Yeah. Drove around the UK a few months ago, rental car had a feature where it displayed the speed limit at all times. It wasn't always right, but it did have this really creepy feature where it knew where the speed limit dropped around obviously-temporary roadwork. No way that was programmed into the nav system.
Forget "for a business meal", why would you want to go there at all? Olive Garden is one of those places you go to because you're in the middle of nowhere, the TripAdvisor and Yelp reviews of area restaurants are all obvious shill crap, and you don't want to die of food poisoning. It's mediocre food at a semi-premium price. I'd honestly rather eat at Waffle House or IHOP.
Wife and I were alone for Thanksgiving - just couldn't work out getting the families together at any point - so we went to a nice little place that had set up a buffet with all the usual expected foods. Not the best Thanksgiving food I've ever had, but you can't exactly make a holiday meal for just two people.
While we were there, I was in full view of a family where the teenage son spent the entire meal on his phone reading posts under the table - Snap, Insta, FB, whatever, I couldn't tell and don't care. I was frankly shocked. I get that you have to pick your battles as a parent, but damn, Thanksgiving dinner is a hill worth dying on. Neither parent had a phone out, so far as I could see, so they certainly had grounds to quarrel with him.
Off the top of my head: the Fairmont and St Francis in SF, and the Monteleone and the Ritz-Carlton in New Orleans, all have had substantial and architecturally dissimilar sections added on. Most large hospitals are even more like this - ten or more segments would not be unusual.
Well, yeah. Once you have status, these problems disappear. I can call Delta and get tickets changed (and usually get a human within seconds of calling), no fee for the change, priority upgrade status, no first bag fee even on the cheapest ticket, blah blah blah - because I have status. I remember that when I first hit their lowest tier of status, one of the benefits was "you can now get an exit-row seat". Yep: if you don't have at least lowest-tier status, you aren't even eligible for those seats.
Yeah, if you want service, it's easy to get. Pay for first class on a decent legacy airline (I haven't flown United in ages, but Delta >> American). If you take pre-deregulation prices as a guide and run them through the CPI calculator, it's pretty much the same now as it was then, for pretty much the same service.
People have spoken with their wallets: they want cheap flights. They may say they'll pay $50 more for a little more legroom, but in practice, most don't. Revealed preferences and all that.
The whole point of quoting ridiculous prices is that you don't have to say no. As for the other, sorry, why did you spend five hours on something you can't fix? The first two hours are for driving out and a basic diagnostic fee, not refundable. If you want to drop the rest later because you really couldn't figure it out, that's on you. I'm not the most aggressive guy out there, but I don't feel bad about sending people a bill for a reasonable time any more than the auto shop feels bad about charging a basic diagnostic fee even if I don't want to pay for the full fix (and they definitely do the "insane quote" for stuff they don't want to do).
If it makes you feel better, then adopt a simple standard: I will give you one minute of free advice. That includes your description of the problem and my response. You can usually get a good feel for the problem in that amount of time, and you can then tell them a brief solution. Your ten-year-old computer running Win 7 isn't so snappy? The cheapest thing for you to do is go get a new one. Your creaky network is throwing strange errors? Maybe I can help, here are my terms, and here's my phone number, call me on Monday morning and we'll set things up.
So quote them prices that make it worth your while. $400/hr, minimum two hours, payable up front. Don’t like it, fine, find someone else. People have done this forever - either you don’t get stuck with jobs you hate, or you make a ton of cash solving trivial problems.
$6000 for business is international-level money. Domestic flights, it's about $1200 even for coast-to-coast. If you want the lay-flat seats, yeah, that will cost you a bunch more, but just plain domestic "first class"? It's not that much more expensive for one or two tickets, though taking a family will run up the cost pretty fast.
Epidural pumps have UI's designed by the summer intern. All of them - I've never seen a good one. (There's nothing particularly special, except that they're accurate at very low flow rates, and they look different from regular IV pumps).
Want to walk down a rabbit hole? I can answer that question in detail if you want, but the short answer is "somewhat, not much". If you're interested, I don't mind writing the answer, but it will be a bit long and possibly very boring.
