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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

• 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
        "No! Not my pseudonymous Internet fame! Anything but that!"
    • magicalhippo 3y ago
      We see this so often with customers. They'll insist on doing stuff in some bass-ackwards way. We keep resisting though, and most of the time we get them to come around and thanking us later for the push-back and helping them evolve.
    • PH95VuimJjqBqy 3y ago
      you know, sometimes those idiosyncratic ways have a reason for existing because they solve actual problems. Technical people have a really bad habit of solving for theory rather than practice and they develop this attitude that those who are seemingly entering into odd behavior are just not as good or smart as them.
      • Terr_ 3y ago
        > you know, sometimes those idiosyncratic ways have a reason for existing because they solve actual problems. True, but "actual" is a rather low bar. I once worked at a company where a big internal enterprise app controlled a lot of operations, and saw that many of the layers of cruft in the app were because it became the preferred battleground of corporate dysfunction. One example is that the sales team kept closing deals ('cuz commissions) which were difficult to fulfill, unprofitable, or cannibalized from other assets and activity. This lead to repeated and increasingly obtuse layers of code for estimating gross-margins, showing values at different interfaces and steps and warning styles, managing and modeling gross-margin reporter/reportee connections and automated alerts and permissions systems where they system would block certain people while e-mailing other people for clicking approval boxes, etc.
        • PH95VuimJjqBqy 3y ago
          your example is a software example, which automatically falls outside the purview of what I'm describing. There's a doctor further up this chain who states they preferred paper.
  • gcnnbdff 3y ago
    [dead]
  • namdnay 3y ago
    It’s the reality for anyone doing “IT”, whatever the domain. Travel, banking, hospitals, police, social security etc ad nauseam
  • bogwog 3y ago
    HN is (probably) read by mostly software development (-adjacent) people, and this thread is basically software developers blaming users for using their software wrong. Maybe that's true, but I think it's at least worth pointing out before someone mistakenly thinks this isn't an echo chamber.
    • gedy 3y ago
      > this thread is basically software developers blaming users for using their software wrong I wouldn't say that, most devs who've worked with product requirements and users have seen issues with users wanting something inefficient or illogical, basically because they don't like change and/or don't understand why they are doing something.
  • cmiles74 3y ago
    In my opinion, this is less about the field (health care, real estate, etc.) and more about automating someone's core role. Many people have learned to do a particular job a particular way: some things they have picked up through trial and error, others were handed down from a more senior co-worker. There are other steps that are taken because something else (regulatory requirements, etc.) require it or don't and have been misunderstood. When we try to automate part of a person's work, we have to encourage the person to take a look at themselves and the way they do their work. This is not easy for people! A lot of times we're asking someone to admit that they don't actually know why something is done a particular way. Or we point out that they are doing the work of another person in another department. And, all the time, this person is worried that at the end they will be replaced by software and lose their job. I think it's really hard to get to a place where everyone is comfortable enough to be frank about what they do, what the software might be able to do, and what makes sense.
• ako 3y ago
  How should operations be changed to address the problems?
  • duffpkg 3y ago
    At ClearHealth/CLH we defined thousands of core business processes in a typical over 100 bed acute care institution. These are complicated animals. A hospital of any size is pretty much a city unto itself. There isn't one thing, there are a lot, a lot of things from how items and equipment are procured which is very complex to simple things like making sure that people wash their hands when they should. How laundry and trash are handled. HVAC and plumbing are insanely complex in a hospital setting. It is absolutely absurd how viscious the fights get between staff and management over parking assignments. It requires virtually a threat of termination to make a lot of doctors follow even a 3 to 8 step evidentially developed checklist for certain situations. ACHC, joint commission, CLSI for laboratory, are groups that outline some very basic frameworks of how facilities should be operated. Less than half of facilities can meet even these extremely low bar standards for operations. It is difficult for me to see how many patients have been harmed by ransomware impacting hospital opertions, this is entirely preventable and no one on the hospital side has been meaningfully held accountable so very little will change. A counter example is the pricing transparency regulations. Failure to meet those is resulting in multi-million dollar a year fines which is resulting in change. It is happening slower than people like or had really conceived of but it is causing some real meaningful change. 99,000 americans a year die from hospital acquired infections that are entirely preventable using procedures and operations (not surgeries) that are known and evidentially proven. It's just really hard to get all of the parts of the orchestra to play the same tune so those people die needlessly.
