure incompetence, not an EMR issue. At the two healthcare systems I go to, both utilize RFID badge readers plus PIN. In the ER and urgent care, nurses need only tap their badge and enter a quick pin and they're in. It's taken them seconds to pull up my records and I've never noticed a delay in care. In the PCP's network, everyone seems to get smooth and quick access often while we're conversing, and I can see all my visits, lab results, and so on. The major annoyance is that I get emails notifying me I have a "message", instead of even offering me the option of receiving an email with the actual message. I don't think people understand how expensive and time consuming the non-electronic stuff was. I remember my mother spending considerable amounts of time trying to get records from labs and doctors and having to shelp a lot of it by hand.
  • Spivak 3y ago
    > That's IT infrastructure incompetence, not an EMR issue. The two cannot be unlinked so easily when I have never met someone so doesn't have the same story of hospital IT. Even the IT workers hate hospital IT. The deployment of an EMR has to take into account the regulatory and security requirements imposed on all digital systems. > I get emails notifying me I have a "message", instead of even offering me the option of receiving an email with the actual message. You need to bash the right heads together and get your email provider and sender in DirectTrust https://directtrust.org/what-we-do/direct-secure-messaging https://directtrust.org/what-we-do/direct-secure-messaging Not gonna say it's not a bitch and a half to implement but you can send sensitive data directly via email. And if you're the SaaS provider you're part of DT that's a huge value add for your offerings.
  • mrcarruthers 3y ago
    The email thing is probably a privacy requirement. Email isn't encrypted meaning your email provider (and the EMR's) can fully read the contents of said email.
    • 8organicbits 3y ago
• RajT88 3y ago
  I used to work at an EHR software company. All of this is true. The most interesting thing I think on the horizon is gluing the ever-increasing intelligence of AI bots with voice assistants. The company that can reliably take a HCP's dictation, store and retrieve that information accurately is going to transform the industry by drastically reducing the administrative overhead, and letting doctors treat more patients.
• perilunar 3y ago
  I spent two hours this morning helping my elderly mother fill in a hospital admission form online. The session timed out just before submission, but we logged in again and everything was saved. I'm grateful that it was online, so I could help her remotely via screen sharing and not have to travel to fill in forms (I'll visit when she goes in, just don't want to have to travel repeatedly for paperwork.) Entering medical history and current medications was a pain in the arse though, and is something we have done many, many times over the last few years. FFS just implement an standard text format that we can upload or link to.
  • consp 3y ago
    > Entering medical history and current medications was a pain in the arse though, and is something we have done many, many times over the last few years. Isn't this something what electronic records should have solved? I know doctors always ask the patient but they all have access to that data here (not us). Especially the pharmacy looks at it to check for cross interactions (or a note waiving them).
    • lostlogin 3y ago
      The idea that patients take the prescribed medications is one that many people believe. Another problem is that people believe the patient’s reply when they are asked what medication they take.
  • morsch 3y ago
    > just implement an standard text format Standards and protocols would go a long way in solving many of the issues in public IT infra. Force the big players to speak them. Enable the small shops to outcompete them (and each other) by sucking less in one area.
  • PetitPrince 3y ago
    > FFS just implement an standard text format that we can upload or link to. This exists, and it's older than the Web: https://en.wikipedia.org/wiki/Health_Level_7 https://en.wikipedia.org/wiki/Health_Level_7 . However agreeing on how to use is another can of worms, see https://www.ihe.net/ https://www.ihe.net/
• deleted 3y ago
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• ianso 3y ago
  Popping up here to mention OpenMRS, a healthy open-source EMR used by hundreds if not thousands of facilities across the world, mostly in Africa and Asia. An old version is packaged/integrated with some other apps into Bahmni, which is a full-blown hospital management system. Honestly, people complain about software all the time and all software sucks to some extent, some more than others of course. Complaining about all EMR just because the USA bodged a national rollout in their uniquely messed up healthcare situation is a bit myopic.
  • yannis 3y ago
    Very true, people complain about software, but my recent experience in a Gulf country, was stellar, all my medical records, were entered properly including procedures, it takes approximately 12 minutes to get medicine from the pharmacy and can view the records online. The patient interface could be improved a bit but did its job perfectly. The article was stellar, as it summarized the state of the art and the issues well.
  • boxed 3y ago
    I believe this article is only about this specific system. The problem is that the name of the system is "Electronic Medical Record", which makes the article sound like all such systems are hated.
    • amarant 3y ago
      If this is the case, the name of the system needs proper capitalization in the title.
    • autarch 3y ago
      I don't think that's the case. AFAIK there's no such system. The article specifically reference Epic, which is one of the biggest (_the_ biggest?) EHR software company in the US. My wife used it as a nurse and I've watched my own providers struggle with it. It sucks.
