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Why Doctors Hate Their Computers (newyorker.com)
Digitization promises to make medical care easier and more efficient. But are screens coming between doctors and patients? Here's an excerpt by Atul Gawande of The New Yorker, which talks about the deployment of Epic, a new medical software which cost Partners HealthCare a staggering $1.6 billion, panned out: On May 30, 2015, the Phase One Go-Live began. My hospital and clinics reduced the number of admissions and appointment slots for two weeks while the staff navigated the new system. For another two weeks, my department doubled the time allocated for appointments and procedures in order to accommodate our learning curve. This, I discovered, was the real reason the upgrade cost $1.6 billion. The software costs were under a hundred million dollars. The bulk of the expenses came from lost patient revenues and all the tech-support personnel and other people needed during the implementation phase.
In the first five weeks, the I.T. folks logged twenty-seven thousand help-desk tickets -- three for every two users. Most were basic how-to questions; a few involved major technical glitches. Printing problems abounded. Many patient medications and instructions hadn't transferred accurately from our old system. My hospital had to hire hundreds of moonlighting residents and pharmacists to double-check the medication list for every patient while technicians worked to fix the data-transfer problem.
Many of the angriest complaints, however, were due to problems rooted in what Sumit Rana, a senior vice-president at Epic, called "the Revenge of the Ancillaries." In building a given function -- say, an order form for a brain MRI -- the design choices were more political than technical: administrative staff and doctors had different views about what should be included. The doctors were used to having all the votes. But Epic had arranged meetings to try to adjudicate these differences. Now the staff had a say (and sometimes the doctors didn't even show), and they added questions that made their jobs easier but other jobs more time-consuming. Questions that doctors had routinely skipped now stopped them short, with "field required" alerts. A simple request might now involve filling out a detailed form that took away precious minutes of time with patients.
In the first five weeks, the I.T. folks logged twenty-seven thousand help-desk tickets -- three for every two users. Most were basic how-to questions; a few involved major technical glitches. Printing problems abounded. Many patient medications and instructions hadn't transferred accurately from our old system. My hospital had to hire hundreds of moonlighting residents and pharmacists to double-check the medication list for every patient while technicians worked to fix the data-transfer problem.
Many of the angriest complaints, however, were due to problems rooted in what Sumit Rana, a senior vice-president at Epic, called "the Revenge of the Ancillaries." In building a given function -- say, an order form for a brain MRI -- the design choices were more political than technical: administrative staff and doctors had different views about what should be included. The doctors were used to having all the votes. But Epic had arranged meetings to try to adjudicate these differences. Now the staff had a say (and sometimes the doctors didn't even show), and they added questions that made their jobs easier but other jobs more time-consuming. Questions that doctors had routinely skipped now stopped them short, with "field required" alerts. A simple request might now involve filling out a detailed form that took away precious minutes of time with patients.
I remember fondly, when one doctor called me to complain about my program I wrote for him
He said it behaved erratically, especially if they lay down a heavy binder on the keyboard to check something.
EHRs are absolutely terrible, they slow everything down and impede communication. They are uses as a tool to hang you with in court. Data entry is abysmal and you may have to click through 3 or 4 screens to enter something simple and keeps switching back and forth. The design seems to be focused on getting everything in but with little thought to doing that in an efficient fashion, also little thought to getting the information out concisely. Now we have 20+ years of info in some of these ehr's it takes a long time to find things. They slow you down and dont integrate very well across systems. They are also costly. They are buggy.
As someone who works in healthcare IT, I understand where this article is going, and the costs associated with installation of an EMR are certainly feasible. However, this is NOT why doctors hate their computers. They don't want to do the part of their job that is arguably one of the most important. Documentation. They want someone else to do it for them. We constantly get requests for scribes to do that. It's PART OF THEIR JOB. That's like me not installing OS updates, not installing anti-virus. Stuff I'd prefer not to do but it's part of my job. Doctors don't want to do to it so they don't want the system to do it. Bad documentation from scribes leads to increased healthcare cost due to errors, and costs organizations because billing in many cases requires that the documentation be completed by the person who did the procedure.
It wasn't that computers are less efficient than old school / antiquated methods. It was a matter of incompetence. Before the transition all people involved should have been properly trained. They shouldn't have made a mass transition to the new system, but rather should have piloted it with a small group of the best in class as the first users, who would then be in a position to help their colleagues thereby greatly minimizing the need to involve IT. The data imports should have been tested properly. Printing issues should have been resolved in the piloting phase. Basically, everything was done wrong, but at least the Hospital Administrator's nephew got a new job out of the deal! (I don't know about that last point, but I do know non-tech people hire people they know, not people *who* know.
Guns don't kill people; Physics kills people! - John Lithgow as Dick Solomon on Third Rock From The Sun
Doctors hate their computers because they tell them facts, research studies, and other material matter.
They hate that shit because THEY are suppose to be the masters of the universe. The rulers of all information. They "know" everything. Even as their patients complain and die under their care because they are too stupid to remember the actual facts of the medications they prescribe. Or more likely, they have never actually tried the horribly debilitating medications they give out.
