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EHRs: The hidden distraction in your doctor's office

71 points by pseudolus 1y ago

localghost3000 1y ago
I worked in health care tech for about 5 years. AI driven before it was cool. Took processes that normally took years down to a couple hours. Cutting edge stuff. What struck me over the years was the open hostility we faced from the staff. The admins would buy our product, then have us come do trainings. The clinicians seemed to resent every second of it and would just never use the tool. Towards the end of my tenure there, a PM said to me “the last thing these people want is to have to learn yet another workflow”. Which is when the penny dropped for me that our tool was just one of a bazillion being force fed to these poor people. They want to spend their time with patients not a screen. Despite it being the most mission driven I have ever felt about a product (we were literally trying to help cure cancer lol). I’ll never work in health care again. Like education, it’s a quagmire.
- Taikonerd 1y ago
  > I’ll never work in health care again. Like education, it’s a quagmire. Remember: there's a lot of "health care" out there. Even if doctors resent EHRs, there's also drug discovery software, telehealth software, embedded software in medical devices, etc!
  - chychiu 1y ago
    I work in building software as medical device. Can confirm it’s still a quagmire
    - Scoundreller 1y ago
      Maybe that's what they meant: doctors can always switch into "drug discovery software, telehealth software, embedded software in medical devices" and resent those too!
- leovander 1y ago
  > we were literally trying to help cure cancer lol Project Ronin?
- zaptheimpaler 1y ago
  Yeah doctors hate them because it's just shit software. It's something like Workday trash - software that's made to be extendable to every possible use case and save costs for the developer while being complete garbage to use. Even if it did work, it's then tailored to the priorities of legal and management rather than doctors.
- II2II 1y ago
  > Towards the end of my tenure there, a PM said to me “the last thing these people want is to have to learn yet another workflow”. I suspect that people entering medicine do so to address human needs, and have very little interest in dealing with technology (or handling traditional paperwork for that matter). Couple that with a perception that pretty much anything digital being obsolete before it reaches market, and even more so when it can take upwards of a decade for the product to reach them, and you are left with a group of people who have nothing but dread about being stuck on a never ending treadmill that is outside their scope of interest and expertise. Take that opinion with a grain of salt though. My background is in that other quagmire: education. I have seen some amazing tools developed over the years that were abandoned, so everyone had to move on. Worse yet, no replacement was created for most of those tools so everyone is back where they were before the revolution happened. (I'm thinking specifically of software used by teachers and administrative staff, but something similar can be said for software used to deliver the curriculum.)
  - Scoundreller 1y ago
    University of Toronto used to basically run on a homegrown curriculum management system called CCNet up until ~2006. Basically run by one professor on a CPU under their desk. Course notes, grades, that kinda thing. I guess for future-proofing, the university moved to Blackboard. For a while, some courses were on Blackboard, others on CCNet. We had a professor poll the class and ask which they preferred, and all 240 of us in unison said "CCNET!" I still remember a quiz on Blackboard where the answer was something like "2" and it responded, sorry, the correct answer is 1.9999999999.
    - 3eb7988a1663 1y ago
      I have been looking for the term to describe this kind of enterprise software. It has glossy dashboards that are sold to VPs with the flash, "Monitor the entire company from one screen!" The actual rank and file users hate the product because little attention is ever given to the day-to-day workflows. Things barely work, super convoluted, etc. An accountant friend was just migrated to Workday(?) for their backend. Apparently whatever labyrinth configuration they have can only export 12,000 rows at a time. The official workaround they were given was to run reports in one week batches when a month of data is required. Previous solution could seemingly export unlimited amounts of data and time windows. A complete technical failure for which everyone should be ashamed.
- lvl155 1y ago
  It’s more than that actually. Where is actual interop? It’s been promised literally 10 years ago. It’s not that hard. People in Healthcare IT are just that bad. The only time I’ve experience interop in healthcare is due to actual organizations merging. That’s it. This entire space is filled with incompetence. Maybe providers will actually use the tools if they work consistently. Food for thought.
  - SoftTalker 1y ago
    It’s also strange to me that every time I go to the doctor I have to sit and fill out forms like I’m a new patient. All my insurance info, again. My entire medical history, again. Consent agreements, again. This experience hasn’t changed in decades, and I don’t understand why. I’ve asked, why do you need all this again and the answer is usually “oh we have a new system” or “we need to know if anything changed” (but that’s not what the forms ask).
    - dboreham 1y ago
      Quick guess: 1. lawyers and 2. principal/agent problem (the providers don't give a crap about your wasted time and the bad data they're collecting).
    - fn-mote 1y ago
      My observation has been that after filling out the form, the office skims it and enters nothing in the computer. I guess that's the "nothing changed" situation. Patient time is worth 0 to the medical system.
  - candiddevmike 1y ago
    FHIR was supposed to be the interopt but the end results look more like schemaless blobs of contained fields. But hey, at least I can find all the data related to a patient ID, I guess.
    - Taikonerd 1y ago
      There's actually been significant progress towards interop in the last 10 years. HIEs (Health Information Exchanges) such as CommonWell are steadily improving and covering more patients. Recently there's been a big push for TEFCA (Trusted Exchange Framework and Common Agreement) as the network-of-networks that federates all the different HIEs. It's been slow, but it's progressing. As usual, the problem isn't really technological -- it's getting all these different stakeholders, with different business models, etc, to agree on how it should work.
- Scoundreller 1y ago
  Most of my experience is on the pharmacy side, and tech basically saved pharmacy, from recordkeeping, insurance claims, accounting to inventory. But it was voluntary (for the organizations, not so much the staff). There was no need for government to shower pharmacies with money to adopt it because it paid for itself. I'm sure a lot of the staff initially met it with the same hostility. Even in 2010 when I was more in the field, we still had staff where their only computer experience/use was at work and otherwise lived an offline life. Can't say I saw a pharmacy that didn't have a computer since the early 90s in Canada (and my memory doesn't go before that). And before that, at least they used typewriters. Meanwhile my GP was all-paper well into the 2000s except for some billing stuff. God help anyone that had to read his notes. But sometimes you're reimbursed sufficiently that there is no driver to change workflows even if it would be economic. Ontario Canada.
- tbs_ 1y ago
  That resistance to change is just human nature. I work on much lower stakes line of business apps and the new thing can be _objectively_ better in every way and there will still be significant pushback from a large percentage of the userbase.
- deleted 1y ago
