I worked in health care tech for about 5 years. AI driven before it was cool. Took processes that normally took years down to a couple hours. Cutting edge stuff.
What struck me over the years was the open hostility we faced from the staff. The admins would buy our product, then have us come do trainings. The clinicians seemed to resent every second of it and would just never use the tool.
Towards the end of my tenure there, a PM said to me “the last thing these people want is to have to learn yet another workflow”. Which is when the penny dropped for me that our tool was just one of a bazillion being force fed to these poor people. They want to spend their time with patients not a screen.
Despite it being the most mission driven I have ever felt about a product (we were literally trying to help cure cancer lol). I’ll never work in health care again. Like education, it’s a quagmire.
I work in hospitals and it's just a constant stream from IT of "oh you just figured it out! congratulations! time to change they way you do things! this time we've solved all your problems that you're not complaining about! try to reengineer how to do anything now! lol! we hear you and feel your pain! here read ten pages of drivel that tells you how important and amazing IT is but won't actually tell you how to do anything with the new new tools and lives in some fantasyland that has nothing to do with the work that you actually need to get done!" all while simultaneously making every single computer and workflow somehow slower and more complex. Add another login here... force a quicker logout there... And then admin will come in with "thanks IT! you're doing amazing work! by the way everyone else we expect your productivity and caseload to increase!"
Meanwhile getting things to work is filing tickets followed by "oh gosh that's so complex!" and months of moron pitcrew showing up " to fix it" who can't fix anything and who seem to think it's just that we're dumbasses who can't figure out who to reboot a computer.
Honestly it's difficult to not grow the instant opinion that IT should just shut the fuck up and fire themselves. Who the hell do they even work for?
In fourteen years at one hospital we have had two completely different EMRs as well as the old electronic record system that didn't have charting but allowed lab lookup, scans of documents, etc. The two older ones are still running in read-only mode because Epic can't look at them, so any records older than 2022 are only in there.
Cardiology, radiology, endoscopy, and labor and delivery all have their own systems for their internal usage while releasing final results to Epic.
I don't object to the idea that these products are made for admins. It's a business and it needs to make money to survive. I object to the idea that making a product for sale to admins precludes making it at least usable for those who actually put in the data.
The fun part is about 4/5 of the way in and starts with
> Some people are pushing back. Neil R. Malhotra is a boyish, energetic, forty-three-year-old neurosurgeon who has made his mark at the University of Pennsylvania as something of a tinkerer. He has a knack for tackling difficult medical problems. In the past year alone, he has published papers on rebuilding spinal disks using tissue engineering, on a better way to teach residents how to repair cerebral aneurysms, and on which spinal-surgery techniques have the lowest level of blood loss. When his hospital’s new electronic-medical-record system arrived, he immediately decided to see if he could hack the system.
This is where user-friendliness is a requirement, not a luxury.
Anyone who has ever looked at an EHR/EPIC screen, can tell you that the 1990s Web called, and wants its tables and frames back.
In fact, one doctor I went to, still ran Windows 95 (in 2009), because they didn't want to deal with new interfaces.
Engineers are notoriously unsympathetic to usability and simple GUIs, but I have found them to be an absolute gold mine, if you want people to actually use your product. Apple and Google are trillion-dollar companies, now, mainly because of their simple, usable UX.
The principal-agent problem means usability isn't actually a deciding factor. Business users might prioritize that but the buyers (C suite) choose on ROI and metric
This is actually not unique to healthcare (see others above posting about Learning Management Systems and Workday). As a result, most enterprise software across verticals is similarly dated. Some research here: https://open.substack.com/pub/healthapiguy/p/there-will-be-b...
I have a rule I don't do charting in front of patients. Maybe I'm old-fashioned, but I think it's rude. I might take a couple notes for later, but I do my charts in my office. I have never logged into an EHR in the exam room.
It’s true that many providers need a custom solution for their unique workflows, and the one-size-fits-all EHR is often a myth. The problem is that many EHRs try to solve this with customizations, which can be expensive and still feel like a compromise.
On the other hand, when a team tries to build their own tools, they quickly realize they have to build a ton of compliance and interop code they never wanted to touch in the first place. That’s why open source platforms that handle the core infrastructure, like Medplum, HAPI, or OpenEMR, can be such a good starting point. They get the team 90% of the way there, so they can focus on what really matters: building a great UI/UX for their users.