    • Naijoko 3y ago
      "99,000 americans a year die from hospital acquired infections that are entirely preventable using procedures and operations (not surgeries) that are known and evidentially proven. It's just really hard to get all of the parts of the orchestra to play the same tune so those people die needlessly." ??? I dont get this. The problem are Antibiotic resistant bacteria. You go to a Hospital (ER) and have a open wound.. chances are you die of an infection. How is this preventable??? This is a big problem atm and there is no good solution. you cant test people if they come in bleeding like hell for Resistant bacteria. I mean you can but ... I would like to hear the solution to that problem. Thank you.
• persnickety 3y ago
  > In-N-Out instead of McDonalds, What is this comparison trying to illustrate?
  • duffpkg 3y ago
    A lot of facilities run on a McDonalds type thinking when they should be looking at how In-N-Out is able to deliver a very similar product that is both dramatically better and either the same price or even cheaper. In-N-Out staff is well compensated, customers rate the institution as one of the most beloved in american life. McDonalds achieves neither of those things. What makes In-N-Out different? The difference is competence in operations. A lot of healthcare today delivers an inferior product at an inferior price, it doesn't have to be that way. A lot of people think that quality is only possible at an increased "price". A change in thinking is what is needed to achieve a change in quality (result/price). Responding to the request below for a specific example. Hand washing, you wash your hands when medically appropriate to prevent facility acquired infections. If you don't you are progressively warned ultimately leading to termination and/or loss of license. If instituted nationally this alone would save at least 5,000 lives a year. Good luck getting it instituted at most facilities. A different example, diesel fuel and generator maintenance is a meaningful part of medical facility physical plant. A shocking number of facilities place procurement responsibility and oversight of this in the hands of a doctor who also has medical responsibilities. The results are as financially and operationally disasterous as you would expect. Data centers have similar requirements. Who do you think pays more and operates better? Formularies are a sort of default medication lookup table. Most organizations have one that was created decades ago by people who aren't with the organization anymore. Review and revise them with someone who understands both the medical/pharmacological aspects of the drugs involved as well as their costs. Win for doctors, win for patients, win for insurers, almost no one does this. They have some clueless administrator carry forward last years formulary with minor changes or alternatively have a medical professional with absolutely no idea what costs are involved do it.
    • deadmutex 3y ago
      Can you please add more details/examples? The current responses seem to be a bit broad/vague to follow. E.g. what are your recommendations? pay staff more? i.e. increase doctor pay?
• hyponatremia121 3y ago
  "Operations (not surgery) are so incredibly bad / incompetent in most healthcare settings that software frequently gets the blame for much deeper problems." "In my experience doctors are a tremendous barrier to resolving problems in healthcare operations," I'm a hospital-based physician that works in a system with great operations and results. The physicians, nurses and other staff work amicably together. Management is reasonable/nice. The EMR, though is universally despised. No one likes it. It is a major factor in burnout. The UI/UX is inconsistent. There are slowdowns and outages daily. There is a well known lag in the appearance of text in text boxes after typing that seems to be variable. I've caught the EMR cancelling orders I placed on critically ill patients in the ICU more times than I can count. We have to actively protect the patients from the EMR. Healthcare workers aren't perfect but they are trying to do their best for very ill people in a high-risk setting and the EMR is well-known blocker. I long for the days of paper records because this is worse. Paper charts didn't go offline, have slowdowns, didn't lose orders, were easily located, and easy to enter data into.
  • davak 3y ago
    HypoNa -- I think you made a throwaway account for this reply, but I would really appreciate continuing this conversation with you. My email is available under my profile.
  • hyponatremia121 3y ago
    I know that devs that work on EMRs might read this thread. I'm pleading with you to take the EMR to the next level when it comes to UI/UX and reliability.
    • duffpkg 3y ago
      I've managed large enterprise health organizations across multiple sites that use Epic. We built an adjunct system that is still used by some of them that papered over serious problems that doctors using them never knew wasn't only Epic. We defined, documented and tested real world workflows before we subjected patients to them. There are a lot of other ways to address those issues operationally. You have management, IT and operations problems, not software EMR vendor problems. No software is perfect, Epic less perfect than most. Your facility chose that system and decided how it was implemented in a way that is dangerous or potentially dangerous to patients. No software vendor can fix that. That's really the heart of my rants in response to this article. I built that EMR, it was/is called ClearHealth/WebVista/HealthCloud. Your facility would never have bought it because incompetent management will only buy Epic. We solved the problem by buying organizations and replacing the incompetent management.
• mjfl 3y ago
  Idk this reads like apologetics for the software industry, which I know people will be more sympathetic to here. But. I know doctors that tell me their EMR log them out after a minute of inactivity and take 3 minutes to login. This can happen multiple times during a patient visit and are totally disruptive. I've heard that it's even begun to affect the throughput of the hospital. So I wouldn't be so dismissive of doctors complaints.
