Unfortunately the problem is much greater than engineers not understanding doctors and other clinical staff, in my experience. For startups that want to sell to health systems and similar-sized/larger entities (really this is the minimum size that can work for most startups, practice sales usually have more friction than value), you unfortunately have to focus on the buyer, which is very rarely someone who is "in the trenches." Best case scenario, having software that is compelling to the end users can help you get your foot in the door early on, but actual adoption will only happen if you can convince the business stakeholders of your value.
In the US healthcare system, clinicians and the business often have opposing objectives and values. This is starting to change with value based care becoming more popular, but it's still all about providing what the business wants, it just happens to align with the clinicians more these days. You'll still need to support IE9 due to that botched Vista upgrade, build out a custom EMR integration, and deliver whatever random feature the sales folks promised (can you automatically fax things?) before you can move on to the features that the clinicians actually want.
The system itself is how we ended up with billing-driven documentation EHRs like Epic. Paradoxically, due to massive adoption, I think Epic and Cerner are some of the only places where real innovation could happen. I think even huge companies like Apple, Amazon, and Google will have a hard time breaking into the space, no matter how much cash they throw at it. For them, the only answer is to go fully vertical like Kaiser-Permanente, but I doubt they have the stomach for this.
I'm sure I'm being naieve, but could we just get rid of billing altogether if we nationalize the health care system? I have to recount an anecdote. My mom was hiking in a foreign country, and got injured. She hobbled to the next town, and found a clinic. They treated her and were ready to let her go. She said:
Q: Okay, how do I pay?
A: You don't pay for health care.
Q: I'm American. I'm not part of your health care system.
A: That's all well and good, but we have no way of knowing how much to charge you, how to take your money, or where to send it. Have a nice vacation.
The clinic probably maintained some accounting records, but they simply had no billing system.
When I was an American military wife, I mostly just flashed my military ID, made an appointment, picked up my meds, etc.
I was diagnosed with atypical CF in my mid thirties and some of the things I was prescribed were not on the formulary of the military hospital. I went in town and had a co-pay of (IIRC) $13 per prescription. One day, I tripped across an old receipt: More than $1200 worth of pills with a $39 co-pay. Probably three months worth of digestive enzymes.
I was also seeing a specialist at a clinic at UC Davis Medical Center in Sacramento. I had been a few times when I noticed a sign prominently displayed on the front desk announcing that they would not see you if you owed money. I asked the person at the desk if I owed anything as I had never paid them anything at all. Surely, I owed some co-pays.
She checked my records. Nope, I didn't owe anything. I was all good.
Well, that was weird. But I was fighting for my life, so I shrugged and moved on with my life. I didn't have the energy to figure out what had happened.
Some years later, I was talking with folks on a CF email list and, silly me, I remarked that "I guess the CF Foundation picked up the co-pays or something." People vociferously informed me that, oh, no, that is not what happened. That's not something they do.
No clue why I was never billed at all by UC Davis Medical Center. But I (apparently* ) wasn't.
I don't know how the military handles it. But when I was a military wife, no, I generally did not see medical bills of any kind.
* I was extremely sick. It's possible my husband paid the bills and I just didn't realize it. But I don't think that's what happened.
We already have a healthcare system within the US where billing seems to mostly not happen. So, presumably, it isn't completely alien and foreign and something America would need to steal from elsewhere.
Billing definitely happens. And one procedure can trigger billing from multiple different providers. I had my appendix out a few years ago and received separate bills from the hospital, the surgeon, the anesthesiologist, and possibly something else (nursing?). I was able to get the hospitals portion written off ($~20,000 and I was unemployed and uninsured at the time) but no such luck with the other providers, and those bills and the collections agencies followed me for years until I could get them paid off.
I'm well aware that's the reality for many. My awareness of that is the reason I commented on the fact that the US already has one very well-developed and well-established medical system that works much like socialized medicine: The military medical system.
We don't need to look to other countries at all to try to figure out how that's done. It's done right here on American soil every single day for military members, military retirees and their dependents.
All we need to do is figure out how to expand on that existing system. And perhaps one first step would be to change the rules such that anyone who serves in the military gets medical benefits for life, even if they don't stay long enough to retire and get all those other benefits.
It's never sat well with me that it is possible to be a veteran and have no benefits at all. Giving all veterans medical benefits would begin expanding coverage in the US under a system where billing is the exception, not the rule.
I hate the civilian US medical care system and it's fucked up coverage. I've been a military dependent basically my entire life. My experience of medical care is vastly different from that of most Americans and it's a crying shame we don't do more for our citizens in that regard.
I can tell you active duty is different from what retirees deal with. Also "vets" doesn't necessarily mean they are retirees. If they didn't serve long enough to qualify for retirement, it's possible to be a veteran without still being part of the military benefits system.
You actually have insurance in the military. When my husband was on recruiting duty, we did not live near a military base. I had to deal with insurance at that time.
But when you get treated at a military facility, you show your ID and there is no bill -- at least, this was true back when I was a military wife.
That’s decidedly not my experience. I’ve certainly been presented with bills for every single thing I’ve done at a hospital, including visits that I was assured I would not be billed for. I’ve even spent months trying to work out arrangements with hospitals and insurance only to have my bills sent to collections. The thousands of people who file bankruptcy each year for medical bills would likely wonder what you mean, too.
I see. I may as well add now, that’s roughly the experience I have receiving care in my home state with Medicaid. The people at the state even said I should never be presented with any sort of bill. Out of state, though, it’s been more difficult to arrange as hospitals in other states may or may not be able to bill my Medicaid, restricted either by lack of agreements or competence.
Somebody will be paying, and will want adequate and auditable documentation about what they are paying for. The potential for fraud is too great. Medicare and states all have to watch for fraud in their claim payments.
What fraud? Going to the doctor is literally useless unless you're ill.
They will literally send you away home if they find you to be fine. The doctors and nurses and personnel and what have you will also get mad at you for wasting their time unjustifiably (and I've done this myself and oh boy they left an impression on me).
If you mean Government fraud, from the ones planning the system yes, indeed, all documentation about how much a healthcare center "costs", how their location and capacity is decided, and etc... should be open and easily accessible to the public.
Medication is partially subsidized and never given for free at a medical center or hospital unless it's an emergency, older than 65+, disabled, etc...
You're right that "patient"-doctor fraud is unlikely, but receiving unnecessary medication (addictive/fun/valuable drugs) or medical people overcharging or charging for unperformed or unnecessary procedures is a possibility for fraud.
Most hospitals have on-call work, overtime, outsourced work, consumables that can be billed for etc.
Pay cheques vary a huge amount depending on work done, and as a radiographer in a regional hospital my yearly wage was more than half made up by penal rates and overtime.
Sure, but adequate and auditable documentation need not involve the patient nor money. Just a "here is the medical care we dispersed, on this date, to this person, it took these resources, these people administered the care." No following up every record for payments, no arguing with insurance companies over the price.
And also, what abuse? If medical care is free and drugs are cheap, the only real abuse is drug abuse (by either seekers or medical personnel). With free access to proper care those drug abuse problems will sharply decrease, killing the market (the cause of the other half of drug abuse).
The only reason there is medicare fraud to worry about right now is because not everyone is supposed to be on it, the "fraud" is attempting to get free health care. Which wouldn't exist if everyone had it.
> Sure, but adequate and auditable documentation need not involve the patient nor money. Just a "here is the medical care we dispersed, on this date, to this person, it took these resources, these people administered the care." No following up every record for payments, no arguing with insurance companies over the price.
This is naive. The source of income (whether it's insurance companies, the government, patients) are not the people who actually buy medical supplies for the hospitals. The simplest way to commit fraud is to charge the insurance company (in a privatized system) or the government (in a public system) for large amounts of care for fake patients in fake cases, which is only caught if an audit shows a mismatch between claims and supply, e.g. a hospital claims that it dispensed 5,000 doses of a $10,000 drug but can only show a purchase order for 100 doses (leading the hospital to fraudulently get $499 million).
