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.
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.
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.
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 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.
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.
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.
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
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.
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.
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.
I wrote a thesis on EHR's 7 years ago. They really haven't seemed to improve much. I personally think a big part of the issue is actually scope, these systems are expected to do everything - medical notes, script ordering, appointment management, billing of course, and 3000 other things. This weirdly leads to a distribution problem, you can't be a serious competitor in just one area, you have to do everything. Only the monolith can shift the monolith. Then combined with the risk (or perceived risk) of working with medical data, and you're left with something that just never improves.
This is very true. There several reasons why most EHRs are so bad:
1) The people who pay generally do not use the system. This is true for enterprise software in general and leads to vendors prioritizing having all features organizations ask for (regardless if they are a good idea or not) and also prioritizing features management deems important over fundamental workflow, UX and polish in general.
2) EHRs are very large and complex and can almost always gain more customers by gaining even more features and replacing smaller more specialized systems. A typical EHR will have features for ordering tests and viewing results (for clinical chmistry, microbiology, radiology and more special stuff like physiology etc), appointments and resource planning (rooms, equipment, personnel, staffing), clinical notes including computing scores and values based on other values, medication (ordering, administering, sending prescriptions electronically) and administration (admissions, discharge, payment, waiting lists). That is a lot of different stuff!
3) Once a vendor wins a contract and installs their EHR, very little can be gained by improving the lives of users. Contracts and sales cycles are very long, and the vendor gains very little financially by improving the system. So many vendors are focused on charging money for customer specific features or adding new features to win new tenders.
I'm not sure what the solution is, public alternatives have failed spectacularly since they are typically run by public administrators who have even less of a clue how to develop software and what users want than the vendors.
> So many vendors are focused on charging money for customer specific features or adding new features to win new tenders.
In turn, this enterprisey anti-pattern creates unfocused products which can be configured to sort-of-solve every niche customer requirement that might block the sale.
The result is a massive ball of muddy configurations and feature-flags, so that learning isn't very portable and backend integrations are very painful.
I would add the point that these dynamics are also present for any large IT system. Just search for people having issues migrating to SAP or Amadeus or whatever
Ironically, it's also a somewhat of a circular problem, given the inherent complexity of medical processes, every organization has organically formed their processes over decades. When choosing software solutions, they pick software that caters to their specific needs, rather than change processes to fit existing software. This results in vendors building endlessly configurable products that add even more complexity. As a potential new entrant, this means you'd need to not only support N processes, but something like (number of clients) * N processes.
There are some initiatives towards EHR interop (e.g. FHIR), but from what I've seen so far, they suffer from similar problems. As in the standard is made so flexible to cover all situations that you can make things that are 100% compliant, but completely incompatible.
Yeah, I've seen the term "sociotechnical" used to describe this relationship between software and process. A process is built in part for a system, and therefore the system in part needs to support the process. Changing the setup isn't just a technical challenge, it's a challenge in creating sociotechnical change. I think it's a very easy thing to underestimate.
>I personally think a big part of the issue is actually scope, these systems are expected to do everything
If I were to guess, the goals of admin and workers might not match because the primary goal of the admins deciding and implementing the EHR is to avoid liability for the organization in the event of an error, but errors are inevitable. And if liability for individual errors are so costly (as they are in the US for healthcare stuff), then the primary goal for the workers also becomes avoiding liability.
In this situation, I can envision something like a crew of people working in the hospital that do good, quick, but undocumented work 99% of the time, are now being slowed down by documentation or other cover their ass needs. Obviously, it is possible that the new documentation needs are also uncovering malpractice that went unnoticed before. The question is are the tradeoffs worth it, which does not have a simple, objective answer.
In Swedens capital region they failed with this too. It's dominated by a system that is largely quite well polished but has some scaling issues that has lead to down times. The region decided to develop their own in cooperation with other regions, but instead of just hiring two-three developers and putting them in a room inside some small hospital, they decided to make a Grand Political Project out of it.