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- fluidcruft 1y ago
  I work in hospitals and it's just a constant stream from IT of "oh you just figured it out! congratulations! time to change they way you do things! this time we've solved all your problems that you're not complaining about! try to reengineer how to do anything now! lol! we hear you and feel your pain! here read ten pages of drivel that tells you how important and amazing IT is but won't actually tell you how to do anything with the new new tools and lives in some fantasyland that has nothing to do with the work that you actually need to get done!" all while simultaneously making every single computer and workflow somehow slower and more complex. Add another login here... force a quicker logout there... And then admin will come in with "thanks IT! you're doing amazing work! by the way everyone else we expect your productivity and caseload to increase!" Meanwhile getting things to work is filing tickets followed by "oh gosh that's so complex!" and months of moron pitcrew showing up " to fix it" who can't fix anything and who seem to think it's just that we're dumbasses who can't figure out who to reboot a computer. Honestly it's difficult to not grow the instant opinion that IT should just shut the fuck up and fire themselves. Who the hell do they even work for?
  - nucleardog 1y ago
    > Honestly it's difficult to not grow the instant opinion that IT should just shut the fuck up and fire themselves. Who the hell do they even work for? Management. Management whose goals and incentives don't align with yours. Or IT's. If management cared about your experience and quality of life, then presumably they'd be riding IT to get shit fixed. They'd be providing staff and resources necessary to resolve the issues. They'd be consulting with the staff using the programs before buying/deploying them. They'd be consulting with IT before buying/deploying them. They're not because they don't care. They went and bought some EHR system and an expensive support contract based pretty much entirely on price and/or how many golf games the vendor would pay for, dropped the steaming pile of turds into IT's lap, and had them implement it. They probably also told them to go ahead and integrate it with all the other systems in use that they sourced the same way. Meanwhile, every time they've done a budget for the past 20 years they've cut IT just a bit more because it's a cost center so the lower you can get that on your spreadsheet, the better you look, so there's like two kids and a grumpy old balding guy who spends most of his day working on reports for audit and compliance and they're responsible for the entire hospital. (At the hospital one friend worked at he was responsible for taking support tickets along-side the two other IT staff, working the on-call, and also _every single integration between systems in the hospital_. He wasn't a software developer or anything. He'd just started as purely help desk and seemed to have a vague idea how to write documentation and only cost like $35k/yr so he was clearly the best person to be responsible for communicating with all the vendors and making sure the EHR system could talk to the MRI machines.) But don't worry, even if this comedy of errors somehow gets to a working state... when that contract's up for renewal, they're going to look at the price and if a better one comes along they'll do the same thing again. Same for every other system in use all of which will have a ripple effect across every other system. Hey, at least you have job securi--what's that? The hospital was just bought by private equity and merged with another hospital and the entire IT department's laid off effective immediately?
- devilbunny 1y ago
  In fourteen years at one hospital we have had two completely different EMRs as well as the old electronic record system that didn't have charting but allowed lab lookup, scans of documents, etc. The two older ones are still running in read-only mode because Epic can't look at them, so any records older than 2022 are only in there. Cardiology, radiology, endoscopy, and labor and delivery all have their own systems for their internal usage while releasing final results to Epic. I don't object to the idea that these products are made for admins. It's a business and it needs to make money to survive. I object to the idea that making a product for sale to admins precludes making it at least usable for those who actually put in the data.
mitchbob 1y ago
Obligatory mention of Atul Gawande's piece in the New Yorker, still a classic: https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers https://www.newyorker.com/magazine/2018/11/12/why-doctors-ha... https://web.archive.org/web/20250104014248/https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers https://web.archive.org/web/20250104014248/https://www.newyo... The fun part is about 4/5 of the way in and starts with > Some people are pushing back. Neil R. Malhotra is a boyish, energetic, forty-three-year-old neurosurgeon who has made his mark at the University of Pennsylvania as something of a tinkerer. He has a knack for tackling difficult medical problems. In the past year alone, he has published papers on rebuilding spinal disks using tissue engineering, on a better way to teach residents how to repair cerebral aneurysms, and on which spinal-surgery techniques have the lowest level of blood loss. When his hospital’s new electronic-medical-record system arrived, he immediately decided to see if he could hack the system.
ChrisMarshallNY 1y ago
This is where user-friendliness is a requirement, not a luxury. Anyone who has ever looked at an EHR/EPIC screen, can tell you that the 1990s Web called, and wants its tables and frames back. In fact, one doctor I went to, still ran Windows 95 (in 2009), because they didn't want to deal with new interfaces. Engineers are notoriously unsympathetic to usability and simple GUIs, but I have found them to be an absolute gold mine, if you want people to actually use your product. Apple and Google are trillion-dollar companies, now, mainly because of their simple, usable UX.
- mulmen 1y ago
  I can't quite tell if you are saying the tables and frames are a better UX than Apple and Google. Personally I find frames and tables far more user friendly than the constantly shifting and indecipherable UX that Apple forces on us with updates.
  - ChrisMarshallNY 1y ago
    Well, it doesn't matter what you or I think of it. It does matter, however, what a doctor thinks of it. As the other comment pointed out, it's a balance. Simple is not the same as user-friendly, but they live on the same street. Doctors routinely deal with concepts that would confound me, but they are often quite technophobic, when it comes to computers. I have a friend that's a really skilled anesthesiologist, and is constantly asking me the most basic questions about his iPhone. Complex interfaces can be trained, but the magic is to have an interface that can be explored. If you train someone on rote, then they go to pieces, when anything changes. However, if you give them an interface that doesn't penalize them for exploring, and has clear, unambiguous affordances, they can easily adapt to things like updates, and they won't force you to have to maintain an ancient UX. But designing that kind of UX is quite difficult, which is why so few people do it.
    - dogmatism 1y ago
      nah I maintain my emacs config the problem is if someone changes something, that immediately impacts my efficiency which slows me down, then the patient's are pissed, and the administrators are too (which is ironic since they're the ones who signed off on the change) It has to be rote, no time for exploring
deleted 1y ago
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classichasclass 1y ago
I have a rule I don't do charting in front of patients. Maybe I'm old-fashioned, but I think it's rude. I might take a couple notes for later, but I do my charts in my office. I have never logged into an EHR in the exam room.
