I created the ClearHealth/HealthCloud open source (GPL) EMR which to my knowledge is the only open source one to receive full federal certification. Operations (not surgery) are so incredibly bad / incompetent in most healthcare settings that software frequently gets the blame for much deeper problems. This article is a doctors perspective on how software did not fix a completely broken workflow. I don't begrudge him that but there is no software in the world that can ever address those types of problems. In my experience doctors are a tremendous barrier to resolving problems in healthcare operations, they are chasing their own incentives that are in some ways opposed from those of the patient just like the insurers are. It is very tortured process to institute proper operations in a medical setting, I spent most of my career doing it, no one complains about the software when operations make sense to begin with. In-N-Out instead of McDonalds, is something that should be incredibly aspirational to healthcare as an industry but doctors tend to despise the comparison.
"Operations (not surgery) are so incredibly bad / incompetent in most healthcare settings that software frequently gets the blame for much deeper problems."
"In my experience doctors are a tremendous barrier to resolving problems in healthcare operations,"
I'm a hospital-based physician that works in a system with great operations and results. The physicians, nurses and other staff work amicably together. Management is reasonable/nice. The EMR, though is universally despised. No one likes it. It is a major factor in burnout. The UI/UX is inconsistent. There are slowdowns and outages daily. There is a well known lag in the appearance of text in text boxes after typing that seems to be variable. I've caught the EMR cancelling orders I placed on critically ill patients in the ICU more times than I can count. We have to actively protect the patients from the EMR. Healthcare workers aren't perfect but they are trying to do their best for very ill people in a high-risk setting and the EMR is well-known blocker. I long for the days of paper records because this is worse. Paper charts didn't go offline, have slowdowns, didn't lose orders, were easily located, and easy to enter data into.
As someone who worked at a fortune 500 company making such EMR software:
There's no incentive to make the UI or workflows better. They don't pay the bills. Software is sold to the suits during dinners and baseball games, not doctors or nurses.
Besides, a great portion of the development is outsourced chasing lower costs. The code reviews were so bad that a coworker used to joke that "we'd get more stuff done if we just fired the overseas team".
The biggest and most well funded dev team was the one that worked on Revenue Cycle.
I worked on EMRs for 20 years. I recently quit that sector completely, and I wish I would have done it sooner.
Almost all of the features/fixes customers are actually begging for (the most popular categories being speed, reliability, reduced cognitive load and UI/UX streamlining) get dumped into the bottom of the backlog to languish. All the board and leadership care about is RCM, stupid ancillary services that patients do not give a shit about but look good in a sales brochure and have a high margin, chasing incentives from insurance and pharmaceuticals, cost cutting, and last minute, bare minimum regulatory/interop work necessary to not lose our ONC certification or violate HIPAA. Patient care and staff happiness just don’t rate that high. EMRs and the people who buy them are purely profit motivated.
It was humiliating watching how angry our customers rightfully have been and knowing there was nothing I could do about it. Now that almost all of our founders, product owners, and SMEs are gone and they just fired all but 7 engineers so they could offshore development to a company we haven’t worked with before and who has no experience with healthcare, our customers are going to be in absolute hell. The sad part is we don’t seem to be an exceptionally incompetent outlier but fairly typical of the industry.
I agree. I also worked on EHR software and what people don’t realize is that the “customer” isn’t the doctor. Not to be disparaging, but the doctor is “just” an employee.
The purchaser of the software is the administrator. And because of harsh regulations and legal liabilities in their industry, they need software that is compliant with regulations and limits legal liability on the institution. Full stop. If they can get that with a good UI/UX, then great! But in the end, this is just another case of “No one ever got fired for buying IBM”. It is all about incentives.
Companies like Epic could make their UX better, but that costs money. And what drives sales is being regulations compliant, and that is hard. It takes a ton of time. There is little time left over to make something work well considering no other software is challenging them on that front. It really is a situation of regulatory capture.
EHRs almost universally suffer from usability problems. people actually love having their medical records available. They hate the UX they have to go through to see them.
The source of the problem is that the people deciding which EHR to use are almost never the people using it. it’s ultimately the CFO or CEO who’s ultimately going to make the call, and they do it based on metrics like price tag or how many accreditation checkboxes it fills, not on user satisfaction scores. Until those user satisfaction numbers make it into CMS guidelines for reimbursement, the situation’s never going to change.
"The source of the problem is that the people deciding which EHR to use are almost never the people using it. "
Yes, this. We are a Cerner (now Oracle, yaaaaa) site, not Epic. The Cerner folks I've met in smallish meetings are nice/great on the front lines. However, the deal that our CEO/CFO/COO/CMIO made with Cerner was years ago and, per rumor, involved large financial penalties for early cancellation. Subsequent people in those roles have chosen to uphold the contract. The local management and healthcare teams in my particular facility are great but I take a dim view of our c-suite as do the majority of the work force. Things are reasonable locally for most people, I think, except for the EHR.
So, I would plead with leadership teams of EMRs, EHRs, healthcare systems, and shareholders of these entities to do the right thing and give healthcare workers working in high-risk settings the proper tools they need. You are currently failing us. No one wants unreliable, difficult software installed in critical settings such as ICUs.
I've submitted tickets, emailed leadership and had conversations with the CMIO. If there is improvement it is so slow that I cannot discern it.
In anecdotal conversations over the years I've observed that the vast majority of healthcare workers hate all EMRs but give Epic the nod because it is the least worst, and for some, reasonable. I have met a few Epic users that are enthusiastic about the software but that is after they arrived at our Cerner site and were in shock.
@duffpkg - my original comment was under yours and I wasn't intending to malign your project. I'm not familiar with it but do like that it is open source.
Respect to the developers that work on EHRs. I recognize you are held down by management.
I'm perplexed by UX/UI problems in EMRs. This must cost more to fix than I suspect. It seems to be the easiest of the issues from my layperson/healthcareworker/tech-enthusiast viewpoint.
One more thing to add: an effect of bad EHR is healthcare worker burnout. Bad EHR is a known contributor. Burned out healthcare workers are at increased risk to make medical errors. Bad EHR -> burnout -> errors -> adverse outcomes. This is a well known flow to us in the clinical setting that we attempt to mitigate. The executive teams of orgs that produce or purchase EHRs are never held accountable for bad outcomes even though, to my view, they share responsibility.
Edit: government regulators (CMS, etc) also share in the blame for bad EHR and outcomes.
This is a much easier fix in Cerner. I would guess based on the limited information at hand there is something wrong in the setup of the order release rules. IT should hire a Cerner specialist and the problem should be able to be resolved in days/weeks.
As someone with a similar working background, I agree, in fact, I wanted to share this same exact sentiment. The software is shit, and everyone knows it how it's shit, and the reason is that the incentive is not there to make it not-shit. The main users, and the people who they record, are not the main concern in these systems. That is why everyone feels bad while using the software. It's not about them, it's not for them. It's not even against them - it just doesn't care. And this really radiates from the UX.
This is so broken and depressing. I had a tour of the EMR system being used in my jurisdiction and it was shocking how bad the UI/UX was. The scenario you describe is exactly what I imagined.