Billions of Swedish crowns later, having written ZERO lines of code, they quietly cancelled the entire thing. This enormous boondoggle didn't even make the news because the waste was all man-hours and consultancy, and not a building or something the media found sexy.
I think a big problem is that politicians need Grand Political Projects to get reelected, but that's not how you build software. Or make meaningful small incremental improvements to science, infrastructure, schools, etc. The incentives are wrong...
The UK government tried this, wasted 12.4 billion pounds over 10 years, and ultimately wrote most the project off. The dream of an EHR is just deceptively tricky, so many smart, well-funded, well-connected teams have tried and failed.
There is (or was) a public competitor. VistA was largely developed by the federal government. Some organizations still use it and it's available for free, but independent reviews have generally rated it as worse than the private industry products.
I believe the Estonian government has long had at least a basic EHR that they use across their public and private medical facilities that is part of their larger e-government system
Private industry is already worse than the older system of keeping notes with pen and paper. (Source: my mother operated her own medical practice and applied for a government subsidy to switch over to electronic medical records, then complained about how it reduced the functioning of her practice.)
Yea. But in that time there has been an absolute revolution in what can be done with that data. FHIR specifically has completely changed the landscape.
Yes. FHIR was pretty well established when I was writing the thesis, but I am very pleased to see it get more and more usage since then. Apart from interoperability the opportunities to do much better data mining from free-text medical notes with AI, are huge now. Back when patient prescription lists ot structured, so many new drug interactions were found, now there's the chance to do similar stuff from open medical records.
Patient-accessible medical systems are more common now too, which is great. EHealth got way more common. At the end of the day though, what your doctor is clicking on still sucks, which is the sad part.
Popping up here to mention OpenMRS, a healthy open-source EMR used by hundreds if not thousands of facilities across the world, mostly in Africa and Asia. An old version is packaged/integrated with some other apps into Bahmni, which is a full-blown hospital management system.
Honestly, people complain about software all the time and all software sucks to some extent, some more than others of course. Complaining about all EMR just because the USA bodged a national rollout in their uniquely messed up healthcare situation is a bit myopic.
I would not dismiss his complaints as broad brush IT disparagement. Despite the title, I think the author is referring to the EHR (Electronic Health Record), specifically of Epic which is unique in that it is essentially a "benevolent tech dictatorship" imposed upon 90% of hospitals through owner/lead programmer Judith Faulkner at Epic (no medical background) lured initially by federal incentives then married to it in perpetuity. That's not really anything like operating system software you can uninstall today (e.g. Microsoft, Linux, Apple). With the onerous hospital system transformation contracts and non-disclosure agreements - Epic exec customers are more like cult followers than standard software consumers.
I suppose that's technically true although wikipedia states that she cofounded Epic with a medical doctor and is married to a medical doctor. As a software developer, I rely on subject matter experts frequently. I'm not an expert in radiology, chemical engineering, or any of the other businesses that I support.
Very true, people complain about software, but my recent experience in a Gulf country, was stellar, all my medical records, were entered properly including procedures, it takes approximately 12 minutes to get medicine from the pharmacy and can view the records online. The patient interface could be improved a bit but did its job perfectly. The article was stellar, as it summarized the state of the art and the issues well.
I believe this article is only about this specific system. The problem is that the name of the system is "Electronic Medical Record", which makes the article sound like all such systems are hated.
I don't think that's the case. AFAIK there's no such system. The article specifically reference Epic, which is one of the biggest (_the_ biggest?) EHR software company in the US. My wife used it as a nurse and I've watched my own providers struggle with it. It sucks.
Disclaimer - I work for a health service that isn't in the USA and has a very extensive EMR.
I don't disagree. I started my career dealing with paper folders of records that were fastidiously organised by a team that made sense of them. Now everything is electronic and fucking _everywhere_. The work didn't go away - but giving everyone a computer made it everyone's problem and nobody's job.
A really good EMR (or other records project) makes the 'work doers' jobs easier and is intuitive. We often severely miss that mark or only do half the job required.