- dogmatism 1y ago
  you must print out old notes and test then and carry them into the room like you're pretending it's still in the paper chart days which is fine until something comes up that you didn't anticipate and print out. Then you can a) fake it, end the visit and follow up with pt later after you've looked it up or b) log in and get the info How do you have the pt's current med list? Does staff print it out after they've roomed the pt? Also, how are you ordering test/procedure? Writing it down for staff to do later? Violates most org's "CPOE" policies. Otherwise pt leaves and your staff has to call to schedule later, including labs that maybe they could do before they leave. You must have re-created a paper chart workflow in an EHR era which is only possible if your staff/org enables this for you Most of us are just employed widgets in the health care factory, and don't have the pull to get staff to work with this kind of workflow
  - classichasclass 1y ago
    I read the chart before I come in and get it fresh in my mind, and I do my orders immediately after I've seen them. This is Epic, so that tends to merge with the workflow, since it really wants you to do your documentation after you've done everything anyway. At least for the health maintenance stuff, I already know what needs to be done on that score before I even enter the room. If I have to grab something out of the record, like a result I wasn't expecting, I can quickly run back to the office (it's just around the corner) and come back. So, no, no paper.
    - dogmatism 1y ago
      I guess you're smarter than I am I can't remember all the details to a sufficient level that I feel comfortable that I'm not forgetting something and how do you know the current vitals and medication list? When the pt tells you they saw Dr X for Y (that you didn't know about) do you not want to look at that in case it impacts your plan? I guess you go out and come back? If you rx a med that needs lab monitoring, did you memorize that too? What about trends in labs? IDK, I need info while I'm seeing the pt
brown 1y ago
It’s true that many providers need a custom solution for their unique workflows, and the one-size-fits-all EHR is often a myth. The problem is that many EHRs try to solve this with customizations, which can be expensive and still feel like a compromise. On the other hand, when a team tries to build their own tools, they quickly realize they have to build a ton of compliance and interop code they never wanted to touch in the first place. That’s why open source platforms that handle the core infrastructure, like Medplum, HAPI, or OpenEMR, can be such a good starting point. They get the team 90% of the way there, so they can focus on what really matters: building a great UI/UX for their users. I don’t think providers truly want to go back to pen and paper, but they are looking for a better way. They can see the promise of what the solution could be, but they just haven't experienced it yet. Disclaimer: I work for Medplum.
- Taikonerd 1y ago
  I had this thought recently: "different hospitals have different workflows, and they want to see different stuff in the UI. But obviously they all want domain objects like "a patient," "an appointment," etc. Some company should offer a standard backend, and a starting template for a frontend that each hospital can customize however they want." It turns out that concept is called "Headless EHR," and it's pretty new.[0] Medplum (that the parent comment mentions) is one of the companies in this space. [0]: https://healthapiguy.substack.com/p/to-ehr-or-not-to-ehr https://healthapiguy.substack.com/p/to-ehr-or-not-to-ehr
- analog31 1y ago
  The custom workflows are because each clinic system is trying to figure out the best way to make money, not the best way to treat patients or serve clinicians. Disclaimer: I know a number of people who work for Epic. ;-)
- Scoundreller 1y ago
  Another issue with customizations is upgrades. Every upgrade you gotta validate all the customer-specific stuff. And you may end up re-creating bad workflows instead of updating to better ones.
osmano807 1y ago
Through the years I've worked with several EHR, be helping their development be using it in my practice, and each had it's idiosyncrasies. In my country there was proposals by the government of integration, but as all things that need coordination, we're nowhere close to sharing information between care centers. On a city we have several places controlled by the same entity, and they use an integrated EHR, so that a doctor who sees a patient at the emergency department has access to it's full history from the tertiary center, but at the same time the major tertiary/quaternary hospital isn't managed by that same entity and doesn't use the same EHR system, so we can't share information digitally. To make things worse, one system is made in Flash and all computers need to have an outdated Chrome version with the Flash plugin to run it. The other system is made in Java and some form of custom frontend framework, which works ok until it doesn't. Expanding on this other system made in Java, it's a federal hospital, and we have other internal systems which doesn't communicate with this main EHR, so for example emitting radiology requests need us to copy paste information from two systems (like address, contact numbers), and on top of that those systems aren't connected to the national patient registry, and daily I have residents redoing requests to merge the information, otherwise the requests are made invalid. I haven't touched on payments, imagine that each health insurance plan have different billings and we need to adapt the reality of what we did to what code better pays and input that in the system, so in practice the records are tailor fitted for each payment system, the actual procedure descriptions change, and we need to remember all that when billing and when treating the patient. Add on top of that system outage and unreliability, and I haven't even touched much on the UI, which sometimes loses input text data or sometimes we have to input in certain fields order or else the system crashes, or the fact that the tabindex isn't set on all fields and we need to click with the mouse to go to a field. Personally I've made a simple system for my private practice, while it doesn't have all the functionality, at least I'm the one to blame for it's particularities. I'm still exploring how to better input the clinical data, and I'm starting to think that general systems doesn't work. Each specialty has specific routines which need to be accommodated in the system, be it structured forms, be it clinical image input with annotations and commentary. The field is huge, and we're looking at how to design UX for immediate input and for later review, which sometimes are at odds (for example, a single textarea is easy to input, but how do we parse that data and present a timeline of clinical signs for example?). I guess we need a Linux of the EHR, something which we can iterate on. I've looked into open source projects, but I don't know if the field is entrenched in inherent complexity or we're all trying to model too generic abstractions on top so that a small team of developers can't comprehend the system. I should publish some code instead of rambling, but as the field is covered in regulations, I fear not even a code license can disclaim legal obligations.
dogmatism 1y ago
Y'all have no idea I'd elaborate but it wouldn't be good for my mental health edit: I'll give one example: my org can't even implement single-sign-on even though it's essentially all MS
UltraSane 1y ago
What is the alternative to EHR software? Thousands of pages of paper records that is impossible to rapidly search? Just being able to index and search health records is enough to justify the existence of EHR software.
- wswope 1y ago