As a software developer I feel so motivated to fix it, I know a small team could do a better job. But I don't even know where to begin to try to enter that industry.
It's not just EMR, it's just capitalism in general. Everything is about squeezing the most value out of the least budget.
If there was a way to factor in costs due to downtime, poor usability, anything like that, might be able to push back and bake some of that in to begin with... but even that is a can they'd kick.
I totally disagree except to the degree the provider is broke, close to broke in which case capitalism can yet help. When you're worried about money one may manage for money the exclusion of all else. It's a distortion only not a counter argument for capitalism.
The issue, ultimately, is crappy management. The need for, the good outcomes that could be achieved profitably, are insane in possibilities. Many country's demographics now include a lot of retiring people.
I continue to think basic TQM (which has gone out of vouge unfortunately) would help a lot.
Look at psychology in the US: a lot of providers will not even get involved in the insurance side of the equation. Patients pay cash. The patient is stuck with the insurance and re-imbursement, if they can figure it out.
The supplier side --- medicine and insurance and to some degree politicians --- made the paperwork system extremely bad. Simplification and elimination have got to be on the table.
Part of the problem is the patient is dis-intermediated The supplier deals with insurance directly --- hospitals in the main:
* the supplier can bill the patient's insurance wrong, for the wrong procedure, for stupid high amounts, and so on. The patient is not empowered to push back on that because the patient doesn't hold the checkbook
* hospitals and outpatient stuff like MRIs etc. don't publish a price list for the patient. Granted this is changing slowly. But why has that taken so long? Because the patient doesn't have the checkbook so why bother? Payment is done out of sight between the supplier and insurance company. It doesn't matter what the customer thinks.
The stuff where capitalism works better is when the customer knows the price, the supplier has no choice but to be upfront about it, and the customer will fire the supplier, refuse payment, or dispute payment for crappy supplier quality. The supplier can't get payment no matter what if the customer isn't going to provide it. Conversely, the supplier can refuse service for bad customers. This way both parties are encouraged to act smartly.
If I could wave my magic want I'd like to see a scenario in which,
* Customers pay insurance premiums to insurance companies in return for a bounded amount of access to a cash account.
* The customer must deal with out-of-pocket and co-insurance to eschew abusing the insurance company, fraud, and feckless spending. There must be bounded access to cash so the customer prioritizes what needs work and what doesn't.
* The supplier presents the customer with an itemized bill
* The customer --- and only the customer --- pays the bill electronically to the supplier through the insurance company's B2B payment system.
* Patients must get involved in, and start owning up the fact they can't refuse to take a zero on the dollars and cents of the care they're getting.
>biggest and most well funded dev team was the one that worked on Revenue Cycle
> no incentive to...
I am working hard to not build and fuel a fully loaded Boeing 787 into high-earth orbit and crash land it on the not-my-problem, told'ya, it's all corrupt-all-the-time, MONEY! money-is-the-measurement-of-all-things, it's bad-here-so-I-left city center fecklessness of it all.
Toyota at its peek performance (say late 1980s) was making king-kong sized money top and bottom line. No manager would ever say their only incentive or even primary care is cash. "Our only incentive is walk around with cash. Cash in the hand, cash in the brief-case, cash in the pocket, cash on the boss' desk. Show me the cash." has never spoken in companies knowing about TQM.
Instead there were aware of the numerous cross-cutting factors that, in net, determine what kind the money the company can make
Maybe medicine cares about cash so much, because it's broke or close to broke all the time. Hmmmm.
There are ton's of great incentives for the docs, the nurses, the customers, and the company's top/bottom-line to name just a few.
Somehow, someway, one day, one time management will have to get sick and tired of the on-going mediocracy. And until then I guess medicine doesn't suck hard enough. Eventually, like in Voltaire's Candide, they'll have to get into lockup, when the lady in the other cell says (paraphrasing): "You think that's bad? Big deal. I only have one ass-cheek" and goes on to tell a serious tale of woe. We're not sure yet if medicine is the one-cheeked lady, our Candide and his charges in the other cell. Only time will tell!
My extended family:
* runs several hospitals in the US
* owned a radiology business w/ multiple branches for a while
* worked at major city trauma care university hospitals that eventually went bust and had to stop operating
A few things I can tell you about them when we spoke about how the US does 16% of GDP on medicine with its high costs, and sometimes poor outcomes in what should be routine stuff,
- On the people: doctors, and nurses love to help and can be counted on same. Wonderful people.
- They did not tolerate quitters
- Good incentives (carrots) and incentives for dumb (sticks) are not per-se key, but rank in the top 10 with several other things to right the ship.
- Crummy hospitals run by crummy people (esp admin, senior staff, and management) that can't even break even can't help patients, because the unit has to close. There was serious contempt for anything contributing to that eventuality
- They tried in some cases to focus on process improvement, and process simplification instead of more automation for crummy processes.
- They were at times despondent about the sectionalism and the fact that software is too compartmentalized by discipline because the IT stuff often came from vendors that could have some integration but certainly not enterprise integration.
One of the biggest scandals in Norwegian health care at the moment is a botched transition to Epic in one of the biggest university hospitals. Doctor dissatisfaction has gone to the roof at the point where 50% of the doctors are considering quitting.
Maybe they are different versions, or I'm an outlier, but I love epic - I used a relatively new build of the software last year for a new months, just the ability to message other staff in the context of a patient's chart saved huge amounts of time and interruptions. They also had this super low friction way of addending to the chart, so you could, say, review a (paper) ECG and start recording your interpretation straight into the correct chart within a second or two, and be done in around 10 seconds (with dicatation software which is usually from a different company but integrated)
I'm assuming the hospitals in Norway & Finland used some form of a public tender where the cheapest solution wins. I don't think you need malice or corruption to explain it, just good intentions.
There's malice on the sell side. If they can't integrate a trial period then its not worth attempting. Its dumb terminal work not like its actually expensive just very very lucrative because its run like a mafia.
Exactly, when selling a big software system like this to the government, the contractor will very deliberately ensure that it follows the requirements exactly (because requirements are never specific enough) so that the government will then have to go back to them for fixes and upgrades forever. If they see a poorly worded requirement that they can implement as-is knowing it will cause a problem, they celebrate because its a future revenue source.
The only way I can see to avoid this is for a government to have its own dedicated software developers who make these types of applications and maintain them. Preferably open-source so that other governments can use them as well. The incentives change and they'd probably save a ton of money.
If they don’t implement that poorly worded requirement, they are entering a world of pain of having to justify the deviation through 10 layers of project managers and qa, all from different organisations (either customer or other contractors). And at the end they’ll be the troublemakers who delayed the milestone
This is also true I don't doubt, but I've heard directly from contractors that they look for requirement holes so they can monetize them to the maximum extent possible.
Having a dedicated developer team who work directly for government whose sole job it is to make and maintain software like this for the long term, still seems like the most cost-effective and durable solution.
Given the nature of EHR systems, it's just not realistic to have trial periods, because everything in a hospital is interdependent. Even the relatively small system I worked on did everything from billing, accounting, insurance, HR, inventory management, scheduling, integrations with medical equipment & third parties (e.g. national health systems) with per-speciality workflows and other automation. Most of it isn't even strictly health-related.
