7 ms·

Why Health Care Tech Is Still So Bad

62 points by digisth 12y ago

masamune__ 12y ago
http://www.bloomberg.com/news/articles/2015-03-20/dozens-of-startups-in-obamacare-s-wake-reveal-law-as-job-creator http://www.bloomberg.com/news/articles/2015-03-20/dozens-of-... I want real statistics...anyone with interesting source?
angersock 12y ago
I work in the medtech/health IT field at a startup doing a lot of clinical analytics. There's a very blunt and obvious explanation of what's wrong here, and it's the very unpolitical one. Here's the deal. Physicians and nurses and administrators are overworked and untrained to handle a modern operational model. The hospitals tend to be based around politics rather than patient care, though the party line is invariably "help the patient". Doctors will, under the aegis of "help the patient", justify hoarding equipment, setting up alarm thresholds that screw up operations across the unit, block acquisitions, and in general just make everything terrible left to their own devices. Nurses are overworked and are charged with increasingly important parts of patient care, and at the same time are treated as annoying appendages of the rest of the medical apparatus and not given the respect or authority that they require to perform well at their jobs. Billing is handled through arcane back-and-forths between the care providers themselves, the hospitals, insurance companies, the government, and collections agencies. I've seen at least one local children's hospital (the economics of such institutions are quite fascinating) have banking and financing services occupying the same building as care (something you'd expect at a car lot, not a place where injured children are healed). Claims may take months or years to process, which is absurd. The whole stinking mess should have been grist for the capitalist grinder decades ago. However, clever regulatory capture by hospitals and manufacturers and labor policies restricting the supply of new physicians has managed to prevent any of the normal efficiencies from being introduced. When trying to introduce new technology, you have to fight the most conservative and risk-averse institutions you'll ever encounter. People that do not understand basic statistics or mathematics, or that flat out refuse to recognize the value of operational data research in making decisions because "they know better". You'll be turned away because you're not one of the chosen few, and ignored unless you can convince them that they get to put their name on the new shiny. This is but the first level of the fractal of sadness and absurdity that is modern medicine in America.
- ddw 12y ago
  Spot on. And then you get the pessimistic doctor that says you're trying to ruin "the art of medicine."
- bsder 12y ago
  > I work in the medtech/health IT field at a startup doing a lot of clinical analytics. There's a very blunt and obvious explanation of what's wrong here, and it's the very unpolitical one. Actually, it's very political--it's the AMA--the American Medical Association. The doctors are fighting the automation of their jobs tooth and nail because once we have data we can see that ... gee ... most of them suck. Nurses could do their job ... better.
  - angersock 12y ago
    I rather meant to explain that the problems--and their implied solutions--are not politically viable, mainly because of what you've mentioned. :)
- refurb 12y ago
  I think your take is remarkably accurate. I have a good friend who works at a world-renoun hospital in the US and the stories he tells! Politics rules decision making in the hospital. Leadership (including the docs) are constantly clamouring for more power. Normal market forces that would normally incentivize efficiency are no match at all.
- siculars 12y ago
  Seconded. I may or may not have left a similar medtech job but this job may or may not have been in the belly of the beast.... a very well known teaching hospital. Politics may or may not have run rampant and the leaders charged with modernizing the organization may or may not have appreciated technology or may or may not have known enough to support those who did. Oh well.
- HillRat 12y ago
  As I told a developer earlier this week, trying to disrupt healthcare is like starting an avalanche by tossing pebbles at a boulder. Between institutions, carriers, and the godawful state of interoperability technologies (I've been on the standards committees, I accept my share of the blame), it's essentially impossible to really advance the state of the art, even though there's a real need for technology that helps enable the organizational advances in clinical practice we've seen over the past several years.
bsder 12y ago
There are political issues, but there is also an impedance mismatch between "medical programming" and 99.9% of all other programming. Nobody in programming gives two shits about quality. "Ship it and patch it later" is a religion. That doesn't work in healthcare. If your software screws up, somebody dies, and you are on the hook for several million dollars. (See: Therac-25 and concurrency problems https://en.wikipedia.org/wiki/Therac-25 https://en.wikipedia.org/wiki/Therac-25) So, the technology pace winds up moving much slower. I also like that they mentioned false positives in the article being a problem. That's an understatement. A friend had to wear a portable defibrillator vest after a heart attack. It was atrocious. It sounded warnings after a shower. The battery was hard to keep in and sounded warnings when one popped out. After a week, lifesaving technology was back with the doctor because it was too irritating to use. This wasn't some random schmuck. This was a person who used to write technical users manuals. A normal person would have had no hope.
- angersock 12y ago