  My ¢2 as someone who works in the space: EHRs are currently mandatory for compliance, reporting, and billing reasons — but completely unnecessary for the practice of medicine. The first big step towards untangling the gordian knot in my book is pivoting the industry to a capitated payment model, so compensation doesn’t require tying everything back to CPT & ICD codes, or tracking super-anal quality metrics for CMS. Once you make that jump, it’s pretty easy to imagine a lightweight note-taking + file-hosting platform that lets providers document summary data on a patient profile wiki-style, and attach notes to the profile in any arbitrary format using customizable templates. (I’m basically picturing a mashup of Google Drive + Wiki.js + Obsidian features.) Handling meds, orders, and referrals in a cross-platform way is starting to become a solved problem with FHIR. Tack on modular plugins for each of the above to the patient profile page, and you’ve reinvented the functionality of an EMR in a way that sucks far less and lets users get shit done.
polarbear67 1y ago
The biggest problem is security. I have yet to see a single EHR provider take security seriously despite HIPPA. It's only a matter of time before our medical records get leaked. My medical records have already been leaked twice, once through an EHR, and then again through my insurance provider.
onewheeltom 1y ago
I love having access to my medical information, but the transition will be difficult for the providers. My primary care doctor joined a practice that was already using electronic records because of the requirement for electronic records.
AngryData 1y ago
I would assume the most important feature for doctors for any device UI is that things don't always change. The entire medical field selects for people with great memory, and so even if it is a bit complex at first, as long as they only have to figure it out once they aren't going to easily forget. Even if some other design is more sleek and intuitive for a first time user, the change is only going to mess up the 95% of the established personnel. Any potential tool changes need to provide significant improvements over the old stuff and need to be done sparingly. To doctors these things are just tools, tools that they want to be able to pick up and put down 100 times a day without having to think about it. A good tool can be operated mostly on muscle memory and needs to remain static 99% of the time. Imagine if the tools a mechanic or carpenter used changed in form and function all the time. Last year they used a right handed circular saw, next year they are forced to use a left handed worm saw. Or imagine a framer picking up his hammer he has used for the last 10+ years and going to give it a swing and missing his mark, only to find out last night his boss took his old hammer and replaced it with one 2 ounces lighter and 2 inches longer and his boss refused to give his old one back. Or a guy digging through his toolbox to pull out a lesser used item like helicoils that he knows is in a medium sized yellow box, wasting tons of time looking and possibly going for a different and less ideal solution, only to find out later the helicoils were at some point put placed into a small sized blue box instead because someone else decided the old box was a bit too big and wasting space.
jmpz 1y ago
I've gotten the sense that many of the doctors I've encountered in Germany, who are busily typing at their computer, are frequently documenting their billing items. I started to think this after seeing the bills from multiple visits, where it's often broken out, in detail, what they had done. It's probably not as bad as that, there probably is some record-keeping happening in there. But considering how overworked most doctors are in the public health system, and how little time is commonly allocated for each patient, it can feel a bit like you didn't actually interact with a human doctor.
esbranson 1y ago
> Several countries are well on their way to this achievement, including Belgium, Denmark, Estonia, Lithuania, and Poland. Outside the E.U., countries such as Israel and Singapore also have very advanced systems, and after a rocky start, Australia’s My Health Record system seems to have found its footing. When any country mentioned hits the population of a small or medium US state, let us know how it goes. > Canada, China, India, and Japan also have EHR system initiatives in place at varying levels of maturity. Apparently the author could not care less. Apparently even the WHO could not care less, given the linked document tells us nothing. As always, it's the US versus the world, and the world is a giant nothingburger, save some flyover countries in Europe that could be part of Greater Germany or Greater Russia for all anyone cares. How is the UK, Germany, France, Russia, or China doing? Oh... > The United Kingdom was hoping to be a global leader in adopting interoperable health information systems, but a disastrous implementation of its National Programme for IT ended in 2011 after nine years and more than £10 billion. No doubt when the US gets the standards and apps done, the rest of the world will magically start working too. All the billions spent and the world piggybacks and gives nothing back, save, quite amusingly, China. As always.
- dllthomas 1y ago
  > When any country mentioned hits the population of a small or medium US state, let us know how it goes. I don't know "how it goes" but Poland has the population of a large US state.
  - esbranson 1y ago
    I stand corrected, chat bot agrees, it's most like Ohio or Illinois in population and GDP. > Ohio has long been a national leader in EHR adoption, with nearly 5,000 primary care physicians signed up through the Ohio Health Information Partnership—more than any other state as of around 2011.[1] Cincinnati-based HealthBridge operates one of the largest and most robust regional Health Information Exchanges (HIEs) in the U.S., servicing over 30 hospitals and 7,500 physicians across multiple states.[1] > In Ohio, a qualitative 2022 study surveyed provider and leadership perspectives on interoperability, finding high adoption rates: 96% of Medicaid‑PI‑eligible providers and hospitals had adopted EHR systems; non‑eligible providers reported adoption at 72%.[2] Epic Systems dominates the state as the top EHR vendor—used by 37% of Medicaid‑PI recipients and over 56% of other providers; smaller practices more often use NextGen, eClinicalWorks, etc.[2] > The 2021 Illinois Health IT Survey, based on 175 respondents representing ~3,800 providers, shows 100% EHR adoption among respondents—up from 61% in 2011.[3] Participation in an HIE rose from 32% in 2016 to 51% in 2021.[3] > For Illinois, key barriers reported: lack of provider Direct message addresses, reluctance of referring providers to accept messages (58%), and vendor cost constraints (46%).[3] Top reported improvements: decreased medication errors (64%), improved throughput (60%), and better reporting and referrals (60% and 57%).[3] The most difficult challenge: meeting program objectives (37%), followed by implementation cost and time (22%).[3] Overall chat bot indicates Poland has unique patient IDs so no record duplication compared to poor US implementations, high interop within P1 compared to poor interop between US vendors, and good patient data access compared to poor implementation by US vendors. Chat bot gave little about burnout but mentioned Polish and US AI developments under way. I would assume there's poor interop between Poland and other EU states, likely much worse than the US IMHO. Not really any mention of other topics like clinician workflow, burnout, and productivity re Poland. [1] https://www.healthpolicyohio.org/files/publications/hitprimer.pdf https://www.healthpolicyohio.org/files/publications/hitprime... [2] https://pmc.ncbi.nlm.nih.gov/articles/PMC10007006/ https://pmc.ncbi.nlm.nih.gov/articles/PMC10007006/ [3] https://hfs.illinois.gov/content/dam/soi/en/web/hfs/sitecollectiondocuments/2021ilhealthitsurvey.pdf https://hfs.illinois.gov/content/dam/soi/en/web/hfs/sitecoll...