This is everywhere. We made everyone their own secretary but gave them crappy tools and no training. Also they’re never gonna be doing it more than very part-time, so will always tend to be bad at it and find it a distraction from the work they’re actually good at.
I’m skeptical computerization has even been a net benefit for productivity for most jobs, for that and other reasons. I think it’s been such a huge boost in a few areas that it looks productive overall, but actually it’s been a step back in most jobs. The high of eliminating positions and of centralized command-economy-style technocratic visibility into everything keeps management hooked on it anyway.
> We made everyone their own secretary but gave them crappy tools and no training. Also they’re never gonna be doing it more than very part-time, so will always tend to be bad at it and find it a distraction from the work they’re actually good at.
This is, 100% exactly it. Then we have to design systems for the absolute lowest common denominator to get any semblance of sense from it and anyone with the slightest bit of clever just has to deal with it.
The problem with the computerization brings benefit lines is that it was demonstratively true back in the mainframe days but became less and less so once the big beast with dedicated attendants and handlers got replaced by "not quite foolproof enough" wintel desktops managed by nobody.
This is also why so few PC centric modernization process are truly successfull.
From the other side of the table, as patients that were very regularly ill and bouncing between medical professionals, EMR were a godsend.
For instance in vacation at the other end of the country, we lost an Anapen with a luggage mishanded at the station, though we had a spare but we actually didn't (was in the same bag...). We went to the closest doctor, showed the insurance card and they got access to the allergologist's diagnosis and original prescription, gave us a new one with a memo in the file, and done.
Same way having two generalists looking at us, one near my work and another near home wasn't an issue. At no point did we have to bring folders full of papers to explain long treatment histories etc. (it still helps to have the key files, in particular scans)
I moved away and everything is back in small silos at each doctor/clinic, and it's a real PITA.
I'm truely sad it's such a pain on the care giving side, because there's so much potential and I think it merits investing a lot to get something decent. It's such an important part of our forseable future.
The problem is that in the US, many EMR's don't automatically connect to each other.
If you're going from a hospital owned by one chain (say, Hospital Corporation of America) to another hospital owned by the same corporation, then yes, it works like you said and doctors have access to your historical data. But God forbid that you should ever end up at a hospital owned by a different corporation, because then you have to call the Medical Records department to release the data, which often takes a couple business days to go through. The system doesn't work if it isn't open, and unfortunately, our patient privacy law (HIPAA) is often used by corporations as an excuse to silo their data away and prevent others from accessing it.
is there any good research or information on various clinic's organizational style? I feel like there are plenty of places where digitalization took its time to get there.
I feel like in general there's gotta be a lot of good sociological research on how stuff is kept straight. I only see stuff regarding DX work, but organizing was a problem even before computers, right?
EHR’s have all the problems of enterprise software, plus some. At the end of the day, the software is made for the people who pay for it. This isn’t the patients, or the providers. It’s the admin, billing, and bureaucracy layer who get to make all the decisions. It’s not surprising that these people don’t prioritize good software.
EMR’s need to do more, but the root of the problem is systemic.
Agreed, you see the same issue with other enterprise software that tries to everything: SAP (including more specialized parts like Concur), Workday, and many others. They’re trying to do everything, then are often badly configured, mostly by following internal (financial) procedures, without considering end user experience.
There’s a whole industry of tools to help you build better interfaces on top of these big systems of records to improve the user experience. So much so that Gartner has even describes it as a desired way of designing system: used to be Pace Layer model, now it’s called Composable Enterprise.
I think they need to do less. Part of the problem is they are trying to be everything for everyone. A hospital is an aggregation of what is really several different businesses into one - and they all have to use the same monolithic application. Each medical speciality has their own unique data and technology needs, as does each specific unit (ie different ICUs for surgery, burns, etc), then add pharmacy, labs, admin, etc.
If the priority is billing, then focus on aggregating and correlating billing data, expose an API for consumption with other systems being used that may or may not be from the same EMR company.
