Why Doctors Hate Their Computers
November 14, 2018 5:45 AM Subscribe

"Something’s gone terribly wrong. Doctors are among the most technology-avid people in society; computerization has simplified tasks in many industries. Yet somehow we’ve reached a point where people in the medical profession actively, viscerally, volubly hate their computers." (SLNewYorker)

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posted by Stark (114 comments total) 49 users marked this as a favorite

My own doctor said the other day, "oh no, circle of death!" when he was looking at my records after a consult.

He spoke in a humorous tone, so I realized he meant there was a slow load problem. But I didn't think it was all that funny.
posted by Jody Tresidder at 5:59 AM on November 14, 2018 [24 favorites]

I suspect on closer analysis they are hating the social, economic and legislative directions that force the software towards unpleasant useability and questionable benefit to the patients. Doctors and nurses often seem less caregivers than inefficient data entry clerks.

"the doc barely looked at me, just typed my answers into the computer"
posted by sammyo at 5:59 AM on November 14, 2018 [38 favorites]

It's hospital/clinic/practice administrators that drive the uselessness of healthcare software. Full stop.
posted by kuanes at 6:19 AM on November 14, 2018 [21 favorites]

If you ever get a chance to work with it - and you'll wish you didn't - you'll find out that EMR software is some of the worst software on the planet, interfaces from the 90s grafted over data storage from the 80's without the slightest nod to the people actually using it.

Given how bad the experience of using it is, it's hard not to think that it's anything more than a tool that a mendacious administration imposes on a system in order to measure the exact inefficiencies it causes and justify cutting said service.
posted by mhoye at 6:28 AM on November 14, 2018 [30 favorites]

The nurse said to me yesterday "they swore the new version would require fewer clicks" while doing the finger tarantella on the touchscreen
posted by ook at 6:29 AM on November 14, 2018 [11 favorites]

It's also legislation and market-capturing that make stuff useless. There are still lots of healthcare markets that are split between major provider networks and getting records from them all is a pain. The most common thing for me to do is to simply log into the other hospitals' systems (since I have privileges at both) to see their records there. Having them automatically reach me in my clinic system is...not a commonplace thing. And patients often get grumpy at having to repeat parts of their history. "It should all be in there!" they say. And if we had only half the EHR interconnection patients seem to think we do I would cry out of joy.

Part of this is policy on multiple levels which make it hard to get automated interconnection but easy to get faxes. Part of this is big EHR vendors trying to corner markets EPIC systems communicate well with other EPIC systems, for instance, but our academic practice considered hiring a full-time health software engineer for an interconnection with the local hospital's EPIC system.
posted by adoarns at 6:29 AM on November 14, 2018 [9 favorites]

I have done some UX testing and a lot of related reading for my library work and, even as a relative layperson, have been pretty appalled by the medical records interfaces that I've had a chance to see.

At my daughter's pediatrician, for example, we're now forced to use a sluggish, mediocre tablet UI to tediously and repeatedly fill out the same paperwork we were for some reason forced to fill out repeatedly before, but now more slowly. One of the receptionists told me the tablets and the legacy patient management system they're using interact poorly, and that they often have to just manually update records by what has been entered into the tablets because of software issues. The legacy interface itself is pretty horrible to look at.

As far as I can tell, it's only online shopping carts that are getting more seamless - anything where there isn't a minute-by-minute cost to ignoring UX seems to either be static or getting worse. Would love to see some examples that undermine my cynicism about the entire state of the art.
posted by ryanshepard at 6:34 AM on November 14, 2018 [27 favorites]

I'll also say I am super not-fond of the division between provider-users and technical wizards. Like depending on the EHR and the local policy, getting a new template or a change in an existing template may involve physically meeting with an IT support person to hash out the changes. That's even when the poor documentation and flat-out undocumented features of the EHR's templating and data-access engines aren't an impediment to my writing them out myself.

I will say that part of the onus on bad documentation is on providers. Copy-paste, as named in Gawande's article, tends to bloat things. I repeatedly harangue my trainees because they produce bloated discharge summaries with Frankensteinisch blobs of text from an entire admission's worth of documents. The point of a discharge summary is that it summarizes and should be easily legible and scannable. But copy-paste is easier than spending more cognitive effort in producing a synthesis. And cognitive effort, in a profession whose chief output is cognitive effort, is hard.

Nurses though are put in a difficult place and the requirements for documentation are onerous. Part of that is policy-based. Part of it is clumsy interfaces. Mouse clicks and typing, mouse clicks and typing. When any kind of primarily keyboard-based macro system or even menu system could be quicker. Stop moving your hands between keyboard and mouse! But I rarely find much of the nursing documentation objectively helpful. Much of it is wasted effort that could be automated and detracts from face-to-face nursing care.
posted by adoarns at 6:38 AM on November 14, 2018 [13 favorites]

1. Elevator Buttons
2. Bed Curtains
3. Cell Phones
4. Computer Keyboards
5. Hands

[COUGH! hack!] I’m OK, thanks. Just picked up a bug somewhere...
posted by cenoxo at 6:39 AM on November 14, 2018 [5 favorites]

you'll find out that EMR software is some of the worst software on the planet

I'm an administrator for Blackboard. Challenge accepted.
posted by soren_lorensen at 6:40 AM on November 14, 2018 [116 favorites]

We had our chance to give away the already developed and paid for, well loved EHR system of the VA, VistA.