      • benglish11 3y ago
• captaincraven 3y ago
  Disclaimer: Worked at Epic for > 3 years. EHR’s have all the problems of enterprise software, plus some. At the end of the day, the software is made for the people who pay for it. This isn’t the patients, or the providers. It’s the admin, billing, and bureaucracy layer who get to make all the decisions. It’s not surprising that these people don’t prioritize good software. EMR’s need to do more, but the root of the problem is systemic.
  • repeekad 3y ago
    Also, even if Epic offered its platform free of charge, it’s incredibly expensive to setup and train staff. Just that initial expense of plugging everything in is a huge risk that many hospitals on a tight budget likely can’t afford to take.
  • ako 3y ago
    Agreed, you see the same issue with other enterprise software that tries to everything: SAP (including more specialized parts like Concur), Workday, and many others. They’re trying to do everything, then are often badly configured, mostly by following internal (financial) procedures, without considering end user experience. There’s a whole industry of tools to help you build better interfaces on top of these big systems of records to improve the user experience. So much so that Gartner has even describes it as a desired way of designing system: used to be Pace Layer model, now it’s called Composable Enterprise.
  • htechenjoyer 3y ago
    I think they need to do less. Part of the problem is they are trying to be everything for everyone. A hospital is an aggregation of what is really several different businesses into one - and they all have to use the same monolithic application. Each medical speciality has their own unique data and technology needs, as does each specific unit (ie different ICUs for surgery, burns, etc), then add pharmacy, labs, admin, etc. If the priority is billing, then focus on aggregating and correlating billing data, expose an API for consumption with other systems being used that may or may not be from the same EMR company. I do agree that there is an issue with stakeholder bias towards admin. Every pet project from admin results in a bolt-on fix to the EMR configuration bloating clinical processes. They are the ones that make the rules and decisions and are often disconnected from both technology and clinical expertise which is perhaps the worst combination for health care technology decisions.
• deleted 3y ago
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• oldgradstudent 3y ago
  When my Israeli health care provider switched to electronic records in the mid-late 1990s, a typical medical appointment had two parts, roughly similar in length. During the first part, the doctor would complain about how the system crashes, how hard is it to type with two fingers, and how computers are pointless. In the second part, I’d complain about my flu/cold symptoms.
  • lostlogin 3y ago
    It could be worse. You could both be complaining about viruses.
• someonehere 3y ago
  As a patient it benefitted me a month ago. I was looking to get Ozempic through a different medical provider. They were offering a discount at the end of 2023 before rates go up in 2024. So in a rush before the end of 2023 I was able to log into One Medical and get a copy of my lab work and medical records from them within 10 minutes. Sign into my account and export the records and lab work and send them to my new provider. I was impressed I didn’t have to jump through a ton of hoops to get the info I need to get the medicine.
• m463 3y ago
  I wonder if it can just be a market. Standardize the data format and install apps that manipulate it. Let pediatricians choose one editor, surgeons another, nurses another, etc... Maybe the surgeon's app is text to speech. The pediatrician hooks into his stethoscope.
  • friendzis 3y ago
    These parts are largely irrelevant at large as they make at most single digit percentage of complexity
• duffpkg 3y ago
  I created the ClearHealth/HealthCloud open source (GPL) EMR which to my knowledge is the only open source one to receive full federal certification. Operations (not surgery) are so incredibly bad / incompetent in most healthcare settings that software frequently gets the blame for much deeper problems. This article is a doctors perspective on how software did not fix a completely broken workflow. I don't begrudge him that but there is no software in the world that can ever address those types of problems. In my experience doctors are a tremendous barrier to resolving problems in healthcare operations, they are chasing their own incentives that are in some ways opposed from those of the patient just like the insurers are. It is very tortured process to institute proper operations in a medical setting, I spent most of my career doing it, no one complains about the software when operations make sense to begin with. In-N-Out instead of McDonalds, is something that should be incredibly aspirational to healthcare as an industry but doctors tend to despise the comparison.
  • danielvaughn 3y ago
    This was my experience trying to create technology in the real estate world. Realtors are the same way.
    • Terr_ 3y ago
      Many of the most painful technical problems are actually three business problems in a trenchcoat. Sometimes too many people are too invested in the crazed/idiosyncratic way of doing things... and unless the humans can be convinced to fundamentally change their process, adding software will only give you... well, craziness with a computer.
      • jdietrich 3y ago
        >Many of the most painful technical problems are actually three business problems in a trenchcoat. This is a superb line and I will be stealing it.