You would think that the way to deal with that issue is to vertically integrate, i.e. the hospital issues orders for medical supplies which it doesn't pay for directly, and the medical supply company is compensated in some other way, probably by government funding. But this turns into a government-run market and it has all kinds of issues. Without pricing as a guide, hospital doctors over-prescribe supplies whose real price is far higher than older but similarly effective alternatives. Drugs which the hospital didn't order, but are absolutely crucial for patient X, are either completely unavailable (if the official supplier doesn't stock it) or tied up in medical bureaucracy (to get a special exemption for a special delivery of the drug). The quality of patient care suffers as a result.
You know there are a hundred countries where this is a solved problem, right?
> The simplest way to commit fraud is to charge the insurance company (in a privatized system) or the government (in a public system) for large amounts of care for fake patients in fake cases
Insurance fraud is a problem for the insurance company. They deal with that already so it's not relevant here. And a govt hospital can be audited just like any other govt entity.
>Sure, but adequate and auditable documentation need not involve the patient nor money.
Since almost all healthcare in the US is private (hospitals, doctors, clinics, etc.) then, yes, it needs to involve money since all those entities will want to get paid. And, no, the government can't take it all over since everyone will fight it (and win).
>Just a "here is the medical care we dispersed, on this date, to this person, it took these resources, these people administered the care." No following up every record for payments, no arguing with insurance companies over the price.
This is basically existing medical billing without the follow through (what was done, why, when and by whom). Not sure why you think money (ie: paying hospitals, doctors, etc.) needs to be removed from the equation for it to work.
>The only reason there is medicare fraud to worry about right now is because not everyone is supposed to be on it, the "fraud" is attempting to get free health care. Which wouldn't exist if everyone had it.
Fraud is also doctors, hospitals, etc. billing for things they didn't do or didn't need to do.
a clinic could mis-report (over-report?) how many patients they treated, and/or the procedure. They can then claim back more money than they actually spent, netting easy profit.
Some years ago, I met a doctor on vacation - bit of an ass, but whatever
Last year, I found out he’d gone to prison for “performing procedures” that he was mot present for, including some whilst he was on the beach in Fiji with me!
So, the federal government already has procedures to catch cheats at every level.
This happened to me. When I first moved to Boston I went to a new dentist who kept remarking how great my dental insurance coverage was. It turned out I had a cavity which was fully covered by my insurance so I went to his office, got the novocaine shot and spent an hour with the guy supposedly drilling in my mouth. I saw the dentist for about a year and had three cavities. The only three I'd ever had in my life.
A year or so later I switched to a dentist who was closer to my office. I told him I had had three cavities but they weren't showing up on the x-rays he took. We did two or three sets of x-rays before we figured out they were never going to show up because he had just been billing my great insurance for work he didn't actually do.
Solved by not allowing money to enter the circle. Results in you needing to sell the drugs/things you overcount on, which is rather easy to track and find out.
If they are public employees, they have sort of a standardized salary coming straight from the healthcare ministry/department/whatever where the specific hospital just administer the HR part. You still think in a for profit manner, where healthcare in most countries is not a for-profit endeavour. As long as it works, it's fine, even if it's a net negative. You try to limit the money you waste and inefficiencies, but not by pulling levers on the staff salaries.
>You still think in a for profit manner, where healthcare in most countries is not a for-profit endeavour.
And in the US it's not.
Assuming that you can simply remake a massive chunk of the economy (hospitals, doctors, nurses, clinics, etc, etc) to be government owned is silly. People will protest, lobbyists will be paid and it won't happen. If your only solution to the problems people point out is essentially magic then, no, it's not a valid solution.
I don't say it isn't beneficial (actually I agree with this, but I consider this more an opinion than a fact), the notion of "normal" is a bit subjective so I won't comment on this, but what did you feel was "scary-sounding"? I thought this was fairly stating something that should be obvious.
> If you are that strong a believer in the evils of socialism do you avoid Freeways, airports and the internet?
Well you are conflating a few things here, it not black and white. It is funny to see how stating something that seems obvious to me gets me downvoted and categorized as an extremist anti-socialism...
I see some evils in socialism, but probably not the one you believe. For instance claiming that healthcare is free in a socialist country is one of the most evil aspect of it. My main grief is that people treats it as something that they can waste and don't need to be careful about. Same for "free" universities: student thinking it is "free" don't have much pressure to actually take the most of it and be careful about their choice (let's do a first year of sociology studies after high school because I don't know what I really want to do, and then I can still do a first year of psychology studies, and I'll figure later what I'll do with all this...).
On the other hand, after growing up in France and now living in the US, I learnt that this is all not free and I consider this very previous for the French society. I won't advocate against these welfare benefits, on the opposite I think they should reinforced in many ways however I would like the state of mind of people to change with respect to these "free" benefits, starting by stopping to use the word "free".
As a concrete action, I would send the full healthcare statements to patients, showing how much it costs and how much the taxpayers money is offsetting. I was in the hospital in France multiple times, I have no idea how much it costs, I didn't pay anything as far as I remember, and didn't have a statement.
The same approach can be used for University and other welfare benefit.
I'm not the GP and think we probably should have more socialized hospitals.
But suggesting people who oppose publicly funded freeways should boycott publicly funded freeways is silly.
Imagine an office Christmas party where everyone is told to chip in for refreshments and then the refreshments will be whatever the boss ends up buying with that money. I may not like that arrangement, and may prefer to keep my money and bring my own food for myself. But, given that I have to pay in, I feel no need to abstain from eating the salad that the boss ends up providing using everyone's money.
Right, indeed I think that in this situation eating the salad does not prevent you from criticizing the party.
But this is the point, you were "forced" to pay for something and you would be okay with not getting it. If only the people who paid for the Christmas party were invited that would be okay.
Do you think this reasoning should also apply to streets and hospitals?
(I am specifically referring to using the word "forced" and the moral implication of using it)
> Do you think this reasoning should also apply to streets and hospitals?
Probably not.
But neither do I find it hypocritical to utilize publicly funded medicine (since you already paid in) while also opposing it (because you would be willing to forgo it to avoid paying in). The opposition is perhaps cruel or inconsiderate of others, but certainly not hypocritical. People who construe it as such are either confused or intellectually dishonest.
That's true. But I think the system could be simpler if there were fewer, and possibly just one, entities. I work in a factory, so we live by SAP. And it's complex, typical "enterprise" software, but I don't think it's even within an order of magnitude as complex as Epic.
We want an audit trail, but most of the transactions are made within a single business entity, e.g., from the stockroom to an assembly area. We've had process improvement projects that reduced the number of SAP transactions required to make something.
So maybe the key isn't so much having a government run system, but simply reducing the number of entities. For instance a hospital doesn't have to make a claim to Medicare, if the hospital is Medicare. Also, the game of figuring out how much to bill the patient goes away.
We don't even know how many entities there are in the medical system, or how much money is going to each one. Were I inclined towards cynicism, I'd suspect that this is by design.
If we had a national healthcare system the documentation would consist of proof of citizenship or permanent residency (or guardian's proof of same in the case of minors). That allows spot-checks to validate that fake or deceased people aren't being "treated" to generate fake charges.
Right now even Medicare/Medicaid need lots of process to verify you are eligible and/or enrolled. That wouldn't be a problem if everyone were covered automatically.
Right, but it’s probably done by auditing resources to treatment records. The actual patient needn’t be involved. And in countries like Canada you may end up with multiple operating agencies that are competing for efficiency, such as Coastal Health vs Providence, even though ultimately it’s the government footing the bill.
Providence is under Vancouver Coastal health. The authorities aren’t competing with each other (well, not really) as they have their own geographic catchments.