But we blew it.
posted by mikelieman at 6:40 AM on November 14, 2018 [10 favorites]

The next year, I got a Commodore 64 from RadioShack

Is that possible? I spent a lot of time at Radio Shack in the 70s and 80s (I'm probably about the same age as the author), and I don't remember ever seeing anything other than Tandy/Radio Shack products. Since the C64 was the biggest competitor to the TRS-80, I can't imagine Radio Shack selling it!
posted by crazy_yeti at 6:41 AM on November 14, 2018 [7 favorites]

I'm an administrator for Blackboard. Challenge accepted.

I've used Moogle. Step aside and hold my beer.
posted by ocschwar at 6:47 AM on November 14, 2018 [17 favorites]

Hi, I support a bunch of applications at a hospital in Boston. A lot of our digital records get printed out on paper and then scanned back in so that the doctors can then look at a non-machine-readable image of a record they can get digitally. We pay for each page of paper we scan.

There are much dumber things, but that one is my favorite.
posted by bondcliff at 6:47 AM on November 14, 2018 [41 favorites]

Beware of the Robot Pharmacist

Pablo had a rare genetic disease that causes a lifetime of infections and bowel inflammation, and as Chan reviewed the orders, he saw that Lucca had ordered 5 mg/kg of Septra, the antibiotic that Pablo took routinely to keep infections at bay.

Chan immediately noticed a problem with this Septra order: the dose of 193 mg the computer had calculated (based on the teenager’s weight) was 17 percent greater than the standard 160-mg Septra double-strength tablets. Because this discrepancy exceeded 5 percent, hospital policy did not allow Chan to simply approve the order. Instead, it required that he contact Lucca, asking her to enter the dose corresponding to the actual pill size: 160 mg. The pharmacist texted Lucca: “Dose rounded by >5%. Correct dose 160 mg. Pls reorder.”
...
Both Chan and Lucca knew that Pablo weighed less than 40 kilograms (38.6 to be exact, or about 85 pounds). But here is where worlds — the worlds of policy, practice and computers — collided. The 40 kilogram policy required that Lucca’s original order be weight-based (in milligrams of medication per kilogram of body weight), but the 5 percent policy meant that Chan needed Lucca to reorder the medication in the correct number of milligrams. What should have been a simple order (one double strength Septra twice daily) had now been rendered hopelessly complex, an error waiting to happen. And so one did.

After receiving Chan’s text message, Lucca reopened the medication-ordering screen in Epic, the electronic health record system used by UCSF. What she needed to do was trivial, and she didn’t give it much thought. She typed “160” into the dose box and clicked “Accept.” She then moved to the next task on her long checklist, believing that she had just ordered the one Septra tablet that she had wanted all along. But she had done something very different.
...
Since doses can be ordered in either milligrams or milligrams per kilogram, the computer program needs to decide which one to use as the default setting. (Of course, it could leave the unit [mg versus mg/kg] box blank, forcing the doctor to make a choice every time, which would actually require that the physician stop and think about it, but few systems do that because of the large number of additional clicks it would generate.)

In UCSF’s version of Epic, the decision was made to have the screen default to milligrams per kilogram for all kids weighing less than 40 kilograms, in keeping with the weight-based dosing policy. That seemingly innocent decision meant that, in typing 160, Lucca was actually ordering 160 mg per kg — not one double-strength Septra, but 38½ of them.

posted by BungaDunga at 6:48 AM on November 14, 2018 [20 favorites]

I'm a user of both Blackboard and Epic, and while they are both terrible, Epic is like the bad parts of Blackboard on steroids. Nothing about it is intuitive, nothing about it is user friendly, nothing about it looks good. It's like navigating an Angelfire Site within Inception and the consequences are both life an death and millions of dollars. As the article points out, because its all customized for each hospital, it is very much the result of Programmers + Sales team + Medical staff + Admin staff and the result is a mess. EMR is in theory a really awesome and important thing, but Epic is just epically bad. But you can change your themes to all sorts of fun things like "rock star" and "outer space" so.

Each patient has a “problem list” with his or her active medical issues, such as difficult-to-control diabetes, early signs of dementia, a chronic heart-valve problem. The list is intended to tell clinicians at a glance what they have to consider when seeing a patient. Sadoughi used to keep the list carefully updated—deleting problems that were no longer relevant, adding details about ones that were. But now everyone across the organization can modify the list, and, she said, “it has become utterly useless.” Three people will list the same diagnosis three different ways. Or an orthopedist will list the same generic symptom for every patient (“pain in leg”), which is sufficient for billing purposes but not useful to colleagues who need to know the specific diagnosis (e.g., “osteoarthritis in the right knee”).

Sigh, I chortled because this is so spot on. I see patients all the time that have listed on the major problem list (which is supposed to be a quick snapshot of overall health problems) hearing loss, sensorineural hearing loss, hearing difficulty, bilateral hearing loss, deafness, severe hearing loss all listed.
posted by Lutoslawski at 6:51 AM on November 14, 2018 [18 favorites]

I've used Moogle. Step aside and hold my beer.

Currently teaching in Desire to Learn's Brightspace, and have used all the major competitors at one point or another - have yet to find a single LMS that isn't basically garbage.
posted by ryanshepard at 6:51 AM on November 14, 2018 [5 favorites]

I'm an administrator for Blackboard.

So do we have a secret handshake, or is it just quietly lying in a corner and sobbing in the fetal position?