        • Terr_ 3y ago
• deleted 3y ago
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• sullivantrevor 3y ago
  i design an EMR for a veterinary company based in LA. can confirm our care team gets quite upset with the software at times. it is incredibly difficult to build a great user experience for all the different positions and use cases that occur throughout the day. with that said, it has been a fun and rewarding experience over the last 4 years. we are hard at work bringing AI into the EMR right now.
  • lostlogin 3y ago
    > we are hard at work bringing AI into the EMR right now I’m sure there are benefits so be had from AI in an EMR at some point, but many would see it as a vast upgrade just to have a system that responds to clicks, doesn’t lag and kind of does what it says it will.
• rurban 3y ago
  I, as patient, love it though, the German system. In January they added electronic receipts ("Rezepte") and this was the deal breaker for me. Lots of smaller doctor offices complained though. Only the bigger ones offer it.
  • avh02 3y ago
    I can say this has its flaws too... I was recently trying to pick up a prescription but the first pharmacy i visited did not have it in stock, they gave me my card back and i went to another pharmacy who could not find a prescription on the card. Turned out the first pharmacy forgot to "release" the prescription back after they told me they don't have it in stock. Had to go back to the first pharmacy, have them unlock it, go back to the second pharmacy, only to be told after they could read the prescription that they do not have it in stock either. The problem here is not the digitalization itself but the tangibility of the implementation. how could i possibly tell that i was wasting my time on my way to the second pharmacy? With paper i would see that someone forgot to hand me back my prescription and i would not have left the first pharmacy prematurely.
• stevebmark 3y ago
  Wow, this is all over the place, not worth reading. Also it fails to point out a critical and very confusing distinction: EHR stands for "electronic healthcare record," as in an individual record / file / document, but in healthcare tech "EHR" usually refers to "Electronic Healthcare Record System" - a product like Epic / Athenahealth / etc. Also surprisingly no mention of the semi-garbag-y healthcare data interchange format FHIR. The author seems confused - confusing issues with EHR system UX and data entry and data fidelity and interoperability itself.
• singingfish 3y ago
  Relevant - paper here https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3250633/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3250633/ - which is the paper that rescued my PhD (on electronic health records rather than medical records, but adjacent). Note that Scotland got electronic medical records much more correct than England by making the whole thing a Clinician lead process rather than the English technocratic approach. Finally it's very difficult to do "proper" scientific research on electronic health records, as control matched research is not achievable. Therefore you have to reach for things like single case study Final brag - when I submitted my PhD it was politically quite sensitive so we had to find the right external assessors. One expert, one person whose judgement we trusted. The expert returned their report saying what a great piece of work it was and it should receive high commendation. The other person said it was solid and thorough but ultimately pretty obvious. Therefore I conclude that I received better than a high commendation for my work :D
  • pas 3y ago
    > Clinician lead process could you tl;dr what does that mean, why the English one relatively failed, and how it would have fared better with a clinician led version? thanks!
    • singingfish 3y ago
      Best outcome is when the people using these systems are the same people as those buying/specifying the systems. And best introduced with limited and constrained scope so you end up meeting the users actual needs. Pretty simple really and a tale as long as enterprise software itself.
• hashishen 3y ago
  about %85 of my wowrk as a sys admin for a medical group was troubleshooting EMR software
• wolverine876 3y ago
  When I watch people use them, the UIs look like information overload and cumbersome for the user. It's just old corporate database development: Develop the database, then dump all the fields into a UI. Add some section headers. I would resent using that so often every day. > There is an illusion that technology automates work—instead it only changes it. That seems like an odd statement. For example, some technology is automating delivering this text to HN servers, and then to you. HN wouldn't exist without that technology.