71 points by pseudolus 1y ago

I worked in health care tech for about 5 years. AI driven before it was cool. Took processes that normally took years down to a couple hours. Cutting edge stuff. What struck me over the years was the open hostility we faced from the staff. The admins would buy our product, then have us come do trainings. The clinicians seemed to resent every second of it and would just never use the tool. Towards the end of my tenure there, a PM said to me “the last thing these people want is to have to learn yet another workflow”. Which is when the penny dropped for me that our tool was just one of a bazillion being force fed to these poor people. They want to spend their time with patients not a screen. Despite it being the most mission driven I have ever felt about a product (we were literally trying to help cure cancer lol). I’ll never work in health care again. Like education, it’s a quagmire.

Taikonerd 1y ago
> I’ll never work in health care again. Like education, it’s a quagmire. Remember: there's a lot of "health care" out there. Even if doctors resent EHRs, there's also drug discovery software, telehealth software, embedded software in medical devices, etc!
- chychiu 1y ago
  I work in building software as medical device. Can confirm it’s still a quagmire
  - Scoundreller 1y ago
    Maybe that's what they meant: doctors can always switch into "drug discovery software, telehealth software, embedded software in medical devices" and resent those too!
leovander 1y ago
> we were literally trying to help cure cancer lol Project Ronin?
zaptheimpaler 1y ago
Yeah doctors hate them because it's just shit software. It's something like Workday trash - software that's made to be extendable to every possible use case and save costs for the developer while being complete garbage to use. Even if it did work, it's then tailored to the priorities of legal and management rather than doctors.
II2II 1y ago
> Towards the end of my tenure there, a PM said to me “the last thing these people want is to have to learn yet another workflow”. I suspect that people entering medicine do so to address human needs, and have very little interest in dealing with technology (or handling traditional paperwork for that matter). Couple that with a perception that pretty much anything digital being obsolete before it reaches market, and even more so when it can take upwards of a decade for the product to reach them, and you are left with a group of people who have nothing but dread about being stuck on a never ending treadmill that is outside their scope of interest and expertise. Take that opinion with a grain of salt though. My background is in that other quagmire: education. I have seen some amazing tools developed over the years that were abandoned, so everyone had to move on. Worse yet, no replacement was created for most of those tools so everyone is back where they were before the revolution happened. (I'm thinking specifically of software used by teachers and administrative staff, but something similar can be said for software used to deliver the curriculum.)
- Scoundreller 1y ago
  University of Toronto used to basically run on a homegrown curriculum management system called CCNet up until ~2006. Basically run by one professor on a CPU under their desk. Course notes, grades, that kinda thing. I guess for future-proofing, the university moved to Blackboard. For a while, some courses were on Blackboard, others on CCNet. We had a professor poll the class and ask which they preferred, and all 240 of us in unison said "CCNET!" I still remember a quiz on Blackboard where the answer was something like "2" and it responded, sorry, the correct answer is 1.9999999999.
  - 3eb7988a1663 1y ago
    I have been looking for the term to describe this kind of enterprise software. It has glossy dashboards that are sold to VPs with the flash, "Monitor the entire company from one screen!" The actual rank and file users hate the product because little attention is ever given to the day-to-day workflows. Things barely work, super convoluted, etc. An accountant friend was just migrated to Workday(?) for their backend. Apparently whatever labyrinth configuration they have can only export 12,000 rows at a time. The official workaround they were given was to run reports in one week batches when a month of data is required. Previous solution could seemingly export unlimited amounts of data and time windows. A complete technical failure for which everyone should be ashamed.
lvl155 1y ago
It’s more than that actually. Where is actual interop? It’s been promised literally 10 years ago. It’s not that hard. People in Healthcare IT are just that bad. The only time I’ve experience interop in healthcare is due to actual organizations merging. That’s it. This entire space is filled with incompetence. Maybe providers will actually use the tools if they work consistently. Food for thought.
- SoftTalker 1y ago
  It’s also strange to me that every time I go to the doctor I have to sit and fill out forms like I’m a new patient. All my insurance info, again. My entire medical history, again. Consent agreements, again. This experience hasn’t changed in decades, and I don’t understand why. I’ve asked, why do you need all this again and the answer is usually “oh we have a new system” or “we need to know if anything changed” (but that’s not what the forms ask).
  - dboreham 1y ago
    Quick guess: 1. lawyers and 2. principal/agent problem (the providers don't give a crap about your wasted time and the bad data they're collecting).
  - fn-mote 1y ago
    My observation has been that after filling out the form, the office skims it and enters nothing in the computer. I guess that's the "nothing changed" situation. Patient time is worth 0 to the medical system.
- candiddevmike 1y ago
  FHIR was supposed to be the interopt but the end results look more like schemaless blobs of contained fields. But hey, at least I can find all the data related to a patient ID, I guess.
  - Taikonerd 1y ago
    There's actually been significant progress towards interop in the last 10 years. HIEs (Health Information Exchanges) such as CommonWell are steadily improving and covering more patients. Recently there's been a big push for TEFCA (Trusted Exchange Framework and Common Agreement) as the network-of-networks that federates all the different HIEs. It's been slow, but it's progressing. As usual, the problem isn't really technological -- it's getting all these different stakeholders, with different business models, etc, to agree on how it should work.
Scoundreller 1y ago
Most of my experience is on the pharmacy side, and tech basically saved pharmacy, from recordkeeping, insurance claims, accounting to inventory. But it was voluntary (for the organizations, not so much the staff). There was no need for government to shower pharmacies with money to adopt it because it paid for itself. I'm sure a lot of the staff initially met it with the same hostility. Even in 2010 when I was more in the field, we still had staff where their only computer experience/use was at work and otherwise lived an offline life. Can't say I saw a pharmacy that didn't have a computer since the early 90s in Canada (and my memory doesn't go before that). And before that, at least they used typewriters. Meanwhile my GP was all-paper well into the 2000s except for some billing stuff. God help anyone that had to read his notes. But sometimes you're reimbursed sufficiently that there is no driver to change workflows even if it would be economic. Ontario Canada.
tbs_ 1y ago
That resistance to change is just human nature. I work on much lower stakes line of business apps and the new thing can be _objectively_ better in every way and there will still be significant pushback from a large percentage of the userbase.
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fluidcruft 1y ago
I work in hospitals and it's just a constant stream from IT of "oh you just figured it out! congratulations! time to change they way you do things! this time we've solved all your problems that you're not complaining about! try to reengineer how to do anything now! lol! we hear you and feel your pain! here read ten pages of drivel that tells you how important and amazing IT is but won't actually tell you how to do anything with the new new tools and lives in some fantasyland that has nothing to do with the work that you actually need to get done!" all while simultaneously making every single computer and workflow somehow slower and more complex. Add another login here... force a quicker logout there... And then admin will come in with "thanks IT! you're doing amazing work! by the way everyone else we expect your productivity and caseload to increase!" Meanwhile getting things to work is filing tickets followed by "oh gosh that's so complex!" and months of moron pitcrew showing up " to fix it" who can't fix anything and who seem to think it's just that we're dumbasses who can't figure out who to reboot a computer. Honestly it's difficult to not grow the instant opinion that IT should just shut the fuck up and fire themselves. Who the hell do they even work for?
- nucleardog 1y ago
  > Honestly it's difficult to not grow the instant opinion that IT should just shut the fuck up and fire themselves. Who the hell do they even work for? Management. Management whose goals and incentives don't align with yours. Or IT's. If management cared about your experience and quality of life, then presumably they'd be riding IT to get shit fixed. They'd be providing staff and resources necessary to resolve the issues. They'd be consulting with the staff using the programs before buying/deploying them. They'd be consulting with IT before buying/deploying them. They're not because they don't care. They went and bought some EHR system and an expensive support contract based pretty much entirely on price and/or how many golf games the vendor would pay for, dropped the steaming pile of turds into IT's lap, and had them implement it. They probably also told them to go ahead and integrate it with all the other systems in use that they sourced the same way. Meanwhile, every time they've done a budget for the past 20 years they've cut IT just a bit more because it's a cost center so the lower you can get that on your spreadsheet, the better you look, so there's like two kids and a grumpy old balding guy who spends most of his day working on reports for audit and compliance and they're responsible for the entire hospital. (At the hospital one friend worked at he was responsible for taking support tickets along-side the two other IT staff, working the on-call, and also _every single integration between systems in the hospital_. He wasn't a software developer or anything. He'd just started as purely help desk and seemed to have a vague idea how to write documentation and only cost like $35k/yr so he was clearly the best person to be responsible for communicating with all the vendors and making sure the EHR system could talk to the MRI machines.) But don't worry, even if this comedy of errors somehow gets to a working state... when that contract's up for renewal, they're going to look at the price and if a better one comes along they'll do the same thing again. Same for every other system in use all of which will have a ripple effect across every other system. Hey, at least you have job securi--what's that? The hospital was just bought by private equity and merged with another hospital and the entire IT department's laid off effective immediately?
devilbunny 1y ago
In fourteen years at one hospital we have had two completely different EMRs as well as the old electronic record system that didn't have charting but allowed lab lookup, scans of documents, etc. The two older ones are still running in read-only mode because Epic can't look at them, so any records older than 2022 are only in there. Cardiology, radiology, endoscopy, and labor and delivery all have their own systems for their internal usage while releasing final results to Epic. I don't object to the idea that these products are made for admins. It's a business and it needs to make money to survive. I object to the idea that making a product for sale to admins precludes making it at least usable for those who actually put in the data.