Fuck these guys and the medications they prescribe.
Translation:
Doctor is trying hard to build a nest egg to retire as a bazillionaire but software and accountability stops him from exploiting patients and staff.
Do they have those already?
... I think I prefer my doctor use a paper-only system, thanks.
Reasons why on a postcard, etc.
"A simple request might now involve filling out a detailed form that took away precious minutes of time with patients."
Wait, the doctor actually spends real time with patients? All these years and I thought the nurse did all the work and the doctor just stopped in for 3 minutes to read what the nurse did and then sign a prescription form if needed.
If the doctors are ignoring the fields on paper forms, why were they even on paper forms?
If the answer is bc doctors are SUPPOSED to fill in these fields, well, shit, can't blame a program for enforcing what doctors are supposed to be doing anyway.
My doctor has a wonderful app that they use for patient sign in and info updates on ipads for patients to use. nice big text, large button for old fogies, simple and straightforward to use and prevents mistakes.
In my experience, most doctors work well with computers, they like that they have the patient's history at their fingertips, as well as all the test data. It streamlines their work quite a bit.
If something like a Field Required is a terrible inconvenience, a bridge too far, an insurrerable inconvenience that destroys th eprecious time that the doctor spends with their patient.........
Yer doin something wrong doctors.
If there is one thing about the medical profession that needs changed badly, it is the concept that doctors are some sort of infallible super being who dare not be questioned.
tl;dr Hey doc? Just fill out the damned form.
The shepherds did so well protecting the flock that the sheep no longer believed that wolves existed.
Modded down, not down voted. You must be thinking of some other site.
Having instant access to comprehensive patient histories gets in the way of "winging it".
But more seriously we have a top down development of software in the medical records industry. It creates sweetheart deals for a few big contractors, and prevents free market forces that evolve and improve software.
Having supported an office that is using 30 year old medical billing software (Medisoft for DOS), I can say that there is little that has changed over the years other than the size of the organizations writing the software. The newer software is easier to train on, but gives people repetitive strain injury, functionally it is equivalent. (that oldie moldie software is HIPAA compliant)
“Common sense is not so common.” — Voltaire
The reason users hate Epic is because Epic sucks - various functions break, randomly, all the bloody time.
#DeleteChrome
a doctor's time is worth more (to themselves, and the facility) if it is time NOT spent sitting in front of a computer screen, but instead is spent on patient visits and procedures.
it's also why they speed talk through their dictations so fast that even trained and experienced transcriptionists have a difficult time, even when the audio is slowed by half or more. their time is worth more than the records personnel's. hell, even computers have a tough time with many doctors' audio.. and i'm not talking just about the pakistani-born doctors, educated in minnesota, and practicing at a south texas facility with a mashed-up accent from hell.
RTFS. The doctor is trying to keep patients healthy, and now has to fund someone's hundred million dollar software.
How the fuck does any software project cost a hundred million dollars. Even the fucking military is usually under that price.
They hate them for the same reasons ALL corporate and centrally-controlled system users hate them - the dump changes on the user, then run away, and leave everyone else to just figure it out on their own.
I first went to Bumrungrad Hospital in Bangkok back in 2006; they had a fully electronic system then, and it worked great for the doctors. Some parts of the workflow are scanned in rather than electronic capture, and it appears the system has had minimal supplemental improvements in the intervening decade, but wow it works.
The doctors seem to love it because reviewing the charts and historical data is a breeze. As an added bonus, the hospital supports at least 5 languages, and the specialists don't need to be fluent in all as the system has automatic translations for common diagnostic comments with a backup human system for specialized comment translation.
Sure they could do more to streamline workflow with tablets or something, but they have a clean electronic medical record system that works. Not sure if it can track medicare codes automatically, but I am guessing it is a separate process.
Had a family member recently try to get a tricky condition diagnosed and dealt with a lot of secondary specialists. He came out of that experience with a new dislike of the stream of uninterested physicians he was referred to.
Well,
That
is
just
capitalism
at
its
best.
Forms by committee with "required fields" leads inevitably to satirical Kafka.
the worst is upgrades: this has several times dropped prescriptions back to zero for the whole hospital (in europe). So diabetic patients loose their treatments... Units change too, ml to cl for no reason at all! It means you have to be very very slow and careful. Rolling updates can change stuff at any moment. It's a nightmare and you are legally liable if it goes wrong. Then there is the hospital system crash which means you can't read the documents for a patient who is having a crisis -- you don't even know why they are in the hospital.
Doctor is trying hard to build a nest egg to retire as a bazillionaire but software and accountability stops him from exploiting patients and staff.
I'm sure that makes sense in your cynical brain but like many simple theories it is wrong.
First thing to remember is that many of the processes used by health care providers were paper based systems that were developed without much if any information about best practices used elsewhere. Out of necessity we had a bunch of doctors and hospitals coming up with systems and procedures and documentation that maybe made sense for their practice but often did not match or even resemble procedures used by other hospitals or practices.