Oh, radiology... here's a fun story: the PACS system hasn't changed (imagine that: an EMR without PACS, which is one of the most useful parts of EMR), except that now, when you open it, it doesn't pull up the images related to the patient whose chart you're in. No, you're going to have to search by name or medical record number. And the best part? The EMR doesn't allow normal Windows copy and paste to work (though it has its own internal copy and paste for notes), presumably as a security measure. So you can't copy and paste that MRN - oh, no, you're going to have to memorize it or write it down, and then enter it by hand. Or search by name (yeah, that never goes wrong). As I said before, tell me again how this is better?
And to answer your first question: at this point, the answer is "worse". When we have a system that works well at a 600-bed hospital, we can talk about whether or not that system is a good solution for a country of over 300 million people. That's leaving aside the entire question of how you manage to protect personal information in a system that large, because it's an enormous hacking target, and yet strangers need to be able to access it even if you're unconscious.
After PPACA made EMR's effectively mandatory for hospitals, the big companies in the business who had been doing specialty-specific things went out and bought the smaller companies who had been doing other specialty-specific things, and then just glued them together to make a package. Then they started selling that.
I played a small role, in that I was part of a large team (about 80 people in total, at least one from every role in the hospital that would need to use it) that went to Cerner HQ for a few days to try to set some parameters for how they needed to integrate our workflow. It didn't help much, but one of the things that I noticed was that in three days there, I met one nurse and zero physicians. There were fewer than five people over the age of 30, and most were 25 or younger. Fresh college grads are smart, and they're cheap, but if I'm watching the team you are putting together and notice that almost nobody has ever done a rollout before (and there were plenty of indications that it was the first time most of these people had done this), and that nobody has ever actually done the job in question... let's just say it's not inspiring.
Well, the per-specialty thing is a problem - some of us really do things differently. And there are ridiculous alerts that come from pharmacy rules (this patient is allergic to codeine, do you really want them to have morphine? Of course I do, because they aren't really allergic to codeine, they just had XYZ bad reaction to it once, or their mom told them that from a childhood exposure, but they just had their gallbladder out, and they're going to fucking hurt.).
Billing is the primary cause of extraneous information in notes - as I said, most doctors are paid more for writing detailed notes, so the EMR defaults to doing that even for those of us who don't get a nickel for it, and it clogs up the notes of those who do.
Even then, though, the amount of useless junk that has to be deleted in order to make the note even approximate what would be written if you had to break out a pen is staggering. Example: anyone being evaluated for bypass surgery on their heart gets an ultrasound of their carotid arteries, because if one set of arteries in your body is blocked, there's a good chance that others are as well, and you might decide that the carotids are more important (given that they are the source of blood for your brain). The auto-populate shows the whole report. My handwritten notes said "carotids OK", or "software can't do that, so the whole thing is included. Cardiac cath report for a bypass, same thing.
The administrative bloat comes in more on the ordering side, where a ridiculous number of things have to be specified by drop-down boxes. At least we can customize our own order sets - I have to write a set of orders for every patient going to recovery, and it's not a small one. This is one of the few places where it's usually faster on the computer than on paper, but overriding alerts is really bad if they have, say, an "allergy" (it's almost certainly not an allergy) to codeine - I have to override at least two, and sometimes five or six, different med orders, each of which requires three clicks in different places on the screen. Or ordering Benadryl/diphenhydramine on a patient who may be breastfeeding - that's another two dialog boxes to go through.
I'll be happy to step into the 21st century at work when software people write a non-completely-fucked-up EMR. The medium-sized hospital I work at shelled out $50 million for a steaming pile of shit, and that doesn't even count the hundreds of new thin clients, wiring, backend upgrades... shouldn't we expect something for our money?
TL, DR: EMR's all suck, and are vastly inferior to "do it on paper and scan it in later" for the vast majority of cases.
Let’s implement an EHR system that everyone can live [with]
Well, that's the hard part, isn't it? They are almost universally despised. My workload has increased significantly since my hospital implemented an EMR, and the only thing that has improved vs paper is that you can read everyone's writing. Of course, those relevant nuggets of information are now buried in pages of auto-generated "content" that load slowly, so they're not necessarily easier to find out.