• friendzis 3y ago
  I have worked for a company developing HMS/EHR and a hospital implementing/integrating these systems. Before you think "my startup can do better" understand the core problem: legal and actual processes. Medical is heavily regulated, not only at the point of care, but likewise on the administrative side. In the event of an adverse effect the hospital and medical team(s) involved must be able to provide clear track record of following the protocols. The administrative team must have the data to provide all the required metrics. Suppose a simple bloodwork protocol: nurse draws blood, delivers to lab, lab does analysis, results are funky, lab releases invalid report indicating rejected sample, doctor issues redoing of bloodwork, nurse draws blood again and so on. Sample rejection is recorded somewhere, distorts statistics for admin, costs time. In practice, in the event of suspected badly drawn sample nurse is internally informed of that to redeliver the sample, lab releases clean report, sample vial is recorded as discarded by nurse, business goes on. Medical is FULL of these tiny optimizations around protocols. However, any HMS must follow the protocol, implement safeguards against divergence from protocol, yet to be user friendly it must accommodate all those deviations while still providing "correct" track record with eventually consistent timestamps and so on. Timings can be very important. For example at ER priority levels dictate not only queue ordering, but also time to care. With HMS implemented it becomes crucial to record times correctly (both from CYOA and metrics standpoints), therefore from the perspective of user, the HMS becomes first priority over caring for patient. Users inevitably complain :) In certain protocols timings also play a huge role in determining care type. Discharge a patient in x hours and it is outpatient care, fail to discharge patient in x hours and the case promotes to inpatient care, with all the associated complexities of care and documentation. Patient returns in x hours - it's the same case. Fail to provide care in x hours - different treatment protocol. Readers may think "just provide sane defaults for common case and let staff explicitly record uncommon cases". That simply does not work. Defaults are defaults and users submit defaults. Having insane defaults actually prevents hospital admin/it/legal from being overwhelmed with correcting submitted data. Users complain. It's ugly. You have to juggle between good care, actual processes, legally required processes, metrics and what not to make the system usable and correct where every user is adversary. EDIT to add: On top of all that, every hospital has unique implementation of processes and structures. The differences may not necessarily be major, but there are differences. Any HMS that intends to become a commodity instead of custom project for a single hospital or department must be highly customizable. first, high customizability typically misses optimization (especially workflow optimization) opportunities. Second, implementing HMS is akin to implementing SAP: the end result is amalgamation between core product developed by a vendor and implementation by hospital admin/legal/it. Many here have either first-hand experience or close knowledge why implementing ERPs (HMS is an ERP) typically lead to barely usable monstrosities. The stakeholders at organization typically have neither working understanding of underlying processes and policies and how they tie together nor will to implement processes and policies more suitable to be managed via ERP.
• hiAndrewQuinn 3y ago
  My first job out of college was working at Epic Systems as a mostly Windows sysadmin. It was a fascinating (and great!) experience. I've never seen such an advanced Windows sysadmin setup before. I only briefly touched upon EMRs and the MUMPS/Cache stuff they did there. However, I also learned PowerShell to a much deeper level than probably 99% of Linux folks ever do. We did TDD, code review, CI/CD pipelines for fucking PowerShell. It was painful right up until the point where I internalized the Tao of PoSH, and then I realized that PowerShell actually rules for readability and maintainability when you have people who know what they're doing. HNers by and large don't understand the economics of PowerShell. There is a very low supply of competent PoSh devs on the market, and even fewer interested in credibly signaling their proficiency, but a very high demand for them, because a lot of places still run everything on Windows, and guess what's installed on virtually all of them? I've even been able to take on a few consulting gigs that boil down to "take our 100,000 line un-version-controlled PowerShell monstrosity hacked together over the last 13 years and turn it into something we can actually understand, please".
  • foofie 3y ago
    > PowerShell actually rules for readability and maintainability when you have people who know what they're doing. Isn't that true for all programming languages ever devised by mankind? > HNers by and large don't understand the economics of PowerShell. There is a very low supply of competent PoSh devs on the market, and even fewer interested in credibly signaling their proficiency, but a very high demand for them, because a lot of places still run everything on Windows, and guess what's installed on virtually all of them? I don't see what point you're trying to make. The fact that Microsoft decided to push PowerShell on virtually all versions of windows it ships only reflects a Product decision by Microsoft to push a Microsoft-only tool. It also shows Microsoft's decision to not offer the same level of support for any other alternative. Where's the economics in that? I also don't understand your broader comment on economics. Are you depicting it as a good or bad thing?
    • hiAndrewQuinn 3y ago
      One would hope, but alas! Perl was notorious for being write-only back in the day. PoSh is closer to read-only for most devs. If someone makes sure to write things out the long way (or uses a linter to do this) it's very easy to grok. Actually learning to write it is the tricky bit.
• throwaway346434 3y ago
  The one group who doesn't hate it: Australian patients. New test result appears in your my health record app, the GP you are seeing has some crippled practiceware, you just show them your phone. Telehealth appointment to renew a script because my GP isn't available? $20 and done in 15 minutes with an eprescription. This won't solve the hospital space issues, but at this rate I can see "tap to check-in with your hl7 2.3 adt a08" as a semi practical workflow
  • rswail 3y ago
    Except that specialists (in particular) hate uploading results into the government EHR. They want to review test results and then communicate with the patient, and the only way to do that is to not upload the results. I had to talk to the pathology supplier, then get a letter from the specialist approving it, before they were allowed to upload the test results that were bulk billed on Medicare. There's no incentive to get specialists to change their record keeping. I've also spoken to several friends that are leading specialists, they had a long list of reasons why it was a bad idea medically, but changes in workflow would solve most of them.
• hoseja 3y ago
  The seventh paragraph, "While medieval Islamic hospitals operated in the contemporary sense..." is pure meanspirited propaganda and renders the article repugnant.