I also develop integrations between Blackboard and our other systems, including the huge new student records system they're bringing in here. The next two-year period is going to be very interesting.
posted by Mr. Bad Example at 6:52 AM on November 14, 2018 [16 favorites]

The College of American Pathologists just did a whole session on physician burnout and electronic medical records came up a lot. They recorded the session- here's a link if you want to watch it.
posted by Mouse Army at 6:52 AM on November 14, 2018 [4 favorites]

A lot of our digital records get printed out on paper and then scanned back in so that the doctors can then look at a non-machine-readable image of a record they can get digitally. We pay for each page of paper we scan.

Omg! Our hospital does this too! Why! We literally print things from a computer, scan them, and then upload them to Epic. I have no say in this. It's just "how we do it." Aaaaggghhhh.
posted by Lutoslawski at 6:52 AM on November 14, 2018 [5 favorites]

Fun fact: the Epic patient portal is mostly coded in Visual Basic 6. And it's probably the most usable part of the entire system.
posted by BungaDunga at 6:54 AM on November 14, 2018 [23 favorites]

(Unrelated, but Canvas is great!)
posted by tofu_crouton at 6:55 AM on November 14, 2018 [6 favorites]

I've had some experience at my hospital with assisting physicians with two different EMR roll-outs; one of the reasons why I, a non-physician (non-clinician, period) was doing this is that very few physicians were willing to be peer support people during the roll-outs; doing so meant taking time away from patients (and billable procedures). I wasn't that good at it simply because, despite having worked in medical libraries for several years, I didn't really know what doctors did while they were rounding in the hospitals. Hanging out on the units and helping with minor technical details of the systems was an education for me, but I'm not sure how much I helped them with some of the more knotty things, including hand-off between physicians and nurses, about whose Epic experience (Epic has somewhat different UIs for different professions) I knew very little.

Couple of other things: WRT printing out info from EMRs, our library has a locked "burn bin" the size of a full-sized garbage can. And this bit from the article stuck out for me:

A 2015 study of scribes for emergency physicians in an Atlanta hospital system found that the scribes produced results similar to what my Boston colleagues described—a thirty-six-per-cent reduction in the doctors’ computer-documentation time and a similar increase in time spent directly interacting with patients. Two-thirds of the doctors said that they “liked” or even “loved” having a scribe. Yet they also reported no significant change in their job satisfaction. With the time that scribes freed up, the system simply got doctors to take on more patients. [emphasis mine] Their workload didn’t lighten; it just shifted.

Studies of scribes in other health systems have found the same effect. Squeezing more patients into an hour is better than spending time entering data at a keyboard. More people are taken care of. But are they being taken care of well?

Chain that up with Gawande's observations about some specialties suffering far less stress (and, it probably goes without saying, being paid much better).
posted by Halloween Jack at 6:56 AM on November 14, 2018 [7 favorites]

I spent quite possibly the worst year of my life working at Epic, plus another bunch of years working for hospital systems on Epic-related stuff, and I loved this article. I love that there is a neurosurgeon who found a colleague to help hack the system to work for him, and I love that he scared and pissed off a bunch of Epic executives while doing so. I loved that Dr. Gawande called out in incredibly vendor-specific language what is busted, what is annoying, and what needs to change. Getting customer feedback into the Epic cult of personality is like shouting into a black hole, and I love that he used his platform at the New Yorker and his fantastic storytelling skills to make his case. It will never work because Epic can’t help technically-inept/unwilling old faculty doctors (so throw a scribe at them!), nor can it prevent other providers from copy/pasting the universe over and over again. But seeing as I currently work in a human services world with software that desperately needs Epic-like case management functionality instead of a lame PDF form filing system, EHR systems have so much potential. It is just failing in so many different real-world ways.
posted by Maarika at 6:56 AM on November 14, 2018 [19 favorites]

In building a given function—say, an order form for a brain MRI—the design choices were more political than technical: administrative staff and doctors had different views about what should be included. The doctors were used to having all the votes. But Epic had arranged meetings to try to adjudicate these differences. Now the staff had a say (and sometimes the doctors didn’t even show), and they added questions that made their jobs easier but other jobs more time-consuming.

I mean, there it is in 4 sentences, right? You take your already shitty legacy behemoth EMR system, sell the hospital on the fact that it can do anything they want, zombo.com-style, and then put all the design choices up to the middle managers. Never mind that every minute a doctor spends using the nigh-on-to-unusable software is the most expensive billable minute possible, and will cause patient outcomes to suffer notably--at least management can keep on counting their beans.
posted by Mayor West at 7:01 AM on November 14, 2018 [11 favorites]

But we think of this as a system for us and it’s not,” he said. “It is for the patients.” While some sixty thousand staff members use the system, almost ten times as many patients log into it to look up their lab results, remind themselves of the medications they are supposed to take, read the office notes that their doctor wrote in order to better

hahahahahahahahahahahahahauahaha

One time a specialist said "oh, do you want me to put these results in the system? So you can show them to your primary care doctor?" How did she get the test results if not through the EHR system? I don't know! But that explains why I've never been able to find them any other time. I've been in three of these systems and never found anything except bills.
posted by Rainbo Vagrant at 7:04 AM on November 14, 2018 [4 favorites]

I had a different take on that, Mayor West. By "administrative staff" I don't think they mean hospital management, I took that to mean the people tasked with making the stuff actually happen. The people who have to interpret a doctor's orders and then send this paper to that department and that request to this clinician and make sure that technician signs this thing in triplicate and the schedulers know how much time to schedule. So they requested stuff be put in the system that forced doctors to be very very detailed and explicit rather than running after various clinicians for clarification after receiving an order that was missing information.
posted by soren_lorensen at 7:08 AM on November 14, 2018 [10 favorites]

A minor counter-example if it makes anyone feel better, the system we use at my work for managing patient records for optical eye care is really quite nice and seamless, at least for my purposes as a lab tech. I can see doctor reports going back 8 years, I can see what was prescribed, any upgrades to the glasses, either sold or lab upgrades, every measurement, adjustment notes (if needed), everything I could want, and it's connected to every other store in our network and several of our most common insurance companies. Going forward we're even going to have digital scans of the written doctor's report so we don't have to walk into the other room to find it in storage. Our doctor has a computer in the exam room, but it's barely touched, opticians and techs enter that data once the exam is over.