The problems being experienced with making software to manage health care systems are many. But the key problems seems to be that A) health care data is REALLY REALLY complicated and hard to standardize, B) processes for managing the data historically varied from practice to practice and doctor to doctor - not for any malicious reason but because there was no mechanism to force standardization, C) big bespoke software systems are really hard to do smoothly, D) there are shockingly few regulations about how to do it nor much data about best practices for how to gather and store data electronically, E) for competitive reasons the companies making the software to manage these health care systems are reluctant to open up their systems to cooperate with other software systems even when doing so might be helpful to patients and doctors.
When I say health care data is hard to standardize I'm not kidding. I'd worked in the field doing process engineering and even seemingly simple tasks have ridiculous numbers of steps and dump off all kinds of data, some of which is difficult to put in a nice tidy database record. My wife's practice went to an EMR fairly recently and even though the one they use is probably best in class for what they do, it still has all sorts of problems that occasionally bite them. The software engineers are mostly doing their level best (not always but mostly) I think but they aren't experts in the day to day practice and administration of medicine and the resulting products often show this.
Don't get sick people! It may kill you... or they will.
The last time I went to the doctor (too many years ago) I walked away just shaking my head. In disgust.
My doctor was recommended to me by mom -- a now retired charge nurse in ER; ie: she knows her shit... I fully trust her opinion and when she told me to go to her GP because he was bar none the best in the area at diagnosing problems. So I went to him (w/ a tummy ache).
He spent more time administering the computer. His hands and eyes were on the laptop a hell of a lot longer than on me. I felt like the computer was the patient.
I absolutely lost it (and left) when the questions started. "Do you have a gun in the house?". WHAT THE FUCK does that have to do w/ my abdominal pain? The government should really stay the hell out of my medical care...
Good 'ol paper and charts were way better IMHO. I'm just old enough to remember doctors making house calls. Miss those days.
Not just in medical. Jira can be configured to be easy to use... or to be "comprehensive". But when it gets too comprehensive, with too many fields required to do quick stuff, people just stop using it. I've aborted placing orders because they require I create a password, which I'd then have to track (put in my password manager), for what I consider a one-time-ever interaction... and then have odd password requirements on top of it!
Those extra required fields are the biggest problem with computerizing forms. On paper, you can skip them. And they don't need them anyhow. Your doctor doesn't need to know your job title, but now it's often required. Requirements creep - it's not just for PMs anymore!
This has been my life for the last twenty years. Most resistance is just from people not wanting to do things a different way. The older doctors may have never used computers much and don't want to start. Their workflow may be a few seconds longer for each case, but be sure that for the first six months they'll spend a few minutes on every case complaining about how they lost time on those few seconds. Eventually, they usually come around and learn and get angry they have to revert to the old ways in case of a downtime because it's inefficient. Still, online workflow is often more of a pain than the way it was done, and probably the greatest contribute to that is that everybody is trying to recreate their old paper workflow with an electronic system. If they would have spent more time planning during implimentation, they could have save time with each exam forever on, but they have Byzantine workflows that were originally created because there was only one sheet of paper that had to be passed around and nobody wants to spend time to even figure out what the workflow is in the big picture, let alone figure out if there's a better way. Next, yes, the doctor's workflow is often a little bit longer, and this is almost always because those required fields were always required but the doctors just were't filling them out in the past, requiring other workers to do their work and run around and directly ask the doctor later. And it was never just one person, the initial person discovering the required field wasn't filled out would have to tell another person, who would have to call somebody to go to talk to the doctor, who would have to talk to the administration to find out where the doctor currently is, and then page or ask them. Doctors complain because they have to do a few seconds extra work rather than make five other people do ten minutes work each later. Still, most hospitals went through this a decade or more ago. New residents and attendings coming in are already used to it as the old doctors and staff will be six months past go live.
Whenever a significant new system is put into place, there will always be start up problems, especially when working with a userbase that is not accustomed to using computers professionally. I see the main problem here as poor planning for the mitigation of startup problems. Whether that poor planning is incomplete training or design hiccups, it is poor planning if one is surprised by these types of problems.
Paper Prototyping would have helped. Using Sketching, and Storyboards as well.
It wasn't that computers are less efficient than old school / antiquated methods. It was a matter of incompetence. Before the transition all people involved should have been properly trained.
Having dealt with software system roll outs in health care, I think you are right in some cases but in others you are blaming the victim so to speak. My wife is an MD and her practice has a EMR system they purchased a few years ago. It's probably best in class for their type of practice but that doesn't mean it is perfect. My wife has spend literally entire days on the phone and in meetings trying to get fairly basic aspects of the system fixed. Simple stuff that even a lay person would look at and know that the software was badly buggy. That's time she doesn't get paid for to fix software that was rolled out before it was ready.
Let me be clear, the problems were NOT training - they were problems of very poorly done and buggy software development. To give one example, at one point if a physician assistant entered incorrect data early in the patient visit there was no mechanism whatsoever for my wife to correct that incorrect data later on. This isn't some rare corner case that doesn't happen much - this is something every practice will deal with multiple times daily. This is the sort of thing that can cause patients to get hurt if not corrected and it took them months to fix the problem.