Migrating one way is already a multi-year process, making it potentially two-way with low-latency data consistency for the duration of the trial sounds impossible.
In an ideal world, the system would be modular and you could evaluate it piecemeal, but none of the big players are incentivized to make it possible. The standards that do exist are also very lax and legacy systems don't even support those. Something like a goverment intervention is probably required to break this stalemate.
> none of the big players are incentivized to make it possible
Yea this is the problem. When well meaning startups attempt to make change they get acquired by a piece of shit sales behemoth. If somehow one could resist the acquisition and just eat everybodies lunch we'd all be better off.
The only way change will come is if some actually independent hospital develops open-source in-house software (under the strongest possible non-cooption license available, likely GPL3) over literal decades until it becomes a standard.
It’ll be fought every step by the entire healthcare industry.
I don't think there is such a thing as an actually independent hospital anywhere. In most countries, the medical system seems to be a government monopoly. In America, it is an oligopoly that egregiously violates the anti-trust laws and whose real customers are the government and the health insurance companies.
The entire industry seems like a politically connected bureaucratic nightmare of one kind or another in every country on earth. Solving that problem would require some way to allow doctors to become genuinely independent again[0] and to ensure that patients could choose their doctor. If doctors were genuinely independent, they would choose the best medical records software and that software would be able to open up files from competitors[1].
[0]: The main American blocker to this would be something called malpractice insurance which is extremely unaffordable and necessary to protect doctors from being bankrupted by lawsuits whenever they make a mistake. Hospitals can afford that insurance much more easily than independent doctors so they can basically buy up all the doctors. I suspect that an affordable public option for this insurance would help restore a competitive free market in medicine.
[1]: I've heard first-hand from family members that the file formats for the different medical records software are incompatible. They convert medical records by actually typing the information from the other hospital's system into their system.
Interestingly your [1] citation may no longer be the case. The 21st Century Cures Act was signed 8 years ago (but compliance was only required as of 2023). It states that Healthcare Institutions (& EHR developers) must provide a mechanism for patients to access their health records electronically in a standardized format (FHIR).
It's what allowed my open-source startup Fasten Health to even exist. I was diagnosed with a chronic condition, and wanted a way to store my health records privately on my own devices. A bit of luck and a POC later, I was able to confirm that patients can access their own records with little-to-no barriers.
Medical malpractice insurance has only limited economies of scale. It's still possible for solo practitioners or small partnerships to afford in most cases. This isn't the biggest factor in driving provider market consolidation.
The real factors driving consolidation are IT costs, negotiating power, and practitioner preferences. Even with modern SaaS products it's expensive for a small organization to operate an EHR and other IT infrastructure. Payer organizations have consolidated through M&A activity and are constantly trying to drive down prices so providers also consolidate to force payers to keep them in network regardless of prices. And many doctors just don't want to manage a small business; they would prefer to focus on treating patients and collect a steady paycheck.
Your family members are wrong. There are standard file formats for sharing medical records across different software. The most common format is HL7 Continuity of Care Document (CCD) which can accommodate an entire patient chart in a single XML file. Every major EHR has supported CCD export and import for years under federal government certification criteria. If your family members had to do manual data entry then either their software wasn't configured correctly or they didn't know how to use it.
In my experience with FHIR, two documents from different sources can both be compliant while still semantically incompatible. The protocols are made flexible enough where human ingenuity lets you represent the same thing in so many similar, yet different ways.
That's why most interoperability requirements are written based on Implementation Guides rather than baseline standards. The base HL7 standards (V2 Messaging, CDA, FHIR) are intended to do pretty much everything everywhere in the world. As such, they're loose on specifics such as required data elements and coding systems. Then IG authors take those baseline standards and constrain them for specific use cases in particular countries (realms).
CCD is very well specified, although you might still find some EHRs that fail to comply with the standard in some minor ways. There is a project underway to migrate that data model to FHIR encoding but it's not finished yet; that will make document construction and parsing a bit easier but won't necessarily address compatibility issues.
In the US malpractice insurance is mostly orthogonal to the costs of health care. I hate having to write the check every year (my wife- a pharmacist- needs this insurance just like doctors do, though it doesn't cost as much because suits aren't as common) but it's really just an annoying drop in the bucket. You can tell this because some states (most prominently, Texas) have put caps on malpractice pain-and-suffering payouts, and they don't have lower medical costs, in fact parts of Texas are some of the most expensive in the country. So if malpractice isn't driving it, what is?
As far as I can tell, the real reason for the costs are consolidation. In my wife's world, independent pharmacies are being killed by PBM's(1) which literally set reimbursement rates for the small guys at below the wholesale cost of the medicine. The user experience here is you go to an independent pharmacy, you hand them your script, and they run the script through their computer systems, then say "Sorry, I can't fill this for you, because it cost me more than the insurance will pay me" and then you have to go to one of the big three which have enough market power to negotiate with their PBM's for higher rates (and even here PBM's routinely end up at least temporarily dropping one of the big boys as part of their hardball negotiations with each other).
There are basically three PBM's for the whole country, they have enormous, basically monopoly power (80% of the insurance market), and if you are a small shop your rates are crap. So the small pharmacies close/sell out and the big three drug stores get bigger. And that is happening in medicine as well, as I understand it, though I haven't seen it from the inside.
The core idea behind the ACA ("Obamacare") was that clear competition from insurance companies (and medical providers) through the exchanges would lower the total costs of health care, and it doesn't seem to have panned out, because there hasn't actually been much competition, instead there has been massive consolidation. Most counties in the US don't actually have much competition on their ACA Exchange(2), and most counties don't have much competition from medical providers either- they've all consolidated to get better rates from the insurance company- so you have monopoly insurance and monopoly providers competing with each other to see who gets more rents, not trying to compete on lowering costs.(3)
3: This is why many Democratic health care wonks are looking more seriously at single-payer over the past decade. If we in practice have unchecked monopolies dominating health care, let's at least have them be government run and therefore responsive to something, even if it's just politics it's still better than the alternative.
"Healthcare" is such a big term that covers so many things that really should be broken out separately so that it can be seen what's what.
Most people really only care about the amount of the insurance deduction, co-pays, and care availability; they don't know or care about the "behind the scenes" details.
The consolidation has been absolutely phenomenal in the last twenty years, and digging into exactly why each town could have an independent hospital and staff 20/30 years ago and why they're all being consolidated now.
So government intervention didn't do what it claimed, in fact the opposite, and the solution (per "Democratic health care wonks") is to...have more government intervention? The leaches didn't work to help your diabetes, so we should apply more leaches?
Things are far better than they were before the government intervention. The consolidation had started happening before the ACA was passed (e.g. Bill Frist and Rick Scott both became rich enough to be senators thanks to hospital consolidation in the 1980's and 1990's), and now that there are regulations the individual insurance market is passable rather than the continuous death spiral that it was in before.
