EHRs: The hidden distraction in your doctor's office

you must print out old notes and test then and carry them into the room like you're pretending it's still in the paper chart days

which is fine until something comes up that you didn't anticipate and print out. Then you can a) fake it, end the visit and follow up with pt later after you've looked it up or b) log in and get the info

How do you have the pt's current med list? Does staff print it out after they've roomed the pt?

Also, how are you ordering test/procedure? Writing it down for staff to do later? Violates most org's "CPOE" policies. Otherwise pt leaves and your staff has to call to schedule later, including labs that maybe they could do before they leave.

You must have re-created a paper chart workflow in an EHR era which is only possible if your staff/org enables this for you

Most of us are just employed widgets in the health care factory, and don't have the pull to get staff to work with this kind of workflow

might be able to incorporate an ambient AI scribe into this flow pretty well, plenty of docs are seeing success with that.

That seems silly. I would WANT my doctor to be looking at Epic while seeing me to have the best data.

> Towards the end of my tenure there, a PM said to me “the last thing these people want is to have to learn yet another workflow”.

I suspect that people entering medicine do so to address human needs, and have very little interest in dealing with technology (or handling traditional paperwork for that matter). Couple that with a perception that pretty much anything digital being obsolete before it reaches market, and even more so when it can take upwards of a decade for the product to reach them, and you are left with a group of people who have nothing but dread about being stuck on a never ending treadmill that is outside their scope of interest and expertise.

Take that opinion with a grain of salt though. My background is in that other quagmire: education. I have seen some amazing tools developed over the years that were abandoned, so everyone had to move on. Worse yet, no replacement was created for most of those tools so everyone is back where they were before the revolution happened. (I'm thinking specifically of software used by teachers and administrative staff, but something similar can be said for software used to deliver the curriculum.)

In fourteen years at one hospital we have had two completely different EMRs as well as the old electronic record system that didn't have charting but allowed lab lookup, scans of documents, etc. The two older ones are still running in read-only mode because Epic can't look at them, so any records older than 2022 are only in there.

Cardiology, radiology, endoscopy, and labor and delivery all have their own systems for their internal usage while releasing final results to Epic.

I don't object to the idea that these products are made for admins. It's a business and it needs to make money to survive. I object to the idea that making a product for sale to admins precludes making it at least usable for those who actually put in the data.

> I’ll never work in health care again. Like education, it’s a quagmire.

Remember: there's a lot of "health care" out there. Even if doctors resent EHRs, there's also drug discovery software, telehealth software, embedded software in medical devices, etc!

It’s more than that actually. Where is actual interop? It’s been promised literally 10 years ago. It’s not that hard. People in Healthcare IT are just that bad.

The only time I’ve experience interop in healthcare is due to actual organizations merging. That’s it. This entire space is filled with incompetence. Maybe providers will actually use the tools if they work consistently. Food for thought.

Most of my experience is on the pharmacy side, and tech basically saved pharmacy, from recordkeeping, insurance claims, accounting to inventory.

But it was voluntary (for the organizations, not so much the staff). There was no need for government to shower pharmacies with money to adopt it because it paid for itself.

I'm sure a lot of the staff initially met it with the same hostility. Even in 2010 when I was more in the field, we still had staff where their only computer experience/use was at work and otherwise lived an offline life.

Can't say I saw a pharmacy that didn't have a computer since the early 90s in Canada (and my memory doesn't go before that). And before that, at least they used typewriters. Meanwhile my GP was all-paper well into the 2000s except for some billing stuff. God help anyone that had to read his notes. But sometimes you're reimbursed sufficiently that there is no driver to change workflows even if it would be economic.

Ontario Canada.

That resistance to change is just human nature. I work on much lower stakes line of business apps and the new thing can be _objectively_ better in every way and there will still be significant pushback from a large percentage of the userbase.

I work in hospitals and it's just a constant stream from IT of "oh you just figured it out! congratulations! time to change they way you do things! this time we've solved all your problems that you're not complaining about! try to reengineer how to do anything now! lol! we hear you and feel your pain! here read ten pages of drivel that tells you how important and amazing IT is but won't actually tell you how to do anything with the new new tools and lives in some fantasyland that has nothing to do with the work that you actually need to get done!" all while simultaneously making every single computer and workflow somehow slower and more complex. Add another login here... force a quicker logout there... And then admin will come in with "thanks IT! you're doing amazing work! by the way everyone else we expect your productivity and caseload to increase!"

Meanwhile getting things to work is filing tickets followed by "oh gosh that's so complex!" and months of moron pitcrew showing up " to fix it" who can't fix anything and who seem to think it's just that we're dumbasses who can't figure out who to reboot a computer.

Honestly it's difficult to not grow the instant opinion that IT should just shut the fuck up and fire themselves. Who the hell do they even work for?