Then there are problems of sharing data. The software at my wife's practice literally cannot talk directly to all but one of the local hospitals. Why? Because there is no economic or regulatory incentive for the software company to do so. They want medical practices and hospitals to use their software and nobody elses. So when my wife's practice has to send a patient record to an outside practice or hospital (happens daily) they have to use a fucking FAX or send paper records. Absolutely insane but that's the world we live in.
My wife is a physician. Physican's hate these EMR systems (e.g. Epic) because these systems are built around billing, rather than patient care. It's a distillation of the greater healthcare problem in the US.
Every single EHR system I've used has had the same problem: The designers think they know my job better than I do. In the old days (1990s) you trusted the doc to write or type down the information that was important and relevant. Today, the EHR designers are worried that I'll forget to ask some clinically important bit of information (like the patient's smoking history), so they force me to fill out dozens of little boxes, check-marks, drop-down menus, etc., just to ensure that all of the clinically important questions are answered (with "clinically important" being defined by a committee of god-knows-who).
It's a fucking mess. Instead of a couple of succinct paragraphs, you get 30 pages of checklists and prefabricated phrases. There are several unintended consequences to this-- when doctors have to click through dozens of checklists (some of which may be of questionable clinical importance), they get in the habit of doing it as quickly as humanly possible, and that's when mistakes get made. That's how you end up with notes that say "Pelvic exam performed and was normal. Prostate exam performed and was normal." Of course, no one would actually TYPE this shit, since it doesn't make any sense-- these are phrases that got inserted into the chart because someone "clicked through" a wall of checkboxes.
You also wind up with situations where you are forced to choose from a limited number of wrong or partially-wrong answers. (I've run across systems where instead of being able to describe the patient's affect, you had to choose from a selection of about five different adjectives to describe the patient's affect).
Look, I get it. Doctors are imperfect and sometimes they really do forget to ask certain questions, perform certain parts of the exam, or issue certain warnings. I'm of the opinion that we need more mechanisms to double-check the work doctors do. But this should NOT be the job of the software developer who writes the EHR software.
Before my doctors were required to enter all my info in the computer, each visit was like I had never seen them before. Since the computers have been installed, the visits are much more productive and we get to the important follow up issues. I don't think they like them, but it has dramatically improved my experience as a patient.
...with private medicine in one phrase:
the expenses came from lost patient revenues
When patients are revenues, who's interested in curing anything?
"Encyclopedia" is to "Wikipedia" what "Library" is to "Some people at a bus stop"
From direct experience: even in a relatively small (6-10 MDs) group practice, over half the MDs never got the concept of "Toyota Lean" or 5S, meaning they never understood that "this is the way I've always done it" doesn't mean it's anywhere near the safest or fastest way to do it. Then they whine because the EPIC form generated by a couple of their colleagues who DO know how to set up a process isn't exactly what they want to use, or makes them do horrible things like proving there's a nonviral infection before prescribing antibiotics.
Yes, Epic's basic setup stinks. But take a bunch of former pre-med weenies who never understood geometry, let alone computers, let alone checklists, and you're doomed.
https://app.box.com/WitthoftResume Code: https://github.com/cellocgw
healthcare for all will fix it by cutting down the paper work / coding bs.
It was a huge transition from an IT system that had evolved upon a dedicated patient SNEAKERnet. Who better motivated than a patient to move essential data/records? It just worked. BUT it wasn't digital.
EPIC solved that problem. BUT at the expense of facetime; medical speak for the amount of minutes M.D.'s spend face-to-face with patients. SO Dr's gave up family time to complete records, notes and messages AT HOME. At home most nights meant 12;00 AM+ eating screen time away from family usually only catching a meal then back to EPIC.
It takes its toll on doctors.
More regulation and more requirements get added every year thanks to various government entities. Just wait until the controlled substance workflows are implemented at the beginning of the year. Right now the best case scenario is 14 steps that are all *required* from retrieving and reviewing the patients controlled substance history before they can issue a new controlled substance prescription.
An old friend of mine used to work in the medical software/hardware field. They had also sorts of interesting software and hardware for doctors to use. Doctors, in general, weren't interested. They didn't want "a screen" between them and their patients. They needed to look at the person, see what they're saying and how they're saying it, sometimes drag details out of them that they don't want to give, etc.
Dentists, on the other hand, loved tech. The more the better.
I understand that writing good software is exceptionally difficult. I'm not saying programmers are idiots. But it's also clear that the vast majority of software developers are not up to the difficult task. With few exceptions, software is shit. There's usually one narrow path through a program that works, and if you deviate only a little from that, you quickly and painfully realize that it's all Potemkin villages. I don't know how to fix this. There are just not enough quality software developers. It's just no surprise to me why people don't want to "digitize". Sorry for the rant.
So the Doctors would decide to just skip the meetings where the decisions were being made as to how the software would work, then complain when it does things differently than how they wanted....
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https://thedailywtf.com/articl...!