mitchbob 1y ago

Obligatory mention of Atul Gawande's piece in the New Yorker, still a classic: https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers https://www.newyorker.com/magazine/2018/11/12/why-doctors-ha... https://web.archive.org/web/20250104014248/https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers https://web.archive.org/web/20250104014248/https://www.newyo... The fun part is about 4/5 of the way in and starts with > Some people are pushing back. Neil R. Malhotra is a boyish, energetic, forty-three-year-old neurosurgeon who has made his mark at the University of Pennsylvania as something of a tinkerer. He has a knack for tackling difficult medical problems. In the past year alone, he has published papers on rebuilding spinal disks using tissue engineering, on a better way to teach residents how to repair cerebral aneurysms, and on which spinal-surgery techniques have the lowest level of blood loss. When his hospital’s new electronic-medical-record system arrived, he immediately decided to see if he could hack the system.

ChrisMarshallNY 1y ago

This is where user-friendliness is a requirement, not a luxury. Anyone who has ever looked at an EHR/EPIC screen, can tell you that the 1990s Web called, and wants its tables and frames back. In fact, one doctor I went to, still ran Windows 95 (in 2009), because they didn't want to deal with new interfaces. Engineers are notoriously unsympathetic to usability and simple GUIs, but I have found them to be an absolute gold mine, if you want people to actually use your product. Apple and Google are trillion-dollar companies, now, mainly because of their simple, usable UX.

mulmen 1y ago
I can't quite tell if you are saying the tables and frames are a better UX than Apple and Google. Personally I find frames and tables far more user friendly than the constantly shifting and indecipherable UX that Apple forces on us with updates.
- ChrisMarshallNY 1y ago
  Well, it doesn't matter what you or I think of it. It does matter, however, what a doctor thinks of it. As the other comment pointed out, it's a balance. Simple is not the same as user-friendly, but they live on the same street. Doctors routinely deal with concepts that would confound me, but they are often quite technophobic, when it comes to computers. I have a friend that's a really skilled anesthesiologist, and is constantly asking me the most basic questions about his iPhone. Complex interfaces can be trained, but the magic is to have an interface that can be explored. If you train someone on rote, then they go to pieces, when anything changes. However, if you give them an interface that doesn't penalize them for exploring, and has clear, unambiguous affordances, they can easily adapt to things like updates, and they won't force you to have to maintain an ancient UX. But designing that kind of UX is quite difficult, which is why so few people do it.
  - dogmatism 1y ago
    nah I maintain my emacs config the problem is if someone changes something, that immediately impacts my efficiency which slows me down, then the patient's are pissed, and the administrators are too (which is ironic since they're the ones who signed off on the change) It has to be rote, no time for exploring

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classichasclass 1y ago

I have a rule I don't do charting in front of patients. Maybe I'm old-fashioned, but I think it's rude. I might take a couple notes for later, but I do my charts in my office. I have never logged into an EHR in the exam room.