And of course as I didn't say in that message but is obviously true, the ACA has led to far more people carrying health coverage than before. It's just that instead of the exchanges, it's the Medicaid expansion that has led to this. Even with Robert's unprincipled last minute rewrite and the 10 states that are still allowing their rural hospital system to be utterly gutted rather than giving Democrats the win, a higher percentage of people have health coverage than at any point in American history before the ACA, and that is entirely because of Obamacare. So that is why reinforcing the successful part (government insurance) and abandoning the failed part ("market reform") is so attractive.
The problem is that the health care market isn't a truly free market. Uwe Reinhardt, Princeton economist, wrote a lot about how it was a broken market, which is why every other developed country (including fairly libertarian states like Singapore and Chile) has significantly more government intervention than the US does- since it's not really much like a free market, unless you are willing to accept many, many more deaths for people like my mother, which I am not.
You can't just build your own EMR and call it a day, unless you are very selective of your patients.
Accepting Medicaid and, if memory serves, Medicare requires using a certified EHR/EMR system, and getting that certification is both time consuming and expensive.
You aren't just fighting the healthcare industry, but also well-intentioned government regulations.
And yet the system is aimed at getting the cheapest possible bid? Perhaps the intentions are good, but the execution is horrible. So maybe not malice or corruption, but incompetence.
In Finland the tender was between Cerner and Epic. Because our largest hospital district wanted to buy American eletronic medical record system. I guess the biggest influencer was Kaiser Permanante (=they are world class and are using Epic, so it has to be best system in the world)
I know that devs that work on EMRs might read this thread. I'm pleading with you to take the EMR to the next level when it comes to UI/UX and reliability.
I've managed large enterprise health organizations across multiple sites that use Epic. We built an adjunct system that is still used by some of them that papered over serious problems that doctors using them never knew wasn't only Epic. We defined, documented and tested real world workflows before we subjected patients to them. There are a lot of other ways to address those issues operationally. You have management, IT and operations problems, not software EMR vendor problems. No software is perfect, Epic less perfect than most. Your facility chose that system and decided how it was implemented in a way that is dangerous or potentially dangerous to patients. No software vendor can fix that. That's really the heart of my rants in response to this article.
I built that EMR, it was/is called ClearHealth/WebVista/HealthCloud. Your facility would never have bought it because incompetent management will only buy Epic. We solved the problem by buying organizations and replacing the incompetent management.
Webvista and HealthCloud are still utilized by some facilities and maintained as an internal system. EMR as a standalone line was <10% of ClearHealth's business when it was acquired in 2017, I remained involved in some capacity until 2019. ClearHealth's main business was as medical/hospital management company.
That, my friend, sounds a lot like The Cat Ate My Source Code [The Pragmatic Programmer]
Price, lead time, quality, (and scope) — pick any two. When the stakes are high, don't rely on your manager to pick quality — that is your responsibility.
And if you can't convince your "boss" to give you enough time to deliver something that meets your bar, quit.
> if you can't convince your "boss" to give you enough time to deliver something that meets your bar, quit.
I did this and while it solved my moral dilemma it made things worse for our users.
Many years ago I started my career working for a startup that got bought by a big government contractor. The most incredible people I've ever worked with tried harder than you can imagine to deliver reliable, usable software for the American taxpayer that met the very high bar we set for ourselves.
Because the incentives weren't aligned, most of the good people eventually quit to work at places where they could deliver something that met their bar and were replaced with junior devs and senior clock-watchers.
Every good person who left made that problem slightly harder for those of us who stayed because there was one less person fighting for quality and usability, but the contracts were as big as ever and the new people were less likely to rock the boat so management didn't care that product quality was dropping off a cliff.
In the end it was primarily our users who suffered.
> [--------] didn't care that product quality was dropping off a cliff.
fill in the blanks! it's not management, it's the customer. if the customer doesn't care management doesn't care.
it's a tragedy, but it's what it is. citizens as users need to demand better. it's just politics. in the end revealed preferences show that users don't care that much. they learn the shitty system to do their thing, and then they go home to their family/dog/MMORPG/life.
and users don't care on the meta level either, to have better procurement processes.
You're right, management was simply the messenger relaying customer priorities.
I will point out that enough consumers are willing to pay for a quality products that many niche companies exist to serve them. Many citizens choose to move to countries/states with better services even if they have to pay higher taxes. There are employees who reject higher-paying jobs that require interacting with poor-quality software or processes. (I work for a niche company that makes and uses high-quality products in a high-tax / high service state so I know many people like this!)
> citizens as users need to demand better.
I get what you mean, but as you point out many people's revealed preferences show that they don't actually want quality in which case they already do "demand better" -- it's just that for them "better" means cheap, fast, and convenient.
> [..] were replaced with junior devs and senior clock-watchers.
That is a sad story indeed.
I guess the silver lining is that you didn't waste your talent contributing to a mismanaged project. Hopefully, given a free market, the service will eventually be replaced by something better.
I don't regret the decision but I do feel a little guilt for what I left behind.
I have friends who moved out of struggling towns and states who describe similar feelings about being part of the "brain drain" death spiral that is hollowing out the place they grew up.
> Hopefully, given a free market, the service will eventually be replaced by something better.
I too believed that something like that would happen eventually but their business is still booming. In the decades since I've learned that the "fitness function" of companies that serve governments or large enterprises do not reward product quality (at least not commensurate with the cost of quality) so companies or teams that insist on wasting effort making quality products do not survive. It's not malice or incompetence, it's just a survival response to misaligned incentives.
Felt the same when saying goodbye to my colleagues, stranded in a golden cage, when the startup we worked for was acquired by Oracle after 8 years. Our beloved product was eventually killed (years after I resigned), but Oracle — despite its obvious mediocre halo — is still alive and kicking.
This is a fair point. If the only agency you have is the choice between following marching orders without questions, or unemployment — don't quit.
But I would be surprised if this is the way all EMR software is built. Software development being a creative process, there should always be a feedback loop where managers ask open questions. There lies the agency to recommend spending more time and money, reduce scope in order to guarantee a level you feel comfortable with. You may not get what you bargain for, but it's up to you to decide if it's enough.
Taking the money in return for doing the work is a way of telling your boss you're on the same page. Given your medical context, that may not mean you fully agree, but it evidently means you accepted it.
And then we have about 90% of working sw devs quit tomorrow - it sounds great but people are not going to leave when they know the next place is basically the exact same.
I beg to disagree. Although I've only worked for European and US companies, my experience is that even bossy bosses appreciate quality design and understand that lack of time, pressure and exploitation cause products to degrade. But pressure can only exist if there is an equally opposing force — you, me, us.
If my recommendation to bluntly quit sounded harsh, I'm happy to tone that down. There is value in compromise, but just make sure your voice is heard, say no if you cannot / will not do it in such little time to the extent that you feel is required. Fighting for the time to do our job well is our struggle. Sometimes it's easy, more frequently it's hard, but when it's simply impossible — have your boss find someone else.
Quality — at least internal quality — is primarily the responsibility of the software developer, not her/his boss or some QA department.
I don't think it sounds harsh, and I have worked with dozens of tech companies and directly for a dozen or so - the only one that wasn't obsessed with cheating out on quality to make a buck was bilking his customers so much that he didn't care.