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So "many of the angriest complaints" basically come from different groups of users wanting data presented different ways. If only there was a way to do that. Oh wait there is. I remember thinking that was a useful concept when I learned about it my very first day of work 17 years ago when I used the bug tracking software and I could switch between engineering mode, product manager mode, or make my own display layout. I have little sympathy for software that doesn't take basics like this into account. As for doctors not showing up to tool design meetings that happens with engineers sometimes too. A decent tool development team will find a way to get the information they need. I'm not on a tools team that does this, but over the years I've seen many creative approaches to getting this data that I'm pretty sure would work on doctors who skip out of design meetings.
EHR creates more documentation of less value by allowing doctors to copy/paste notes from previous visits. On the surface, copy/paste seems to cover their liability for seeing a patient. But the additional text with no new valuable information means that incoming doctors have to re-read the same thing multiple times to grok a chart before seeing the patient. Or skip the pages of text because it is presented in a small window on a low-resolution screen. EHRs haven't caught up with the notion of quoting text, or having AI summarize notes/scan notes for new changes when a lazy doctor copies/pastes the previous write-up.
EHRs are a step toward every treatment plan being codified as a flow chart, which is a step toward better AI doctor assistants.
I am glad that doctors will be able to read computer font instead of hand-written illegible notes. But now the problem is too many redundant copy/paste notes.
The EHR presents new privacy problems - instead of having to physically go look up a file, in some systems anybody with access can snoop on anybody else's charts or insurance history. This prevents health care professionals from seeking treatment because they know their co-workers will be able to find out. This is especially true for mental health treatment of medical professionals. I know of doctors who have resorted to waiting at a free psychiatric emergency clinic next to heroin addicts to seek mental health treatment to stay out of their hospital's EMR system.
The article highlights another problem - more bureaucracy in hospitals. More administrators who haven't ever treated patients but are needed to ensure the business runs until they have too much power and make bad decisions that drives doctors/patients elsewhere and the hospital into bankruptcy.
Hospitals are dirty places, and the keyboards/mice are often not cleaned well. My doctor friend brings a laptop to be able to type without fingers sticking to keys.
The IT staff support size for hospitals is another issue; EHRs contribute to the problem. The article complains about immediate effects, but what does the long-term cost recovery look like? Where are the gains in efficiency? Some gains, like computers catching bad dosages, rely on knowledge-based codifications that aren't there yet.
There are many problems associated with EHRs/EMRs after the productivity/workflow kinks are worked out. The idea of them is a step in the right direction.
If the time doctors have to spend with patients is so scarce then this is a sign that we need more doctors (or fewer patients). However, the guild is against increasing the number of doctors because it would create wage competition and lower doctor salaries.
You can lead a horse to water, but you can't make it dissolve.
Ya but if you work at Epic you can now ride Elia's Deli merry-go-round. How's that for $1.6 billion?
because they run system-md
Table-ized A.I.
The complaints are not unlike the air traffic controller's complaints about IBM's computer system, on which billions had been spent. Nobody thought to consult the end-users. When they were shown the prototype, they just said "Nope, those planes are coming at me at 500MPH, I don't have the time to fill out all those fields".
Most doctors I met had resistance to technology and that's OK. Their intuition -- if they are any good -- is on the living patient first, then lab results and science. Computers and data flow are the last thing they care about. Software made for them should be particularly easy to use.
Most of us would rather pick a doctor who's clueless about computers but good about understanding the patient.
Who were involved in the changeover (in WI), it was a complete catastrophuck. Scheduled surgeries disappeared, patient records disappeared etc. What had been a solid, working system was now a steaming POS.
I wonder if any hospitals use an open source EMR, open-emr.org for example?
Conceptually it seems like a good fit. A hospital could spend a fraction of what it would have paid for licensing fees on a few programmers to push the project forward. It'd be a lot less work to customize the flows clinicians use to match the procedures at that organization. The customizations could be shared with the wider community and become best practices, etc.
Assuming no major hospital is using an open source EMR, why not?
I think many doctors would argue they are never consulted in how software should work. I don't know that every piece of medical software is bad. But the development should include consulting the very people who use it every day.
Still accurate after 20 years.
Medicine + computer = computer
"Make sure the doctor fills in the pharmacy address and phone number for us."
(-1: Post disagrees with my already-settled worldview) is not a valid mod option.
In the first five weeks, the I.T. folks logged twenty-seven thousand help-desk tickets -- three for every two users
What kind of metric is "3 for ever 2 users"? Just write it in plain english, it's an average on 1.5 tickets per person. And 1.5 per person on average over 5 weeks sounds sounds like an amazingly successful rollout.
Once I started a new job which had a few nice things like getting reimbursed for decent home Internet service (because I was on call). But the system used to request reimbursement was clearly designed for the people cutting the checks, not for the people entering the requests, so after three months I just gave up and paid for my home Internet service the old fashioned way, out of my own damn pocket.
The fundamental problem is that whoever is designing the system gets to choose where they can freeride. If an insurance company designs the system, they're going to push work off on medical facilities and doctors. If a hospital designs the system, they're going to push work off on doctors and nurses. If doctors design the system, they're going to push work off on medical facilities and insurance providers. The key problem is that patient representation is lost in the process. If you stepped back and said "What option would provide the best patient outcome?", you'd start to consider questions like "How do we ask this question to get the best data, but to prevent people from getting irritated and pushing random buttons to make progress?" So, often a required field goes from having one of two or three answers to including options like "I don't know" or "Not applicable". And just to be safe, there should be a "I don't want to answer", so that you know whether or not the doctor actually thought about the question, rather than just pressing "Not applicable" to get the question to go away. Then, of course, you need people designing backends to reflect this ambiguity.