  So, that's the shitty thing, right? If you're software is being used in, say, an ICU--guess what? The patient is already in bad shape. There's some weird conception in the medical industry and public at large that the software has to be perfect the first time, every time. And that just isn't possible or economical. And then when people try to do that, they find out that getting test data or trials done is near impossible. Hell, you can't even get the standards to develop with without shelling out thousands and thousands of dollars. The same institutions that clamor so hard for absurd reliability in software make it almost impossible to test that software safely without a gigantic war chest. And they look the other way when they fail to provide patient care or outright butcher people. The difference between your code and a doctor? You can fix your code after it kills a patient. EDIT: And no, this doesn't mean that I suggest that we all should write bad software until the bodycount suggests a refactor. What I mean is that we should write it as well as we're able, and that we should fix it as data for improvement becomes available. On a related note, this is why decision-making should--for now anyways--rest with a physician. We can give them better advice, but the moral accountability should remain with the human at the bedside.
  - 12y ago
karzeem 12y ago
"In health care, changes in the way we organize our work will most likely be the key to improvement. This means training students and physicians to focus on the patient despite the demands of the computers. It means creating new ways to build teamwork once doctors and nurses are no longer yoked to the nurse’s station by a single paper record. It means federal policies that promote the seamless sharing of data between different systems in different settings." I think the author is right about the problems, and these solutions seem sound. These are the kinds of things ossified institutions always say, and they're actually usually right (e.g. Bill Gates's prescient Internet Tidal Wave memo which predicted the ways in which Microsoft would fail to become a dominant player on the web, or the peanut butter memo at Yahoo). The trouble is that actually implementing changes like these at an incumbent institution is hard. Really hard. So hard, in fact, that failure is overwhelmingly the rule. In most industries, the way that plays out is that incumbents fail to change, new competitors emerge with the new processes baked into them from the beginning, and they then kill the incumbents. A few years later, those new folks ossify and then themselves get killed by the next wave. And so on. A healthy industry offers all its players a choice: "Evolve or die. Do whichever one you want, but one of those two things will happen." There's no third option, "Do your best to evolve". The institution succeeds at changing or it dies, and that's all there is to it. The trouble in healthcare is that incumbents do get that third option. And the reason they get it is that for the most part, there are no new competitors to kill them off.
siculars 12y ago
"It means federal policies that promote the seamless sharing of data between different systems in different settings." I've been promoting this concept for quite some time [1]. The state of electronic medical records is not very good and integrating data from multiple systems is even worse. [1] http://siculars.posthaven.com/health-data-integration-regulation-and-incentivization http://siculars.posthaven.com/health-data-integration-regula... EDIT: To clarify, I'm in no way advocating that the government set data model or schema standards. I'm simply suggesting that the government level the playing field by mandating that if you do anything with health data you openly publish your specification and methods by which others can programmatically read or write to those data repositories. Obviously, this is separate from having the security access to do so. Ive worked with EMR systems that have thousands of tables. Yes. Thousands of tables. I can't tell you how many hours of reverse engineering I've dedicated to groking these schemas. Not to mention on the wire protocol decoding from medical devices. It's insane and the government should not allow it to happen.
- IndianAstronaut 12y ago
  Seems like they keep running into this issue over and over again. https://xkcd.com/927/ https://xkcd.com/927/ I am inclined to think an older unified data format such as XML will probably be enough to deal with this. This may require government intervention, especially since individual doctors offices are often at ransom to tech companies.
- snappy173 12y ago
  easier said than done. every system has its own perspective of the patient, but you can't simply share that. there has to be a canonical format that works in multiple contexts, but all of the so called standards have been horrible. just consider the case of drug records. most standard vocabularies are based around the pharmacy's view of the data, which does not work for prescribing meds. and then there's the problem of importing data ... you're usually downloading a prescription history, but what the doctor almost always wants is a record of meds the patient is currently on ... not prescriptions from years ago. and then there's privacy issues when it comes to certain specialties that make it difficult to share prescription data freely. and this doesn't even get into all of the units problems that lazy software developers can't ever get right!
georgeoliver 12y ago
The article mentions time-consuming and distracting data entry. Other than wearables, does anyone have a good solution for this?
- douche 12y ago
  Yes, non-terrible data entry UI. Seriously, have you ever looked at the software your nurse or doctor is dealing with while they are supposed to be talking to you? It's hot garbage.
  - jobposter1234 12y ago
    Why is it garbage? It seems to me that most programmers who care about their craft would make a halfway decent UI by default. I believe that interfaces end up the way they do for a reason. I'm curious what the reason is for healthcare -- is it a disconnect between stakeholders in the design stage? Lack of budget? I'm hoping you can help me learn beyond the "design by committee" or other cliches. or at least understand those cliches in a medical setting.
    - FLUX-YOU 12y ago