I do agree that there is an issue with stakeholder bias towards admin. Every pet project from admin results in a bolt-on fix to the EMR configuration bloating clinical processes. They are the ones that make the rules and decisions and are often disconnected from both technology and clinical expertise which is perhaps the worst combination for health care technology decisions.
Also, even if Epic offered its platform free of charge, it’s incredibly expensive to setup and train staff. Just that initial expense of plugging everything in is a huge risk that many hospitals on a tight budget likely can’t afford to take.
My first job out of college was working at Epic Systems as a mostly Windows sysadmin. It was a fascinating (and great!) experience. I've never seen such an advanced Windows sysadmin setup before.
I only briefly touched upon EMRs and the MUMPS/Cache stuff they did there. However, I also learned PowerShell to a much deeper level than probably 99% of Linux folks ever do. We did TDD, code review, CI/CD pipelines for fucking PowerShell. It was painful right up until the point where I internalized the Tao of PoSH, and then I realized that PowerShell actually rules for readability and maintainability when you have people who know what they're doing.
HNers by and large don't understand the economics of PowerShell. There is a very low supply of competent PoSh devs on the market, and even fewer interested in credibly signaling their proficiency, but a very high demand for them, because a lot of places still run everything on Windows, and guess what's installed on virtually all of them? I've even been able to take on a few consulting gigs that boil down to "take our 100,000 line un-version-controlled PowerShell monstrosity hacked together over the last 13 years and turn it into something we can actually understand, please".
> PowerShell actually rules for readability and maintainability when you have people who know what they're doing.
Isn't that true for all programming languages ever devised by mankind?
> HNers by and large don't understand the economics of PowerShell. There is a very low supply of competent PoSh devs on the market, and even fewer interested in credibly signaling their proficiency, but a very high demand for them, because a lot of places still run everything on Windows, and guess what's installed on virtually all of them?
I don't see what point you're trying to make.
The fact that Microsoft decided to push PowerShell on virtually all versions of windows it ships only reflects a Product decision by Microsoft to push a Microsoft-only tool. It also shows Microsoft's decision to not offer the same level of support for any other alternative.
Where's the economics in that?
I also don't understand your broader comment on economics. Are you depicting it as a good or bad thing?
Re/ the economics: It's okay, many people don't get a formal course in this stuff. First look at the graph with two lines on https://en.wikipedia.org/wiki/Supply_and_demand. Notice that the y-axis is P for Price.
Now imagine first off what happens to Price when you shift the downward sloping curve forward. That is what economists call the demand curve. Does Price go up or down?
Finally, imagine what happens to Price when you shift the upward sloping curve backward. That is what economists call the supply curve. Does Price go up or down?
One would hope, but alas! Perl was notorious for being write-only back in the day.
PoSh is closer to read-only for most devs. If someone makes sure to write things out the long way (or uses a linter to do this) it's very easy to grok. Actually learning to write it is the tricky bit.
>HNers by and large don't understand the economics of PowerShell.
That's not true ...
PowerShell is the "lingua franca" for Windows system administration, I think everyone understands that. Much of the power of Powershell isn't the syntax (which is unnecessarily cumbersome), but rather that most core windows system services have PowerShell bindings.
Powershell isn't a tool you would use for Linux scripting and administration, because it isn't ubiquitous the way bash is.
So what exactly is your point? That Linux administrators adopt PowerShell? Or are you arguing a strawman that HNers advocate for using bash in Windows?
The reason why we use Bash on Linux is because it’s ubiquitous. Even though my terminal is ZSH, all my scripts will be Bash because I can trust it to run on any system.
Same goes for Windows, I want to make sure those scripts can be run without having to install anything. Powershell is there, and it’s powerful.
Python is better for anything complicated. Even though Bash is ubiquitous, it's kind of a pain in the ass, and it's actually not that portable since there is no real "standard library", and everything basically depends on system tools being installed and/or configured in a particular way.