Right, but they're able to be audited against each other, even though they have separate geographic catchments. Significant discrepancies can be then analyzed.
Folks who view single-payer as a system without checks need to know how those checks do in fact occur.
There's a balance though. A huge bureaucracy to stop all fraud is expensive and cumbersome. There's going to be an acceptable level of fraud in order to keep the administration costs of the system in check.
Other countries have figured this out. The US could use the experience of our allies that already have systems that are working to design a system for us.
As an Australian I always struggle with the idea that healthcare would cost money above a couple of dollars for things that aren't essential.
But almost every American I've ever spoken to who hasn't experienced decent national healthcare seem to have a bizzare view that "if it's free then obviously it will be abused", not realising that it's just as open to abuse as a system where end customer are also involved because shockingly customers arent usually the ones committing the fraud.
It genuinely feels like theres a view that some people might not "deserve" healthcare, and the way we determine who "deserves" healthcare is not the very humane "well they need it, therefore they deserve it" but rather "capitalism. Definitely the answer."
Makes me a little sad, but I guess when you have nothing else to compare it to...
There is a massive propaganda machine pushing against any sort of universal health care here. The idea that not everyone deserves care is definitely one of the angles they push. Another angle is that socialized medicine is garbage, a view which tends to confuse people who have lived with it.
The concept of abuse seems hilarious. What abuse? That people might visit their local doctor more frequently? That's a good thing! Many ailments get more expensive to treat the longer they are left untreated.
Once you come to terms with the fact it's permanently cheap/free, the psychological incentive to be wasteful ("use it or lose it") disappears completely. By comparison the American capitalist health system continually reinforces the notion that healthcare has monetary value, which means failing to take advantage of it feels wasteful.
The concept of abuse seems hilarious. What abuse? That people might visit their local doctor more frequently? That's a good thing!
In the UK A&E is flooded with people with minor ailments that could have been treated at home with a first aid kit, or people who are just drunk. The system is definitely taken for granted. People even call ambulances for a ride to an appointment, not even an emergency.
Source: once spent 5 hours waiting to be seen in A&E, sitting on a plastic chair with a broken leg, while kids with grazed knees and people with minor colds were seen before me. If I needed the bathroom or a glass of water, I had to get up and hobble there on my broken leg. The NHS were great once I actually got seen, but they are swamped with idiots demanding unnecessary medical attention, because it's free.
Sounds like NHS could open more local surgeries and save a lot of money. Or at the very least, add a wing to every A&E to allow stupid stuff to be handled by nurses and trainees.
In Australia, ambulance rides are not free unless you have a membership plan or private insurance.
It is absurd that the UK could not at minimum issue fines against abuse of ambulances. (Not to mention abuse of 999 calls!) The fact that this was an issue for more than five minutes is absurd and cannot be used as an indictment against public systems.
And even if the ambulance issue was unsolvable (ha!) it would still represent a fraction of a percentage of the waste occurring in the American system.
he fact that this was an issue for more than five minutes is absurd and cannot be used as an indictment against public systems.
We also have issues with prescription abuse, such as people getting prescriptions filled who no longer need them, and don't take them anyway. The NHS tried to fix this by printing the real cost of the drug on the label, so people would be aware of the waste. But they had to stop because it was making people who genuinely needed the drugs feel guilty about how much it was costing. No easy answers to this, but something will need to happen because as I say, it is simply taken for granted by so many people.
Unfortunately, the NHS is something of a "sacred cow", any criticism no matter how evidence based of it is seen as a heinous blasphemy. Which means its problems are always brushed under the carpet and will never be fixed. "The envy of the world", we're told, but I doubt the French or the Germans or the Canadians or the Japanese or any number of other nations are envious of it!
Also UK. Some 'abuse' of A&E happens because people cannot alway get access to a local surgery as opposed to driving to a nearby hospital, especially at weekends.
I had half of my face stop working and had recently moved (and not yet registered with a new GP.)
I went to my previous GP and they turned me away (no longer in the catchment area) so I eventually ended up in A&E.
It doesn't help that the local ones near me at the time seem to live in the past... No call queuing or online scheduling, have to call within a 1 hour slot for appointments (so that's an hour of busy tones, oh well let's try again tomorrow)
Surely you should be allowed to visit any GP anywhere
A GP practice is a private business, usually all the GPs are partners just as lawyers or accountants would be, and the staff such as receptionists are not NHS employees, they work for the practice. If they can't bill the NHS for their services because you're not on their books, they aren't interested. It is surprising perhaps, but many people in the UK are unaware of this, they think the GPs surgery is directly a branch of the main NHS, and get angry about "privatisation" without realising that GPs have always been private.
Right, but why are private practices artificially limited for whom they can bill the NHS? That seems like pointless, unnecessary bureaucracy that comes back to bite them with more A&E visits.
I'm guessing because each one is only set up to bill a particular NHS Trust? But you're right, it should be possible keyed just off an NI number or something.
There is a hospital in my town but it's A&E was closed in 2007 IIRC, so if you can't see a GP you can't even go there, you have to drive a couple of towns over.
If you're inside the catchment area it's very difficult for the GP to not register you. GPs are expected to provide service to almost anyone living in their region.
If you're outside the catchment area the GP can chose to offer full service; offer limited service; or offer no service.
The full service includes things like home visits, so it's not surprising that GPs seek to limit that to patients who live far away.
For people who are travelling there are temporary registrations, but also GP walk in centres and GP out-of-hours services.
I once did an experiment: I tried to get an appointment at a local clinic.
(Note: This anecdote was ~15 years ago. Things seem better now.)
Having failed to get an appointment the normal way, because they didn't have any slots available, I decided to test a theory.
I woke before 8pm and continuously dialled during the time slot from 8am-9am when it was, theoretically, possible to book an appointment. I'd wait for the busy tone, then immediately hang up and dial again. For an hour.
I did not get past the busy tone for the first 2 weeks.
After 9am I'd get through, and they told me there we no bookings available and I would need to call back the next day, and they recommended I call between 8am-9am...
In the end I got an appointment but it took 2 weeks and literally hundreds of call attempts to get one.
Apparently this was because the clinics keep statistics on how long people have to wait between making an appointment and attending.
To keep this number down, they set a limit on how far an advance it's possible to book an appointment.
Unfortunately, it had the side effect of preventing people from making appointments when all slots within the limit were filled.
The _true_ waiting time was therefore grossly hidden from reported statistics. And for many, it was enough to make them give up trying to get an appointment at all, further distorting the reported figures.
It took quite a long time before government, which had set the reporting requirements, learned how they were having the opposite of the intended effect.
I also recall that a lot of local clinics one would normally go to end up closing thanks to lower funding... so, let's fund more walk-in clinics around?
Epic is often compared to Salesforce, which is to say even if there is a better localized app for a specialty (of which there are many in healthcare), the next questions are: How do integrate this into the other apps, how does it get into the record, how can people in other specialties receive information downstream to act appropriately from medical side to billing side. Then there's the last non-app part, what is the cost structure, what are the hardware requirements, who's going to watch it when it goes down, what disaster recovery strategies are available, what downtime-protocols should be followed when it goes down and up, who can I call when there's a problem I need fixed now, and finally who out there is already using it and demonstrated success with it?
I used to work at Epic and have seen in the field the requirements the immediate people need as I listed above. Billing driven documentation is an accurate way to label it. The software is implemented to maximize revenue for the hospitals and organizations, without reliable targeted information coverage agencies won't pay for what was supposedly done. There are whole teams in health care and applications from suites like Epic for such teams just for refining billing. A physician knows what they are ordering for a patient, a temp worker downstream refining billing data doesn't, therefore prioritizing accurate data from the physician will result in better likelihood of obtaining claims downstream. That however competes with the immediate need of the patient.
> There are whole teams in health care and applications from suites like Epic ... just for refining billing.
To anyone interested in AI in healthcare, I suspect that datasets of procedure and diagnosis billing codes could be some of the most accurate and immediately usable of their size.