Insurance authorization, and clicking confirm boxes that should be assumed are the only problems with it, and the insurance part is squarely on the insurance companies (why, in this day and age, there should sometimes be hour+ wait times on a fax, I'll never know).

Optical care is obviously very different from life and death, millions of dollars at stake general health care, but it does seem like there is a workable solution to some of these problems. Specificity seems to be a big part, trying to have one front-end fit for all sorts of healthcare that happens in a proper hospital seems like a bad idea. The expectations I have from the doctor who takes care of my knees is quite different than the expectations I have for my bowel situation, and they should probably have different tools.
posted by neonrev at 7:09 AM on November 14, 2018 [2 favorites]

I work on this issue pretty closely. Couple of thoughts:
1) EHR makers have little/no incentive to make things better now. For a while CMS was giving out billions to digitize our health system (can I get a holla for Meaningful Use?), but that money has dried up. Why would they spend money making their software better, when they could use that money on M&A and business development?

2) Part of the reason Docs hate EHRs is because they suck, another part is a loss of practice autonomy. Doctors used to be the most respected folks in town, the height of achievement, and they were deeply trusted. The current state of our system has made many of them feel like they're just a cog in the machine. The decision to go to med school, work 16-hour days, go hundreds of thousands in debt, etc., is becoming less and less appealing. See also the dramatic rise in physician suicides.
posted by matrixclown at 7:10 AM on November 14, 2018 [23 favorites]

Boston Children’s Hospital investigating Alexa skills for doctors in the clinic [MobiHealthNews, 8/9/2018]:

Alexa and other similar voice technologies offer a clear opportunity to connect with patients directly, but that’s not to say that the hands-free applications won’t benefit the practitioner as well. In her talk, Nadar described how her group at Boston Children’s Hospital is investigation the role voice-first applications could play in the clinical setting.
...
Nadar said that she conducted follow-up interviews with 21 doctors from the survey and her own hospital to demo one of the specific clinical Alexa skills Boston Children’s is piloting. After explaining step-by-step how the technology could be used in practice, all of these doctors said they would be willing to help test the implementation.

“The real big value out of this is real-time, hands-free solutions with the potential to reduce human error and aid in infection control,” Nadar said. “One of the things we’ve been focusing on with our pilots is just getting people comfortable with voice technology. I think there’s a lot of barriers, but there will be a day when voice is everywhere, so the sooner you can get physicians comfortable with using it, the sooner you can kind of feel that voice already has a role, I think the more successful we’ll be down the line in tackling really big problems and questions about integrating [voice] in the ER.”

posted by cenoxo at 7:11 AM on November 14, 2018 [2 favorites]

As someone funnier that I once said, enterprise somewhere is like prisoner food, the people who buy it don't have to eat it.
posted by Damienmce at 7:12 AM on November 14, 2018 [17 favorites]

Anyway, my take as someone who is tasked with getting very smart, busy people to adopt new technology is that we need more human assistants. We need to toss out this notion that computers mean that no one now needs a secretary, or admin assistant or scribe and everyone everywhere should be able to adopt, learn and DIY it with any new digital system thrown at them. Computers are complex systems that require the full time and expertise of the people using them and we should hire and pay handsomely people whose actual full time job it is to assist in the interfacing of humans with technology.
posted by soren_lorensen at 7:13 AM on November 14, 2018 [35 favorites]

I work in the software division of a large healthcare system and our CTO sent this article to the whole team last week. We work with doctors often and are keenly aware of how much they hate computers.

Because our system has acquired so many smaller health systems, we use EPIC, Cerner, Medipac, some smaller commercial EMRs and some hacked together homegrown systems. It's as nightmarish as that sounds.
posted by octothorpe at 7:15 AM on November 14, 2018 [3 favorites]

Oh my god, the tablet interface for patients, yes hello, thank you for introducting a MAJOR DISEASE VECTOR by requiring every person in a doctor's office to touch the same screen with their germ-ridden fingers. (I did not see anyone clean the screen after use).
posted by emjaybee at 7:29 AM on November 14, 2018 [23 favorites]

Last month my GP and I spent a few minutes of my annual physical fiddling with Mac OS to see whether he could dictate my pulse measurement into the EMR. We did get it, but we agreed it took too much time — and, worse, too much focus on the computer when the patient might accidentally say something important.

Dr. Rex said that the next time I showed up they would be using scribes during appointments. I wonder if he’s seen that article....
posted by wenestvedt at 7:32 AM on November 14, 2018 [1 favorite]

I've used Moogle. Step aside and hold my beer.

Awesome typo, kupo!
posted by supercrayon at 7:43 AM on November 14, 2018 [7 favorites]

Up until a couple of years ago, my doctor's office was located in a Victorian-era house that had knob-and-tube wiring and so had one (1) grounded plug, located in what had been a pantry. About 7 years ago now, I was waiting for some really urgent test results. I called the testing clinic and they said they kept trying to fax the results, but that my doctor's office fax wouldn't receive them. So I called my doctor's office.