> Patient R was in a hurry. I signed into my computer—or tried to. Recently, IT had us update to a new 14-digit password. Once in, I signed (different password) into the electronic medical record
That's IT infrastructure incompetence, not an EMR issue.
At the two healthcare systems I go to, both utilize RFID badge readers plus PIN. In the ER and urgent care, nurses need only tap their badge and enter a quick pin and they're in. It's taken them seconds to pull up my records and I've never noticed a delay in care.
In the PCP's network, everyone seems to get smooth and quick access often while we're conversing, and I can see all my visits, lab results, and so on. The major annoyance is that I get emails notifying me I have a "message", instead of even offering me the option of receiving an email with the actual message.
I don't think people understand how expensive and time consuming the non-electronic stuff was. I remember my mother spending considerable amounts of time trying to get records from labs and doctors and having to shelp a lot of it by hand.
> That's IT infrastructure incompetence, not an EMR issue.
The two cannot be unlinked so easily when I have never met someone so doesn't have the same story of hospital IT. Even the IT workers hate hospital IT. The deployment of an EMR has to take into account the regulatory and security requirements imposed on all digital systems.
> I get emails notifying me I have a "message", instead of even offering me the option of receiving an email with the actual message.
Not gonna say it's not a bitch and a half to implement but you can send sensitive data directly via email. And if you're the SaaS provider you're part of DT that's a huge value add for your offerings.
The email thing is probably a privacy requirement. Email isn't encrypted meaning your email provider (and the EMR's) can fully read the contents of said email.
I think people want to waive that privacy concern. My email provider has access to tons of my private data including lots of health data. Given the option, I suspect many would prefer to just get an email.
Yeah, as a patient I don't have any problem with EMRs. When I visit a specialist I can fill out all the forms and pay the copay online. The app notifies the office when you arrive, so you just sit down and get called in. I used to go to NYU Langone but switched to Mt. Sinai and all my records came over fine.
I'm a "visit the doctor once every 0.9 years" kind of a person, so I guess my needs are not incredibly complicated, but I've found the experience to be pretty fine overall. Good, I'd say, honestly.
I could see that badge system easily costing a million+ dollars, fyi. RFID identity management is an entire platform in itself and is extremely expensive.
Note that Scotland got electronic medical records much more correct than England by making the whole thing a Clinician lead process rather than the English technocratic approach.
Finally it's very difficult to do "proper" scientific research on electronic health records, as control matched research is not achievable. Therefore you have to reach for things like single case study
Final brag - when I submitted my PhD it was politically quite sensitive so we had to find the right external assessors. One expert, one person whose judgement we trusted. The expert returned their report saying what a great piece of work it was and it should receive high commendation. The other person said it was solid and thorough but ultimately pretty obvious. Therefore I conclude that I received better than a high commendation for my work :D
Best outcome is when the people using these systems are the same people as those buying/specifying the systems. And best introduced with limited and constrained scope so you end up meeting the users actual needs. Pretty simple really and a tale as long as enterprise software itself.
Readit News
"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.
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 quit a few years ago and haven't looked back.
https://www.nrk.no/trondelag/70-leger-soker-aktivt-ny-jobb-v...
Who's been protecting this EMR?
(Who likes using it?, who doesn't lose their job by continuing to choose that vendor?, who gets kickbacks from that vendor?)
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.
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.
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.
(We can argue about whether health plans should be tied to employers at all but that's a separate issue.)
What is this comparison trying to illustrate?
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.
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.
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.
Dead Comment
it is fairly popular in europe. What is required for federal certification ?
0. https://openehr.org/ 1. https://openehr.org/products_tools/platform/
Deleted Comment
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.
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.
Source - I've done diligence on at least 75+ EMRs/EHRs.
Whenever I make this analogy here people jump in to say how much better McDonalds is :(
If your curious, here's where I discuss these points in the thesis https://barnett.surge.sh/welcome/complexity.html
1) The people who pay generally do not use the system. This is true for enterprise software in general and leads to vendors prioritizing having all features organizations ask for (regardless if they are a good idea or not) and also prioritizing features management deems important over fundamental workflow, UX and polish in general.