I'm an anesthesiologist, and my job is not like that of other doctors. Unlike the vast majority of doctors, I don't get paid to write notes with more details. My notes are very, very brief. I can write down "healthy" and leave it at that, and still get paid. What I do have to do is find all those nuggets of information. In the previous system we had, charts were done on paper, and scanned in after discharge. Lab results and anything dictated (operative notes, radiology results, pathology results) were easily found in the computer. Now? Happy hunting. My note auto-includes all recent radiology results, even when they are irrelevant to what I'm going to do. If I want a nice, clean note that is in any way as concise as my paper notes were, I have to go and delete all of that manually.
There's a nice little section where diagnoses are entered as the patient comes into the system. If someone has put these in, it auto-populates. Great, right? Except that if you've ever been pregnant, then "pregnant" shall forevermore be on your list. I have to hover over a very specific box to delete that when, for example, you've had your baby. Or babies - I'll get one "pregnant" diagnosis for every one of those. It helpfully includes information like whether the patient is sexually active or not - even if the patient is currently pregnant. There is no reason that should ever appear in my note, because the only thing that is relevant to me is whether or not you are currently pregnant.
So, just to make a simple example, let's have a healthy 19-year-old woman with appendictis. No allergies, no medications, no prior surgeries, no family history of anesthetic complications, normal airway exam, brief list of labs, negative pregnancy test, plan general anesthesia, ASA physical status 1E. That is what my paper note looked like. The EMR note would fill pages.
The thing about paper medical records, for all their faults, is that they were a highly refined method for transmitting maximum information in minimum space. Even after the entire rest of the VA had switched to electronic records (and although the backend was apparently a nightmare, the user experience wasn't too awful), anesthesia records were done on paper and then scanned in, because they occupied the front and back of one sheet of paper and were dense with information that just can't be represented in text. Even simple things like blood chemistry were typically recorded in a skeleton so that you didn't have to read line-by-line.
Having said all that, every doctor can tell you something similar about their own specialty. Irrelevant or incorrect information clogs notes, especially as they are more or less cut-and-pasted day to day, with the newest day usually coming at the bottom. I was investigating a case where a patient who was in the ICU quit breathing and had to be intubated. It happens, no surprise there, and one of the physician notes written at the time suggested that it was correlated with starting a specific medication. I decided to look up the nurse's notes to see whether that was true or not - ICU nurses are a dedicated bunch, and there's no way that it wasn't documented. In the ancient days, that would have required a trip to medical records. In the immediately-past system, I would have been able to pull up the scanned i
Ha. My wife commented recently that our eight year old niece, her brother’s daughter, seems to get along better with me than with anyone else. I pointed out that I’m the only one who doesn’t try to please her all the time, and says no to screens unless we are being social with each other (e.g., split-screen video games). If she wants to hang out with me, she gets 100% of my attention, but she has to give 100% of her attention too. Funny how that works.
I was passing through immigration on a visit to Mexico. Couple of people start crossing lines, some try to get in front of me and my wife. I said no, line starts back there, you want to skip things then fine, skip yourself behind us. Guy looks at me and says "oh, what are you going to do? This isn't elementary school, nobody's going to make me." Said I, "You're right - but you're still an asshole for doing it." He told me, "I've been an asshole all my life, why stop now?" I said fine, walked in front of him, and nothing happened. If I had any presence of mind, I would have told the immigration officer that those people right behind me were acting strangely and were obsessed with getting into a particular spot in the line. I wasn't going to deck the guy for it - didn't need the headaches - but that would have been fun to watch.
Maybe on some. I drove from Prague to Stuttgart last year, plenty of uncontrolled speed sections, doing about 160, and I passed many more cars than passed me. A few doing about 180, a couple in the 200+ range, but most hanging out around 130-140.
It’s supplying something, or it wouldn’t be there. My guess would be Dallas, which is also a much better place to put your manufacturing - population is there, excellent transportation links. The big farm along 287 between Wichita Falls and Amarillo... there is a reason almost nobody lives there.
So why can't I buy it for iOS? Other than the me/nee misinterpretation, that was my favorite app on Android. I know, you don't work there anymore, but the swiping keyboards for iOS (SwiftKey, GBoard) are far inferior to Swype on Android.