      Some of these solutions have code from 15-20 years ago. After the original authors left the company with deep knowledge, a complete UI redesign went from uphill battle to sheer cliff climb. Once every generation comes and goes, rewrites just get more complex. Even then, the code then was probably based on standards from that long ago, and its quality will most definitely slow you down. Now couple that with the problem of high turn over, and no one wants to handle the shit pile. We keep shoveling things over to get paid. Considering the staggering size some of these projects are (peripheral evidence of complexity like table counts as mentioned here, and more solid evidence like raw lines of code, number of UI controls from big to small), it quickly becomes economically infeasible to put a modern shine on things when you have features you could be building to make more sales. A decent UI in 2000 looked much different from now anyway. Also, the programmers probably aren't in charge of looks/design.
    - 12y ago
Gatsky 12y ago
To me the question comes down to money. How much is it going to cost to create a modern, technology-aided health infrastructure that is actively utilized, in a top-down fashion? I think the answer is a lot more than we would guess, and a lot more than anyone is willing or able to pay. I don't think a startup really wants to be in this space, even though it seems like a great idea. The size of the necessary workforce, the legal complexities, the complicated interface with government and regulatory bodies and the enormity of the required indemnity make life impossible. I mean Dropbox of all companies has Condeleeza Rice on their board to smooth over dealing with the government - the mind boggles who on earth a successful startup in the healthinfotech space would need on their board, but half of congress might be a start... I would stop trying to kill yourself dealing with hospitals, it isn't worth it. They are run by either status quo bureaucrats or cost slashers. The only way to reform things is bottom-up - creating applications that patients or clinical staff will use en masse outside of a hospital's IT system eg on their smart phones.
- bduerst 12y ago
  The EMR industry has a huge bureaucratic barrier to entry, which is why you don't see it technologically progressing at the rate of other industries. The space is dominated by major players that have existed since the 1980's (Epic, Cerner, etc.), which also employ the technology of the same era (MUMPS, Caché, etc.). If anyone is going to disrupt the EMR industry, it is going to be a bigger company that can sink the costs necessary to get up to speed for an entire HMO, and a couple HMO's willing to take the risk of piloting the software.
  - leonth 12y ago
    I want to add that a lot of value of the EMR system comes from integration - i.e. smooth data flow between touch points / care areas / visits / institutions. So it is rather hard to disrupt the industry using the typical "disruptive technology" idea because your niche solution may not play well with the rest of the system. And the incumbent has every incentive to make integration with a potential disruptor as difficult as possible.
danso 12y ago
A few months ago, I went to a dentist in Palo Alto for the first time...by far the most hi-tech dentist office I've been in...though it's been awhile for me. I guess I was most impressed with the digital x-ray machine, in which they could snap shots, and we'd see them pop up right away in front of the flatscreen in front of me. However, the experience was marred when I went upstairs from the xray room to the dentist's operating room. He couldn't find the digital files. The reason was, he told me, because over the past few days, the office was finally upgrading its system from Windows XP...to Windows 7. I wish I had taken notes overhearing him talk to the assistant and the totally random sounding hacks and procedures they had for just getting through the computer system, I'm surprised I didn't hear "Turn off the computer, wait at least 30 seconds, then turn it back on"...suffice to say, the mystery of the missing digital files was never really solved and took up about half an hour of the appointment time. I'm surprised a Palantir-for-Doctors hasn't yet come up...a company that maybe doesn't build anything revolutionary but makes billions from an audience with a lot of money and very low standards.
- zachalexander 12y ago
  OT, but what exactly does Palantir do?
  - electronvolt 12y ago
    From the recruiting presentations I saw while at university: they primarily do large scale information grouping and retrieval. It seemed like their systems (at least the ones they were public about while trying to recruit from undergrads) were aimed at taking large numbers of random facts about actors ("this person has made a lot of phone calls to this person", "this person was seen in place a", etc.) and making them all traversable as a sort of information-visualization graph. It seemed likely rather math-y and very interesting. So basically the "information collation and noise reduction" part necessary for any mass surveillance system to be actually useful. Palantir for doctors would basically just be Palantir with people's medical information and medical research plugged in, and maybe family connections, instead of "Person a called person b", "Person b has known terror connections.", etc.
  - 12y ago
ddw 12y ago
I believe in developing a product, especially the UI, by constantly getting feedback from the user but I'm racking my brain on how to do that for a product for medical professionals. I can't observe them when they are with a patient and its impossible to schedule time to get feedback, they are so overworked. My theory why the UIs of these EMRs are so awful is because of this very reason: there's no feedback loop. And I'm not blaming the doctors, they have no time.
mbtmbt 12y ago
Everything in this article is true. I work for Syapse (http://www.syapse.com http://www.syapse.com), and we are trying to do something about this problem. As a startup, we have a laser focus - we are building systems that help practicing doctors, mainly oncologists, take advantage of genomic data. We focus on improving UI, workflows, alerts, access to up-to-date knowledge and yes, data entry. If you are interested in this field, please consider applying for one of the open positions. We are looking for server engineers, data systems engineers, UI engineers, DevOps, etc. We are located in downtown Palo Alto, CA.