2) EHRs are very large and complex and can almost always gain more customers by gaining even more features and replacing smaller more specialized systems. A typical EHR will have features for ordering tests and viewing results (for clinical chmistry, microbiology, radiology and more special stuff like physiology etc), appointments and resource planning (rooms, equipment, personnel, staffing), clinical notes including computing scores and values based on other values, medication (ordering, administering, sending prescriptions electronically) and administration (admissions, discharge, payment, waiting lists). That is a lot of different stuff!
3) Once a vendor wins a contract and installs their EHR, very little can be gained by improving the lives of users. Contracts and sales cycles are very long, and the vendor gains very little financially by improving the system. So many vendors are focused on charging money for customer specific features or adding new features to win new tenders.
I'm not sure what the solution is, public alternatives have failed spectacularly since they are typically run by public administrators who have even less of a clue how to develop software and what users want than the vendors.
In turn, this enterprisey anti-pattern creates unfocused products which can be configured to sort-of-solve every niche customer requirement that might block the sale.
The result is a massive ball of muddy configurations and feature-flags, so that learning isn't very portable and backend integrations are very painful.
Ironically, it's also a somewhat of a circular problem, given the inherent complexity of medical processes, every organization has organically formed their processes over decades. When choosing software solutions, they pick software that caters to their specific needs, rather than change processes to fit existing software. This results in vendors building endlessly configurable products that add even more complexity. As a potential new entrant, this means you'd need to not only support N processes, but something like (number of clients) * N processes.
There are some initiatives towards EHR interop (e.g. FHIR), but from what I've seen so far, they suffer from similar problems. As in the standard is made so flexible to cover all situations that you can make things that are 100% compliant, but completely incompatible.
If I were to guess, the goals of admin and workers might not match because the primary goal of the admins deciding and implementing the EHR is to avoid liability for the organization in the event of an error, but errors are inevitable. And if liability for individual errors are so costly (as they are in the US for healthcare stuff), then the primary goal for the workers also becomes avoiding liability.
In this situation, I can envision something like a crew of people working in the hospital that do good, quick, but undocumented work 99% of the time, are now being slowed down by documentation or other cover their ass needs. Obviously, it is possible that the new documentation needs are also uncovering malpractice that went unnoticed before. The question is are the tradeoffs worth it, which does not have a simple, objective answer.
Billions of Swedish crowns later, having written ZERO lines of code, they quietly cancelled the entire thing. This enormous boondoggle didn't even make the news because the waste was all man-hours and consultancy, and not a building or something the media found sexy.
I think a big problem is that politicians need Grand Political Projects to get reelected, but that's not how you build software. Or make meaningful small incremental improvements to science, infrastructure, schools, etc. The incentives are wrong...
ref: https://barnett.surge.sh/welcome/intro.html
https://worldvista.org/AboutVistA
https://e-estonia.com/solutions/healthcare/e-health-records/
Patient-accessible medical systems are more common now too, which is great. EHealth got way more common. At the end of the day though, what your doctor is clicking on still sucks, which is the sad part.
Honestly, people complain about software all the time and all software sucks to some extent, some more than others of course. Complaining about all EMR just because the USA bodged a national rollout in their uniquely messed up healthcare situation is a bit myopic.
I suppose that's technically true although wikipedia states that she cofounded Epic with a medical doctor and is married to a medical doctor. As a software developer, I rely on subject matter experts frequently. I'm not an expert in radiology, chemical engineering, or any of the other businesses that I support.
https://en.wikipedia.org/wiki/Judith_Faulkner
I don't disagree. I started my career dealing with paper folders of records that were fastidiously organised by a team that made sense of them. Now everything is electronic and fucking _everywhere_. The work didn't go away - but giving everyone a computer made it everyone's problem and nobody's job.
A really good EMR (or other records project) makes the 'work doers' jobs easier and is intuitive. We often severely miss that mark or only do half the job required.