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Yeah. Drove around the UK a few months ago, rental car had a feature where it displayed the speed limit at all times. It wasn't always right, but it did have this really creepy feature where it knew where the speed limit dropped around obviously-temporary roadwork. No way that was programmed into the nav system.
Fuck yourself gently with a chainsaw if you think I'm no longer even allowed to notice when people are rude to each other.
Forget "for a business meal", why would you want to go there at all? Olive Garden is one of those places you go to because you're in the middle of nowhere, the TripAdvisor and Yelp reviews of area restaurants are all obvious shill crap, and you don't want to die of food poisoning. It's mediocre food at a semi-premium price. I'd honestly rather eat at Waffle House or IHOP.
Wife and I were alone for Thanksgiving - just couldn't work out getting the families together at any point - so we went to a nice little place that had set up a buffet with all the usual expected foods. Not the best Thanksgiving food I've ever had, but you can't exactly make a holiday meal for just two people.
While we were there, I was in full view of a family where the teenage son spent the entire meal on his phone reading posts under the table - Snap, Insta, FB, whatever, I couldn't tell and don't care. I was frankly shocked. I get that you have to pick your battles as a parent, but damn, Thanksgiving dinner is a hill worth dying on. Neither parent had a phone out, so far as I could see, so they certainly had grounds to quarrel with him.
Off the top of my head: the Fairmont and St Francis in SF, and the Monteleone and the Ritz-Carlton in New Orleans, all have had substantial and architecturally dissimilar sections added on. Most large hospitals are even more like this - ten or more segments would not be unusual.
I'm a frequent flyer with them
Well, yeah. Once you have status, these problems disappear. I can call Delta and get tickets changed (and usually get a human within seconds of calling), no fee for the change, priority upgrade status, no first bag fee even on the cheapest ticket, blah blah blah - because I have status. I remember that when I first hit their lowest tier of status, one of the benefits was "you can now get an exit-row seat". Yep: if you don't have at least lowest-tier status, you aren't even eligible for those seats.
Yeah, if you want service, it's easy to get. Pay for first class on a decent legacy airline (I haven't flown United in ages, but Delta >> American). If you take pre-deregulation prices as a guide and run them through the CPI calculator, it's pretty much the same now as it was then, for pretty much the same service.
People have spoken with their wallets: they want cheap flights. They may say they'll pay $50 more for a little more legroom, but in practice, most don't. Revealed preferences and all that.
The whole point of quoting ridiculous prices is that you don't have to say no. As for the other, sorry, why did you spend five hours on something you can't fix? The first two hours are for driving out and a basic diagnostic fee, not refundable. If you want to drop the rest later because you really couldn't figure it out, that's on you. I'm not the most aggressive guy out there, but I don't feel bad about sending people a bill for a reasonable time any more than the auto shop feels bad about charging a basic diagnostic fee even if I don't want to pay for the full fix (and they definitely do the "insane quote" for stuff they don't want to do).
If it makes you feel better, then adopt a simple standard: I will give you one minute of free advice. That includes your description of the problem and my response. You can usually get a good feel for the problem in that amount of time, and you can then tell them a brief solution. Your ten-year-old computer running Win 7 isn't so snappy? The cheapest thing for you to do is go get a new one. Your creaky network is throwing strange errors? Maybe I can help, here are my terms, and here's my phone number, call me on Monday morning and we'll set things up.
Go take a Dale Carnegie course. Really.
So quote them prices that make it worth your while. $400/hr, minimum two hours, payable up front. Don’t like it, fine, find someone else. People have done this forever - either you don’t get stuck with jobs you hate, or you make a ton of cash solving trivial problems.
$6000 for business is international-level money. Domestic flights, it's about $1200 even for coast-to-coast. If you want the lay-flat seats, yeah, that will cost you a bunch more, but just plain domestic "first class"? It's not that much more expensive for one or two tickets, though taking a family will run up the cost pretty fast.
Correct.
Epidural pumps have UI's designed by the summer intern. All of them - I've never seen a good one. (There's nothing particularly special, except that they're accurate at very low flow rates, and they look different from regular IV pumps).
As for regular pumps, BD Alaris is not awful.
Want to walk down a rabbit hole? I can answer that question in detail if you want, but the short answer is "somewhat, not much". If you're interested, I don't mind writing the answer, but it will be a bit long and possibly very boring.