- ZanyProgrammer 12y ago
  I looked at your website, but alas I didn't go to Stanford or a UC.
  - jhedwards 12y ago
    Don't worry about that, I work at Syapse too and I have an MA in Chinese lit from UMASS. You could be totally self taught like me and as long as you have skills and a good attitude you will be considered. Everyone there is super nice and open minded.
- Gatsky 12y ago
  Thanks, looks like a great product. I'm a medical oncologist doing targeted sequencing for breast cancer at an academic center in Australia. We're small by American standards but there isn't a similar service in the country as far as I know. At the moment we're doing it for free as we have some research funding and are still refining the sequencing workflow. I would love to have a platform like this. At the moment the analysis, curation, reporting and suggestion of clinical trials is all done manually by me.
ridgeguy 12y ago
Apologies if too far OT. I accompanied my wife earlier this week to two appointments with her docs. Both docs showed up wearing Google Glass, which is a New Thing at this clinic. This use case provides an audio feed through Glass to a human transcriber. I asked both docs about it, and they said that they'd started with video feed as well but patients were not comfortable with it. Both docs were happy to spend 10 minutes each answering questions about the new thing. Both docs were able to call up my wife's records on Glass, which saved their having to break contact with the patient, sit at the computer, enter passwords and start searching. Seamless. Both docs said they liked it because it kept them connected with their patients and offloads composing their after-visit notes. My wife liked it for keeping connection with her docs during the visits. I learned a lot from these two encounters. On its face, the clinic's Glass use is pretty primitive - stream audio to a human scribe and serve the patient's records to the doc's FOV. But I saw that this simple use greased the interactions to everyone's benefit. My wife found her experience considerably improved over earlier non-Glass visits.
- Gatsky 12y ago
  Fascinating, thanks for sharing.
- yumraj 12y ago
  Very interesting - do you mind sharing where/which clinic was this..
  - ridgeguy 12y ago
    Palo Alto Medical Foundation, at their Palo Alto location
pcurve 12y ago
I've been in the sector for about 11 years and I've grown to take very dim view of the entire industry. There is so much money sloshing around in the industry, yet people are getting less and less for their dollars. Everyone loves to criticize financial and telecom companies for bad behavior but healthcare puts them to shame. You have Copay, out of pocket, deductible, co-insurance, HSA, HRA, FSA, preferred drugs, generic drugs, single source, multi source, in-network, out of network, lifetime CAP, etc. These are essentially instruments that healthcare companies use to reduce their payouts and shift costs. Where is all the money going? (no need to answer) It makes me sick that this year's SXSW focus was on healthcare. We don't need more startups and MBA types trying to 'fix' healthcare. The current healthcare problem is purely political and regulatory in nature.
- mgkimsal 12y ago
  While not in the healthcare space, I have the same default view of many industries. In many cases, the entrenched problems are not specifically technical in nature, and just waiting for some smart person to point out "feature X will solve Y!" and everything falls in to place. Yet... in many cases when I'm talking to startups, this seems to be the mentality. I tend to notice it in younger folk (probably moreso as I get older), but it's actually a little bit annoying (or can be - not always so). I did a bit of work with some guys who wanted to do a focused "udemy for medical students" - extremely focused content from top professors. "We really need this - no one's thought of this before!, etc". I pointed out that very likely the professors had some sort of IP/publishing tie with their universities which would at least require approval (if not in fact prevent such deals from happening). "Oh no, we've got professors lined up already - we're ready to get moving!" 3 months in... a sum total of 10 minutes of content was produced - poorly. Most of the professors, when pressed, admitted they had to get approval because they had IP deals - not specifically with their universities, but many with existing publishers (note: don't ask published medical professors to create web content for you, as it'll likely be a conflict of interest with their publisher). The team didn't want to have lesser-known professors - only top published name-brand professors... so it all died. "This was a lot harder than we thought it would be" was the final parting discussion, and was my initial point I'd made when we first started - "this is going to be harder than you think it is. the core idea is brain-dead simple - there's a reason it's not being done the way you want it done, and it's not because the two of you are the first humans on the planet to think of it". Sounds a bit harsher in retrospect when writing it, but back to healthcare - yes, the current mess is not due to a lack of smart people - it's those existing people with industry knowledge and experience not being able to work effectively.
nighthawk24 12y ago
http://health.gnu.org http://health.gnu.org + https://arvados.org https://arvados.org
supercanuck 12y ago
The important point seems to be the absence of user centered design.
deepsun 12y ago
There's OneMedical.com, a kinda startup as far as I understand. $140/year doesn't sound too much, so I signed up for it, will see how it goes, don't have an opinion for now. As far as I understand, they do only physicians stuff, have offices in major metropolias. Their main point I liked was that they finally do documentation/appointments/labs online, and treat online as first-class. Anyone had experience with it?