I had this thought recently: "different hospitals have different workflows, and they want to see different stuff in the UI. But obviously they all want domain objects like "a patient," "an appointment," etc. Some company should offer a standard backend, and a starting template for a frontend that each hospital can customize however they want."

It turns out that concept is called "Headless EHR," and it's pretty new.[0] Medplum (that the parent comment mentions) is one of the companies in this space.

[0]: https://healthapiguy.substack.com/p/to-ehr-or-not-to-ehr

The custom workflows are because each clinic system is trying to figure out the best way to make money, not the best way to treat patients or serve clinicians.

Disclaimer: I know a number of people who work for Epic. ;-)

Another issue with customizations is upgrades. Every upgrade you gotta validate all the customer-specific stuff.

And you may end up re-creating bad workflows instead of updating to better ones.

The principal-agent problem means usability isn't actually a deciding factor. Business users might prioritize that but the buyers (C suite) choose on ROI and metric

This is actually not unique to healthcare (see others above posting about Learning Management Systems and Workday). As a result, most enterprise software across verticals is similarly dated. Some research here: https://open.substack.com/pub/healthapiguy/p/there-will-be-b...

I can't quite tell if you are saying the tables and frames are a better UX than Apple and Google. Personally I find frames and tables far more user friendly than the constantly shifting and indecipherable UX that Apple forces on us with updates.

Simplicity and usability are not the same thing.

On one hand you have massive GUIs spanning the whole screen containing hundreds of controls. On the other you have airy GUIs with more empty space than actual content and every time you want something you have to open 3 layers of menus to find it.

Both are wrong. The correct thing is to find a balance. The balance depends on the usecase as well as the users.

This is what makes it hard. You can't just code up an app and throw is over the fence. You have to actually engage with the users, watch them perform their work, even try it yourself. You have to understand what is important and what is a distraction. You have to understand when these things chance. And you have to understand that beginner users evolve into experts all the while you have new beginner users coming in.

The problem is a bit more complex than just UX from my experience. It's not as if the people designing these portals are going out for their way to make it user unfriendly, it's that the underlying data model all these hospitals use for their EHR is usually completely insane.

Hospitals were among the first to get "computers", I'm talking the big mainframes and such that used to be popular in big institutions & universities. On these systems many hospitals each individually hired programmers to construct custom databases for their record keeping. While most have by now have transitioned into a more standardized structure, like HL7, the original sin has carried forward enormously bizarre data structures that make you wonder if the designers were deliberately trying to sabotage the possibility of good software in the industry. I can't think of a better example of why you should never design by committee.

Yet in parallel to all this, capturing medical data is already hard. Doctors are most comfortable just writing notes freehand, recording the patients current state, notable observations, treatments and so on. When modeling this it becomes very tricky because you basically need a proper medical background and be a good at data modeling / programming. This kind of person is basically a unicorn in the industry everyone wants but can never get.

Consider, just for a moment, all the complexities that come with dealing with the thousands of different units and their conversions within the industry. Some doctors don't even use the same units for certain measurements, entirely out of personal preference. Then remember that measurements are the easiest part of the system to model, even what should be the simplest part of the entire thing is hard. Also yes, you will have to re-write all this from scratch, there is no special library or open source software to help. Everytime someone makes tools for this they keep it proprietary.

But that's just the tip of the iceberg, to really get an idea of what I mean, just look at HL7. It's basically a data format that is like a cursed csv with about 5 layers of deliminators for nested entries, since all hospitals like to be super special, the specification tries to be "flexible", so what exactly these characters are is not actually standardized! It wasn't enough for HL7 to just be a data model, they needed to violate a few OSI layers and interlace it with the transport protocol too!

So in essence you must establish a bizarre handshake on top of tcp to learn what the hospitals super special configuration of the standard is, the very syntax itself! Worse, 90% of it is the same for all hospitals but the 10% that isn't is entirely unpredictable!

Then you have the actual data model itself, like demographics, lab records and so on. They change the specification every few years! You need to support it all since this committee of monsters don't seem to care much about the migration path! All the changes they make seem pretty arbitrary to me but what do I know?

I'm still only scraping the surface here but my exposure has been limited to what I do, which was processing all this from the perspective of a medical device that only needed to deal with a subset. When I imagine the struggle one would have with actually dealing with the entire thing holistically I feel empathy and a desire to never have their job.

It's like building a house on top of an active volcano. Any illusion I had that my medical records could be used for anything other than basic notes for another doctor to read have long since shattered, because clearly that's how all of this mess is actually being used in practice.

Oh and don't forget HIPPA! Even when you roll up your sleeves and try to fix the problem, you learn you aren't even allowed to thanks to the governments overbearing regulations against using medical data for things that could help society. Wish they just made it a crime for insurance companies to use instead of whatever this is.

The fact any of this works at all is a fucking miracle honestly.

> When any country mentioned hits the population of a small or medium US state, let us know how it goes.

I don't know "how it goes" but Poland has the population of a large US state.