At every phase of the conversation is management saying they have this hard deadline and
I have been fired multiple times for being too vocal about the failures of process or technology, though mostly I just get ghosted for pushing back when things are unreasonable, at this point I exclusively go for visualizations, gantt charts, etc - to communicate that the timelines are not possible with the current investment in the team/tech/whatever.
I just got laid off for (as far as I can tell) being the person who kept asking the question about why we were doing a thing that provided no technical or business value for a year, and in most of these cases some exec thinks they know best because they read some magazine equivalent that tells them this is the new hype revolution.
Basically if you can find some highly skilled or highly profitable company that's concerned about losing their edge you might be able to do this, but your next boss might change the entire equation.
If you quit, they'll just hire someone who's willing to do the crappy stuff. As a bonus, they'll probably pay less for that person. Or they'll spread the burden over the remaining staff. Or they'll outsource the whole team to some remote hell. Quality is not a bottom-up thing, everybody has to be in on it.
Most management will exchange quality for quick gain whenever they can because they're there to make money and don't plan for long term. Because they can also leave the ship when the sum of their mistakes starts to sink it.
> Quality is not a bottom-up thing, everybody has to be in on it.
I like it. But I've seen at least one place (a start up) where (to some extent) quality was a bottom up thing. Eventually it became a share value, but it was rooted in developers saying: No, we need more time.
On the other hand, I don't know of examples where quality was forced top-down — places where a senior developer would say: I'm done/I don't care/this is good enough and their manager telling them to spend more time on a feature or teaching them about software design.
Ah yes, rogue quality enforcement, I've done it too. It's all fun and games until some nosey manager questions the overeager developer who naively lets them in on the scheme and thus exposes the whole team for the bunch of non productive rebels that they are and then it's back to square zero.
Quality conscious management doesn't impose strict rules themselves but rather maintain a climate of mutual trust between business and technical where constraints and problems can be surfaced, discussed and addressed openly. Respect for technology is sorely missing from the business class curriculum, yet so much depends on it.
This is the underlying issue for anything where software isn’t the primary goal. Nobody wants to change their workflow that they’ve trained over years, no matter how absolutely broken and absurd it might be.
This sounds a lot like Epic. Respectfully I don't understand how your facility can face those issues with a system like that and also be considered to have great operations and results. With Epic it is possible to workaround a lot of notorious problems but management has to understand and have in place the operational capacity to do it. If a system is allowed to persist in an organization that may have or actually did result in patient deaths in the ICU and it was up to me I would see the facility shuttered until that got sorted out.
I also want to be clear that doctors are not by any means the only obstacle to resolving workflow problems. You being put in a position to protect patients from a business process of the facility that may accidentally result in their death is the literal definition of incredibly bad / incompetent operations. That software didn't magically appear and become responsible for ICU ordering magically on it's own. In this instance whatever insane people have been given responsibility for that implementation are responsible.
After consideration, this comment from a doctor, in a nutshell encapsulates so much of what is wrong. A doctor on the front lines alluding to staff burnout, thinking that people almost or actually dieing because orders are being cancelled inappropriately in the ICU is somehow "a software problem", while simulatenously praising the management, operations and results of their institution. Welcome to healthcare.
Are you saying that the cancelled orders are due to a management decision/policy, and not a software bug? Or that EMR wasn't intended for managing orders and the decision to use it in such a way was wrong? Asking as someone who's mostly unfamiliar with this.
Edit - I'm trying to make sense of this thread, and it seems like this might be a reasonable summary: There's good and bad software (epic). The fact that management chooses epic instead of good software makes it a management problem.
@hyponatremia121 says that EMR software (epic) is terrible, which doesn't contradict the above. @hyponatremia121 pleading for EMR devs to focus on UX might be misplaced since their only experience is epic and not better EMR software.
@duffpkg saying that epic shouldn't be blamed here seems overreaching. If epic were good/hard to misuse this conversation wouldn't happen in the first place. But there's always well marketed terrible software, and I agree organizations that aren't able to avoid this do have organizational problems.
I am lacking all the information as to whether we are even talking about Epic but Epic is a lousy tool. It is still just a tool though. For the unititiated Epic is not some tiny little software program to manage an ICU, it's a city scale platform to run most of a hospital city. You can do a lot of good things with it and a lot of stupid things with it. If in fact orders are being randomly cancelled in the ICU that's a problem that should have never reached a live rollout to an ICU without some sort of consideration for how to resolve it, that isn't a software vendor problem, that's a management problem. This is nicking an artery and blaming the scalpel. Maybe if it happens once but if it happens consistently the problem isn't the scalpel. The problem is with how the scalpel is being used. Epic dates some of it's underlying pieces to the 1980's at least, it has some well known problems and bugs. Better managed facilities develop workflows that successfully route around those problems.
In-N-Out does not as I understand it develop it's own Point of Sale system, they work with a vendor. What do you think would happen if In-N-Out had a location that was consistently failing to ring up orders or lose them randomly? Would the cashier blame the POS vendor and store management stand by and do nothing while the problem persisted? Would the system be rolled out without definition and documentation of workflow, reliability testing and proper training of the cashiers? Can we not operate our hospitals at least as well as we operate a burger stand?
In and out can fire their vendor and walk away, this is nearly impossible for an public institution to do once the procurement contract is awarded, so those systems end up "too big to fail" no matter how bad or unfixable the situation is.
It just takes management with a spine. I work in the public sector, it absolutely can be done.
My guess, it's partially the softwares fault and partially the organization for trying to force a particularly bad workflow on bad software. It's probably fixable without throwing the baby out with the bathwater, but it takes someone willing to go dig in and figure it out. Those people can be hard to find in any organization, and doubly so in public sector organizations.
> this is nearly impossible for an public institution to do once the procurement contract is awarded
I think a big part of why these big projects fail is that a procurement contract is absolutely the worst way to decide which vendor to go with. Especially since most of the time, price is a big factor in who wins, and actual price is by far the hardest to pin down for projects of any non-trivial size.
Another big reason is that a lot of people at the top of the organizations on the customer side have little to no actual IT experience, and are too far removed from actual operations.
The best outcomes I've seen in large projects that we have been involved in has been when the customer didn't care too much about the sticker price, had decent IT knowledge up top or knew when to defer, and included people close to operations early on and throughout.
I have tried a lot of tools. Epic is terrible. capital T terrible. And its still better than just about every other thing out there.
Epic suffers from "it has to be all things for all people". so it is nothing for anyone. It is bloated, big, overly customizable, yet doesn't fit. Steep learning curve, bad UI/UX, expensive, just all around terrible.
And yet it is still better than everything else i have ever seen, except native single-hospital EMRs like Beth Isreal hospital, Boston, EMR.
Part of the problem is that every provider organization wants to have their own unique forms and workflow; there is a lot of "not invented here" syndrome and everyone falsely believes that their institution is special. This forces a lot of customization in the EHRs and actually makes the UX worse. If providers nationwide could get together and agree on standardized forms and workflow (at least within practice specialties) then it would become a lot easier to build good EHR software.