62 points by digisth 12y ago

http://www.bloomberg.com/news/articles/2015-03-20/dozens-of-startups-in-obamacare-s-wake-reveal-law-as-job-creator http://www.bloomberg.com/news/articles/2015-03-20/dozens-of-... I want real statistics...anyone with interesting source?

angersock 12y ago

I work in the medtech/health IT field at a startup doing a lot of clinical analytics. There's a very blunt and obvious explanation of what's wrong here, and it's the very unpolitical one. Here's the deal. Physicians and nurses and administrators are overworked and untrained to handle a modern operational model. The hospitals tend to be based around politics rather than patient care, though the party line is invariably "help the patient". Doctors will, under the aegis of "help the patient", justify hoarding equipment, setting up alarm thresholds that screw up operations across the unit, block acquisitions, and in general just make everything terrible left to their own devices. Nurses are overworked and are charged with increasingly important parts of patient care, and at the same time are treated as annoying appendages of the rest of the medical apparatus and not given the respect or authority that they require to perform well at their jobs. Billing is handled through arcane back-and-forths between the care providers themselves, the hospitals, insurance companies, the government, and collections agencies. I've seen at least one local children's hospital (the economics of such institutions are quite fascinating) have banking and financing services occupying the same building as care (something you'd expect at a car lot, not a place where injured children are healed). Claims may take months or years to process, which is absurd. The whole stinking mess should have been grist for the capitalist grinder decades ago. However, clever regulatory capture by hospitals and manufacturers and labor policies restricting the supply of new physicians has managed to prevent any of the normal efficiencies from being introduced. When trying to introduce new technology, you have to fight the most conservative and risk-averse institutions you'll ever encounter. People that do not understand basic statistics or mathematics, or that flat out refuse to recognize the value of operational data research in making decisions because "they know better". You'll be turned away because you're not one of the chosen few, and ignored unless you can convince them that they get to put their name on the new shiny. This is but the first level of the fractal of sadness and absurdity that is modern medicine in America.

ddw 12y ago
Spot on. And then you get the pessimistic doctor that says you're trying to ruin "the art of medicine."
bsder 12y ago
> I work in the medtech/health IT field at a startup doing a lot of clinical analytics. There's a very blunt and obvious explanation of what's wrong here, and it's the very unpolitical one. Actually, it's very political--it's the AMA--the American Medical Association. The doctors are fighting the automation of their jobs tooth and nail because once we have data we can see that ... gee ... most of them suck. Nurses could do their job ... better.
- angersock 12y ago
  I rather meant to explain that the problems--and their implied solutions--are not politically viable, mainly because of what you've mentioned. :)
refurb 12y ago
I think your take is remarkably accurate. I have a good friend who works at a world-renoun hospital in the US and the stories he tells! Politics rules decision making in the hospital. Leadership (including the docs) are constantly clamouring for more power. Normal market forces that would normally incentivize efficiency are no match at all.
siculars 12y ago
Seconded. I may or may not have left a similar medtech job but this job may or may not have been in the belly of the beast.... a very well known teaching hospital. Politics may or may not have run rampant and the leaders charged with modernizing the organization may or may not have appreciated technology or may or may not have known enough to support those who did. Oh well.
HillRat 12y ago
As I told a developer earlier this week, trying to disrupt healthcare is like starting an avalanche by tossing pebbles at a boulder. Between institutions, carriers, and the godawful state of interoperability technologies (I've been on the standards committees, I accept my share of the blame), it's essentially impossible to really advance the state of the art, even though there's a real need for technology that helps enable the organizational advances in clinical practice we've seen over the past several years.

bsder 12y ago

There are political issues, but there is also an impedance mismatch between "medical programming" and 99.9% of all other programming. Nobody in programming gives two shits about quality. "Ship it and patch it later" is a religion. That doesn't work in healthcare. If your software screws up, somebody dies, and you are on the hook for several million dollars. (See: Therac-25 and concurrency problems https://en.wikipedia.org/wiki/Therac-25 https://en.wikipedia.org/wiki/Therac-25) So, the technology pace winds up moving much slower. I also like that they mentioned false positives in the article being a problem. That's an understatement. A friend had to wear a portable defibrillator vest after a heart attack. It was atrocious. It sounded warnings after a shower. The battery was hard to keep in and sounded warnings when one popped out. After a week, lifesaving technology was back with the doctor because it was too irritating to use. This wasn't some random schmuck. This was a person who used to write technical users manuals. A normal person would have had no hope.