  • namdnay 3y ago
    I very much doubt it’s the software vendor who has chosen to implement the automatic logout after a minute. Most probably someone wrote that down in a requirement because that’s how the previous system worked or that’s what they saw on the internet, and once that’s done it’s set in stone
    • peteradio 3y ago
      Maybe so but 3 minutes to get logged back in is hilariously bad.
      • nradov 3y ago
        Again, that's not an EHR problem. All modern EHRs support fast SSO and OS security integration. If it takes more than a few seconds to log back in then the fault lies with the customer. They have either configured the system incorrectly or are running on inadequate hardware.
  • htechenjoyer 3y ago
    This is entirely a data security issue. Depending on the environment, without a logout this is seriously risking a HIPAA violation. Say you're in the hospital and your doctor pulls up your record on a computer in the hallway after they've done rounds on you to put in their observations and notes. However just as he's finishing, his pager goes off, he's off to an emergency, and he forgets to log off. How many minutes are you okay with your medical record being open for inspection by anyone that walks by? Other medical staff, admin staff, janitorial staff, other patients getting steps in, other patient's families? It's one of many instances where there's a valid reason for the technology to be implemented as such but since doctors usually aren't thinking about the technology or security aspects they just perceive it as annoying.
• dboreham 3y ago
  I worked for a couple of years in a company that both developed EMR software and ran clinics -- we employed care providers directly. I assumed going in that this would present amazing opportunities for applying modern technology to improve efficiency, outcomes and both patient and provider experience. Of course that didn't work out the way I expected. I'm not sure if doctors were the problem because to be honest I didn't get to interact with doctors much. The medical providers I did talk to were very interested in using software to improve things, and also extremely smart -- much brighter than the average s/w engineer to be honest. What I did see however was that the need to make (more) money began to dominate, and nothing that we were doing to improve our EMR really had much of an impact on that, at least not a direct or profound one.
• dboreham 3y ago
  > In-N-Out instead of McDonalds Whenever I make this analogy here people jump in to say how much better McDonalds is :(
  • MOARDONGZPLZ 3y ago
    Make a less divisive or controversial analogy then. If people are getting hung up on the analogy and not focusing on the point you’re making, you’re making a bad analogy.
  • pif 3y ago
    Why do you care about the opinion of people who care about comparing fast food chains?
• voicedYoda 3y ago
  Hey Duff, you're right, healthcare is broken in so many places, and insurers are probably the worst in this morass. They selectively follow Milligan care guidelines, build tools that actively discourage anyone from understanding and/or fighting for fair care and bills, and basically pretend they're doing you a favor but making you pay for your services, then showing a marked down EoB that pretend like they saved you money but knocking off 80% of a bill that was prenegotiated, and you're the one footing the bill. Insurers have no incentive to make healthcare better, and though hospitals are disjointed they still make so much money, it doesn't matter how badly they are run. But aside from the insurance companies, the first large scale emr systems (Cerner, McKesson, and even Epic) were built as operational tools to essentially give accounting access to Crystal reports. Sure, electronic charts should make the patient's life better, and assist trained medical staff in tracking, however they ultimately are used to figure out how the CBO can game the insurer financial incentive system. CPT + ICD +modifiers (oh, and 85% of those cpt codes are under copyright by the corrupt AMA - yup i have a different bone to pick with them). I agree that operational dysfunction is the biggest problem in these behemoths, and there's so much ineptitude in administrative staffing that it's a nightmare. Doctors like to believe they're the bees knees and everyone should kowtow to them, but they usually can't run a business to save their lives. It's easy for them to simply blame an EMR than to acknowledge the truth of a dysfunctional system they are a part of. Glad to see you're still kicking ass, better than sameday.
  • nradov 3y ago
    Most patients who are unhappy about how much they have to pay should complain to their employer, not their nominal health insurer. The majority of US consumers reading this obtain their medical coverage from self-insured employers who use "insurance" companies mostly for network management and claims administration. It's the employer who ultimately pays for treatments. An insurance company will be happy to put together a custom plan for an employer under which plan members get as much care as they want for $0 out of pocket. This will be extremely expensive for the employer. (We can argue about whether health plans should be tied to employers at all but that's a separate issue.)
• tuxguy 3y ago
  what about openehr [0,1] it is fairly popular in europe. What is required for federal certification ? 0. https://openehr.org/ https://openehr.org/ 1. https://openehr.org/products_tools/platform/ https://openehr.org/products_tools/platform/
• deleted 3y ago
  [deleted]
• beaugunderson 3y ago
  OpenEMR also touts ONC certification.