I’m skeptical computerization has even been a net benefit for productivity for most jobs, for that and other reasons. I think it’s been such a huge boost in a few areas that it looks productive overall, but actually it’s been a step back in most jobs. The high of eliminating positions and of centralized command-economy-style technocratic visibility into everything keeps management hooked on it anyway.
This is, 100% exactly it. Then we have to design systems for the absolute lowest common denominator to get any semblance of sense from it and anyone with the slightest bit of clever just has to deal with it.
This is also why so few PC centric modernization process are truly successfull.
Which is absurd when you consider just how many jobs are so-called "bullshit jobs".
From the other side of the table, as patients that were very regularly ill and bouncing between medical professionals, EMR were a godsend.
For instance in vacation at the other end of the country, we lost an Anapen with a luggage mishanded at the station, though we had a spare but we actually didn't (was in the same bag...). We went to the closest doctor, showed the insurance card and they got access to the allergologist's diagnosis and original prescription, gave us a new one with a memo in the file, and done.
Same way having two generalists looking at us, one near my work and another near home wasn't an issue. At no point did we have to bring folders full of papers to explain long treatment histories etc. (it still helps to have the key files, in particular scans)
I moved away and everything is back in small silos at each doctor/clinic, and it's a real PITA.
I'm truely sad it's such a pain on the care giving side, because there's so much potential and I think it merits investing a lot to get something decent. It's such an important part of our forseable future.
If you're going from a hospital owned by one chain (say, Hospital Corporation of America) to another hospital owned by the same corporation, then yes, it works like you said and doctors have access to your historical data. But God forbid that you should ever end up at a hospital owned by a different corporation, because then you have to call the Medical Records department to release the data, which often takes a couple business days to go through. The system doesn't work if it isn't open, and unfortunately, our patient privacy law (HIPAA) is often used by corporations as an excuse to silo their data away and prevent others from accessing it.
Each clinic have their own speciality and therefore their own way of filing stuffs
I feel like in general there's gotta be a lot of good sociological research on how stuff is kept straight. I only see stuff regarding DX work, but organizing was a problem even before computers, right?
EHR’s have all the problems of enterprise software, plus some. At the end of the day, the software is made for the people who pay for it. This isn’t the patients, or the providers. It’s the admin, billing, and bureaucracy layer who get to make all the decisions. It’s not surprising that these people don’t prioritize good software.
EMR’s need to do more, but the root of the problem is systemic.
There’s a whole industry of tools to help you build better interfaces on top of these big systems of records to improve the user experience. So much so that Gartner has even describes it as a desired way of designing system: used to be Pace Layer model, now it’s called Composable Enterprise.
If the priority is billing, then focus on aggregating and correlating billing data, expose an API for consumption with other systems being used that may or may not be from the same EMR company.
I do agree that there is an issue with stakeholder bias towards admin. Every pet project from admin results in a bolt-on fix to the EMR configuration bloating clinical processes. They are the ones that make the rules and decisions and are often disconnected from both technology and clinical expertise which is perhaps the worst combination for health care technology decisions.
I only briefly touched upon EMRs and the MUMPS/Cache stuff they did there. However, I also learned PowerShell to a much deeper level than probably 99% of Linux folks ever do. We did TDD, code review, CI/CD pipelines for fucking PowerShell. It was painful right up until the point where I internalized the Tao of PoSH, and then I realized that PowerShell actually rules for readability and maintainability when you have people who know what they're doing.
HNers by and large don't understand the economics of PowerShell. There is a very low supply of competent PoSh devs on the market, and even fewer interested in credibly signaling their proficiency, but a very high demand for them, because a lot of places still run everything on Windows, and guess what's installed on virtually all of them? I've even been able to take on a few consulting gigs that boil down to "take our 100,000 line un-version-controlled PowerShell monstrosity hacked together over the last 13 years and turn it into something we can actually understand, please".
Isn't that true for all programming languages ever devised by mankind?