• junon 3y ago
  Like other comments here I also went down the road of making an EHR system a number of times. It's not worth it. Competing with the hell scape that is Epic (not Epic Games, but another EMR software) is seemingly futile.
• ako 3y ago
  Overall, while we as developers often prefer to focus on complex software engineering challenges, it looks like here the core problem is the user experience of complex data entry/administrative applications. Designing for so many different types of users, different (customizable) processes/operations, different organizations using the software, is equally difficult to any engineering problem. Unfortunately, the area of user experience is still very much undervalued for enterprise software, especially by the financial buyers. And without buyers valuing these aspects, vendors will not focus on these aspects.
• noirscape 3y ago
  There was a documentary around here (not-US) a couple years ago about the main EMR provider in the country. Because it's so onerous to install and set up a replacement (just a lot of demands and requirements), the market gravitates towards only a few "established" providers, one of which are overseas/US software that are infamous for their issues (Epic is the one that jumps to mind), but the focus was on the local provider. The local one apparently is insanely expensive, doesn't have intranet support (because it started as some ancient Windows version as a surgeon-for-hires (the CEO of the company was one) payment record), meaning that hospitals have to move computers on wheeled desks around, lacks a lot of views for medical staff and the operator rolls in "service fees" for things that aren't fees and demands constant cash for upgrades that don't seem to change or fix anything. If a hospital indicates they're planning to replace any component, the CEO apparently just starts screaming and threatening to cut off the hospital out of their stuff entirely (which means that hospitals are unable to invest in startups that might provide the components they need). It's pretty awful, considering the software is supposedly rather glitchy and has already resulted in numerous patient deaths due to inaccurate medicine prescriptions being loaded in (something which the company denies, but there's ~20 or so reported cases of this at different hospitals). I've heard doctors keep a second physical copy of any patient records, just because that system could screw it up and cause issues down the line, completely nullifying the use for it.
• tempaway35641 3y ago
  The answer is halfway through the article: "Healthcare isn’t structured around patient needs; it is a business that prioritizes profit."
• deleted 3y ago
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• glimshe 3y ago
  What's the point of electronic medical records if I have to fill out the same stupid paper form every time I go to a doctor?
  • analogj 3y ago
    There's actually a "Patient-contributed data" initiative being run by the standards body (HL7) that's gaining traction. In an ideal world it would allow patients to "push" their electronic records to a new practitioner, meaning that intake forms could be much simpler. In practice I think the implementation is going to start with Observations/Lab Results first though. I hope to eventually support it with my open source personal health record (PHR) Fasten Health. IMO this would be a "killer app" for PHRs.
• phaedrus441 3y ago
  This article (and many like it) often mention how intuitive and speedy the Dept. of Veterans Affair EMR is. I can guarantee not a single one of these authors has ever used it. CPRS (the VA's EMR) is easily one of the biggest reasons physicians don't want to work at the VA, and most facilities have fewer patients per team (compared to academic or community hospitals) because of how much extra effort is required to use it. It is just startlingly bad.
• MarkMc 3y ago
  My doctor was target of bitcoin extortionists. Now her system is so locked down and doesn’t interface with any other system. To transfer information to another system she prints it out and scans it into the new system
• cik 3y ago
  Sounds like people in a specific country, dislike a specific implementation. Clickbait. In my country, we have and love EMRs. They enable me to change health authorities at will, as I move cities. They enable me to carry nothing, anywhere - including prescriptions. My phone can serve as my booking tool, and I have instant access to results (such as a blood test) at the same time as a doctor. EMRs enable activities - business and government decisions might limit them. Centralization of data for me, in a socialist health care system, delivered by capitalist competition is ideal. It's allowed me to be a consumer, having my daughter's eye operation occur at a hospital far away, but her doctor, literally around the corner have access to all results, without my intervention. This is one of the best parts (by far) of living here.
• miketery 3y ago
  Related, I recommend watching Bill Gurley's talk [1] on regulatory capture from 4 months ago. It basically covers why the path to solving this is a difficult if not impossible one. 1 - https://www.youtube.com/watch?v=F9cO3-MLHOM https://www.youtube.com/watch?v=F9cO3-MLHOM
• intalentive 3y ago
  When you craft a solution around the needs of users, soliciting their feedback, then they might end up with something they appreciate. When you force a solution on people and give them no say in the matter, then there’s a good chance they’re not going to like it. Instructive case that reveals a lot about Soviet America.