I don’t think providers truly want to go back to pen and paper, but they are looking for a better way. They can see the promise of what the solution could be, but they just haven't experienced it yet.
Through the years I've worked with several EHR, be helping their development be using it in my practice, and each had it's idiosyncrasies.
In my country there was proposals by the government of integration, but as all things that need coordination, we're nowhere close to sharing information between care centers.
On a city we have several places controlled by the same entity, and they use an integrated EHR, so that a doctor who sees a patient at the emergency department has access to it's full history from the tertiary center, but at the same time the major tertiary/quaternary hospital isn't managed by that same entity and doesn't use the same EHR system, so we can't share information digitally. To make things worse, one system is made in Flash and all computers need to have an outdated Chrome version with the Flash plugin to run it. The other system is made in Java and some form of custom frontend framework, which works ok until it doesn't.
Expanding on this other system made in Java, it's a federal hospital, and we have other internal systems which doesn't communicate with this main EHR, so for example emitting radiology requests need us to copy paste information from two systems (like address, contact numbers), and on top of that those systems aren't connected to the national patient registry, and daily I have residents redoing requests to merge the information, otherwise the requests are made invalid.
I haven't touched on payments, imagine that each health insurance plan have different billings and we need to adapt the reality of what we did to what code better pays and input that in the system, so in practice the records are tailor fitted for each payment system, the actual procedure descriptions change, and we need to remember all that when billing and when treating the patient.
Add on top of that system outage and unreliability, and I haven't even touched much on the UI, which sometimes loses input text data or sometimes we have to input in certain fields order or else the system crashes, or the fact that the tabindex isn't set on all fields and we need to click with the mouse to go to a field.
Personally I've made a simple system for my private practice, while it doesn't have all the functionality, at least I'm the one to blame for it's particularities. I'm still exploring how to better input the clinical data, and I'm starting to think that general systems doesn't work. Each specialty has specific routines which need to be accommodated in the system, be it structured forms, be it clinical image input with annotations and commentary. The field is huge, and we're looking at how to design UX for immediate input and for later review, which sometimes are at odds (for example, a single textarea is easy to input, but how do we parse that data and present a timeline of clinical signs for example?).
I guess we need a Linux of the EHR, something which we can iterate on. I've looked into open source projects, but I don't know if the field is entrenched in inherent complexity or we're all trying to model too generic abstractions on top so that a small team of developers can't comprehend the system.
I should publish some code instead of rambling, but as the field is covered in regulations, I fear not even a code license can disclaim legal obligations.
What is the alternative to EHR software? Thousands of pages of paper records that is impossible to rapidly search? Just being able to index and search health records is enough to justify the existence of EHR software.
The biggest problem is security. I have yet to see a single EHR provider take security seriously despite HIPPA. It's only a matter of time before our medical records get leaked. My medical records have already been leaked twice, once through an EHR, and then again through my insurance provider.
I love having access to my medical information, but the transition will be difficult for the providers. My primary care doctor joined a practice that was already using electronic records because of the requirement for electronic records.
I would assume the most important feature for doctors for any device UI is that things don't always change. The entire medical field selects for people with great memory, and so even if it is a bit complex at first, as long as they only have to figure it out once they aren't going to easily forget. Even if some other design is more sleek and intuitive for a first time user, the change is only going to mess up the 95% of the established personnel. Any potential tool changes need to provide significant improvements over the old stuff and need to be done sparingly.
To doctors these things are just tools, tools that they want to be able to pick up and put down 100 times a day without having to think about it. A good tool can be operated mostly on muscle memory and needs to remain static 99% of the time. Imagine if the tools a mechanic or carpenter used changed in form and function all the time. Last year they used a right handed circular saw, next year they are forced to use a left handed worm saw. Or imagine a framer picking up his hammer he has used for the last 10+ years and going to give it a swing and missing his mark, only to find out last night his boss took his old hammer and replaced it with one 2 ounces lighter and 2 inches longer and his boss refused to give his old one back. Or a guy digging through his toolbox to pull out a lesser used item like helicoils that he knows is in a medium sized yellow box, wasting tons of time looking and possibly going for a different and less ideal solution, only to find out later the helicoils were at some point put placed into a small sized blue box instead because someone else decided the old box was a bit too big and wasting space.
I've gotten the sense that many of the doctors I've encountered in Germany, who are busily typing at their computer, are frequently documenting their billing items.