Standards like SMART-on-FHIR [1] and CDS Hooks [2] have the potential to allow innovation developed outside of Epic and Cerner inside of those products. Both of those vendors even have "App Stores" [3] [4]. So far, though, there aren't a lot of apps in these stores, and none of my doctors (all of whom work for large academic medical centers and use Epic) have access to any third-party apps - so I do wonder whether the vendors (or their customers) may be putting up roadblocks that are slowing adoption.
Epic, Cerner, and their major competitors are actually a lot more open now and no longer putting up major roadblocks. The real roadblocks appear to be in the hospital and clinic IT departments. They have to upgrade to a current version of the EHR which supports SMART on FHIR (many organizations are several versions behind) and then enable the app store feature. Some organizations have concerns about using third-party apps due to training requirements, security, and malpractice liability.
I do think that SMART on FHIR makes it easier to turn clinicians into software developers, so hopefully that will spur some innovative apps.
It also helps to have them as a conduit for your communications to other doctors. It’s sad that you have to pay someone a lot to (partly) forward your emails, but it works.
If responding to internal emails had a billing code, I think they would fight over who gets to respond.
I work in the public sector of Denmark, and I’d recommend doing this. The companies who hire actual domain knowledge and listens to it are simply miles ahead on making software that doesn’t suck for the end-users.
It would be better if we allowed departments to build their own software, because our in-house software is honestly the only stuff that truly does the job right, but I don’t see that being prioritised. So having contractors hire a few doctors is probably the best we get.
Exactly.. short of the parent company of a hospital also owning a software company for the software this likely won't happen. Even then, software engineers RARELY get to interact with the people using said software for any meaningful time... It's usually meetings with your PM, Manager, their manager, and maybe the same on the other side. That's like 3-6 layers of separation in this telephone game.
> For startups that want to sell to health systems and similar-sized/larger entities (...), you unfortunately have to focus on the buyer, which is very rarely someone who is "in the trenches."
This is my current experience. The person bankrolling the project delivers lists of requirements, and nearly half of them end up being removed later when someone "in the trenches" either says they don't need/want it or it's too confusing of a feature.
Another part of the problem? "Confusing features" for doctors includes some very standard app features, like back buttons and refresh buttons. This honestly frightens me. We had to remove the back button -- which was requested by the buyer -- because it became a patient safety issue.
It’s true that Epic and Cerner are the dominant players when it comes to hospital EMRs, but they have less of an influence in outpatient settings outside of academic medical centers.
For larger outpatient practices that are participating in value based programs (ACOs, care bundles, etc.), such as the type apple amazon or google may choose to work with or, less likely, build, there’s less of a need to rely existing EHR vendors and a greater likelihood to rely on a variety of tools that are able to interact with each other.
The trend is for more and more care to move outpatient. There’s opportunity for innovation there.
I am an orthopedic surgeon during the day and at night I write code. I just don't believe that spending a few hours watching surgery actually helps. You need to really work with the software, a solve daily problems and be aware of what problems are trivial software fixes.
For instance, when I sign lab results I get to see the references for twenty year old subjects. It would be much more helpful to see the patients last lab result (in 60+% of the cases this is available).
Another example is in the ER where we have a list of all the patients. There is a column for my name so that I know which cases I am handling, unfortunately that column is too the far right and only visible after resizing the other columns. This setting is also not saved so each time I open the list I have to resize over and over again. If you could move that column to the left would be great, or even just bold font my patients' name.
The major problem that I see is that we have:
- huge monolithic software that make any change a living nightmare
- all changes are treated as we were doing open heart surgery. Most stuff we do is trivial but having a standard that high makes it almost impossible to deploy updates - especially the minor changes that really would change things.
- 80% of users complain about the software but very few understand the underlying problem.
- much of our software is spec driven - I can sign my lab results and I can see the patients in the ER, no one bothered to add the last tweaks to actually make it easy.
All that you mention points to lack of proper UX design process as part of SDLC. Observation is part this process, it is important and better not to be skipped, because it can provide very useful insights, but it’s just a single stage of research - there are more techniques and methods to solve problems that you mention.
Yes, there have been numerous people pointing out this in this thread. I think that UX design is viewed as frosting on the cake instead of the thing that actually makes it work. Unfortunately I think one of the issues is that the SDLC is broken.
For some reason we keep getting features that few of us actually requested but that often make sense in that they are life saving, that is if people actually used them. I have a ton of indicators flashing all-over the place and after a while your brain simply adapts and ignores them. I doubt that anyone has actually done any analysis to see if these tools actually save lives.
I've been involved in some projects when I've spent 30 minutes with UX people and then never heard back from them. When the final product arrives it is full of annoying flaws, e.g. the latest software I was involved in the work flow is:
1. click on "open software" from the patient chart
2. a new window opens where I manually have to click on "log in" (note, I'm not adding a password)
3. the UI goes into authentication
4. the UI goes back to the login screen
5. the UI asks me a question that I _always_ answer the same thing to
6. I actually get to the data I was interested in
The most annoying part is number 4 - if I accidentally click on "log in" everything breaks and I have to close the window and redo everything from start.
Most of these UX issues fall under the category - murder by a thousand cuts. It is mentally tiring to be faced with all these issues but none of them is like open heart surgery where one mistake can be fatal. What happens is that doctors/nurses become tired and don't put the effort into the patient interaction where the actual value in healthcare is created. I'm pretty sure that bad UX in the end kills many more patients through this than malfunctioning critical hardware.
I truly wish that people in this forum that create health-care software think of UX and actually use their software more than just "I clicked through and everything works". Your bosses will probably never ask for UX features because they have a deadline, but you are in charge of designing and during that process it is easy to fix many of these annoyances (e.g. just disable the log in button).
Epic and Cerner have been around since before UX and SDLC were common parlance, so their software and processes are likely locked into what we consider bad practices today.
Healthcare software exists in a weird trap where it can't move too quickly because hospitals are resistant to change, but it's software, and the software world normally moves quickly (including things around software like UX and SDLC concepts and ideas).
Simultaneously, hospitals can be slow getting off of deprecated platforms because of dysfunctional IT leadership, bad budgeting, and staff that can't or don't want to learn new software.
I am biased, but I spent almost half a decade building/designing systems for Healthcare. I had direct interaction with the users, the vendors and the actual go-live planning for a number of facilities.
Healthcare has a lot of issues, EPIC was a stone-walling garden, Siemens wanted to steal stuff, OpenVista was a non starter, Philips talked a big talk but never followed through, Not everyone was truly HL7 compliant, Users didnt believe on Apps on the iphone/ipod-touch as the screens were too small and the average age of users was ~57, The number of employees in a large hospital is in the thousands, Patient Entertainment systems were snake-oil-jokes, "medical grade" devices were a fraud, and selling into them at this time was a unique process for every hospital -- and while the users (clinical staff) really really want to (and do) provide good care, training 1,000+ Staff/Nurses on your new tech is very daunting.
Obviously we have made a ton of progress in tech in healthcare, but finding a way to consume more time with staff/processes can be a difficult problem to figure out access.
Silicon valley needs an actual research hospital for tech - if I were throwing my billionaire last name on SFGH/UCSF/Oakland etc's hospitals - I'd do a lot more than just buying the name of the building - seeking how to work together to make an SV research hospital happen in an innovative way.
(We had a fully integrated HL7 iphone app which could interact with OpenVista, and other systems like Vocera and Philips and Siemens systems. We had a channel to work with hospitals around here but the screen size and costs of providing handhelds to nurses were too high for 2007. YC Turned us down, Epic and Cerner would allow integrations... We opensourced it to Openvista.)
I think eventually we'll have to sidestep most of this fraud entirely by enabling self-serve early diagnostics and cranking up the doctor-replacing technologies to the max. Machines are good at recognizing patterns in non-adversarial environments not starved for compute. There's every possibility that they could do diagnostics better than a human could. Treatment will be up to human doctors for the foreseeable future, though.