Unfortunately, it's easier to just force a selection at the front end, even though it messes up your data. So you can say with 100% confidence that a particular question was answered "Yes" or "No", but you have no confidence as to whether the person answering the questions actually made any effort to have them correspond with reality.
"Modded" is another word for n1ggered down, just like opinion of shitty minorities in the article Fuck you
Your doctor doesn't need to know your job title, but now it's often required.
You say that as if it were obvious, but the kind of work you do may well be a factor in quickly and accurately diagnosing your condition. Should it be a required field? Maybe, maybe not—but if it's not required then they're less likely to have that information available when it would be genuinely useful.
"The state is that great fiction by which everyone tries to live at the expense of everyone else." - Bastiat
I'm guessing you didn't read the article, and who could blame you? It's a long slog. But the problem presented in the summary, the implementation of Epic at a particularly hospital, is not really what the article is about or why the premise that "physicians hate computers" is posited.
It's that while the goal of technology in healthcare is to improve things, it very often gets in the way and slows things down, particularly for the clinician. Many physicians are frustrated to the point of burnout because the time required to see the same number of patients has increased dramatically, often taking much of their documentation work home with them. One physician noted (and found solace in the idea) that the software is meant to improve the experience for the patient, not the clinician.
The article is a good a read. I actually work in healthcare but I'm fairly removed from the clinical side of things, and rarely interact with physicians anymore. But I know exactly the pain many of these doctors feel because I see the absurdly inefficient way they have to operate.
I have my own pain to deal with when it comes to Epic. There has long been a standard in electronic health records known as HL7. It's an older, frankly outdated, position-specific method of moving health info around; but it does work. Epic went totally off the reservation and fails to follow much of the standard.
Epic isn't a 'normal' software company. They developed a system that different parts of a hospital (with different needs) could all feed into. It's complex, buggy, doesn't conform to establish norms or expectations, and takes a large staff just to keep afloat. However, they were the only company to attempt this level of hospital integration. So they took mountains of cash to DC, and used it to pay for lobbyists to push congress to require hospitals use this level of integration when putting an EMR system into place...an EMR system that only Epic provides. At least, that's the story.
That's why nearly every hospital that upgrades its EMR system uses Epic...they don't have much of a choice. It's also why Epic has a sprawling campus in Wisconsin that looks more like Disneyland, complete with a treehouse, a carousel and a giant dragon statue.
https://www.atlasobscura.com/p...
I'm sorry, but your opinion seems to be wrong.
The medical system and software system need to evolve together. In a few cases doctors take the big leap to help fix the software development process by adding "app store" like customization which was initially opposed by the software publishers but not servicing billion dollar clients is never a good business practice.
The financial system, the insurance companies, are forcing consolidation of the US medical system, profession medical practices are being bought out by large medical groups associated with hospitals. The high cost of medical service in the US, which are higher priced than the global market. The doctors are being "Taylorized" similar to factory work on the conversion to mass production. Profession medical practice evolved largely without constraints outside the medical community and there will be complaints until the doctors get with the system.
Because the systems is not for the doctors, It is for the patient who actually receive better care because of the information they receive.
Questions that doctors had routinely skipped now stopped them short, with "field required" alerts. A simple request might now involve filling out a detailed form that took away precious minutes of time with patients.
Imagine that, a DOCTOR being required to take time to follow the rules like an ordinary plebeian.
I'm surprised the cardiologists didn't all drop dead of simultaneous heart attacks.
0 1 - just my two bits
In three words, there is the major difference between health care in the USA and health care in Canada. (I know, this is intensely political, off-topic, and irrelevant to the subject under discussion. Just wanted to point out what is often missing in discussions of the differences.)
...with private medicine in one phrase:
the expenses came from lost patient revenues
When patients are revenues, who's interested in curing anything?
Most people are interested in curing, but most things they can sort of help out with a bit. It's not like there's a shortage of people who need medicine.
Doctors hate their computers because they are doctors, not programmers, and they don't like using crappy EMR (Electronic Medical Records) systems. A 15 minute patient visit includes 2 minutes actually examining the patient and 13 minutes trying to navigate through programmer-designed forms that have too many fields and not enough spaces for notes.
I've known nurses who have retired rather than use the horribly-designed EMR systems.
Even now, EMR systems routinely crash in the switch from DST standard time. Turning the clocks back an hour sometimes erases the last hour's worth of data. Not bad for doctor's offices, but terrible for hospitals and nurses on the 11-7 shift.
"Job title" =/= "type of work you do". Asking about "job title" may tell the doctor nothing about what I do. My job title of "Solutions Engineer", which is what it says o my business card, doesn't actually tell anybody that I install, configure and support scanners and document imaging systems.
