3 ms·

Given the nature of EHR systems, it's just not realistic to have trial periods, because everything in a hospital is interdependent. Even the relatively small sy

by Zanfa 3y ago

Given the nature of EHR systems, it's just not realistic to have trial periods, because everything in a hospital is interdependent. Even the relatively small system I worked on did everything from billing, accounting, insurance, HR, inventory management, scheduling, integrations with medical equipment & third parties (e.g. national health systems) with per-speciality workflows and other automation. Most of it isn't even strictly health-related. Migrating one way is already a multi-year process, making it potentially two-way with low-latency data consistency for the duration of the trial sounds impossible. In an ideal world, the system would be modular and you could evaluate it piecemeal, but none of the big players are incentivized to make it possible. The standards that do exist are also very lax and legacy systems don't even support those. Something like a goverment intervention is probably required to break this stalemate.

peteradio 3y ago
> none of the big players are incentivized to make it possible Yea this is the problem. When well meaning startups attempt to make change they get acquired by a piece of shit sales behemoth. If somehow one could resist the acquisition and just eat everybodies lunch we'd all be better off.
- bombcar 3y ago
  The only way change will come is if some actually independent hospital develops open-source in-house software (under the strongest possible non-cooption license available, likely GPL3) over literal decades until it becomes a standard. It’ll be fought every step by the entire healthcare industry.
  - bdw5204 3y ago
    I don't think there is such a thing as an actually independent hospital anywhere. In most countries, the medical system seems to be a government monopoly. In America, it is an oligopoly that egregiously violates the anti-trust laws and whose real customers are the government and the health insurance companies. The entire industry seems like a politically connected bureaucratic nightmare of one kind or another in every country on earth. Solving that problem would require some way to allow doctors to become genuinely independent again[0] and to ensure that patients could choose their doctor. If doctors were genuinely independent, they would choose the best medical records software and that software would be able to open up files from competitors[1]. [0]: The main American blocker to this would be something called malpractice insurance which is extremely unaffordable and necessary to protect doctors from being bankrupted by lawsuits whenever they make a mistake. Hospitals can afford that insurance much more easily than independent doctors so they can basically buy up all the doctors. I suspect that an affordable public option for this insurance would help restore a competitive free market in medicine. [1]: I've heard first-hand from family members that the file formats for the different medical records software are incompatible. They convert medical records by actually typing the information from the other hospital's system into their system.
    - nradov 3y ago
      Medical malpractice insurance has only limited economies of scale. It's still possible for solo practitioners or small partnerships to afford in most cases. This isn't the biggest factor in driving provider market consolidation. The real factors driving consolidation are IT costs, negotiating power, and practitioner preferences. Even with modern SaaS products it's expensive for a small organization to operate an EHR and other IT infrastructure. Payer organizations have consolidated through M&A activity and are constantly trying to drive down prices so providers also consolidate to force payers to keep them in network regardless of prices. And many doctors just don't want to manage a small business; they would prefer to focus on treating patients and collect a steady paycheck. Your family members are wrong. There are standard file formats for sharing medical records across different software. The most common format is HL7 Continuity of Care Document (CCD) which can accommodate an entire patient chart in a single XML file. Every major EHR has supported CCD export and import for years under federal government certification criteria. If your family members had to do manual data entry then either their software wasn't configured correctly or they didn't know how to use it. https://www.healthit.gov/topic/certification-ehrs/certification-criteria https://www.healthit.gov/topic/certification-ehrs/certificat...
      - Zanfa 3y ago
        In my experience with FHIR, two documents from different sources can both be compliant while still semantically incompatible. The protocols are made flexible enough where human ingenuity lets you represent the same thing in so many similar, yet different ways.
        nradov 3y ago
        That's why most interoperability requirements are written based on Implementation Guides rather than baseline standards. The base HL7 standards (V2 Messaging, CDA, FHIR) are intended to do pretty much everything everywhere in the world. As such, they're loose on specifics such as required data elements and coding systems. Then IG authors take those baseline standards and constrain them for specific use cases in particular countries (realms). CCD is very well specified, although you might still find some EHRs that fail to comply with the standard in some minor ways. There is a project underway to migrate that data model to FHIR encoding but it's not finished yet; that will make document construction and parsing a bit easier but won't necessarily address compatibility issues. https://www.hl7.org/implement/standards/product_brief.cfm?product_id=447 https://www.hl7.org/implement/standards/product_brief.cfm?pr... https://hl7.org/fhir/us/ccda/ https://hl7.org/fhir/us/ccda/
  - zdragnar 3y ago
    You can't just build your own EMR and call it a day, unless you are very selective of your patients. Accepting Medicaid and, if memory serves, Medicare requires using a certified EHR/EMR system, and getting that certification is both time consuming and expensive. You aren't just fighting the healthcare industry, but also well-intentioned government regulations.