It turns out it was tea time at my doctor's office so they'd unplugged the fax/printer/whatever machine to make tea.

I'm sorry for anything that stresses doctors out and takes away from patient care but I kind of feel pro-technology here.
posted by warriorqueen at 7:45 AM on November 14, 2018 [10 favorites]

Is that possible? I spent a lot of time at Radio Shack in the 70s and 80s (I'm probably about the same age as the author), and I don't remember ever seeing anything other than Tandy/Radio Shack products. Since the C64 was the biggest competitor to the TRS-80, I can't imagine Radio Shack selling it!

The answer is MAYBE. Certainly you would never see this in a company owned-and-operated Radio Shack store, but there were independents who might have carried a C-64.
posted by mikelieman at 7:53 AM on November 14, 2018 [4 favorites]

In my senior year of college, I interviewed at Epic (they hired a lot of new grads from my college). They showed us the newest version of the software. I laughed out loud and said, "This looks like it was made in the early 2000s!" I didn't get the job.
posted by astapasta24 at 7:53 AM on November 14, 2018 [13 favorites]

This is just to say
The administrators
Who set my "productivity target"
At one patient every fifteen minutes
Have also selected without my input

An electronic record system
That requires 20 minutes
Of charting per patient.

Forgive me
For not making eye contact
As you tell me about your trauma.
It is structured data,
And must be appropriately documented.
- Your PCP
posted by Richard Saunders at 7:54 AM on November 14, 2018 [78 favorites]

Man, this all makes me really appreciate my doctor and her scribe, and our record system, and now I'm going to have to ask what they're using.

We communicate almost entirely online through the system and it isn't horrible. After each visit I have it set up so I get no paperwork at all, and instead it saves it as a visit report I can review online, and I can even view our visit summaries and details.

Almost every metric forms a time based graph, so when I get blood tests done I usually get all the results in 24 hours right in my online chart, and then that data can also see changes as a graph. This includes base stats like weight, BP, heart rate, etc for each visit.

Based on previous record systems I've encountered, my hospital apparently knows what the heck it's doing.
posted by loquacious at 7:56 AM on November 14, 2018 [2 favorites]

My neurologist uses a scribe at our appointments,

When I first read this sentence, I figured scribe was a specific electronic gizmo whose nature was about to become clearer through context. But no, it actually is a scribe.

I would be pleased if my neurologist used a scribe, as I imagine a medieval type hunched over a vellum scroll, the tip of his quill twitching back and forth in the air.
posted by ricochet biscuit at 7:58 AM on November 14, 2018 [14 favorites]

I loathe Epic with the fire of a thousand burning suns.

When I open a chart to review, I have 20 tabs across the top. Half of them I don't even know what they mean. What the hell is an LDA?

When I open an encounter (different from opening a chart, don't ask me why), there are THIRTY-EIGHT different tabs in the sidebar. I care about eight (vitals, allergies, meds, progress note, orders, patient instructions, level of service, sign/route). There is no way to highlight the eight I want, or hide the rest -- they all show up in the same 10 pt font down the side, and if you click on the wrong tab or scroll too quickly, the system hangs and I can't do shit until it wakes up. If I want to look at an MRI or labs or anything, I have to click out of the visit, back to the non-visit chart, find the labs or imaging tab out of the 20 on top, scroll around till I find the MRI or whatever, clicking on it pulls up a different system that takes its own sweet time to load.... All that time is time I'm not talking to the patient or

Not to mention "Epic-generated notes" which are garbage to read. "Patient complains of pain. Pain is in the foot. Pain is a 3 out of 10. Aggravating factors include pressing on the foot. Alleviating factors include none. Orders placed this encounter include ambulatory referral to neurology." I toss Epic-generated notes from referring docs straight in the shred bin, because they convey absolutely no useful information aside from whatever was required to bill at a level 5.

I am not a super-tech user and don't line up at the Apple store for the latest release or anything, but I have been using computers since preschool. Epic is at best annoying, at worst actively bad for medical care.

Sorry for venting. This has touched a nerve.
posted by basalganglia at 8:00 AM on November 14, 2018 [32 favorites]

I would be pleased if my neurologist used a scribe, as I imagine a medieval type hunched over a vellum scroll, the tip of his quill twitching back and forth in the air.

FWIW, I took shorthand in High School back in the 80's, so I'd do this.
posted by mikelieman at 8:04 AM on November 14, 2018 [1 favorite]

Oemjaybee – Disinfecting the iPad: evaluating effective methods [PubMed.gov, 2014]:

FINDINGS: With the exception of Clostridium difficile, Sani-Cloth CHG 2% and Clorox wipes[*] were most effective against MRSA and VRE, and they were significantly better than the Apple-recommended plain cloth (P ≤ 0.001). A substantial residual antimicrobial effect was seen for >6h after wiping the iPad with Sani-Cloth CHG 2% despite repeated recontamination and without further disinfection. The functionality or visual appearance of the iPad was not damaged by repeated use of Sani-Cloth CHG 2% wipes.

CONCLUSIONS: Sani-Cloth CHG 2% wipes effectively disinfect the iPad against MRSA and VRE, with a residual antibacterial effect and without causing damage.