Too bad Theranos salted the earth for much of this innovation for the next decade. But it's still happening, starting with EKG and ultrasound.
>But it's still happening, starting with EKG and ultrasound.
Whole-body ultrasound? How would an AI understand how to interpret images with low signal:noise? Who will be performing the actual ultrasound image capture? Who will be ordering the imaging tests? How will an AI understand a patient that can't meaningfully interact with an AI?
What's the utility of "EKG" [sic] for diagnosing non-cardiac problems? Or, do you come from the perspective that all medical problems can be diagnosed with an ECG, urine analysis, ultrasound (of what?), blood test, and CT scan? Do you realize that an ECG is more complex than a single vector ECG via Kardia mobile?
I thought we were trying to reduce healthcare costs, but you're recommending over-utilization of expensive diagnostics?
Why are you limiting treatment to doctors only, why not have AI do everything?
Everything you've written demonstrates an extremely limited understanding of the practice of medicine, a characteristic far too common shared by those who are trying to "disrupt" medicine.
The fact of the matter is that an ECG and an EKG are the exact same thing. That’s right, the most surprising difference between an ECG and an EKG is that there is no difference at all. Both ECG and EKG stand for electrocardiogram.
So, if an ECG is the same thing as an EKG, then why are there two different abbreviations? It’s actually quite simple—when the word electrocardiogram is translated into the German language, it is spelled Elektro-kardiographie. EKG is just the way some people choose to say ECG based on this translation.
EKG also avoids confusing patients. ECG and EEG are a little to close to each other. And don't get me started on explaining what EGG is when you already have ECG and EEG to worry about.
Sure, I realize there's much that the current tech does not cover. But you gotta start somewhere, and through extremely wide deployment tens of thousands of lives will be saved, and important feedback will be collected to improve products. $400 watch that does a dozen other things and that the user would buy even if it didn't have ECG is not "expensive diagnostics".
This is where things are at, whether you like it or not, especially for the working poor who can't afford to fork over a few hundred dollars every time something feels "off". The current crop of devices is not affordable to them, but 5-10 years from now they'll be bundled in cereal boxes. Hook up sensors to wearables, catch diseases early and at a massive scale, cure or treat them before they get extremely expensive. To me it looks like it's the only way out of the ripoff "healthcare" scheme we're in right now. I'm pretty convinced the solution to the US healthcare problem will be technological in nature.
And don't tell me universal healthcare will fix things. It won't, because US doctors (unlike their counterparts elsewhere) expect to be earning a pretty penny after they go through the trouble (and expense) of educating themselves for a decade, and that's not going to change. There simply needs to be less demand for doctors, and the ones that remain should be able to use their time efficiently.
>This is where things are at, whether you like it or not, especially for the working poor who can't afford to fork over a few hundred dollars every time something feels "off".
But you think they'll fork over hundreds of dollars for misguided tech toys that won't even address their actual medical problem?
>Hook up sensors to wearables, catch diseases early and at a massive scale, cure or treat them before they get extremely expensive.
Which diseases are you talking about? Hypertension? Diabetes? Obesity? Smoking? You don't need fancy medical toys to diagnose these problems, yet they're responsible for most morbidity.
Do you think a medical toy will somehow detect cancer? How exactly do you think this would work? Someone feels "off" one day so they plug in a "device"... ECG? Ultrasound? Urine analysis?
>To me it looks like it's the only way out of the ripoff "healthcare" scheme we're in right now.
The ripoff isn't from physicians practicing medicine, it's from outsiders who interfere with the patient-physician relationship to get their slice of the pie, ie insurance companies, healthcare MBAs, device manufacturers, pharmaceutical companies. You think tech will replace physicians, but it's obvious you're completely misguided regarding the actual source of problems in healthcare.
Smart/Self-serving diagnostic tools occasionally fail for legal feasibility reasons before they are adopted by the market. Consider a smart heart monitoring system, maybe connected to a canary that will alert a healthcare professional or first responders if something is amiss. Absolutely nobody wants to be liable for misdiagnosing acute symptoms, which may lead to death or false positives.
It doesn't even have to be acute symptoms, either. A large healthcare company a friend worked at was working on a smart heart monitor that for some reason they wanted to connect to an app. In their head, the app would be used by both the patient and their doctor who would check on the patient. If they have a lot of patients, that's an overwhelming amount of data streaming in 24/7. The time commitment to really evaluate those data for anomalies was too high, as were the stakes. Doctors were scared that if they missed something they might be held liable for unrelated medical emergencies which is terrifying for them. At the time, algorithms were really not good enough to catch the really subtle markers of an impending medical problem. At least according to the guy that told me this, he was a biomed/hardware engineer not a programmer or statistician by any means.
Even if you had some legalese associated with the product to make this a non-issue, doctors still wouldn't trust the idea. So they pivoted the technology to something else that was more traditional. It is much harder to pursue justice for an algorithm than a human. I guess what I want to get at here is: sometimes the software and hardware are working as intended, but subtleties can be lost on the technical side (programmers, biomed engineers) can kill a product. Stuff like market research, liability and legality, and public perception of the tech.
Sure, there will be cases where your device will say "I'm at a loss here, go see a doctor". The point is, right now the majority of (very expensive!) doctor visits are a total waste of everyone's time, and your money.
There's no rational reason why I need to drive to a lab for bloodwork or simple diagnostics, and have a human do it: a robot at a local convenience store should be able to do the job. There's no rational reason why I need a doctor to misdiagnose my elbow pain as something requiring surgical intervention (I just stopped using my laptop in bed and it went away). Another doctor ordered a ($900) MRI to diagnose pain in my left shoulder and then told me I have a SLAP tear there based on extremely blurry results (again $$$$, surgical intervention, and 6 months of recovery). Bullshit, bud, I don't - it's a non-dominant arm, and I'm someone who doesn't do a lot of throwing or work above shoulder level. It was that dang laptop in bed again. Someone with weaker critical thinking skills and google-fu would be thousands of dollars poorer thanks to taking that doctor's "advice". In fact they could end up with a permanently fucked up shoulder and elbow, too.
Did you know that medical errors are the third leading cause of death in the US, right after heart attack and cancer? Seems to me that "human" doctors are also a dangerous proposition.
>The point is, right now the majority of (very expensive!) doctor visits are a total waste of everyone's time, and your money.
Honestly, what are you talking about? A doctor's visit costs between $0 and $150, depending on insurance/government, and it is a focused encounter to determine the source of a medical complaint and a most likely effective treatment for that problem.
You want to stick a one-lead ECG on someone and expect that it's supposed to spit out a diagnosis, or heaven forbid, a recommendation to see a doctor who can actually figure out how to diagnose and treat the patient.
Your statement in fact points to the uselessness of this proposed medical device if it can't actually figure out what's going on and instead will send you to an actual expert (physician). How reliable would it be for everything else it "diagnoses"?
You haven't come up with a single situation where a non-cardiac medical problem can be diagnosed solely with a handheld single vector ECG.
You don't mention anything about false positives or false negatives, sensitivity, specificity, pathophysiology, anatomy, pharmacology, diagnostics, or medical decision making.
You have no understanding of how your magical tech device would bridge every aspect of the practice of medicine, but you make an audacious claim with a bit of hand waving, saying "this will work better than physicians, and cost far less".
>Did you know that medical errors are the third leading cause of death in the US, right after heart attack and cancer? Seems to me that "human" doctors are also a dangerous proposition.
Where's your citation?
Here's what the CDC says about leading causes of death:
Attributing death to a medical error instead of the underlying condition that would have been the cause of death anyway is missing the forest through the trees.
If you go into the hospital because you have stage IV colon cancer, and you die because a palliative surgery resulted in infection, you died because of the colon cancer, not the infection.