• hn_throwaway_99 3y ago
  I thought this was an excellent, excellent read. This post, about how well-meaning legislation to increase EMR usage had some strong negative unintended consequences, dovetailed with thoughts I've had a lot recently about the concept of "bullshit jobs" (a popular discussion topic on HN). I've wondered what the true source is for these bullshit jobs. After all, corporations voraciously want to increase profits, which should be a strong incentive to eliminate unnecessary jobs. The conclusion I've come to is that the side effects of government laws and regulations lead to a negative "codependent relationship" between government and companies that exist to implement the complexity required by the regulations. There is no incentive on either side to reduce complexity. To be clear, I am not blanket "anti regulation", and I've seen the benefits of strong (usually simple) regulations - for example, I live in Texas (usually famously anti-regulation), and there is good evidence that old laws restricting home equity loans, due to an old animosity of Texas farmers against bankers, helped uniquely limit the damage of the Great Recession in Texas: https://www.aeaweb.org/research/charts/texas-home-equity-limits-foreclosure-rates https://www.aeaweb.org/research/charts/texas-home-equity-lim.... However, I've also seen the damage and useless work created by well-meaning regulations that create a lot of complexity, and then companies spring up to "tame that complexity". For example, most people in the US are familiar with FSAs, flexible spending accounts. There is a HUGE amount of work that goes into managing FSAs. The rules around what is a qualified expense are complex, and lots of companies have sprung up trying to work around those rules (e.g. companies that will churn out a "medical letter of necessity" for any massage you want). And all FSAs do is let you save taxes on medical expenses. But since FSA money is "use it or lose it", it turns out that 23% of the funds go unused every year! So all this complexity was created to save consumers money, but at the end of the day it ends up being (in aggregate) basically a total wash! All we've gotten is tons of administrators and companies that are paid to manage that total wash. I don't have a great solution, as again, I don't see incentives on either side to reduce complexity. But more and more "tear down the whole f'ing system" is the only answer I see.
• just_1_comment 3y ago
  I implement EMR’s and related software. They slow down the process of providing healthcare to the point that medical scribes - personal note takers / assistants - are basically necessary to keep things rolling smoothly.
• crabbone 3y ago
  > There is an illusion that technology automates work—instead it only changes it. And a number of follow-up attacks on technology totally in the spirit of Jacques Ellul. My wife is a physician, and through her and some of my personal experience of working with hospitals, this is how I understand the problem: * Programmers who write EMR systems critically lack the knowledge of how hospitals or physicians operate. There are multiple causes to this: the process of writing such software isn't a grass-root movement. It's heavy design-first of large, well, huge systems before they are implemented by grunts who never have any idea about how the whole of the system is intended to operate or even how the tiny slice of it they work on is supposed to be used. I should know this, since I was one of those. * Doctors despise programmers. Doctors also don't want to be programmers. To a typical doctor, a hospital's staff programmer is similar to a medical secretary: a hoop they need to jump to get their work done rather than an actual aid. Being a programmer, try advising a doctor to do something differently, even if that's about how they use their computer, and be exposed to an hour-long lecture on how they studied for N long years, and how their education was so much more intense than yours, and how they had to endure and so on. Of course, doctors see doing programming work as being beneath them. So, what happens is that instead of interfaces that could enable doctors to be productive at using their computers, they get absolute garbage that's impossible to automate and requires arduous manual labor. I.e. if doctors wanted to learn how to use SQL to access their hospital database, and, let's say, were able to write some short scripts that automated patient processing, communication with other departments and so on, they'd be spending way less time in front of their systems. But they don't. Instead they get MS-Windows-styled GUI garbage. Impossible to automate, with the source locked away from them, written by someone they couldn't bother to meet and chat with for an hour because their paycheck likely has an extra digit. My wife being in radiology department reported that, eg. most times patients are sent to them, even inside the hospital for some imaging, they don't get their forms properly filled by the sending doctor. Not only the sending doctors don't know how to fill those forms correctly, they don't want to know. An incorrectly filled form will result in the radiologist calling them back, and they'll be able to communicate what they want done to the patient in this way. It's both because the forms are too inflexible, because there's no trust in the system, and, especially that even if the form is filled correctly the receiving end might not know how to process it correctly. And this doesn't depend on the country. Countries with mostly uniform, long-standing healthcare systems suffer the same fate. ---- To me, it's clear that the change that needs to happen is that doctors need to become more like programmers. It's unfortunate that they need to spend so much time learning their trade, and it seems like on top of that they need to study something far divorced from the rest of their main subject, but I don't see any other way. It's not about technology failing doctors, it's the doctors who don't want to embrace technology.