*Check drugstores, big box retailers, Amazon, etc.
posted by cenoxo at 8:05 AM on November 14, 2018 [6 favorites]

Oh, and anecdotally, my rheumatologist is retiring at the end of the year, and since we talk about tech a lot ( he's really into it ) and lament how it's never met expectations, cited the shitty "best of breed" EHR he was using for one reason he was getting out.
posted by mikelieman at 8:06 AM on November 14, 2018

I don't like how it seems like most of the time the doctor isn't even LOOKING at me and is just reading and typing on the screen. One thing my orthopedic did that I liked is that when he came into the exam room he took the tablet they had for him to input things on and put it screen down--THEN talked to me--THEN looked at the tablet to check some stuff.

This is presumably a solveable problem (your orthopedic has come up with the answer already) but since it won’t occur to everybody, it should be trained.

Teachers, for example, are trained on how they use materials and give instructions to direct their students’ attention, including more-or-less common sense ideas like “hold the materials over your body, not out to the side”, “make eye contact” “don’t talk into the chalkboard”, etc. Obviously it isn’t the same context, and it sounds as though time pressure is an issue in many clinical settings, but stuff like “look away from the monitor and at your patient whenever you can” would probably be quite helpful advice in many cases.

It might sound patronising, but so did the checklist thing when that started taking off in healthcare.
posted by chappell, ambrose at 8:16 AM on November 14, 2018 [4 favorites]

Sorry for venting. This has touched a nerve.
posted by basalganglia

Say it with me, people.
posted by Halloween Jack at 8:30 AM on November 14, 2018 [63 favorites]

I interviewed at Epic (they hired a lot of new grads from my college). They showed us the newest version of the software. I laughed out loud and said, "This looks like it was made in the early 2000s!"

The administrative back-end is straight out of the 80s, it looks something like this, but without colors.
posted by BungaDunga at 8:44 AM on November 14, 2018 [8 favorites]

See: VistA.

Yeah. This. If we wanted to take healthcare seriously in the US, we'd give this out to each and every practice. Literally pre-natal to grave care. Already paid for with my PARENT'S tax dollars.

I'll be over on the fucking-fuck venting thread.
posted by mikelieman at 8:53 AM on November 14, 2018 [15 favorites]

Things are made worse because most EHR software is still written in Mumps, which seems to be the worst programming language known to man.

Example code:

GREPTHIS()
NEW SET,NEW,THEN,IF,KILL,QUIT SET IF="KILL",SET="11",KILL="l1",QUIT="RETURN",THEN="KILL"
IF IF=THEN DO THEN
QUIT:$QUIT QUIT QUIT ; (quit)
THEN IF IF,SET&KILL SET SET=SET+KILL QUIT
posted by monotreme at 8:59 AM on November 14, 2018 [11 favorites]

Wait, why are EPIC et all still around if VistA is as awesome as it sounds?
posted by ChrisHartley at 9:00 AM on November 14, 2018 [2 favorites]

I think I'd have to disagree with the characterization of doctors as technophiles. I did tech support for an MSP that had a lot of doctors as their clients and almost to a person the doctors were very anti-tech and anti-computer. Didn't like 'em, didn't trust 'em, didn't want 'em. Most didn't even know how to type, and these were not old doctors these were young doctors. How they got through medical school (or any college) not typing is beyond me.

That said, I'll also agree that medical software is some of the ugliest kludges you'll ever have the misfortune to have to use or support. Yeesh.

And it costs a fortune to license. I can only guess that the companies have huge Scrooge McDuck style money vaults they swim around in, because they aren't spending one cent of those huge licensing fees on improving the software.
posted by sotonohito at 9:01 AM on November 14, 2018 [8 favorites]

Just signed into my patient account, where my (exceptional, unique, diligent) primary care doctor always puts in notes and tests, to see what software it is and yes, way down at the bottom it says Epic. It should be also noted that my primary care doctor, since I started seeing her 6 or so years ago, has reduced her primary care days to two a week. I imagine she can only provide the level of care she does (best doctor I've ever had) because she limits her patients so much.
posted by wellifyouinsist at 9:02 AM on November 14, 2018 [1 favorite]

Capitalism corrupts.
Late capitalism corrupts completely.
posted by DigDoug at 9:07 AM on November 14, 2018 [4 favorites]

As mentioned in the article, other professionals hate computers as well. Much of one's time as a public school teacher is also spent with a computer instead of with students.
posted by kozad at 9:10 AM on November 14, 2018 [2 favorites]

THEN IF IF,SET&KILL SET SET=SET+KILL QUIT

All computer languages used to look like this - it's like an optimization game to see how much computing you can jam onto a single line, even if it takes another expert an hour to understand and modify it.
posted by The_Vegetables at 9:12 AM on November 14, 2018 [2 favorites]

I'd be down for working as a scribe for healthcare providers, either the software-wrestling kind or the vellum-and-quill kind.
posted by bagel at 9:15 AM on November 14, 2018 [2 favorites]

Yes, I missing something: "The VistA system is public domain software, available through the Freedom Of Information Act directly from the VA website[12] or through a growing network of distributors, such as the OSEHRA VistA-M.git tree." according to Wikipedia. Why don't more places use it if it is free? Why isn't there a Red Hat style company offering installation and support services for the free software?
posted by Canageek at 9:18 AM on November 14, 2018 [4 favorites]

* reads title "Why Doctors Hate Their Computers" *
Lemme guess - horrible software?
* reads comments *
Ayup.
posted by Greg_Ace at 9:18 AM on November 14, 2018 [2 favorites]

See: VistA.

Yeah. This. If we wanted to take healthcare seriously in the US, we'd give this out to each and every practice. Literally pre-natal to grave care. Already paid for with my PARENT'S tax dollars.

I'll be over on the fucking-fuck venting thread.