We had a fully integrated HL7 iphone app which could interact with OpenVista, and other systems like Vocera and Philips and Siemens systems.
So you were attempting to provide charting capabilities on the first generation iPhone? Honestly even now with larger screens, etc I can't imagine that working well on anything smaller than a tablet, and HL7 would only be a selling point to potential partners or investors - 90+% of potential end users wouldn't have a clue about it. You might as well say "our app supports JSON and EDI!"
In 2007 that would have been a dancing bear - amazing to see, but not because of how well it dances.
WEll - we had an ESB appliance which would tie into the various HL7 capable systems such that we could integrate for certain services, and provide interfaces/applications which turned an ipod touch into a quick duty/assignment/nurse-call/alert/control device.
Basically the intention was initially to integrate the ipod touch as effective a remote to the hospital.
Tie in with RTLS, assignments, results, orders...
So, yeah - it worked pretty well. Had support from nurses and doctors, but it was too early...
We were told by too many people it was too expensive and too small and nobody would want to interact on the phone.
We knew the ipad was coming... but failed to convince people.
About two years afterward, the iPad came out - we had already folded and released what did open source to OpenVista, and then Dr. Chrono was able to get traction where we couldnt.
They had told us that they wanted to integrate with us - then they expressed interest in buying us and had us come in for several meetings with their tech staff so they could ostensibly perform some due diligence - and had us go through our arch and demo for them and explain the vision and the features we had - claiming that they'd be forthcoming with an offer... then ghosted us after and it became clear they were then trying to create their own system based on our archtecture and what we shared with them.
Recall that scene from (was it silicon valley) where they did the whole thing on the whiteboard at the VC - where they stole the idea from there... yeah that happened to us.
We did, but Ascom were generally viewed as being ugly and the "blackberry" of handsets, and had their own issues. I can't recall the details too clearly now - but I think at that time, Vocera was also the new sexiness in the market and so most hospitals were going Vocera.
I worked a tiny bit over a year around 2013 at a hospital network and was on a team that maintained custom integrations with Cerner, an EHR system.
It was by far one of the coziest jobs I ever had. Low stress environment, redundant meetings, etc. But development of any kind of god awful. It was extremely sluggish, lots of red type, and seemed to follow a manual QA approach over any sort of automated testing. Things were just too lax in general.
Myself and another junior developer left after we noticed that an intermediate engineer on our time hadn't committed in over 3 months.
My point of this story is that hospitals didn't seem to attract/retain passionate software developers. With high turnover or apathetic developers, most software built custom for hospitals is probably Frankensteined.
Agreed, this mirrors my experience in healthcare. Hospitals pay the highest amount of money, for the lowest quality of software (regardless of whether developed internal, or purchased through healthcare software vendors).
The jobs are easy, and you can go months without doing any real work whatsoever. The company might not even care (since for hospitals, sales cycles are often measured in years, and minor upgrade cycles are often measured in months).
But this kills any desire to do anything. Almost no developer with any motivation or skills, wants to work somewhere where they do nothing useful and have no real work to do -- even if the pay is good, you can literally feel your brain rot out, and you start to be worried you'll never get hired at a "real job" ever again.
This was my experience in government work too. For every three engineers that accomplished nothing, there was one doing real work. Most good engineers would work there for 6 months or less and then flee in boredom or fear of not finding work at a "real job" again. The good engineers that stayed often found a niche they really liked, and were worshipped as rock stars by management and stakeholders, so they were pretty happy.
More time? I wish I was given _any_ time with my users so I could actually understand what features would make their lives easier. I actually did get to spend about two hours with some actual users of my software a month ago and I noticed that they were scrolling up and down a lot. I asked if it would make their workflow quicker if I made the save button float in the lower-right corner of the browser (I.e. position: fixed). They said, “you can do that? Oh my God, that would be amazing!” It took two seconds of CSS and has saved them hours already.
The problem is that it may take 2 seconds of CSS, but it is a software change that then requires the product to be revalidated, along with the matching paperwork (functional design doc, software design, technical design, customer support documentation and training material) and validation evidence to be submitted to your official document control system. And this process can take days, weeks, or months, depending on how complicated (due to extreme CYA) your compliance department makes the process. And the company compliance folks want to go overboard as they want to make sure the FDA auditors are happy the next time there is a surprise audit.
Oh absolutely - it was as simple as a fix can be, given (perfectly legitimate) quality control concerns, but it never would have happened if I hadn’t had a rare opportunity to actually observe how they work.
When I was developing internal software at a big company, I went to observe some actual users at the company. (I thought what we were building didn't make sense, so I wanted to see if they actually used it that way.) I got a tongue lashing from management for that one! "You're a developer. You're not supposed to talk to users."
The entire project, of course, was eventually cancelled.
I see that a lot too. There are a lot of well-paid managers whose only role is to be middlemen between engineers, customers and other departments and they protect that role jealously.
I agree that some developer probably shouldn't be talking to customers but overall they should. I have had many occasions where we received a spec and after discussion with users quickly saw how we could meet their needs in a much simpler way than the middlemen had come up with.
The entire project, of course, was eventually cancelled
Been there, done that. Once spent months working on a project but when I finally got to talk to the users they told me it didn’t do what they wanted and even if it did they wouldn’t change their working practices (union rules maybe?)
At the end of the year the manager who had assigned me this project dinged me on my appraisal for not having delivered it.
I once was in a position where I could observe, and I can confirm that:
> the most powerful method of requirements gathering was observation.
But the vast majority of my time has been at companies where engineers are never cleared to travel to meet with customers and gather information. It's insanity IMHO. It was the one bright spot about doing contract wor.
The problem though is that university curriculum hasn't caught up with the reality yet which is a role called 'Product Manager'. While I was in college there was a mention of 'System Analysts' whose job was roughly matched that of product managers of today.
In general though, I doubt any reasonably sized company will let engineers gather requirements. The divide between product manager and engineer has only hardened over last few years or so.
My neighbor’s son is a doctor who needed some software written. He learned to write the software and now runs a software business (in addition to being a doctor). I guess it was easier than trying to bring developers in. Ive seen the same thing with a pilot who learned programming to write an incident management system for airlines. Only once the software was successful did he seek advice from ‘professionals’. Learning to code is not the deepest skill around.
Healthcare has lots of low-hanging fruit that's solved by simple CRUD apps, and those can be reasonably maintainable (and secure) if you build it using easy frameworks and well-known patterns that are commonly found in tutorials lying about the internet.
It'll be so simple that it's equally maintainable.
The real issue is adoption, but that's expedited if you're a doctor who's also a software developer and makes it easier to sell.
In each of these cases the successful professional was able to pay people to maintain and improve the software after they’d proven the code enough to make it pay for itself many times over. That’s a real mark of “maintainable” and is outside the thinking of most programmers.
One of the things that worries me about the not quite professional developing software of this nature is does it actually follow the regulations and restrictions that medical software needs to follow. HIPAA is not an easy thing to navigate and has deep implications on how data itself is stored.
As a semi retired software engineer and currently 4th year Med student, I still maintain a dream of building a usable EHR that puts the clinical, patient-focused side of things first. Currently implementations allow for increased billing recovery, but at a cost to both doctors and patients.
I just don’t know how you’d start in competing with something like Epic or Cerner, from a business side of things.
Speaking as someone still working at a big non-epic/cerner EHR company-that-might-have-just-gone-private: it's not easy. When the money is controlled by large insurers who care about government and billing minutiae, and big hospital/health-care groups choose which software solutions to use, it's an uphill battle to make stuff that is really, truly patient centric.
Everyone I work with cares really strongly about making a really good product. We have great designers/UXers, a lot of experience in building different pieces of the workflows that tens of thousands of doctors and hundreds of thousands of nurses, MA, PAs, front-office staff _and_ patients, but when you spend a whole year readying for ICD-10 and then some yokels in DC push the deadline back a year... I belabor my point.