It's quite simple, with automation comes PHB's who think they can outsource the entire process to cheaper labour (ie nurses and prescreening intake). "Documentation" has little to do with it from a patient standpoint but EVERYTHING from a procedural. The systems are built to create drones, following established procedures and workflows. The medical field is NOT an episode of Scrubs.
The biggest gripe quite frankly is I don't want everyone with access to those systems knowing the inner details of my condition. I don't want that data stored anywhere but in a paper file, in a desk or preferably with me. We're absolutely no where near that level of security nor privacy required otherwise. Hell you can't even get access to your own damn files let alone request an audit of who has viewed them.
Now downvote your leftist little hearts.
Your doctor doesn't need to know your job title, but now it's often required.
You say that as if it were obvious, but the kind of work you do may well be a factor in quickly and accurately diagnosing your condition. Should it be a required field? Maybe, maybe not—but if it's not required then they're less likely to have that information available when it would be genuinely useful.
You hang a lot on that "may well be a factor". The doctor can ask, if for example it seems like a repetitive stress injury. But if I went in with a broken arm from skiing, or a disease just off vacation, or for my annual with no specific complaint, this is just wasteful and probably didn't come up in conversation... so you're advocating for making the system more expensive and time-consuming for a tiny potential advantage that already has a better solution-vector - that the physician ask if it seems appropriate rather than because it's "required."
A friend of mine suffered a lizard crash when her iguana walked across her keyboard tray: the power switch for the buss strip that everything was plugged in to was attached upside down under the top of the desk, and the iguana brushed the switch and killed everything. She lost a few hours of database development when that happened.
In our case, our standard poodle is adept at conducting Google searches on my wife's work laptop. We have not yet decoded the results, our having failed to break the secret poodle code.
When you sympathize with stupidity, you start thinking like an idiot.
#doctorsaredicks
I suspect doctors hate computers for the same reason a lot of workers hate computers, it makes their work easily transparent and forces them to be accountable. I think the reality is that doctors are an obvious target for AI. A lot of what doctors are now valued for is their mastery of information, not their human skills or their judgment. Computers are great at mastering information and training people to gather information is a lot cheaper if they don't have to be able to evaluate it. If I were a young person, being a doctor is not the future I would be looking at. I think a lot of doctors recognize this intuitively, they find themselves easily relying on the computer for current information about topics they spent years learning.
Ah, must be a Windows-based system. Our core software reports any exceptions it encounters so that we can proactively provide support to users and fix bugs with our system. Sample label printing is a very small part of what our software does, yet printing exceptions account for more than half of the reports. Bottom line is that Windows' printing subsystems are shit, generating seemingly random errors even for USB-connected printers. Network printers are even worse due to poor choice of timeouts and protocols lacking reliable delivery.
An older couple had issues with their new laptop. I showed them the function key to turn off the track pad they didn't use and their ghosts went away.
It's the people that use it that suck.You are talking about hospital scale (read around 10000 people) numbers of people who, even coming from another EMR, are supposed to all interact with the new system in the correct way or they have failed it. The system is fine, the users are what fails. You might argue that the users shouldn't be able to fail the system, but you cannot argue that you can create a system to deal with such a complex issue and then also address all issues a user introduces from all of the ancillary systems that are introduced. This is not possible without an extended period of troubleshooting in a live environment for such a complex set of solutions. Then there is the bureaucracy and that is where the majority of the errors firm into real life persistant issues instead of user errors. At this point, people are making decisions on a transition from whatever system, paper or otherwise, that will affect system operation. Also at this point, comes the territorial attitudes, the jillion "what about this?" questions, many of which are from stupid people, the never ending issue of who decides how what is done. We haven't even walked into EPIC territory yet and already we have a swamp of stupidity on deck. We just made the transition to EPIC from the hodge-podge homebuilt EMR that we were on and there are still issues months later. I could solve most of them by going straight to the cause: the doctors. They HATE fully documenting anything. That's too bad for them, they won't get paid for a lot of work because of that. They are doing things on the front end that make the back end not work properly. They haphazardly enter information into the records. They use unspecified dx codes for everything. How is anyone supposed to treat you other than that exact same doctor when your documentation is generic copypasta from the last note you wrote? No, the problem isn't the system, it's the doctors and their hatred of documentation. They are extremely obstinate about it, too.
The money quote in that article was, "The system wasn't designed in the best interests of the physicians. It was designed in the best interests of the patients."
Sure, workflows can be good or bad. Poor design is poor design. However physicians designing systems entirely for their own predilections and satisfaction, led us to a paper dominant system with high costs and poor adoption of the latest clinical knowledge. So clean up the workflows, optimize the system as much as you can, do all that. But the days of a doc scribbling off an indecipherable prescription pad, so someone else can spend the time and effort to figure it out? Those days are over, because physicians are now part of a care team.
The old days were more about physician Lone Rangers who could ride off into the sunset. They got a lot done that way but times, they are a changin'.
Also? Every industry sector went through this transition already. Name one that hasn't. Logistics, transportation, manufacturing, services, energy, consumer goods, retail, pharma, travel, education. Healthcare has been a lagging adopter of technology and was one of the final holdouts. I understand the reasons why; biology is complicated and the number of relevant data attributes you must track is simply huge (this is a data perspective of systems design). However now it can be done and the time has arrived.