dogmatism 1y ago
you must print out old notes and test then and carry them into the room like you're pretending it's still in the paper chart days which is fine until something comes up that you didn't anticipate and print out. Then you can a) fake it, end the visit and follow up with pt later after you've looked it up or b) log in and get the info How do you have the pt's current med list? Does staff print it out after they've roomed the pt? Also, how are you ordering test/procedure? Writing it down for staff to do later? Violates most org's "CPOE" policies. Otherwise pt leaves and your staff has to call to schedule later, including labs that maybe they could do before they leave. You must have re-created a paper chart workflow in an EHR era which is only possible if your staff/org enables this for you Most of us are just employed widgets in the health care factory, and don't have the pull to get staff to work with this kind of workflow
- classichasclass 1y ago
  I read the chart before I come in and get it fresh in my mind, and I do my orders immediately after I've seen them. This is Epic, so that tends to merge with the workflow, since it really wants you to do your documentation after you've done everything anyway. At least for the health maintenance stuff, I already know what needs to be done on that score before I even enter the room. If I have to grab something out of the record, like a result I wasn't expecting, I can quickly run back to the office (it's just around the corner) and come back. So, no, no paper.
  - dogmatism 1y ago
    I guess you're smarter than I am I can't remember all the details to a sufficient level that I feel comfortable that I'm not forgetting something and how do you know the current vitals and medication list? When the pt tells you they saw Dr X for Y (that you didn't know about) do you not want to look at that in case it impacts your plan? I guess you go out and come back? If you rx a med that needs lab monitoring, did you memorize that too? What about trends in labs? IDK, I need info while I'm seeing the pt

brown 1y ago

It’s true that many providers need a custom solution for their unique workflows, and the one-size-fits-all EHR is often a myth. The problem is that many EHRs try to solve this with customizations, which can be expensive and still feel like a compromise. On the other hand, when a team tries to build their own tools, they quickly realize they have to build a ton of compliance and interop code they never wanted to touch in the first place. That’s why open source platforms that handle the core infrastructure, like Medplum, HAPI, or OpenEMR, can be such a good starting point. They get the team 90% of the way there, so they can focus on what really matters: building a great UI/UX for their users. I don’t think providers truly want to go back to pen and paper, but they are looking for a better way. They can see the promise of what the solution could be, but they just haven't experienced it yet. Disclaimer: I work for Medplum.

Taikonerd 1y ago
I had this thought recently: "different hospitals have different workflows, and they want to see different stuff in the UI. But obviously they all want domain objects like "a patient," "an appointment," etc. Some company should offer a standard backend, and a starting template for a frontend that each hospital can customize however they want." It turns out that concept is called "Headless EHR," and it's pretty new.[0] Medplum (that the parent comment mentions) is one of the companies in this space. [0]: https://healthapiguy.substack.com/p/to-ehr-or-not-to-ehr https://healthapiguy.substack.com/p/to-ehr-or-not-to-ehr
analog31 1y ago
The custom workflows are because each clinic system is trying to figure out the best way to make money, not the best way to treat patients or serve clinicians. Disclaimer: I know a number of people who work for Epic. ;-)
Scoundreller 1y ago
Another issue with customizations is upgrades. Every upgrade you gotta validate all the customer-specific stuff. And you may end up re-creating bad workflows instead of updating to better ones.

osmano807 1y ago

Through the years I've worked with several EHR, be helping their development be using it in my practice, and each had it's idiosyncrasies. In my country there was proposals by the government of integration, but as all things that need coordination, we're nowhere close to sharing information between care centers. On a city we have several places controlled by the same entity, and they use an integrated EHR, so that a doctor who sees a patient at the emergency department has access to it's full history from the tertiary center, but at the same time the major tertiary/quaternary hospital isn't managed by that same entity and doesn't use the same EHR system, so we can't share information digitally. To make things worse, one system is made in Flash and all computers need to have an outdated Chrome version with the Flash plugin to run it. The other system is made in Java and some form of custom frontend framework, which works ok until it doesn't. Expanding on this other system made in Java, it's a federal hospital, and we have other internal systems which doesn't communicate with this main EHR, so for example emitting radiology requests need us to copy paste information from two systems (like address, contact numbers), and on top of that those systems aren't connected to the national patient registry, and daily I have residents redoing requests to merge the information, otherwise the requests are made invalid. I haven't touched on payments, imagine that each health insurance plan have different billings and we need to adapt the reality of what we did to what code better pays and input that in the system, so in practice the records are tailor fitted for each payment system, the actual procedure descriptions change, and we need to remember all that when billing and when treating the patient. Add on top of that system outage and unreliability, and I haven't even touched much on the UI, which sometimes loses input text data or sometimes we have to input in certain fields order or else the system crashes, or the fact that the tabindex isn't set on all fields and we need to click with the mouse to go to a field. Personally I've made a simple system for my private practice, while it doesn't have all the functionality, at least I'm the one to blame for it's particularities. I'm still exploring how to better input the clinical data, and I'm starting to think that general systems doesn't work. Each specialty has specific routines which need to be accommodated in the system, be it structured forms, be it clinical image input with annotations and commentary. The field is huge, and we're looking at how to design UX for immediate input and for later review, which sometimes are at odds (for example, a single textarea is easy to input, but how do we parse that data and present a timeline of clinical signs for example?). I guess we need a Linux of the EHR, something which we can iterate on. I've looked into open source projects, but I don't know if the field is entrenched in inherent complexity or we're all trying to model too generic abstractions on top so that a small team of developers can't comprehend the system. I should publish some code instead of rambling, but as the field is covered in regulations, I fear not even a code license can disclaim legal obligations.

dogmatism 1y ago

Y'all have no idea I'd elaborate but it wouldn't be good for my mental health edit: I'll give one example: my org can't even implement single-sign-on even though it's essentially all MS

UltraSane 1y ago

What is the alternative to EHR software? Thousands of pages of paper records that is impossible to rapidly search? Just being able to index and search health records is enough to justify the existence of EHR software.

wswope 1y ago
My ¢2 as someone who works in the space: EHRs are currently mandatory for compliance, reporting, and billing reasons — but completely unnecessary for the practice of medicine. The first big step towards untangling the gordian knot in my book is pivoting the industry to a capitated payment model, so compensation doesn’t require tying everything back to CPT & ICD codes, or tracking super-anal quality metrics for CMS. Once you make that jump, it’s pretty easy to imagine a lightweight note-taking + file-hosting platform that lets providers document summary data on a patient profile wiki-style, and attach notes to the profile in any arbitrary format using customizable templates. (I’m basically picturing a mashup of Google Drive + Wiki.js + Obsidian features.) Handling meds, orders, and referrals in a cross-platform way is starting to become a solved problem with FHIR. Tack on modular plugins for each of the above to the patient profile page, and you’ve reinvented the functionality of an EMR in a way that sucks far less and lets users get shit done.

polarbear67 1y ago

The biggest problem is security. I have yet to see a single EHR provider take security seriously despite HIPPA. It's only a matter of time before our medical records get leaked. My medical records have already been leaked twice, once through an EHR, and then again through my insurance provider.

onewheeltom 1y ago

I love having access to my medical information, but the transition will be difficult for the providers. My primary care doctor joined a practice that was already using electronic records because of the requirement for electronic records.