I've started joining design meetings for a new streamlined way for nurses to do their tasks in the EHR. Multiple times now we've got stuck in a little back and forth about how to do something, and someone suggests a setting to allow either option. And each time I try to interject "no settings!". It's a pain for support and code maintenance, increases potential bugs, and means that some organizations could get left behind on new features that aren't compatible with niche settings that they refuse to change.
I am a patient at UTSW in Dallas for over a decade. They seem to have implemented Epic successfully? I even like their mobile app. I can contact all my doctors in UTSW (over a dozen), see my lab results, and ask for refills through the app. Billing is still a bit of a mystery but I believe that is due to balance billing.
Yep I’m happy as a patient. My doctor is very in tune and uses it for everything effectively so prescriptions are easily handled, she comments on lab results, answers messages etc. it’s amazing for someone like me.
> Are you saying that the cancelled orders are due to a management decision/policy, and not a software bug?
The first time the order gets cancelled unintentionally, it's a software bug. Shit happens. When a bug happens, management makes a choice how to respond to that.
When the bug is permitted to persist and result in cancelled orders again and again and again, that's no longer a software bug, that's a management decision to continue to let broken software run rampant and affect their operations.
Think of it as the software equivalent of fool me once, shame on you; fool me twice, shame on me.
Clearly it’s both mismanagement and a software issue. I can’t believe the people here trying to ensure the software platform and provider never looks like the bad guy by defining “bad” in the most convenient way. (Again, management is bad. I’m not denying that. But two things can be bad.)
Competent management would atcept the report of this and scream about it. That means lawyers taking whoever is at fault to court. That means invoking the contract line to to pay (which they would have put there). That means of course a way to report things like this that any busy doctor can figure out.
Are you running Epic? As a patient it has been amazing to use and have everything available. My doctor uses it effectively and it’s quite cool she can do all prescription management etc through it. Now even virtual meetings.
I think you made a throwaway account for this reply, but I would really appreciate continuing this conversation with you. My email is available under my profile.
I'm not seeing substantial investment back in the EHR, wherever the money is going it's not being spent on improving the product. Epic remains a thick desktop app served over Citrix sessions, their web-based workflows still haven't materialized.
I worked for a couple of years in a company that both developed EMR software and ran clinics -- we employed care providers directly. I assumed going in that this would present amazing opportunities for applying modern technology to improve efficiency, outcomes and both patient and provider experience. Of course that didn't work out the way I expected. I'm not sure if doctors were the problem because to be honest I didn't get to interact with doctors much. The medical providers I did talk to were very interested in using software to improve things, and also extremely smart -- much brighter than the average s/w engineer to be honest. What I did see however was that the need to make (more) money began to dominate, and nothing that we were doing to improve our EMR really had much of an impact on that, at least not a direct or profound one.
Hey Duff, you're right, healthcare is broken in so many places, and insurers are probably the worst in this morass. They selectively follow Milligan care guidelines, build tools that actively discourage anyone from understanding and/or fighting for fair care and bills, and basically pretend they're doing you a favor but making you pay for your services, then showing a marked down EoB that pretend like they saved you money but knocking off 80% of a bill that was prenegotiated, and you're the one footing the bill. Insurers have no incentive to make healthcare better, and though hospitals are disjointed they still make so much money, it doesn't matter how badly they are run.
But aside from the insurance companies, the first large scale emr systems (Cerner, McKesson, and even Epic) were built as operational tools to essentially give accounting access to Crystal reports. Sure, electronic charts should make the patient's life better, and assist trained medical staff in tracking, however they ultimately are used to figure out how the CBO can game the insurer financial incentive system. CPT + ICD +modifiers (oh, and 85% of those cpt codes are under copyright by the corrupt AMA - yup i have a different bone to pick with them).
I agree that operational dysfunction is the biggest problem in these behemoths, and there's so much ineptitude in administrative staffing that it's a nightmare. Doctors like to believe they're the bees knees and everyone should kowtow to them, but they usually can't run a business to save their lives. It's easy for them to simply blame an EMR than to acknowledge the truth of a dysfunctional system they are a part of.
Glad to see you're still kicking ass, better than sameday.
Most patients who are unhappy about how much they have to pay should complain to their employer, not their nominal health insurer. The majority of US consumers reading this obtain their medical coverage from self-insured employers who use "insurance" companies mostly for network management and claims administration. It's the employer who ultimately pays for treatments. An insurance company will be happy to put together a custom plan for an employer under which plan members get as much care as they want for $0 out of pocket. This will be extremely expensive for the employer.
(We can argue about whether health plans should be tied to employers at all but that's a separate issue.)
A lot of facilities run on a McDonalds type thinking when they should be looking at how In-N-Out is able to deliver a very similar product that is both dramatically better and either the same price or even cheaper. In-N-Out staff is well compensated, customers rate the institution as one of the most beloved in american life. McDonalds achieves neither of those things. What makes In-N-Out different? The difference is competence in operations. A lot of healthcare today delivers an inferior product at an inferior price, it doesn't have to be that way. A lot of people think that quality is only possible at an increased "price". A change in thinking is what is needed to achieve a change in quality (result/price).
Responding to the request below for a specific example. Hand washing, you wash your hands when medically appropriate to prevent facility acquired infections. If you don't you are progressively warned ultimately leading to termination and/or loss of license. If instituted nationally this alone would save at least 5,000 lives a year. Good luck getting it instituted at most facilities.
A different example, diesel fuel and generator maintenance is a meaningful part of medical facility physical plant. A shocking number of facilities place procurement responsibility and oversight of this in the hands of a doctor who also has medical responsibilities. The results are as financially and operationally disasterous as you would expect. Data centers have similar requirements. Who do you think pays more and operates better?
Formularies are a sort of default medication lookup table. Most organizations have one that was created decades ago by people who aren't with the organization anymore. Review and revise them with someone who understands both the medical/pharmacological aspects of the drugs involved as well as their costs. Win for doctors, win for patients, win for insurers, almost no one does this. They have some clueless administrator carry forward last years formulary with minor changes or alternatively have a medical professional with absolutely no idea what costs are involved do it.
That diesel maintenance example gets even more interesting when read through the lense of the ongoing Boeing threads: there, consensus is that the root problem is authority erosion for the core discipline: in old Boeing, engineering was a requirement for responsibility, but that is gone. In hospitals, the core discipline still holds on, but the blanket implicitness (or is it already a struggle? "we can't give up the diesel!"?) leads to terrible outcomes as well. Extremes rarely end well.
"Responding to the request below for a specific example. Hand washing, you wash your hands when medically appropriate to prevent facility acquired infections. If you don't you are progressively warned ultimately leading to termination and/or loss of license. If instituted nationally this alone would save at least 5,000 lives a year. Good luck getting it instituted at most facilities."
Sad thing is most staff in hospital doesnt wash hands. Reality is it would cost so much time. Handwashing is like a minute and staff has to go in an out of rooms where hand washing is needed so many times an hour it would slow everything down. And then trying to fire staff about this is not real because this would kick out half of it and it isnt replaceble. The problem is more why has staff to get in and out of stations so frequently. And multiresitence bacteria.
