5 ms·

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 a

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.
FwarkALark 3y ago
Is this something where a public competitor might help? It surely can't be worse than private industry.
- timekiller 3y ago
  Oh it could be much worse. You should see how bad government run HIE’s are.
  - happytiger 3y ago
    To back you up. They are profoundly worse. It’s an area where private dominates entirely, as the government HIEs are almost unusable.
  - FwarkALark 3y ago
    Again, I don't see how a private industry per se could even possibly be worse given the demand for a profit margin. Your beef is with some other aspect of this process.
    - pas 3y ago
      the same higher-level forces shape the public project's fate into certain doom that led to hospitals buying the absolutely shittiest tech. because there's no clear signal (in the private sector there's some drive for sales, market share, profit), only made-up hyperpoliticized bullshit requirements and maybe some barely coherent vision. as long as there's not a clear technocratic organization with sufficient independence and competence these projects are rudderless yellow duckies on the sea of tragisocial medicine mismanagement madness. no party involved really has enough resources to deliver something nice. it's like high speed rail in the UK or the US. as a public project it's already stillborn, because it's too expensive to do it right (or if it would get the right amount of funding it immediately attracts unlimited scope creep, and the usual vultures show up, it becomes a typical everything bagel project, solve EMR but also education and childcare and whatnot), and to do it efficiently it would require draconian standardization and heroic amount of data migration work. and on top it gets over promised and under staffed and so on
Zanfa 3y ago
This is absolutely true in my experience as well. Ironically, it's also a somewhat of a circular problem, given the inherent complexity of medical processes, every organization has organically formed their processes over decades. When choosing software solutions, they pick software that caters to their specific needs, rather than change processes to fit existing software. This results in vendors building endlessly configurable products that add even more complexity. As a potential new entrant, this means you'd need to not only support N processes, but something like (number of clients) * N processes. There are some initiatives towards EHR interop (e.g. FHIR), but from what I've seen so far, they suffer from similar problems. As in the standard is made so flexible to cover all situations that you can make things that are 100% compliant, but completely incompatible.
- JusticeJuice 3y ago
  Yeah, I've seen the term "sociotechnical" used to describe this relationship between software and process. A process is built in part for a system, and therefore the system in part needs to support the process. Changing the setup isn't just a technical challenge, it's a challenge in creating sociotechnical change. I think it's a very easy thing to underestimate.
  - deleted 3y ago
    [deleted]
  - Terr_ 3y ago
    > Yeah, I've seen the term "sociotechnical" used to describe this relationship between software and process. Maybe "cybernetic", although that has largely been taken over by sci-fi connotations.
jharsman 3y ago
This is very true. There several reasons why most EHRs are so bad: 1) The people who pay generally do not use the system. This is true for enterprise software in general and leads to vendors prioritizing having all features organizations ask for (regardless if they are a good idea or not) and also prioritizing features management deems important over fundamental workflow, UX and polish in general. 2) EHRs are very large and complex and can almost always gain more customers by gaining even more features and replacing smaller more specialized systems. A typical EHR will have features for ordering tests and viewing results (for clinical chmistry, microbiology, radiology and more special stuff like physiology etc), appointments and resource planning (rooms, equipment, personnel, staffing), clinical notes including computing scores and values based on other values, medication (ordering, administering, sending prescriptions electronically) and administration (admissions, discharge, payment, waiting lists). That is a lot of different stuff! 3) Once a vendor wins a contract and installs their EHR, very little can be gained by improving the lives of users. Contracts and sales cycles are very long, and the vendor gains very little financially by improving the system. So many vendors are focused on charging money for customer specific features or adding new features to win new tenders. I'm not sure what the solution is, public alternatives have failed spectacularly since they are typically run by public administrators who have even less of a clue how to develop software and what users want than the vendors.
- Terr_ 3y ago
  > So many vendors are focused on charging money for customer specific features or adding new features to win new tenders. In turn, this enterprisey anti-pattern creates unfocused products which can be configured to sort-of-solve every niche customer requirement that might block the sale. The result is a massive ball of muddy configurations and feature-flags, so that learning isn't very portable and backend integrations are very painful.
- namdnay 3y ago
  I would add the point that these dynamics are also present for any large IT system. Just search for people having issues migrating to SAP or Amadeus or whatever
lotsofpulp 3y ago
>I personally think a big part of the issue is actually scope, these systems are expected to do everything If I were to guess, the goals of admin and workers might not match because the primary goal of the admins deciding and implementing the EHR is to avoid liability for the organization in the event of an error, but errors are inevitable. And if liability for individual errors are so costly (as they are in the US for healthcare stuff), then the primary goal for the workers also becomes avoiding liability. In this situation, I can envision something like a crew of people working in the hospital that do good, quick, but undocumented work 99% of the time, are now being slowed down by documentation or other cover their ass needs. Obviously, it is possible that the new documentation needs are also uncovering malpractice that went unnoticed before. The question is are the tradeoffs worth it, which does not have a simple, objective answer.
Gravityloss 3y ago
Archive.org link: https://web.archive.org/web/20180625225731/https://barnett.surge.sh/welcome/complexity.html https://web.archive.org/web/20180625225731/https://barnett.s...
demondemidi 3y ago
They’ve improved tons since the 1990s. Let’s have some perspective.