Engineers wanting to start a health care company should try working for a big EHR company first. Then go start somewhere else using modern technology, modern development practices with just a little more wisdom. Maybe.
Epic lets you change provider context to Emergency department, internal medicine, etc. I think they just need to make the provider context suck a whole lot less. Epic Haiku (mobile) is a pathetic joke as well. Nevermind, I think you're right actually, the whole thing needs to be burned to the ground and built completely different. The only thing Epic has going for it is that it's not Cerner.
I worked for a little bit with these guys on this product called phrHero which focuses on making these EHRs more much more patient-friendly using the new FHIR protocol. https://www.phrhero.com/
I don't work with them anymore due to some fundamental differences (it's been almost a couple of years) but thought it was related to what you're talking about and possibly something you'd be interested in.
Possibly the only way you could compete with Epic or Cerner is to innovate on things in a way that can't be denied. It wouldn't be the first time slow giant companies fall because they did not advance, but it is much harder because the barrier to entry is absolutely enormous.
Dont beat them, join em. Build a solution to a problem and integrate it into one of their html5 modules. Both systems offer breadth, not depth when it comes to solving problems.
Healthcare is a heavily regulated industry and as such only large companies are able to successfully navigate the bureaucracy. The only way to usurp coercive monopolies is by creatively destroying it (e.g. uber)
It's more nuanced than that. I've spent 13 years working for two successful healthcare/biotech companies, both having attained FDA clearance (one class I and two class III devices) while I was there. I was brought on as the 21st employee and then the 17th employee. At no time could these have ever been considered large companies.
Products like LIMS and hospital systems are hard to replace because of vendor lock in and the cost to replace it all, not regulatory hurdles.
The regulatory requirements for security and interoperability are all things that every EHR vendor ought to be doing anyway. Regulations aren't a significant obstacle to new market entrants.
One of my previous professional experience was working for a company that delivered a complete hospital information system that was used in two of the biggest health institutions in the Middle East.
Initial software development was done offsite, but then, the owner and CTO of the company thought it more wise to bring in the developers on-site. On-site here meant that our team was provided an actual area in the hospital where we were given freedom to observe, collect and synthesize as much information related to the system we were building.
One major challenge we faced was that, for example, we have three doctors all specializing in the same category, i.e. cardiologist. All of them would have different ways of wanting how the technology will support their process. One would want information laid out in a different manner, with quicker access to other information he need from other facets of the system. There's just no way to standardize a specific process. This lead to us delivering solutions that allow the doctors to customize as much as they can of the application based off their preferred procedures.
Being there in the hospital itself I would say has tremendously helped the team deliver a lot of innovative functionality that I have still yet to see at this day and age. I was interfacing HL7 data with Siemens and GE Radiology and providing the doctors to automatically perform dictation through Philips Dictaphone - where the recording is sent to an offshore transcription company in Asia, and the data returned and tied to the actual radiology exam it is designated for - all under intense security, compliance, and anonymity.
I've also observed through working in different hospitals, there is a lot of variations in the workflows, hence the necessity for engineers to actually be present and on-site. This provides the developers a real-world picturesque view of what needs to be built that will make every hospital staff (doctors, nurses, aides) become very productive.
A problem with so many local customizations becomes apparent when it’s upgrade time. You must do several X the testing and there’s a higher risk of something breaking.
Maybe we need a profession, you know, people who create experiences ... maybe we can call them 'UX designers' or 'UI designers' or something. Where they investigate how people use and relate to information before the Engineers build stuff.
Jakob Nielsen was writing for decades now that the first job of an interface designer is to sit down with future users and see how they do their work. (Always users, more than one.)
It doesn't take years of experience in the target field. It just takes hours of watching and listening and figuring out what people are actually trying to do.
I am familiar with Jakob Nielsen's writings, and I stand by my statement. Effective UX design in the medical field takes years of experience. It's far more complex than most other business domains because every medical specialty has different requirements and there are so many edge cases. No one is capable of learning that stuff in a few hours.
But, for companies that can't/won't (I consulted for one that wouldn't even hire professional BAs - they expected line staff to write the specs)... at least have the PMs and programmers go spend several hours in the client's dept. (around month-end is usually good) to get a feel for how things actually work.
I have often wondered if it would be better to just hire professional data entry people to follow the doctor around and enter all the information into the system. Does it really make sense paying someone $500K a year to peck and tap into a EHR?
> I have often wondered if it would be better to just hire professional data entry people to follow the doctor around and enter all the information into the system.
Those data people are called "medical scribes," my doctor has started using one. Seems like they're mostly pre-med college students looking to get exposure to healthcare environments.
They even have eScribes from foreign countries through video chat. One of my doctors has one from the Phillipines which was familiar with his very uncommon EMR. The scribe company gave him an iPad to video chat.
> Sounds ideal - they can even remind the doctors to wash their hands before touching the patient.
I don't think doctors (or anyone else for that matter) is going to tolerate being followed around by an assistant who's going to nag them about how to do their job.
Hiring a medical assistant to effectively take dictation and record things in the EMR happens, but far more common are voice recognition systems and templating (which leads to its own set of issues). Long additional hours charting are another thing that happens - most doctors I know seem to spend at least a couple extra hours charting, dealing with labs, etc after they've seen their last patients for the day.
With any of these tech inroads into non-tech fields, the issue is always communicating to the non-tech people that your solution has value, and not developing the tech solution itself. If you're a salesman walking into a person's house, telling them they live their life wrong, and your (expensive) solution will fix it, good luck with that.
It also doesn’t help that to break into this market you have to overcome years of customization and millions upon millions of dollars in sunk costs that management isn’t likely to throw out for something that “works better for clinicians.” Not to mention the cost of retraining entire hospitals worth of staff to use the new system.
So true. After over 30 years as a programmer, I recently switched to being a nurse in a hospital where half the day (it seems) is spent charting in the very old DOS legacy charting system. No one would write a system like that today, but with thousands of people muscle-memory trained on the old system, what reasonable argument could be made for a change?
The issues the NHS has with IT (with the glaring exception of WannaCry) are related to the vast fortunes they expend with outsourcing companies for custom software that doesn’t work. Doing the same thing but on Ubuntu won’t be any better. But the engineers don’t care, they have an ideological axe to grind so they focus on something irrelevant.
Example of a more general problem: developers not understanding the business domain. Developers often blame “poor requirements” for schedule and budget overruns, but they didn’t spend any time learning the business domain.
If you do learn the business, you have to explain to management why you wasted all that time. You cant say your application is cheaper in user errors, downtime, maintenance, licences, change requests etc... as that would mean all the other expensive software is garbage.
Domain expertise is not wasted time. It makes the difference between a useful application and a pile of code. Developers should not assume they know more about a business domain than the people working in it.
Ideally. When I started as a programmer companies had business analysts who had domain expertise and made sure software mapped to the domain and actual users. Now we have PMs, usually glorified project managers, too often with little or no domain expertise or technical understanding. I freelance so I don’t have PMs or analysts, I have to learn the domain and deal with the management/client/users directly.
Yes, but I don't think it's wise or effective to put the onus all on a PM. As a dev, we often can have great insights into how much work/effort/maintainability one feature or another is, and having a rough knowledge of the business domain allows us to make much better recommendations regarding what we should do.
Additionally, in my experience the best engineers have been part product manager anyway, just as the best product managers have been part engineers.
tacit knowledge especially in an hands-on field like medicine where patients are involved cannot be conveyed by a manager with a power point presentation.
This compartmentalisation in the name of efficiency is actively harmful. Developers should get out more and get first hand experience of the environments they develop software for.
Could not agree more. It's a bit like the game of telephone that many of us played as children. The more hops in the connection, the greater ability for knowledge loss and distortion.