I'm always terrified to see surgical caps and such on doctors in a hospital cafeteria. Also a nurse or surgeon wearing scrubs on public transit. Whether they're coming into work and carrying unknown filth into the facility, or leaving with deadly resistant hospital pathogens on high density transport... they're both terrible. Unless you're outpatient, don't wear scrubs to/from work. Don't be Dr Oz wearing your status on your shirt sleave for giggles while risking patients and public.
Specifically with handwashing which is a problem I have been very successful at solving, time is not the main factor. It is wear and tear on the hands and this comes down to the soap used and water quality, really. If you get those too things right people mostly find it no problem to wash their hands when appropriate. Also for non-medical people this is not washing your hands before surgery washing, this is routine washing between patients, bathrooms, and duties.
Regarding gloves, gloves don't solve disease transmission from dirty hands. You need both hand washing and gloves.
> Handwashing is like a minute and staff has to go in an out of rooms where hand washing is needed so many times an hour it would slow everything down.
Sounds like the workflow is poorly designed then. Use gloves instead of hand washing.
McDonald’s menu is enormous, much larger than In n Out. If you’ve ever worked in the quick service food industry (it sounds like you haven’t), you’d know this considerably affects how every facet of the restaurant functions.
I also completely disagree that In n Out is “dramatically better” and I’d be very surprised if that was the resounding opinion across Americans. It is fine, but again, it serves a different purpose, so making such broad apples-to-apples comparisons seems a little short sighted.
“Competence in operations” is a nice sound bite but without some real examples related to restaurant management I’m just not convinced. I ensure you that it has indeed come up in a McDonald’s boardroom that raising their wages would result in more competitive hiring, that is not a novel observation. I did three years at McDonald’s and another several at other restaurants; admittedly it doesn’t sound like this comment was made from a place of experience, more a place of convenient idealism.
Also don’t forget scale—-in/out might have ‘dozens’ of restaurants but McDonald’s has ‘thousands’.
They also have software that was developed entirely in house that is unbelievably optimized. Weird, but usable. They are a company that fully understands the problem space they operate in. Hospitals should be doing everything they can to run like them but no one likes to hear that.
I don’t understand the people who rave about it. There’s very little difference other than the fact that they have a “secret” menu with their own coded language.
I’ve been to both good and bad McDonalds. Burgers and fries from well-run ones can taste very good. In-n-Out has better consistency, and it’s on par with the quality of well-run McDonalds. It’s probably due to the fact that In-n-out has fewer items? I don’t know.
Huh. I like the slightly toasted bun and the generous amount of veggies they put in the Inn n Out burger. I’m not aware of a similar looking or tasting burger on the McDonald’s menu.
> customers rate the institution as one of the most beloved in american life.
That's a bit overstated, the majority of Americans haven't been to an In-and-Out, ever, because they are a mostly-California chain. They're only available in a very small handful of states.
In-and-Out can probably run so efficiently because their menu is extremely tiny.
Respectfully, I’m not sure what you are asking for. In-N-Out is only in a small fraction of the US so most people from the US wouldn’t know much about it either. I believe that’s why the GP comment provided a little more context which was more or less sufficient for me to understand the comparison.
Initially the In-N-Out example was made without explaining what it is, and even with the added context i think it doesn't really explain how In-N-Out differs from McDonalds. Their operations are better, what does that mean, how does that impact customers, how does that impact cost, etc.
I wouldn't say Rolls-Royce, more like Lexus. Fuddruckers would be closer to Rolls quality as they actually allow for something other than well-done, preformed, meat pucks.
In-n-Out has saturated the southwestern coast, which is a pretty significant fraction of the United States.
The key is they have an absolute ton of employees in the restaurant (a busy McDonald’s might have four or five, In-n-out can have double or triple that. I’ve seen other fast food with two employees, never an In-n-Out) and they work exceptionally hard on specific tasks.
They also only deploy in areas where they’ve determined they’ll be able to keep the store busy enough.
Am too from Europe, and never heard about it until last year when visiting my colleagues in LA and was taken to a In-n-out. It was packed and I agree that it’s tastier than Mcdonald’s. My colleagues were very surprised that I didn’t hear about that company because “everyone knows it”.
What they don’t understand (until explained) is that what we get in a European countries are just a small selection of big franchises (McDonald’s, Burger King, Starbucks etc) and maybe a handful of other ones. In America there are dozens and dozens of restaurant franchises where you can eat for weeks each time in a different fast food restaurant in the same city without going to the same place twice. This is what always amazes me as a European, that huge amount of choice of everything you can have there.
Even a ton of Americans wouldn't know In-n-Out. They only really recently started expanding a lot. Until a few years ago its was pretty much a Southern California only thing. There are no locations east of Texas, and even then there are only locations in the core triangle of Texas. If you're in El Paso or Corpus Christi or Amarillo or Lubbock or McAllen or Brownsville you're several hundred miles from the closest location despite there being many locations in Texas. There are zero in New Mexico, Oklahoma, Kansas, or Washington. All of New England is about a thousand miles from a location.
These people acting like "everone knows it" essentially have the same world view that the entire world that matters is Southern California.
Some of these suggestions seem like non-trivial management problems, though, I think?
Diesel fuel and generator maintenance: how do you hire for that? Does that position require experience? In what? Where do you post that job ad to get qualified candidates? If you hire wrong, it seems like the results could be worse than foisting the task on a doctor, no?
Revising formularies: how many doctors at a hospital have the right expertise for that? Who cares for their patients while the formulary work is happening? Can you hire someone temporary to come do it so it doesn’t disrupt operations, and how expensive is that person and how good is the result?
I’m a software person, not a doctor, but I _can_ see how these choices would be made if the alternative seemed riskier to someone inexperienced at hiring for hospitals.
>Diesel fuel and generator maintenance: how do you hire for that?
This is typically part of the job of a facilities manager, someone who is in charge of maintaining the physical structure and amenities of a building or complex of buildings. You hire for it the same way you hire for everything else; you find someone in the category that you want, who has apparent success doing something similar to what you're doing.
Many of the most painful technical problems are actually three business problems in a trenchcoat.
Sometimes too many people are too invested in the crazed/idiosyncratic way of doing things... and unless the humans can be convinced to fundamentally change their process, adding software will only give you... well, craziness with a computer.
you know, sometimes those idiosyncratic ways have a reason for existing because they solve actual problems.
Technical people have a really bad habit of solving for theory rather than practice and they develop this attitude that those who are seemingly entering into odd behavior are just not as good or smart as them.
> you know, sometimes those idiosyncratic ways have a reason for existing because they solve actual problems.
True, but "actual" is a rather low bar. I once worked at a company where a big internal enterprise app controlled a lot of operations, and saw that many of the layers of cruft in the app were because it became the preferred battleground of corporate dysfunction.
One example is that the sales team kept closing deals ('cuz commissions) which were difficult to fulfill, unprofitable, or cannibalized from other assets and activity.
This lead to repeated and increasingly obtuse layers of code for estimating gross-margins, showing values at different interfaces and steps and warning styles, managing and modeling gross-margin reporter/reportee connections and automated alerts and permissions systems where they system would block certain people while e-mailing other people for clicking approval boxes, etc.