I wondered how hard it would be to get VistA for non-VA hospitals, since it sounds pretty good, and came across this in Wikipedia:
Under the Freedom of Information Act (FOIA), the VistA system, the CPRS graphical interface, and unlimited ongoing updates (500–600 per year) are provided as public domain software.[16]

This was done by the US government in an effort to make VistA available as a low cost Electronic Health Record (EHR) for non-governmental hospitals and other healthcare entities....In one state, the cost of a multiple hospital VistA-based EHR network was implemented for one tenth the price of a commercial EHR network in another hospital network in the same state ($9 million versus $90 million for 7–8 hospitals each). (Both VistA and the commercial system used the MUMPS database).

You mean instead of paying Epic or Cerner god knows how many millions of dollars for an EHR no one likes, we could have gotten a reasonably good one for free? I think I'll join you in the fucking fuck thread. At least this article makes me less bothered about having to use Cerner rather than Epic. It seems like cable companies and banks, commercial EHRs all suck roughly equally, just in slightly different ways.
posted by TedW at 9:19 AM on November 14, 2018 [5 favorites]

On the one hand, VistA is free and generally regarded as pretty good compared to the competition. On the other hand, it's written in Mumps and maybe society can do better than this?
posted by pwnguin at 9:25 AM on November 14, 2018 [1 favorite]

How much would it cost to develop a replacement for Epic? Do it as a government program, let companies submit bids with the promise that the winner gets to repatriate all their offshore money tax-free if they do a great job, and then see what Apple comes up with.

If one took a snapshot of existing needs today, then even assuming showering money on it, it would still take some five years to implement (in an incredibly unlikely best case scenario).

But during those five or more years, federal and state laws would be changing. Hospital and medical group policy would change. Insurance procedures would change. Medical practice itself would change.

And all of these changes would happen without regard to how much violence they do to whatever fundamental abstractions you originally chose, giving you the choice of re-conceptualizing things and meticulously looking at the consequences and side-effects of changing it, or of implementing some workaround on top of your current abstractions and hoping that it doesn't prove too brittle. You'd find yourself running as fast as you could to try to keep up.

And your goal can't be just to beat what the current system is, but to beat it by so much that organizations would be inspired to incur the massive difficulty of switching.

There's a lot of reason for inertia to be really hard to overcome here.
posted by Zed at 9:34 AM on November 14, 2018 [5 favorites]

Thanks for posting. Can't read it for the dancing donut ad!
posted by KleenexMakesaVeryGoodHat at 9:44 AM on November 14, 2018

So many of the comments in this thread are very much in line with my own experience. If you are interested in a really good in-depth look at how computers and EHRs can harm patients, the story linked in BungaDunga's comment above is excellent. Part one is here; it is worth it to read the whole thing if this topic interests you. The dosing "help" in the EHR can be incredibly annoying. I get med orders where I have to override an allergy alert that is totally unrelated to the medicine I am trying to order, and alerts that I am not giving a high enough dose of a medicine because I rounded the dose to 1 mg instead of the 1.025 mg that the system wants me to order and which no one wants to try to precisely give that extra fraction of a drop that the extra 0.025 mg would be. For some reason the people writing and implementing the software seem to think that more significant digits is better no matter what.

And with all the griping about the EHR, I am surprised no one has brought up passwords. Although we are supposed to have implemented using the same password throughout our software, in practice I have to remember one password for most stuff, a second for the drug dispensing machine in pharmacy, and a third for the scheduling software I use to make the call schedule for our group (since the last is not actually used outside our department I understand why it is not included) But for one brief shining moment earlier this year, I actually had all my passwords the same! Then about a week later I got the dreaded email from IT: " Your password will expire in 2 weeks. Please change it at www...." And of course our password criteria are kept in a semisecret location on the intranet so when I go to change it, my first few choices are usually rejected, but without explanation. Was it too short? One of the dozens of passwords I've used before? Needs a special character/numeral/capital letter? I'm using the wrong special character? No easy way to tell. Someone above stated that physicians were not technophiles in their experience. I work in the OR, where we love the latest fancy technology. But when it comes to just using the computer to do our jobs, it is no surprise that many of us have lost any interest in dealing with the technology.
posted by TedW at 9:44 AM on November 14, 2018 [12 favorites]

Example code:

GREPTHIS()
NEW SET,NEW,THEN,IF,KILL,QUIT SET IF="KILL",SET="11",KILL="l1",QUIT="RETURN",THEN="KILL"
IF IF=THEN DO THEN
QUIT:$QUIT QUIT QUIT ; (quit)
THEN IF IF,SET&KILL SET SET=SET+KILL QUIT

So, this piece of code is sort of weird. It's abusing the system by redefining keywords, which you can do in C just as easily (see: Bourne shell, which #defined macros to make it feel more like ALGOL). So it's much worse than idomatic MUMPS.

The true horror of MUMPS is more complicated. To start with, in practice idomatic MUMPS writes every single keyword is actually written with only one or two letters. This is not required, but the original implementation didn't have a tokenizer, so shorter source code ran faster, and the specification allows you to cut down every keyword to just its first letter. Oh, and whitespace is significant. And, there's no order of operations, so you have to make sure your arithmetic and logical operators are always parenthesized, otherwise it's done left-to-right.