I once had a PM tell us to do a feature a certain way, despite engineers saying we thought it was dumb. We shipped and had lots of user complaints, and lost millions of dollars ultimately in lost revenue due to cancellations that we think were at least in part to this. We eventually reversed course but much damage had been done.
Afterward there was a witch hunt (which I staunchly oppose, but I digress). It turned out that the PM had taken the word of another PM who in turn heard from another that had gone on location and misunderstood what the customer was saying. To save a few thousand bucks the company only sent one person and expected them to brief everybody else on their findings. In hindsight I'm sure that skinnier travel budget wasn't so worth it.
To be a true engineer, one should use technology to solve problems. PMs are suppose to help with that, but to be called an engineer, one should have that mindset. Otherwise, we're just code-monkeys.
If a developer is relying only on the product manager without first hand experience. It's a recipe for failure. I am a huge promoter of making devs do CSR, hell even make them do sales calls on occasion. The insight to the end user pain points is important. Devs need to hear it first hand.
Of course there should be people who's primary concern is firguring out what to build, but the buck doesn't stop there.
If you're not solving problems you're just a medoicre code jockey. I want to work with people who build iseful things, not people who stop and understanding syntax and think that code is a goal into itself.
I have yet to work for a company that doesn't value time spent learning the domain. I'm not impkying these places don't exist, but your comment enters the realm of trope (e.g. all managers are spiky haired, know nothing MBA's).
If you work in a place like that, I'm sorry, that sucks.
A lot of startups work this way. A group of people with technical talent but little domain expertise. And they tend to see every problem as a technical problem.
At work we make a program which essentially makes and sends electronic declarations, which fall under government rules and regulations.
I had zero domain knowledge when I joined. However the majority of our support team were hired from our customers, and they know the domain very well. We include them when we need to implement new rule changes and other features, to make sure we don't miss things.
After a few years of working here I of course have a lot more domain knowledge, but it's always helpful to be able to quickly run some questions past someone who knows the domain well should I happen to get some doubt in the middle of coding.
I work on a telemedicine product using Google Glass Enterprise and the current version of our product was shaped greatly from feedback provided by one early user (physician). It really focused our use cases and made the product much better. That being said, optimizing the current medical process will only get you so far. It will probably not result in large disruptive positive changes. Those will have to come from outside the current process.
It will probably not result in large disruptive positive changes. Those will have to come from outside the current process.
Rest assured that anything that makes a significant impact on health will cause people to completely freak out if it hasn't been vetted via the current medical system, even though this vetting process kills a lot of therapies that people then lament that they wish they had access to.
I'm well aware of that. I have a form of cystic fibrosis. I used to be on multiple maintenance drugs. I currently manage my condition with diet and lifestyle and no longer take medication.
I also no longer belong to any CF lists. It's too much drama. I was constantly attacked and, among other things, accused of irresponsibly endangering lives for trying to talk to people about what I found helpful.
Sounds like doctorsplaining. A better idea would be to hire nurses and technicians who spend thousands of hours in the trenches and let them tell you everything that really goes on.
Absolutely. It's vital to listen carefully to users and think broadly and wisely. The programmer must understand what the users have to deal with in order to provide something useful to them. If not, the user will hate the result, it will make them miserable, cost the employer time to redo it and the cost of not being able to do what needs doing (or worse) without software.
tl;dr: get to something most useful soonest by quick, small iterations until it's satisficing. No BDU project fails, and no assumption fails.
I've worked in biomedical informatics IT at a clinical research university. I think it's reasonable to understand what the user's goals and priorities are by going to the point of use, Genchi Genbutsu (現地現物), in order to tailor something to make work processes smoother and better. I wouldn't hold off on assuming anything negative without more listening to understand them.
The only nurses who spend more time behind the computer than doctors are those who are shopping. Unfortunately the doctor profession has turned from patient caregiver to note taker
When I was a programmer at a non software company I would frequently sit with the users and watch how they used the existing software or how they did a task that we were considering creating software to help with. It was a great way to make a useful product right away rather than get back and lot of negative feedback about how it doesn't do what they need or expect if the software was written without that insight.
To what extent is this an exclusively American problem? How much of the health care “tech” opportunity is tied to managing the complicated multi-party bureaucracy of the U.S. system?
The article highlights how docs are spending too much time doing “desktop medicine” related to paperwork and billing. There’s a whole layer of adminstrative staff at every hospital doing this stuff too.
If we get Medicare For All someday, what will the impact be on the healthcare tech startup space?
For example I met someone at a bar the other day whose startup was all about managing medical bills. Consumers can scan their bills and they’ll look for optimizations and payment plans and budgeting or something. This would just go poof under M4A.
I managing projects that specifically integrating Epic data with dozens of clinical healthcare applications, HR data, medications access data as well as provider behavior data to offer security, privacy and unified monitoring capabilities for privacy and compliance officers in healthcare.
It really does helps to “eat our own dog food” and spend time in hospitals.
For example I spent few days in large New York hospital studying operations of secure drug dispensing cabinets before building solution for medications security analytics.
Tons of interesting data with valuable insights on how narcotics are secured and accessed.
This is the Design Thinking approach IDEO pioneered and continues to pursue. It’s also how Apple approached their retail store, for instance, by composing a team made up not just of the designers, but also people who worked in retail on the ground floor and understood the reality of the problem they were solving.
Ideally every developer should have to spend a significant amount of time actually interacting with their customer, and in this case the customers customer. It would give a different perspective about that feature that is being built. It sounded good in a planning meeting and will never be used in the real world.
I'm have the desire to make an attempt of developing a new type of EMR system, putting special focus on the documentation part of things.
Is there any health care practitioner around here with time for a 15-minutes phone interview or willing to exchange a few emails so I can better understand his/her needs?
One issue with software at hospital is that the various departments buy what's best for them, with little regard to interop needs with other departments.
So, admissions, for example, buys what they want, and don't care about the integration with, say, radiology.
Click bait title. Actual title should be: "Doctors are asking Silicon Valley engineers to spend more time in the hospital before building MEDICAL apps"
Software developers are incredibly poor at gathering requirements. The best choice for gathering those requirements is to have a management consultant who does nothing but study business process and document the current clinical process. Once that's documented then you can discuss what needs to change from that document to extract the core requirements. Having a software person shadow a medical professional will only lead to the medical professional telling the software person what they think is needed.
In other words, decouple system analysis from system design.
Software developers are incredibly poor at gathering requirements.
I've had the opposite experience. Good software developers are good at gathering and understanding requirements. The information loss from management consultants and software developers is pretty nasty. Frankly, if the the people coding the system are going off a requirements document that they didn't have a hand in then you might as well outsource the development. If the software developers don't become domain experts then you should be worried about the correctness of the software.
I often wonder if the general dislike of DSLs is caught up in this separation.
> Software developers are incredibly poor at gathering requirements.
Customers are also often incredibly poor at defining their requirements, at least in my experience. Like having undocumented routines which are only recalled by that one employee once they have to actually perform them, once a year or so.
Of course it's usually a really critical, time-sensitive issue when they discover that the routine they never told us about hasn't been implemented and thus cannot be done... almost never fails that.
In the US healthcare system, clinicians and the business often have opposing objectives and values. This is starting to change with value based care becoming more popular, but it's still all about providing what the business wants, it just happens to align with the clinicians more these days. You'll still need to support IE9 due to that botched Vista upgrade, build out a custom EMR integration, and deliver whatever random feature the sales folks promised (can you automatically fax things?) before you can move on to the features that the clinicians actually want.
The system itself is how we ended up with billing-driven documentation EHRs like Epic. Paradoxically, due to massive adoption, I think Epic and Cerner are some of the only places where real innovation could happen. I think even huge companies like Apple, Amazon, and Google will have a hard time breaking into the space, no matter how much cash they throw at it. For them, the only answer is to go fully vertical like Kaiser-Permanente, but I doubt they have the stomach for this.