The ultimate service provider tries to automate their own job by having the service requester fill in information. The problem is, the requester is not always *qualified* to answer those questions, so is stymied, and the service provider never receives the request because the requester can't submit the incomplete form.
Some things are much easier when you can just pick up the phone and ask the expert to do their job instead of filling out a form that tries to do part of the job for them (with you doing the work).
Sounds like the real problem is that they didnâ(TM)t employee a few doctors to consult and test with before rolling out the software and rolled out too ambitiously.
Does your mechanic require you to stay with him at the garage and help him fix your car? No, you pay him to do it. You IT jackasses want to be special and think that we should do your work for you. You're paid to fix the computers. FIX THE GODDAMNED COMPUTERS. Get off your ass, get out of your cave, and walk down to my desk. I'm not rebooting, I'm not checking menus, I AIN'T DOING SHIT. I have my own job (which isn't medical, I'm an engineer). I won't be asking you to climb up to the top of the smoke stacks to change the goddamned blinken light, so don't ask me to send you event logs and ramdumps, umkay?
The real reason that doctors hate computers is because doctors don't know shit about them. This makes them feel less secure, less superior, and an insult to their egos. Doctors try to put on a facade of superior intelligence yet outside of medicine they are some of the stupidest people. Just ask a financial planner or loan officers that specialize working with these people. cough cough. STUPID as in a box of chocolates.
Christ, dude, if I wanted to use drugs, there are a lot more interesting things out there than opioids.
I havenâ(TM)t seen anyone talk about how records typically get used by physicians, so I thought I might provide some insight. The TL;DR is that the modern EMR is about billing, not about patient care.
There are multiple types of notes in a patient chart, but one of the most basic and informative ones is the âoehistory and physicalâ, or H&P. It is the type of note you write when you meet a patient for the first time and are admitting them to the hospital, for example. There are different flavors, but there is the same general format that all doctors commonly expect.
Part one is the âoehistory of present illnessâ or HPI. It is the story you tell your doctor about what is bothering you. It includes things like when the problem started, what your symptoms are, what youâ(TM)ve tried that helps, what things make it worse, etc. Along with that you include the patientâ(TM)s known diagnoses. This requires the doctor to convert the stream of conscious/conversational information they gather during the interview into a single coherent story.
Part two is the objective data, things like vital signs, physical exam, and lab values they might have available.
Part three and four are the assessment and plan. As you might expect, the assessment is the name of the diagnosis and the plan is what youâ(TM)re going to do about it. If you donâ(TM)t have a final diagnosis yet, you pick the most likely and include a list of other things that are possible or you work with some umbrella term and discuss how you plan to narrow things down. You repeat this process for each of the the patientâ(TM)s problems (medical, social, etc) that requires the physicianâ(TM)s attention. If youâ(TM)re dealing with a simple cold you might have one problem, if youâ(TM)re taking care of a very sick ICU patient you may have 15-25.
Hereâ(TM)s a fictional example of what you might see as an entry to an item on a problem list:
1. Congestive Heart Failure
NYHA Stage 1. Due to an MI in 2003, most recent TTE from 2017 showed LVEF of 45 with mild anterior wall hypokinesis. Has tried lisinopril in the past but had side effects so we switchted to losartan which he now tolerates. Completed cardiac rehab and continues to maintain active lifestyle. No changes in treatment indicated at this time.
In this way, the H&P is primarily a tool for collecting, organizing, and analyzing data. It supports decision making and serves as a record of the diagnoses, past treatments, current plans, and possibly future treatment options. A good note represents a substantial amount of thought and illustrates to the next reader what you were considering, what data you used to get there, and what youâ(TM)ve tried so that ideally they can start where you left off. This prevents repeating the same tests or treatments. It saves time because it efficiently gets the next reader (who may be the original writer, may be another provider) up to speed because they donâ(TM)t have to re-invent the wheel (though, they have the ability to recognize a flaw in your reasoning and can potentially re-investigate).
Furthermore, this note works as a todo list in your daily work flow. Imagine an ICU physician with 40 patients, each with a 25 item problem list. Thatâ(TM)s 1000 things the physican needs to track, which is impossible without a good synopsis to keep them organized. Of course, if this is someone elseâ(TM)s work, its the physicianâ(TM)s duty to make sure its accurate, but that is far less time intensive.
A patient care focused EMR would preserve and encourage this type of note, but the current trend does not. Instead of a problem list entry like you see above with a summary of the diagnosis, treatment, and current sate of the patient, EMRs strip it down to a billing code. So you have a list of generic diagnoses in a list without any rhyme or reason. And then on a separate screen you have a list of medications that the patient has bee
DR is name of new data system my X doctor is using. Intake questions are done on tablets after agreeing to a new contract between me & DR. Lets skip all the contract except 3 parts. 1, I agree to irrevocable contract. 2, I agree that DR can change contract in any way it wants any time & it is irrevocable. 3, I can not change contract or limit DR access to my data. Who is DR? I do not care. My care is finding a new doctor.