HN is (probably) read by mostly software development (-adjacent) people, and this thread is basically software developers blaming users for using their software wrong. Maybe that's true, but I think it's at least worth pointing out before someone mistakenly thinks this isn't an echo chamber.
> this thread is basically software developers blaming users for using their software wrong
I wouldn't say that, most devs who've worked with product requirements and users have seen issues with users wanting something inefficient or illogical, basically because they don't like change and/or don't understand why they are doing something.
In my opinion, this is less about the field (health care, real estate, etc.) and more about automating someone's core role. Many people have learned to do a particular job a particular way: some things they have picked up through trial and error, others were handed down from a more senior co-worker. There are other steps that are taken because something else (regulatory requirements, etc.) require it or don't and have been misunderstood.
When we try to automate part of a person's work, we have to encourage the person to take a look at themselves and the way they do their work. This is not easy for people! A lot of times we're asking someone to admit that they don't actually know why something is done a particular way. Or we point out that they are doing the work of another person in another department. And, all the time, this person is worried that at the end they will be replaced by software and lose their job.
I think it's really hard to get to a place where everyone is comfortable enough to be frank about what they do, what the software might be able to do, and what makes sense.
Idk this reads like apologetics for the software industry, which I know people will be more sympathetic to here. But. I know doctors that tell me their EMR log them out after a minute of inactivity and take 3 minutes to login. This can happen multiple times during a patient visit and are totally disruptive. I've heard that it's even begun to affect the throughput of the hospital. So I wouldn't be so dismissive of doctors complaints.
I very much doubt it’s the software vendor who has chosen to implement the automatic logout after a minute. Most probably someone wrote that down in a requirement because that’s how the previous system worked or that’s what they saw on the internet, and once that’s done it’s set in stone
Again, that's not an EHR problem. All modern EHRs support fast SSO and OS security integration. If it takes more than a few seconds to log back in then the fault lies with the customer. They have either configured the system incorrectly or are running on inadequate hardware.
This is entirely a data security issue. Depending on the environment, without a logout this is seriously risking a HIPAA violation. Say you're in the hospital and your doctor pulls up your record on a computer in the hallway after they've done rounds on you to put in their observations and notes. However just as he's finishing, his pager goes off, he's off to an emergency, and he forgets to log off.
How many minutes are you okay with your medical record being open for inspection by anyone that walks by? Other medical staff, admin staff, janitorial staff, other patients getting steps in, other patient's families?
It's one of many instances where there's a valid reason for the technology to be implemented as such but since doctors usually aren't thinking about the technology or security aspects they just perceive it as annoying.
> It's one of many instances where there's a valid reason for the technology to be implemented as such but since doctors usually aren't thinking about the technology or security aspects they just perceive it as annoying.
No, there is never a good reason to prevent a professional from doing his job. If the user finds it annoying, it is annoying: that's it!
Learn to work for the user rather than against the user, and you'll become a better developer.
That's simply not true. The user is not the only stakeholder. The example I gave opens up the hospital to fines from the government and in the worst case scenario a massive legal judgement from the patient who's data was breached by a physician leaving his workstation with a patient record opened and it was compromised by a malicious actor.
edit: in any case this is very likely a security configuration by the hospital infosec team, not the developer of the EMR.
The specific example isn't a developer decision. It's a combination of vendor risk management teams, hospital InfoSec/security/compliance, legal teams, laws, and location of computers. Nevermind that setting is just as often a workstation GPO to lock the screen and not even the choice of the software.
(Work for a PACS vendor, subject to the same stuff).
At ClearHealth/CLH we defined thousands of core business processes in a typical over 100 bed acute care institution. These are complicated animals. A hospital of any size is pretty much a city unto itself. There isn't one thing, there are a lot, a lot of things from how items and equipment are procured which is very complex to simple things like making sure that people wash their hands when they should. How laundry and trash are handled. HVAC and plumbing are insanely complex in a hospital setting. It is absolutely absurd how viscious the fights get between staff and management over parking assignments. It requires virtually a threat of termination to make a lot of doctors follow even a 3 to 8 step evidentially developed checklist for certain situations.
ACHC, joint commission, CLSI for laboratory, are groups that outline some very basic frameworks of how facilities should be operated. Less than half of facilities can meet even these extremely low bar standards for operations. It is difficult for me to see how many patients have been harmed by ransomware impacting hospital opertions, this is entirely preventable and no one on the hospital side has been meaningfully held accountable so very little will change.
A counter example is the pricing transparency regulations. Failure to meet those is resulting in multi-million dollar a year fines which is resulting in change. It is happening slower than people like or had really conceived of but it is causing some real meaningful change.
99,000 americans a year die from hospital acquired infections that are entirely preventable using procedures and operations (not surgeries) that are known and evidentially proven. It's just really hard to get all of the parts of the orchestra to play the same tune so those people die needlessly.
Is there some way a non expert can assess a particular hospital by these measures? What I'm getting is that most hospitals introduce more risk than they should, but if I find myself needing one I have zero idea how to not make picking one feel like flipping a coin.
"99,000 americans a year die from hospital acquired infections that are entirely preventable using procedures and operations (not surgeries) that are known and evidentially proven. It's just really hard to get all of the parts of the orchestra to play the same tune so those people die needlessly."
??? I dont get this. The problem are Antibiotic resistant bacteria. You go to a Hospital (ER) and have a open wound.. chances are you die of an infection. How is this preventable??? This is a big problem atm and there is no good solution. you cant test people if they come in bleeding like hell for Resistant bacteria.
I mean you can but ...
I would like to hear the solution to that problem. Thank you.
I once spoke with a nurse who said they have the walls scrubbed on a regular basis. I can't recall if it was daily or weekly, I think weekly.
They're not paying the nurses to do that, the people who are doing it probably consider it shitty work and I wouldn't be surprised if things get missed due to the sheer crappiness of the work.
I think there's probably a reality there that can't reasonable worked around. Sure, in theory a perfect scrub will solve the problem but how do you regulate that into effectiveness?
The best you can do is to design tools to make it less shitty but you'll never make it non-shitty.
In germany we have this allready but it doesnt work. It reduce the problem. But the real problem is ER. In a life death situation it doesnt work. ER are very hard to keep clean. But yes you are absolutly right
EDIT:// I am no doctor but did work in Hospitals. Doctor friends working in ER are telling me about those dangers. And also bigger Hospitals have less control about it.
220nm light is under investigation since it's germicidal but so far appears far less harmful to humans than other UV ranges. If those findings are validated we might see some permanent narrow-band, low-power UV lights in hospitals.
For one, the payment setup in the US is a massive burden to proper care. For every screen and procedure that gets logged into an EMR system, there is some resulting billing setup that is complex, overburdensome and user hostile. The billing setup is so bad in the US that there are whole armies of companies who's job is literally to just collect revenue for unpaid bills (RCM - Revenue Cycle Management), many of which are the result of a confusing billing and invoicing system.
Source - I've done diligence on at least 75+ EMRs/EHRs.
Make a less divisive or controversial analogy then. If people are getting hung up on the analogy and not focusing on the point you’re making, you’re making a bad analogy.