AngryData 1y ago

I would assume the most important feature for doctors for any device UI is that things don't always change. The entire medical field selects for people with great memory, and so even if it is a bit complex at first, as long as they only have to figure it out once they aren't going to easily forget. Even if some other design is more sleek and intuitive for a first time user, the change is only going to mess up the 95% of the established personnel. Any potential tool changes need to provide significant improvements over the old stuff and need to be done sparingly. To doctors these things are just tools, tools that they want to be able to pick up and put down 100 times a day without having to think about it. A good tool can be operated mostly on muscle memory and needs to remain static 99% of the time. Imagine if the tools a mechanic or carpenter used changed in form and function all the time. Last year they used a right handed circular saw, next year they are forced to use a left handed worm saw. Or imagine a framer picking up his hammer he has used for the last 10+ years and going to give it a swing and missing his mark, only to find out last night his boss took his old hammer and replaced it with one 2 ounces lighter and 2 inches longer and his boss refused to give his old one back. Or a guy digging through his toolbox to pull out a lesser used item like helicoils that he knows is in a medium sized yellow box, wasting tons of time looking and possibly going for a different and less ideal solution, only to find out later the helicoils were at some point put placed into a small sized blue box instead because someone else decided the old box was a bit too big and wasting space.

jmpz 1y ago

I've gotten the sense that many of the doctors I've encountered in Germany, who are busily typing at their computer, are frequently documenting their billing items. I started to think this after seeing the bills from multiple visits, where it's often broken out, in detail, what they had done. It's probably not as bad as that, there probably is some record-keeping happening in there. But considering how overworked most doctors are in the public health system, and how little time is commonly allocated for each patient, it can feel a bit like you didn't actually interact with a human doctor.

esbranson 1y ago

> Several countries are well on their way to this achievement, including Belgium, Denmark, Estonia, Lithuania, and Poland. Outside the E.U., countries such as Israel and Singapore also have very advanced systems, and after a rocky start, Australia’s My Health Record system seems to have found its footing. When any country mentioned hits the population of a small or medium US state, let us know how it goes. > Canada, China, India, and Japan also have EHR system initiatives in place at varying levels of maturity. Apparently the author could not care less. Apparently even the WHO could not care less, given the linked document tells us nothing. As always, it's the US versus the world, and the world is a giant nothingburger, save some flyover countries in Europe that could be part of Greater Germany or Greater Russia for all anyone cares. How is the UK, Germany, France, Russia, or China doing? Oh... > The United Kingdom was hoping to be a global leader in adopting interoperable health information systems, but a disastrous implementation of its National Programme for IT ended in 2011 after nine years and more than £10 billion. No doubt when the US gets the standards and apps done, the rest of the world will magically start working too. All the billions spent and the world piggybacks and gives nothing back, save, quite amusingly, China. As always.

dllthomas 1y ago
> When any country mentioned hits the population of a small or medium US state, let us know how it goes. I don't know "how it goes" but Poland has the population of a large US state.
- esbranson 1y ago
  I stand corrected, chat bot agrees, it's most like Ohio or Illinois in population and GDP. > Ohio has long been a national leader in EHR adoption, with nearly 5,000 primary care physicians signed up through the Ohio Health Information Partnership—more than any other state as of around 2011.[1] Cincinnati-based HealthBridge operates one of the largest and most robust regional Health Information Exchanges (HIEs) in the U.S., servicing over 30 hospitals and 7,500 physicians across multiple states.[1] > In Ohio, a qualitative 2022 study surveyed provider and leadership perspectives on interoperability, finding high adoption rates: 96% of Medicaid‑PI‑eligible providers and hospitals had adopted EHR systems; non‑eligible providers reported adoption at 72%.[2] Epic Systems dominates the state as the top EHR vendor—used by 37% of Medicaid‑PI recipients and over 56% of other providers; smaller practices more often use NextGen, eClinicalWorks, etc.[2] > The 2021 Illinois Health IT Survey, based on 175 respondents representing ~3,800 providers, shows 100% EHR adoption among respondents—up from 61% in 2011.[3] Participation in an HIE rose from 32% in 2016 to 51% in 2021.[3] > For Illinois, key barriers reported: lack of provider Direct message addresses, reluctance of referring providers to accept messages (58%), and vendor cost constraints (46%).[3] Top reported improvements: decreased medication errors (64%), improved throughput (60%), and better reporting and referrals (60% and 57%).[3] The most difficult challenge: meeting program objectives (37%), followed by implementation cost and time (22%).[3] Overall chat bot indicates Poland has unique patient IDs so no record duplication compared to poor US implementations, high interop within P1 compared to poor interop between US vendors, and good patient data access compared to poor implementation by US vendors. Chat bot gave little about burnout but mentioned Polish and US AI developments under way. I would assume there's poor interop between Poland and other EU states, likely much worse than the US IMHO. Not really any mention of other topics like clinician workflow, burnout, and productivity re Poland. [1] https://www.healthpolicyohio.org/files/publications/hitprimer.pdf https://www.healthpolicyohio.org/files/publications/hitprime... [2] https://pmc.ncbi.nlm.nih.gov/articles/PMC10007006/ https://pmc.ncbi.nlm.nih.gov/articles/PMC10007006/ [3] https://hfs.illinois.gov/content/dam/soi/en/web/hfs/sitecollectiondocuments/2021ilhealthitsurvey.pdf https://hfs.illinois.gov/content/dam/soi/en/web/hfs/sitecoll...