Oh, radiology... here's a fun story: the PACS system hasn't changed (imagine that: an EMR without PACS, which is one of the most useful parts of EMR), except that now, when you open it, it doesn't pull up the images related to the patient whose chart you're in. No, you're going to have to search by name or medical record number. And the best part? The EMR doesn't allow normal Windows copy and paste to work (though it has its own internal copy and paste for notes), presumably as a security measure. So you can't copy and paste that MRN - oh, no, you're going to have to memorize it or write it down, and then enter it by hand . Or search by name (yeah, that never goes wrong). As I said before, tell me again how this is better?
And to answer your first question: at this point, the answer is "worse". When we have a system that works well at a 600-bed hospital, we can talk about whether or not that system is a good solution for a country of over 300 million people. That's leaving aside the entire question of how you manage to protect personal information in a system that large, because it's an enormous hacking target, and yet strangers need to be able to access it even if you're unconscious.
After PPACA made EMR's effectively mandatory for hospitals, the big companies in the business who had been doing specialty-specific things went out and bought the smaller companies who had been doing other specialty-specific things, and then just glued them together to make a package. Then they started selling that.
I played a small role, in that I was part of a large team (about 80 people in total, at least one from every role in the hospital that would need to use it) that went to Cerner HQ for a few days to try to set some parameters for how they needed to integrate our workflow. It didn't help much, but one of the things that I noticed was that in three days there, I met one nurse and zero physicians. There were fewer than five people over the age of 30, and most were 25 or younger. Fresh college grads are smart, and they're cheap, but if I'm watching the team you are putting together and notice that almost nobody has ever done a rollout before (and there were plenty of indications that it was the first time most of these people had done this), and that nobody has ever actually done the job in question... let's just say it's not inspiring.
Well, the per-specialty thing is a problem - some of us really do things differently. And there are ridiculous alerts that come from pharmacy rules (this patient is allergic to codeine, do you really want them to have morphine? Of course I do, because they aren't really allergic to codeine, they just had XYZ bad reaction to it once, or their mom told them that from a childhood exposure, but they just had their gallbladder out, and they're going to fucking hurt.).
Billing is the primary cause of extraneous information in notes - as I said, most doctors are paid more for writing detailed notes, so the EMR defaults to doing that even for those of us who don't get a nickel for it, and it clogs up the notes of those who do.
Even then, though, the amount of useless junk that has to be deleted in order to make the note even approximate what would be written if you had to break out a pen is staggering. Example: anyone being evaluated for bypass surgery on their heart gets an ultrasound of their carotid arteries, because if one set of arteries in your body is blocked, there's a good chance that others are as well, and you might decide that the carotids are more important (given that they are the source of blood for your brain). The auto-populate shows the whole report. My handwritten notes said "carotids OK", or "software can't do that, so the whole thing is included. Cardiac cath report for a bypass, same thing.
The administrative bloat comes in more on the ordering side, where a ridiculous number of things have to be specified by drop-down boxes. At least we can customize our own order sets - I have to write a set of orders for every patient going to recovery, and it's not a small one. This is one of the few places where it's usually faster on the computer than on paper, but overriding alerts is really bad if they have, say, an "allergy" (it's almost certainly not an allergy) to codeine - I have to override at least two, and sometimes five or six, different med orders, each of which requires three clicks in different places on the screen. Or ordering Benadryl/diphenhydramine on a patient who may be breastfeeding - that's another two dialog boxes to go through.
I'll be happy to step into the 21st century at work when software people write a non-completely-fucked-up EMR. The medium-sized hospital I work at shelled out $50 million for a steaming pile of shit, and that doesn't even count the hundreds of new thin clients, wiring, backend upgrades... shouldn't we expect something for our money?
Christ, dude, if I wanted to use drugs, there are a lot more interesting things out there than opioids.
Let’s implement an EHR system that everyone can live [with]
Well, that's the hard part, isn't it? They are almost universally despised. My workload has increased significantly since my hospital implemented an EMR, and the only thing that has improved vs paper is that you can read everyone's writing. Of course, those relevant nuggets of information are now buried in pages of auto-generated "content" that load slowly, so they're not necessarily easier to find out.