> HNers by and large don't understand the economics of PowerShell. There is a very low supply of competent PoSh devs on the market, and even fewer interested in credibly signaling their proficiency, but a very high demand for them, because a lot of places still run everything on Windows, and guess what's installed on virtually all of them?
I don't see what point you're trying to make.
The fact that Microsoft decided to push PowerShell on virtually all versions of windows it ships only reflects a Product decision by Microsoft to push a Microsoft-only tool. It also shows Microsoft's decision to not offer the same level of support for any other alternative.
Where's the economics in that?
I also don't understand your broader comment on economics. Are you depicting it as a good or bad thing?
The guy literally just mentioned MUMPS.
https://thedailywtf.com/articles/A_Case_of_the_MUMPS
Now imagine first off what happens to Price when you shift the downward sloping curve forward. That is what economists call the demand curve. Does Price go up or down?
Finally, imagine what happens to Price when you shift the upward sloping curve backward. That is what economists call the supply curve. Does Price go up or down?
PoSh is closer to read-only for most devs. If someone makes sure to write things out the long way (or uses a linter to do this) it's very easy to grok. Actually learning to write it is the tricky bit.
That's not true ...
PowerShell is the "lingua franca" for Windows system administration, I think everyone understands that. Much of the power of Powershell isn't the syntax (which is unnecessarily cumbersome), but rather that most core windows system services have PowerShell bindings.
Powershell isn't a tool you would use for Linux scripting and administration, because it isn't ubiquitous the way bash is.
So what exactly is your point? That Linux administrators adopt PowerShell? Or are you arguing a strawman that HNers advocate for using bash in Windows?
Same goes for Windows, I want to make sure those scripts can be run without having to install anything. Powershell is there, and it’s powerful.
I’ve got a job to do, and a problem to solve.
That's IT infrastructure incompetence, not an EMR issue.
At the two healthcare systems I go to, both utilize RFID badge readers plus PIN. In the ER and urgent care, nurses need only tap their badge and enter a quick pin and they're in. It's taken them seconds to pull up my records and I've never noticed a delay in care.
In the PCP's network, everyone seems to get smooth and quick access often while we're conversing, and I can see all my visits, lab results, and so on. The major annoyance is that I get emails notifying me I have a "message", instead of even offering me the option of receiving an email with the actual message.
I don't think people understand how expensive and time consuming the non-electronic stuff was. I remember my mother spending considerable amounts of time trying to get records from labs and doctors and having to shelp a lot of it by hand.
The two cannot be unlinked so easily when I have never met someone so doesn't have the same story of hospital IT. Even the IT workers hate hospital IT. The deployment of an EMR has to take into account the regulatory and security requirements imposed on all digital systems.
> I get emails notifying me I have a "message", instead of even offering me the option of receiving an email with the actual message.
You need to bash the right heads together and get your email provider and sender in DirectTrust https://directtrust.org/what-we-do/direct-secure-messaging
Not gonna say it's not a bitch and a half to implement but you can send sensitive data directly via email. And if you're the SaaS provider you're part of DT that's a huge value add for your offerings.
I'm a "visit the doctor once every 0.9 years" kind of a person, so I guess my needs are not incredibly complicated, but I've found the experience to be pretty fine overall. Good, I'd say, honestly.
Note that Scotland got electronic medical records much more correct than England by making the whole thing a Clinician lead process rather than the English technocratic approach.
Finally it's very difficult to do "proper" scientific research on electronic health records, as control matched research is not achievable. Therefore you have to reach for things like single case study
Final brag - when I submitted my PhD it was politically quite sensitive so we had to find the right external assessors. One expert, one person whose judgement we trusted. The expert returned their report saying what a great piece of work it was and it should receive high commendation. The other person said it was solid and thorough but ultimately pretty obvious. Therefore I conclude that I received better than a high commendation for my work :D
could you tl;dr what does that mean, why the English one relatively failed, and how it would have fared better with a clinician led version? thanks!