• Decabytes 3y ago
  My time to shine. I work in the healthcare industry as an analyst and deal with all types of EMRs, Databases, and Molecular profiles. Before working in the healthcare industry, I would have assumed that the data quality in healthcare would be higher because you know, data quality errors can negatively effect patient outcomes. This is not the case. A lot of these issue lie (lay?) with the UI of these systems. They are just not intuitive. This causes data to be entered incorrectly as honest mistakes. There are also fields which are free text, which should not be. I can't count how many times, I received data from a free text field for drugs, for example, and instead of information about drugs it said "The patient's pet passed away and they were sad today". Furthermore, a lot of the data comes in separated value files, mostly CSVS (though I try to have them use TSVs if they can modify it). For such a ubiquitous format, at the volumes of data we receive, we get issues with the CSVs all the time. Lots of fields have strings that are improperly quoted, newlines in the strings, variable amount of fields per line, the usual. That's on top of encoding issues. Randomly we will get files that aren't utf-8 and our parsers will blow up, and then we have to go back to the vendor and ask them to regenerate the data. Also trying to harmonize data across a bunch of proprietary file formats, and software is terrible Also physicians and nurses are generally pretty skeptical when it comes to new technology even if you have a good product, and for good reason. They have been BURNED many times but companies coming in and promising the world, and delivering a half baked product. Anyone can get an MVP together quickly that kind of does what they need done, but to really support end users requires a lot more investment. I'm talking on-site trainings, software engineers actually watching the faculty USING THE TOOL, and taking notes when they struggle, being proactive about the wants and needs of the staff instead of adding features that seem useful. This almost never happens Then there are factors outside of just EMRS and the user experience that just make the patient experience much more difficult, even when everyone involved is following standard practices. Data is king in this space, and companies are reticent to share it without lots of money and an books worth of clauses and agreements. You can win in this space just by having more data, or rare data. Lots of patient populations for obscure diseases require large sample sizes before you will have enough patients to perform a study. Pharma companies will approach you with prospective studies and the more data you have the more feasibility work you do that end up leading to studies where you get paid, and your name on paper. This HURTS patients and does nothing but help to keep competitive advantages. On the bright side, since the U.S healthcare system is so capitalistic, we can usually find what we need coded in the billing data, because patients are nickle and dimed for everything that happens at a medical facility. I have about twenty more pages of things I could talk about. This whole system is terrible and it doesn't have to be. On a more positive note, I love being able to track patient outcomes and see them improving, and I really enjoy working with huge datasets.
• nurbl 3y ago
  While I haven't worked with EMR systems directly, I have some experience working with care giver organisations, from the perspective of trying to use their digital records for analysis and prediction. My impression was that this is something nobody has time for, and therefore nobody is doing it, or even really interested in it. It would seem quite wasteful to have this big expensive machinery for producing data that nobody has time to look at. After all it's one of the big reasons to make it digital in the first place; being able to "crunch the numbers". On the other hand, as soon as you get those numbers someone will turn them into "performance indicators" and use them for optimization, and we all know where that tends to lead... I can understand the feeling of being forced to work with a system designed to get rid of you.
• htechenjoyer 3y ago
  Disclaimer: The electronic health record system in the united states is a mess. A monolithic monstrosity lacking interoperability, touching the most sensitive data, and leading to the worst possible outcomes if errors occur. That being said, as someone that works in healthcare technology, has done clinical shadowing of physicians, worked the admin side of healthcare providers, worked technology for payers and providers, and has multiple close relationships with front line healthcare workers: I think this article missed the mark in several places. I've interacted enough with nurses and doctors to recognize rants about electronic health records and how they come from a valid place but use many poor examples. 1. Theres a weird implicit assumption throughout the entire essay that EHR implementations are uniquely bad in introducing friction and errors to the medical system. Take the example of his electronic orders to the lab and lamenting how in the old days that would be a simple note to lab on paper and that was somehow inherently better. As if errors around misreading notes or misplacing them didn't occur beforehand. 2. "There's an illusion that technology automates work - instead it only changes it". This is a faulty premise. There is a lot of work that has been completely automated away within healthcare not just changed. EHR enabled patient monitoring comes to mind. You can remotely capture and store vital signs for patients instead of rounding to each room and writing them down. With staffing shortages for all jobs in healthcare we would probably be in a much worse place if we were still relying on paper. 3. "There is also more clinical work. Increasing corporatization of medicine and staff shortages have increased the volume of patient care for each healthcare worker, accelerated since the pandemic". There is definitely blame on admin for some of this but there is also artificial limiting of the number of new doctors each year by the AMA and it's lobbying. If there were more medical professionals I suspect that much of the "burnout from EHR's" would decrease. Add in the authors vitriol for a profit maximization even though profit of a health system allows them to hire more and pay more to compete with other industries for workers. 4. The author does not understand why the technology is implemented in a specific way. He is one stakeholder - the doctor and while an important one is not the only one that needs the data generated by a clinical interaction. Example: his complaint for there being multiple lab types for HIV in a drop down for ordering. This is specifically to reduce ambiguity and resulting medical errors, allows for more precise audit and reviewing of a patient's history, and carries a different cost for billing. He also blames EHR's for issues with different implementations of UI and workflows between hospitals even though most times hospitals are to blame for adding their own customizations. While the author brings up good points he has an explicit bias against the current system even when it doesn't deserve the treatment he gives it. Most of the piece is generated more from a hatred of capitalism and a desire to refute the libertarian paternalism that he talks about rather than a fair and even treatment of the problem with the electronic health record system in the United States.