I'm an anesthesiologist, and my job is not like that of other doctors. Unlike the vast majority of doctors, I don't get paid to write notes with more details. My notes are very, very brief. I can write down "healthy" and leave it at that, and still get paid. What I do have to do is find all those nuggets of information. In the previous system we had, charts were done on paper, and scanned in after discharge. Lab results and anything dictated (operative notes, radiology results, pathology results) were easily found in the computer. Now? Happy hunting. My note auto-includes all recent radiology results, even when they are irrelevant to what I'm going to do. If I want a nice, clean note that is in any way as concise as my paper notes were, I have to go and delete all of that manually.
There's a nice little section where diagnoses are entered as the patient comes into the system. If someone has put these in, it auto-populates. Great, right? Except that if you've ever been pregnant, then "pregnant" shall forevermore be on your list. I have to hover over a very specific box to delete that when, for example, you've had your baby. Or babies - I'll get one "pregnant" diagnosis for every one of those. It helpfully includes information like whether the patient is sexually active or not - even if the patient is currently pregnant. There is no reason that should ever appear in my note, because the only thing that is relevant to me is whether or not you are currently pregnant.
So, just to make a simple example, let's have a healthy 19-year-old woman with appendictis. No allergies, no medications, no prior surgeries, no family history of anesthetic complications, normal airway exam, brief list of labs, negative pregnancy test, plan general anesthesia, ASA physical status 1E. That is what my paper note looked like. The EMR note would fill pages.
The thing about paper medical records, for all their faults, is that they were a highly refined method for transmitting maximum information in minimum space. Even after the entire rest of the VA had switched to electronic records (and although the backend was apparently a nightmare, the user experience wasn't too awful), anesthesia records were done on paper and then scanned in, because they occupied the front and back of one sheet of paper and were dense with information that just can't be represented in text. Even simple things like blood chemistry were typically recorded in a skeleton so that you didn't have to read line-by-line.
Having said all that, every doctor can tell you something similar about their own specialty. Irrelevant or incorrect information clogs notes, especially as they are more or less cut-and-pasted day to day, with the newest day usually coming at the bottom. I was investigating a case where a patient who was in the ICU quit breathing and had to be intubated. It happens, no surprise there, and one of the physician notes written at the time suggested that it was correlated with starting a specific medication. I decided to look up the nurse's notes to see whether that was true or not - ICU nurses are a dedicated bunch, and there's no way that it wasn't documented. In the ancient days, that would have required a trip to medical records. In the immediately-past system, I would have been able to pull up the scanned i
Ha. My wife commented recently that our eight year old niece, her brother’s daughter, seems to get along better with me than with anyone else. I pointed out that I’m the only one who doesn’t try to please her all the time, and says no to screens unless we are being social with each other (e.g., split-screen video games). If she wants to hang out with me, she gets 100% of my attention, but she has to give 100% of her attention too. Funny how that works.
I was passing through immigration on a visit to Mexico. Couple of people start crossing lines, some try to get in front of me and my wife. I said no, line starts back there, you want to skip things then fine, skip yourself behind us. Guy looks at me and says "oh, what are you going to do? This isn't elementary school, nobody's going to make me." Said I, "You're right - but you're still an asshole for doing it." He told me, "I've been an asshole all my life, why stop now?" I said fine, walked in front of him, and nothing happened. If I had any presence of mind, I would have told the immigration officer that those people right behind me were acting strangely and were obsessed with getting into a particular spot in the line. I wasn't going to deck the guy for it - didn't need the headaches - but that would have been fun to watch.
Maybe on some. I drove from Prague to Stuttgart last year, plenty of uncontrolled speed sections, doing about 160, and I passed many more cars than passed me. A few doing about 180, a couple in the 200+ range, but most hanging out around 130-140.
It’s supplying something, or it wouldn’t be there. My guess would be Dallas, which is also a much better place to put your manufacturing - population is there, excellent transportation links. The big farm along 287 between Wichita Falls and Amarillo... there is a reason almost nobody lives there.
So why can't I buy it for iOS? Other than the me/nee misinterpretation, that was my favorite app on Android. I know, you don't work there anymore, but the swiping keyboards for iOS (SwiftKey, GBoard) are far inferior to Swype on Android.