angersock 12y ago
So, that's the shitty thing, right? If you're software is being used in, say, an ICU--guess what? The patient is already in bad shape. There's some weird conception in the medical industry and public at large that the software has to be perfect the first time, every time. And that just isn't possible or economical. And then when people try to do that, they find out that getting test data or trials done is near impossible. Hell, you can't even get the standards to develop with without shelling out thousands and thousands of dollars. The same institutions that clamor so hard for absurd reliability in software make it almost impossible to test that software safely without a gigantic war chest. And they look the other way when they fail to provide patient care or outright butcher people. The difference between your code and a doctor? You can fix your code after it kills a patient. EDIT: And no, this doesn't mean that I suggest that we all should write bad software until the bodycount suggests a refactor. What I mean is that we should write it as well as we're able, and that we should fix it as data for improvement becomes available. On a related note, this is why decision-making should--for now anyways--rest with a physician. We can give them better advice, but the moral accountability should remain with the human at the bedside.
- 12y ago

karzeem 12y ago

"In health care, changes in the way we organize our work will most likely be the key to improvement. This means training students and physicians to focus on the patient despite the demands of the computers. It means creating new ways to build teamwork once doctors and nurses are no longer yoked to the nurse’s station by a single paper record. It means federal policies that promote the seamless sharing of data between different systems in different settings." I think the author is right about the problems, and these solutions seem sound. These are the kinds of things ossified institutions always say, and they're actually usually right (e.g. Bill Gates's prescient Internet Tidal Wave memo which predicted the ways in which Microsoft would fail to become a dominant player on the web, or the peanut butter memo at Yahoo). The trouble is that actually implementing changes like these at an incumbent institution is hard. Really hard. So hard, in fact, that failure is overwhelmingly the rule. In most industries, the way that plays out is that incumbents fail to change, new competitors emerge with the new processes baked into them from the beginning, and they then kill the incumbents. A few years later, those new folks ossify and then themselves get killed by the next wave. And so on. A healthy industry offers all its players a choice: "Evolve or die. Do whichever one you want, but one of those two things will happen." There's no third option, "Do your best to evolve". The institution succeeds at changing or it dies, and that's all there is to it. The trouble in healthcare is that incumbents do get that third option. And the reason they get it is that for the most part, there are no new competitors to kill them off.

siculars 12y ago

"It means federal policies that promote the seamless sharing of data between different systems in different settings." I've been promoting this concept for quite some time [1]. The state of electronic medical records is not very good and integrating data from multiple systems is even worse. [1] http://siculars.posthaven.com/health-data-integration-regulation-and-incentivization http://siculars.posthaven.com/health-data-integration-regula... EDIT: To clarify, I'm in no way advocating that the government set data model or schema standards. I'm simply suggesting that the government level the playing field by mandating that if you do anything with health data you openly publish your specification and methods by which others can programmatically read or write to those data repositories. Obviously, this is separate from having the security access to do so. Ive worked with EMR systems that have thousands of tables. Yes. Thousands of tables. I can't tell you how many hours of reverse engineering I've dedicated to groking these schemas. Not to mention on the wire protocol decoding from medical devices. It's insane and the government should not allow it to happen.

IndianAstronaut 12y ago
Seems like they keep running into this issue over and over again. https://xkcd.com/927/ https://xkcd.com/927/ I am inclined to think an older unified data format such as XML will probably be enough to deal with this. This may require government intervention, especially since individual doctors offices are often at ransom to tech companies.
snappy173 12y ago
easier said than done. every system has its own perspective of the patient, but you can't simply share that. there has to be a canonical format that works in multiple contexts, but all of the so called standards have been horrible. just consider the case of drug records. most standard vocabularies are based around the pharmacy's view of the data, which does not work for prescribing meds. and then there's the problem of importing data ... you're usually downloading a prescription history, but what the doctor almost always wants is a record of meds the patient is currently on ... not prescriptions from years ago. and then there's privacy issues when it comes to certain specialties that make it difficult to share prescription data freely. and this doesn't even get into all of the units problems that lazy software developers can't ever get right!

georgeoliver 12y ago

The article mentions time-consuming and distracting data entry. Other than wearables, does anyone have a good solution for this?

douche 12y ago
Yes, non-terrible data entry UI. Seriously, have you ever looked at the software your nurse or doctor is dealing with while they are supposed to be talking to you? It's hot garbage.
- jobposter1234 12y ago
  Why is it garbage? It seems to me that most programmers who care about their craft would make a halfway decent UI by default. I believe that interfaces end up the way they do for a reason. I'm curious what the reason is for healthcare -- is it a disconnect between stakeholders in the design stage? Lack of budget? I'm hoping you can help me learn beyond the "design by committee" or other cliches. or at least understand those cliches in a medical setting.
  - FLUX-YOU 12y ago
    Some of these solutions have code from 15-20 years ago. After the original authors left the company with deep knowledge, a complete UI redesign went from uphill battle to sheer cliff climb. Once every generation comes and goes, rewrites just get more complex. Even then, the code then was probably based on standards from that long ago, and its quality will most definitely slow you down. Now couple that with the problem of high turn over, and no one wants to handle the shit pile. We keep shoveling things over to get paid. Considering the staggering size some of these projects are (peripheral evidence of complexity like table counts as mentioned here, and more solid evidence like raw lines of code, number of UI controls from big to small), it quickly becomes economically infeasible to put a modern shine on things when you have features you could be building to make more sales. A decent UI in 2000 looked much different from now anyway. Also, the programmers probably aren't in charge of looks/design.
  - 12y ago