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.

FwarkALark 3y ago

Is this something where a public competitor might help? It surely can't be worse than private industry.

timekiller 3y ago
Oh it could be much worse. You should see how bad government run HIE’s are.
- happytiger 3y ago
  To back you up. They are profoundly worse. It’s an area where private dominates entirely, as the government HIEs are almost unusable.
- FwarkALark 3y ago
  Again, I don't see how a private industry per se could even possibly be worse given the demand for a profit margin. Your beef is with some other aspect of this process.
  - pas 3y ago
    the same higher-level forces shape the public project's fate into certain doom that led to hospitals buying the absolutely shittiest tech. because there's no clear signal (in the private sector there's some drive for sales, market share, profit), only made-up hyperpoliticized bullshit requirements and maybe some barely coherent vision. as long as there's not a clear technocratic organization with sufficient independence and competence these projects are rudderless yellow duckies on the sea of tragisocial medicine mismanagement madness. no party involved really has enough resources to deliver something nice. it's like high speed rail in the UK or the US. as a public project it's already stillborn, because it's too expensive to do it right (or if it would get the right amount of funding it immediately attracts unlimited scope creep, and the usual vultures show up, it becomes a typical everything bagel project, solve EMR but also education and childcare and whatnot), and to do it efficiently it would require draconian standardization and heroic amount of data migration work. and on top it gets over promised and under staffed and so on

Zanfa 3y ago

This is absolutely true in my experience as well. Ironically, it's also a somewhat of a circular problem, given the inherent complexity of medical processes, every organization has organically formed their processes over decades. When choosing software solutions, they pick software that caters to their specific needs, rather than change processes to fit existing software. This results in vendors building endlessly configurable products that add even more complexity. As a potential new entrant, this means you'd need to not only support N processes, but something like (number of clients) * N processes. There are some initiatives towards EHR interop (e.g. FHIR), but from what I've seen so far, they suffer from similar problems. As in the standard is made so flexible to cover all situations that you can make things that are 100% compliant, but completely incompatible.

JusticeJuice 3y ago
Yeah, I've seen the term "sociotechnical" used to describe this relationship between software and process. A process is built in part for a system, and therefore the system in part needs to support the process. Changing the setup isn't just a technical challenge, it's a challenge in creating sociotechnical change. I think it's a very easy thing to underestimate.
- deleted 3y ago
  [deleted]
- Terr_ 3y ago
  > Yeah, I've seen the term "sociotechnical" used to describe this relationship between software and process. Maybe "cybernetic", although that has largely been taken over by sci-fi connotations.

jharsman 3y ago

This is very true. There several reasons why most EHRs are so bad: 1) The people who pay generally do not use the system. This is true for enterprise software in general and leads to vendors prioritizing having all features organizations ask for (regardless if they are a good idea or not) and also prioritizing features management deems important over fundamental workflow, UX and polish in general. 2) EHRs are very large and complex and can almost always gain more customers by gaining even more features and replacing smaller more specialized systems. A typical EHR will have features for ordering tests and viewing results (for clinical chmistry, microbiology, radiology and more special stuff like physiology etc), appointments and resource planning (rooms, equipment, personnel, staffing), clinical notes including computing scores and values based on other values, medication (ordering, administering, sending prescriptions electronically) and administration (admissions, discharge, payment, waiting lists). That is a lot of different stuff! 3) Once a vendor wins a contract and installs their EHR, very little can be gained by improving the lives of users. Contracts and sales cycles are very long, and the vendor gains very little financially by improving the system. So many vendors are focused on charging money for customer specific features or adding new features to win new tenders. I'm not sure what the solution is, public alternatives have failed spectacularly since they are typically run by public administrators who have even less of a clue how to develop software and what users want than the vendors.

Terr_ 3y ago
> So many vendors are focused on charging money for customer specific features or adding new features to win new tenders. In turn, this enterprisey anti-pattern creates unfocused products which can be configured to sort-of-solve every niche customer requirement that might block the sale. The result is a massive ball of muddy configurations and feature-flags, so that learning isn't very portable and backend integrations are very painful.
namdnay 3y ago
I would add the point that these dynamics are also present for any large IT system. Just search for people having issues migrating to SAP or Amadeus or whatever

lotsofpulp 3y ago

>I personally think a big part of the issue is actually scope, these systems are expected to do everything If I were to guess, the goals of admin and workers might not match because the primary goal of the admins deciding and implementing the EHR is to avoid liability for the organization in the event of an error, but errors are inevitable. And if liability for individual errors are so costly (as they are in the US for healthcare stuff), then the primary goal for the workers also becomes avoiding liability. In this situation, I can envision something like a crew of people working in the hospital that do good, quick, but undocumented work 99% of the time, are now being slowed down by documentation or other cover their ass needs. Obviously, it is possible that the new documentation needs are also uncovering malpractice that went unnoticed before. The question is are the tradeoffs worth it, which does not have a simple, objective answer.

Gravityloss 3y ago

Archive.org link: https://web.archive.org/web/20180625225731/https://barnett.surge.sh/welcome/complexity.html https://web.archive.org/web/20180625225731/https://barnett.s...

demondemidi 3y ago

They’ve improved tons since the 1990s. Let’s have some perspective.