I started to think this after seeing the bills from multiple visits, where it's often broken out, in detail, what they had done. It's probably not as bad as that, there probably is some record-keeping happening in there. But considering how overworked most doctors are in the public health system, and how little time is commonly allocated for each patient, it can feel a bit like you didn't actually interact with a human doctor.
> Several countries are well on their way to this achievement, including Belgium, Denmark, Estonia, Lithuania, and Poland. Outside the E.U., countries such as Israel and Singapore also have very advanced systems, and after a rocky start, Australia’s My Health Record system seems to have found its footing.
When any country mentioned hits the population of a small or medium US state, let us know how it goes.
> Canada, China, India, and Japan also have EHR system initiatives in place at varying levels of maturity.
Apparently the author could not care less. Apparently even the WHO could not care less, given the linked document tells us nothing.
As always, it's the US versus the world, and the world is a giant nothingburger, save some flyover countries in Europe that could be part of Greater Germany or Greater Russia for all anyone cares. How is the UK, Germany, France, Russia, or China doing? Oh...
> The United Kingdom was hoping to be a global leader in adopting interoperable health information systems, but a disastrous implementation of its National Programme for IT ended in 2011 after nine years and more than £10 billion.
No doubt when the US gets the standards and apps done, the rest of the world will magically start working too. All the billions spent and the world piggybacks and gives nothing back, save, quite amusingly, China. As always.
19 comments
[ 1.7 ms ] story [ 55.9 ms ] threadWhat struck me over the years was the open hostility we faced from the staff. The admins would buy our product, then have us come do trainings. The clinicians seemed to resent every second of it and would just never use the tool.
Towards the end of my tenure there, a PM said to me “the last thing these people want is to have to learn yet another workflow”. Which is when the penny dropped for me that our tool was just one of a bazillion being force fed to these poor people. They want to spend their time with patients not a screen.
Despite it being the most mission driven I have ever felt about a product (we were literally trying to help cure cancer lol). I’ll never work in health care again. Like education, it’s a quagmire.
Meanwhile getting things to work is filing tickets followed by "oh gosh that's so complex!" and months of moron pitcrew showing up " to fix it" who can't fix anything and who seem to think it's just that we're dumbasses who can't figure out who to reboot a computer.
Honestly it's difficult to not grow the instant opinion that IT should just shut the fuck up and fire themselves. Who the hell do they even work for?
Cardiology, radiology, endoscopy, and labor and delivery all have their own systems for their internal usage while releasing final results to Epic.
I don't object to the idea that these products are made for admins. It's a business and it needs to make money to survive. I object to the idea that making a product for sale to admins precludes making it at least usable for those who actually put in the data.
https://www.newyorker.com/magazine/2018/11/12/why-doctors-ha...
https://web.archive.org/web/20250104014248/https://www.newyo...
The fun part is about 4/5 of the way in and starts with
> Some people are pushing back. Neil R. Malhotra is a boyish, energetic, forty-three-year-old neurosurgeon who has made his mark at the University of Pennsylvania as something of a tinkerer. He has a knack for tackling difficult medical problems. In the past year alone, he has published papers on rebuilding spinal disks using tissue engineering, on a better way to teach residents how to repair cerebral aneurysms, and on which spinal-surgery techniques have the lowest level of blood loss. When his hospital’s new electronic-medical-record system arrived, he immediately decided to see if he could hack the system.
Anyone who has ever looked at an EHR/EPIC screen, can tell you that the 1990s Web called, and wants its tables and frames back.
In fact, one doctor I went to, still ran Windows 95 (in 2009), because they didn't want to deal with new interfaces.
Engineers are notoriously unsympathetic to usability and simple GUIs, but I have found them to be an absolute gold mine, if you want people to actually use your product. Apple and Google are trillion-dollar companies, now, mainly because of their simple, usable UX.
This is actually not unique to healthcare (see others above posting about Learning Management Systems and Workday). As a result, most enterprise software across verticals is similarly dated. Some research here: https://open.substack.com/pub/healthapiguy/p/there-will-be-b...
On the other hand, when a team tries to build their own tools, they quickly realize they have to build a ton of compliance and interop code they never wanted to touch in the first place. That’s why open source platforms that handle the core infrastructure, like Medplum, HAPI, or OpenEMR, can be such a good starting point. They get the team 90% of the way there, so they can focus on what really matters: building a great UI/UX for their users.
I don’t think providers truly want to go back to pen and paper, but they are looking for a better way. They can see the promise of what the solution could be, but they just haven't experienced it yet.