Gatsky 12y ago

To me the question comes down to money. How much is it going to cost to create a modern, technology-aided health infrastructure that is actively utilized, in a top-down fashion? I think the answer is a lot more than we would guess, and a lot more than anyone is willing or able to pay. I don't think a startup really wants to be in this space, even though it seems like a great idea. The size of the necessary workforce, the legal complexities, the complicated interface with government and regulatory bodies and the enormity of the required indemnity make life impossible. I mean Dropbox of all companies has Condeleeza Rice on their board to smooth over dealing with the government - the mind boggles who on earth a successful startup in the healthinfotech space would need on their board, but half of congress might be a start... I would stop trying to kill yourself dealing with hospitals, it isn't worth it. They are run by either status quo bureaucrats or cost slashers. The only way to reform things is bottom-up - creating applications that patients or clinical staff will use en masse outside of a hospital's IT system eg on their smart phones.

bduerst 12y ago
The EMR industry has a huge bureaucratic barrier to entry, which is why you don't see it technologically progressing at the rate of other industries. The space is dominated by major players that have existed since the 1980's (Epic, Cerner, etc.), which also employ the technology of the same era (MUMPS, Caché, etc.). If anyone is going to disrupt the EMR industry, it is going to be a bigger company that can sink the costs necessary to get up to speed for an entire HMO, and a couple HMO's willing to take the risk of piloting the software.
- leonth 12y ago
  I want to add that a lot of value of the EMR system comes from integration - i.e. smooth data flow between touch points / care areas / visits / institutions. So it is rather hard to disrupt the industry using the typical "disruptive technology" idea because your niche solution may not play well with the rest of the system. And the incumbent has every incentive to make integration with a potential disruptor as difficult as possible.

danso 12y ago

A few months ago, I went to a dentist in Palo Alto for the first time...by far the most hi-tech dentist office I've been in...though it's been awhile for me. I guess I was most impressed with the digital x-ray machine, in which they could snap shots, and we'd see them pop up right away in front of the flatscreen in front of me. However, the experience was marred when I went upstairs from the xray room to the dentist's operating room. He couldn't find the digital files. The reason was, he told me, because over the past few days, the office was finally upgrading its system from Windows XP...to Windows 7. I wish I had taken notes overhearing him talk to the assistant and the totally random sounding hacks and procedures they had for just getting through the computer system, I'm surprised I didn't hear "Turn off the computer, wait at least 30 seconds, then turn it back on"...suffice to say, the mystery of the missing digital files was never really solved and took up about half an hour of the appointment time. I'm surprised a Palantir-for-Doctors hasn't yet come up...a company that maybe doesn't build anything revolutionary but makes billions from an audience with a lot of money and very low standards.

zachalexander 12y ago
OT, but what exactly does Palantir do?
- electronvolt 12y ago
  From the recruiting presentations I saw while at university: they primarily do large scale information grouping and retrieval. It seemed like their systems (at least the ones they were public about while trying to recruit from undergrads) were aimed at taking large numbers of random facts about actors ("this person has made a lot of phone calls to this person", "this person was seen in place a", etc.) and making them all traversable as a sort of information-visualization graph. It seemed likely rather math-y and very interesting. So basically the "information collation and noise reduction" part necessary for any mass surveillance system to be actually useful. Palantir for doctors would basically just be Palantir with people's medical information and medical research plugged in, and maybe family connections, instead of "Person a called person b", "Person b has known terror connections.", etc.
- 12y ago

ddw 12y ago

I believe in developing a product, especially the UI, by constantly getting feedback from the user but I'm racking my brain on how to do that for a product for medical professionals. I can't observe them when they are with a patient and its impossible to schedule time to get feedback, they are so overworked. My theory why the UIs of these EMRs are so awful is because of this very reason: there's no feedback loop. And I'm not blaming the doctors, they have no time.

mbtmbt 12y ago

Everything in this article is true. I work for Syapse (http://www.syapse.com http://www.syapse.com), and we are trying to do something about this problem. As a startup, we have a laser focus - we are building systems that help practicing doctors, mainly oncologists, take advantage of genomic data. We focus on improving UI, workflows, alerts, access to up-to-date knowledge and yes, data entry. If you are interested in this field, please consider applying for one of the open positions. We are looking for server engineers, data systems engineers, UI engineers, DevOps, etc. We are located in downtown Palo Alto, CA.