by Zanfa 3y ago

peteradio 3y ago

> none of the big players are incentivized to make it possible Yea this is the problem. When well meaning startups attempt to make change they get acquired by a piece of shit sales behemoth. If somehow one could resist the acquisition and just eat everybodies lunch we'd all be better off.

bombcar 3y ago
The only way change will come is if some actually independent hospital develops open-source in-house software (under the strongest possible non-cooption license available, likely GPL3) over literal decades until it becomes a standard. It’ll be fought every step by the entire healthcare industry.
- bdw5204 3y ago
  I don't think there is such a thing as an actually independent hospital anywhere. In most countries, the medical system seems to be a government monopoly. In America, it is an oligopoly that egregiously violates the anti-trust laws and whose real customers are the government and the health insurance companies. The entire industry seems like a politically connected bureaucratic nightmare of one kind or another in every country on earth. Solving that problem would require some way to allow doctors to become genuinely independent again[0] and to ensure that patients could choose their doctor. If doctors were genuinely independent, they would choose the best medical records software and that software would be able to open up files from competitors[1]. [0]: The main American blocker to this would be something called malpractice insurance which is extremely unaffordable and necessary to protect doctors from being bankrupted by lawsuits whenever they make a mistake. Hospitals can afford that insurance much more easily than independent doctors so they can basically buy up all the doctors. I suspect that an affordable public option for this insurance would help restore a competitive free market in medicine. [1]: I've heard first-hand from family members that the file formats for the different medical records software are incompatible. They convert medical records by actually typing the information from the other hospital's system into their system.
  - nradov 3y ago
    Medical malpractice insurance has only limited economies of scale. It's still possible for solo practitioners or small partnerships to afford in most cases. This isn't the biggest factor in driving provider market consolidation. The real factors driving consolidation are IT costs, negotiating power, and practitioner preferences. Even with modern SaaS products it's expensive for a small organization to operate an EHR and other IT infrastructure. Payer organizations have consolidated through M&A activity and are constantly trying to drive down prices so providers also consolidate to force payers to keep them in network regardless of prices. And many doctors just don't want to manage a small business; they would prefer to focus on treating patients and collect a steady paycheck. Your family members are wrong. There are standard file formats for sharing medical records across different software. The most common format is HL7 Continuity of Care Document (CCD) which can accommodate an entire patient chart in a single XML file. Every major EHR has supported CCD export and import for years under federal government certification criteria. If your family members had to do manual data entry then either their software wasn't configured correctly or they didn't know how to use it. https://www.healthit.gov/topic/certification-ehrs/certification-criteria https://www.healthit.gov/topic/certification-ehrs/certificat...
    - Zanfa 3y ago
      In my experience with FHIR, two documents from different sources can both be compliant while still semantically incompatible. The protocols are made flexible enough where human ingenuity lets you represent the same thing in so many similar, yet different ways.
      - nradov 3y ago
        That's why most interoperability requirements are written based on Implementation Guides rather than baseline standards. The base HL7 standards (V2 Messaging, CDA, FHIR) are intended to do pretty much everything everywhere in the world. As such, they're loose on specifics such as required data elements and coding systems. Then IG authors take those baseline standards and constrain them for specific use cases in particular countries (realms). CCD is very well specified, although you might still find some EHRs that fail to comply with the standard in some minor ways. There is a project underway to migrate that data model to FHIR encoding but it's not finished yet; that will make document construction and parsing a bit easier but won't necessarily address compatibility issues. https://www.hl7.org/implement/standards/product_brief.cfm?product_id=447 https://www.hl7.org/implement/standards/product_brief.cfm?pr... https://hl7.org/fhir/us/ccda/ https://hl7.org/fhir/us/ccda/
- zdragnar 3y ago
  You can't just build your own EMR and call it a day, unless you are very selective of your patients. Accepting Medicaid and, if memory serves, Medicare requires using a certified EHR/EMR system, and getting that certification is both time consuming and expensive. You aren't just fighting the healthcare industry, but also well-intentioned government regulations.