• iav 3y ago
  Apple Health does a great job of integrating with EMR providers. I can see notes from every doctors visits, my blood test results, Covid tests, and so on all integrated into one app. I can see my sodium levels have gone down since 2019 in a plot chart, or when was the last time I got sick.
  • analogj 3y ago
    Disclaimer: I built an Open-Source PHR The thing that most people don't realize is that the legally enforced HIPAA protections they take for granted no longer apply when they request their medical data from a healthcare institution and store it in a third party app -- like Apple Health. The only thing protecting your medical records from being data-mined and monetized is Apple Health's privacy policy and (current) technical architecture. You've seen examples of it in the news with women's period tracking apps, but it'll become even more common as apps start leveraging APIs opened by the 21st Century Cure's Act. I'm not a tin-foil hat wearing engineer, but I can forsee a day when Apple's reputation of being "Privacy-conscious" might not be worth as much money as the medical data they've collected from their customers. It's one of the reasons why I decided to build my own open-source PHR, so that the incentives between the software and me as an individual are kept in alignment. https://github.com/fastenhealth/fasten-onprem https://github.com/fastenhealth/fasten-onprem
• ryanisnan 3y ago
  The real reason EMRs are frustrating is that they attempt to provide structure around a chaotic underlay of insurance reporting schemes. The way clinicians get paid for service is to report everything they do, in obscure and highly-specific codes. Practices on average have to consider arrangements with 25 or so payer entities, and must consider the varying requirements with each. EMRs are still playing catch up, but there is hope. One of the best applications of AI is translation, something EMRs desperately need.
  • burnte 3y ago
    Healthcare CIO here, there are more major issues and much bigger ones in the EMR space than insurance. One is cost, the compliance cost is so high that it's a huge barrier to entry, and makes new competition difficult. The limited sales channel means you need to charge each of your small customer base more to pay the bills. Another is interoperability. They're all garbage in one way or another so all the vendors work very hard to secure client lock in. Another is medical regulations. We have a whole mess of buttons and check boxes providers need to fill out for regulatory reasons. Yet another is needing to create a complicated system to do complicated things, but the people operating it generally get little to no training on an EMR, so the learning curve is STEEP, and breeds problems. I could go on all day. I kind of wish I could lead a startup to create a new EMR from the ground up. With what I've learned over the years I really think it's possible, but would need real investment up front.
  • tuna74 3y ago
    Health care staff in the Nordic countries hate their systems as well.
• renegat0x0 3y ago
  logicmag.io The site advertises itself as "tech with ideology". I hate that. Quote from the site """ In 2023, Logic Magazine was relaunched as Logic(s), the first queer Black and Asian tech magazine """ I would hate tech with Christianity, tech with asian people, tech with conservatives. As an engineer I do not care what color skin, or what your beliefs are. They are only important to me if I am uncertain about author biases.
• brovid19 3y ago
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• tcmart14 3y ago
  Is it that EMR is bad or is it market capture. About the only company I hear about doing EMR/EHR is EPIC. My wife is a nurse, and in all the places she has worked it is EPIC. Every doctors office I've been to, its EPIC. It seems like EPIC pretty much owns most of the market, so there isn't any competition to really encourage EPIC to be better and there is no will for medical systems most of the time to choose an alternative to EPIC.
• yoden 3y ago
  Having worked in medical software for a long time now, it's not surprising. Medical software is purchased by upper management based on features. Usability is rarely considered, and hard to evaluate anyway since it depends on integration. Hospitals themselves create this incentive because they will rarely if ever change their processes to fit more smoothly into a different workflow. The core purpose of an EMR is to integrate different parts of the hospital, though, so the only possible solution is a huge do-everything piece of software like Epic. I spent years on a project to try to standardize exams between a major research hospital and its satellites. The ended up quitting about half-way through because they realized there just wasn't going to be enough political power at the main campus to convince the doctors at the satellites to follow their lead. You'll even see this at smaller regional hospitals. We'll bring software and workflows developed in tandem with the top hospitals in the world, and they'll tell us that they don't care and they want to keep doing things the way they've always done them. Everyone may hate EMR, but hospitals seem to be getting exactly the EMR they're asking for.
• NanoYohaneTSU 3y ago
  This is what the so called Free Market brings when combined with anything medical. It's a mess of systems that are incompatible with every other system, creates more work for everyone.