ZanyProgrammer 12y ago
I looked at your website, but alas I didn't go to Stanford or a UC.
- jhedwards 12y ago
  Don't worry about that, I work at Syapse too and I have an MA in Chinese lit from UMASS. You could be totally self taught like me and as long as you have skills and a good attitude you will be considered. Everyone there is super nice and open minded.
Gatsky 12y ago
Thanks, looks like a great product. I'm a medical oncologist doing targeted sequencing for breast cancer at an academic center in Australia. We're small by American standards but there isn't a similar service in the country as far as I know. At the moment we're doing it for free as we have some research funding and are still refining the sequencing workflow. I would love to have a platform like this. At the moment the analysis, curation, reporting and suggestion of clinical trials is all done manually by me.

ridgeguy 12y ago

Apologies if too far OT. I accompanied my wife earlier this week to two appointments with her docs. Both docs showed up wearing Google Glass, which is a New Thing at this clinic. This use case provides an audio feed through Glass to a human transcriber. I asked both docs about it, and they said that they'd started with video feed as well but patients were not comfortable with it. Both docs were happy to spend 10 minutes each answering questions about the new thing. Both docs were able to call up my wife's records on Glass, which saved their having to break contact with the patient, sit at the computer, enter passwords and start searching. Seamless. Both docs said they liked it because it kept them connected with their patients and offloads composing their after-visit notes. My wife liked it for keeping connection with her docs during the visits. I learned a lot from these two encounters. On its face, the clinic's Glass use is pretty primitive - stream audio to a human scribe and serve the patient's records to the doc's FOV. But I saw that this simple use greased the interactions to everyone's benefit. My wife found her experience considerably improved over earlier non-Glass visits.

Gatsky 12y ago
Fascinating, thanks for sharing.
yumraj 12y ago
Very interesting - do you mind sharing where/which clinic was this..
- ridgeguy 12y ago
  Palo Alto Medical Foundation, at their Palo Alto location

pcurve 12y ago

I've been in the sector for about 11 years and I've grown to take very dim view of the entire industry. There is so much money sloshing around in the industry, yet people are getting less and less for their dollars. Everyone loves to criticize financial and telecom companies for bad behavior but healthcare puts them to shame. You have Copay, out of pocket, deductible, co-insurance, HSA, HRA, FSA, preferred drugs, generic drugs, single source, multi source, in-network, out of network, lifetime CAP, etc. These are essentially instruments that healthcare companies use to reduce their payouts and shift costs. Where is all the money going? (no need to answer) It makes me sick that this year's SXSW focus was on healthcare. We don't need more startups and MBA types trying to 'fix' healthcare. The current healthcare problem is purely political and regulatory in nature.

mgkimsal 12y ago
While not in the healthcare space, I have the same default view of many industries. In many cases, the entrenched problems are not specifically technical in nature, and just waiting for some smart person to point out "feature X will solve Y!" and everything falls in to place. Yet... in many cases when I'm talking to startups, this seems to be the mentality. I tend to notice it in younger folk (probably moreso as I get older), but it's actually a little bit annoying (or can be - not always so). I did a bit of work with some guys who wanted to do a focused "udemy for medical students" - extremely focused content from top professors. "We really need this - no one's thought of this before!, etc". I pointed out that very likely the professors had some sort of IP/publishing tie with their universities which would at least require approval (if not in fact prevent such deals from happening). "Oh no, we've got professors lined up already - we're ready to get moving!" 3 months in... a sum total of 10 minutes of content was produced - poorly. Most of the professors, when pressed, admitted they had to get approval because they had IP deals - not specifically with their universities, but many with existing publishers (note: don't ask published medical professors to create web content for you, as it'll likely be a conflict of interest with their publisher). The team didn't want to have lesser-known professors - only top published name-brand professors... so it all died. "This was a lot harder than we thought it would be" was the final parting discussion, and was my initial point I'd made when we first started - "this is going to be harder than you think it is. the core idea is brain-dead simple - there's a reason it's not being done the way you want it done, and it's not because the two of you are the first humans on the planet to think of it". Sounds a bit harsher in retrospect when writing it, but back to healthcare - yes, the current mess is not due to a lack of smart people - it's those existing people with industry knowledge and experience not being able to work effectively.

nighthawk24 12y ago

http://health.gnu.org http://health.gnu.org + https://arvados.org https://arvados.org

supercanuck 12y ago

The important point seems to be the absence of user centered design.

deepsun 12y ago

There's OneMedical.com, a kinda startup as far as I understand. $140/year doesn't sound too much, so I signed up for it, will see how it goes, don't have an opinion for now. As far as I understand, they do only physicians stuff, have offices in major metropolias. Their main point I liked was that they finally do documentation/appointments/labs online, and treat online as first-class. Anyone had experience with it?