Disclaimer: I work for Medplum.
And you may end up re-creating bad workflows instead of updating to better ones.
On a city we have several places controlled by the same entity, and they use an integrated EHR, so that a doctor who sees a patient at the emergency department has access to it's full history from the tertiary center, but at the same time the major tertiary/quaternary hospital isn't managed by that same entity and doesn't use the same EHR system, so we can't share information digitally. To make things worse, one system is made in Flash and all computers need to have an outdated Chrome version with the Flash plugin to run it. The other system is made in Java and some form of custom frontend framework, which works ok until it doesn't.
Expanding on this other system made in Java, it's a federal hospital, and we have other internal systems which doesn't communicate with this main EHR, so for example emitting radiology requests need us to copy paste information from two systems (like address, contact numbers), and on top of that those systems aren't connected to the national patient registry, and daily I have residents redoing requests to merge the information, otherwise the requests are made invalid.
I haven't touched on payments, imagine that each health insurance plan have different billings and we need to adapt the reality of what we did to what code better pays and input that in the system, so in practice the records are tailor fitted for each payment system, the actual procedure descriptions change, and we need to remember all that when billing and when treating the patient.
Add on top of that system outage and unreliability, and I haven't even touched much on the UI, which sometimes loses input text data or sometimes we have to input in certain fields order or else the system crashes, or the fact that the tabindex isn't set on all fields and we need to click with the mouse to go to a field.
Personally I've made a simple system for my private practice, while it doesn't have all the functionality, at least I'm the one to blame for it's particularities. I'm still exploring how to better input the clinical data, and I'm starting to think that general systems doesn't work. Each specialty has specific routines which need to be accommodated in the system, be it structured forms, be it clinical image input with annotations and commentary. The field is huge, and we're looking at how to design UX for immediate input and for later review, which sometimes are at odds (for example, a single textarea is easy to input, but how do we parse that data and present a timeline of clinical signs for example?).
I guess we need a Linux of the EHR, something which we can iterate on. I've looked into open source projects, but I don't know if the field is entrenched in inherent complexity or we're all trying to model too generic abstractions on top so that a small team of developers can't comprehend the system.
I should publish some code instead of rambling, but as the field is covered in regulations, I fear not even a code license can disclaim legal obligations.
I'd elaborate but it wouldn't be good for my mental health
edit: I'll give one example: my org can't even implement single-sign-on even though it's essentially all MS
To doctors these things are just tools, tools that they want to be able to pick up and put down 100 times a day without having to think about it. A good tool can be operated mostly on muscle memory and needs to remain static 99% of the time. Imagine if the tools a mechanic or carpenter used changed in form and function all the time. Last year they used a right handed circular saw, next year they are forced to use a left handed worm saw. Or imagine a framer picking up his hammer he has used for the last 10+ years and going to give it a swing and missing his mark, only to find out last night his boss took his old hammer and replaced it with one 2 ounces lighter and 2 inches longer and his boss refused to give his old one back. Or a guy digging through his toolbox to pull out a lesser used item like helicoils that he knows is in a medium sized yellow box, wasting tons of time looking and possibly going for a different and less ideal solution, only to find out later the helicoils were at some point put placed into a small sized blue box instead because someone else decided the old box was a bit too big and wasting space.
I started to think this after seeing the bills from multiple visits, where it's often broken out, in detail, what they had done. It's probably not as bad as that, there probably is some record-keeping happening in there. But considering how overworked most doctors are in the public health system, and how little time is commonly allocated for each patient, it can feel a bit like you didn't actually interact with a human doctor.
When any country mentioned hits the population of a small or medium US state, let us know how it goes.
> Canada, China, India, and Japan also have EHR system initiatives in place at varying levels of maturity.
Apparently the author could not care less. Apparently even the WHO could not care less, given the linked document tells us nothing.
As always, it's the US versus the world, and the world is a giant nothingburger, save some flyover countries in Europe that could be part of Greater Germany or Greater Russia for all anyone cares. How is the UK, Germany, France, Russia, or China doing? Oh...
> The United Kingdom was hoping to be a global leader in adopting interoperable health information systems, but a disastrous implementation of its National Programme for IT ended in 2011 after nine years and more than £10 billion.
No doubt when the US gets the standards and apps done, the rest of the world will magically start working too. All the billions spent and the world piggybacks and gives nothing back, save, quite amusingly, China. As always.