Practical MUMPS code looks like this:
i fooValue["K" d
. S N=N+1
. S foo("K",N,"?")="Edit YYY record"

Functions are defined in records which are a bit like files (but aren't), which can only have 6 letters and have no explicit hierarchy. So you might have a bunch of functions related to the ETP record type (all record types have a three-letter code and are always referred to by it) in the "file" called ETPFP1, and a few more in ETPFP2, etc, as you fill up each file. So to invoke a particular function, you run "d funcName^ETPFP1". There's a different syntax if your function returns a value- "S v=$funcName^ETPFP1(foo,bar)".

My very favorite problem with MUMPS is the following. IF statements simply set a global flag. The "else" statement checks the flag and decides whether to run the "false" branch. So if you have an if statement that calls a function in the true branch, and that function has an IF, and that IF evaluates to false, the global flag is set to FALSE so both the TRUE and FALSE branch runs- by the time the outside ELSE statement is executed, the flag is now FALSE!

The solution is to stick a no-op "IF TRUE" right before the ELSE statement.

VistA is also written in MUMPS, so you can't escape it by going open-source.

P.S. There is a proprietary object oriented language extension, and at some point a "MUMPS Server Language" was considered. They are both too awful for even Epic to use.
posted by BungaDunga at 9:45 AM on November 14, 2018 [18 favorites]

NEW SET,NEW,THEN,IF,KILL,QUIT SET IF="KILL",SET="11",KILL="l1",QUIT="RETURN",THEN="KILL"
IF IF=THEN DO THEN
QUIT:$QUIT QUIT QUIT ; (quit)
THEN IF IF,SET&KILL SET SET=SET+KILL QUIT

If The Shining were about a programmer instead of a writer
posted by echo target at 9:45 AM on November 14, 2018 [15 favorites]

NEW SET,NEW,THEN,IF,KILL,QUIT SET IF="KILL",SET="11",KILL="l1",QUIT="RETURN",THEN="KILL"
IF IF=THEN DO THEN

BungaDunga has covered some of this already, but...oh, my sweet summer children. This is MUMPS as written by the quill of Shakespeare after it's been dipped in rainbows barfed out by a unicorn. This is MUMPS as a gentle kiss on the forehead from a pixie made out of good wishes and sunbeams who whispers in your ear that your ex was an idiot for breaking up with you. This is good MUMPS.

Know what most MUMPS is like? Specifically, MUMPS as used in VistA? Get any children and pets out of the room and gaze upon just a few lines:

IJ(N) ;build I & J arrays given subfile number N
 N A K I,J
 S J(0)=N,N=0
0 I $D(^DIC(J(0),0,"GL")) S I(0)=^("GL") Q
 S A=$G(^DD(J(0),0,"UP")) Q:A=""
 S I=$O(^DD(A,"SB",J(0),0)) Q:'I
 S I=$P($P($G(^DD(A,I,0)),U,4),";") Q:I=""
 I +I'=I S I=""""_I_""""
 F J=N:-1:0 S J(J+1)=J(J) S:J I(J+1)=I(J)
 S J(0)=A,I(1)=I,N=N+1 G 0

This isn't some relic of part of the system from the 80s, either. This is from a file written three years ago. All of VistA is like this.
posted by Mr. Bad Example at 10:02 AM on November 14, 2018 [35 favorites]

Just for fun, here's some random VistA co de.
posted by BungaDunga at 10:03 AM on November 14, 2018 [4 favorites]

MUMPS may be terrible but EPIC is also written in MUMPS so it can't be the reason to chose EPIC vs VistA. Why did Kaiser spend $6 billion to implement EPIC instead of going with VistA? Fancy sales lunches with executives can only explain so much.
posted by ChrisHartley at 10:17 AM on November 14, 2018 [3 favorites]

Just for fun, here's some random VistA code.

Ah, I see they're writing and querying XML files from MUMPS. How nice.

/checks wind, pulls halyard, sails away on a close reach and is never seen from again
posted by RobotVoodooPower at 10:20 AM on November 14, 2018 [8 favorites]

Great thread, learned much about why I don't want to work at EPIC.

Skimming the Wikipedia entry on MUMPS, I get the feeling that the only reason why so many healthcare IT companies use MUMPS is because so many healthcare IT companies already do so, and because it's easier than translating everything into a modern programming language.
posted by ZeusHumms at 10:22 AM on November 14, 2018

I found some MUMPS code for interpreting MUMPS code once. Also, MUMPS code for generating SHA hashes.

One difference between VistA and Epic is you can pay a small army of consultants who have experience implementing Epic at different sites. And when you implement Epic, you have a vendor that provides support and you can pay to do novel development or walk you through configuring it. Probably no such thing exists for VistA. Like, there's a ready to go Epic app for patients to log in to their patient portal on mobile. Is there a comparable VistA app?
posted by BungaDunga at 10:27 AM on November 14, 2018 [1 favorite]

I remember first learning about MUMPS via the daily WTF good lord, 11 years ago now. So far my proudest professional moment was advising a cousin to stay far, far away from a mumps shop.
posted by Kikujiro's Summer at 10:28 AM on November 14, 2018 [2 favorites]

I don't mind that it's all in MUMPS as long as I get to actually write some of the MUMPS myself. Waiting for IT staff without any medical experience to implement my simple ideas is frustrating.
posted by adoarns at 10:52 AM on November 14, 2018

All computer languages used to look like this - it's like an optimization game to see how much computing you can jam onto a single line, even if it takes another expert an hour to understand and modify it.

M doesn't scare me. I use Perl in production.
posted by mikelieman at 10:53 AM on November 14, 2018 [2 favorites]

BungaDunga, how do you maintain a thing like that? It seems ... difficult.
posted by Mr. Excellent at 10:57 AM on November 14, 2018 [1 favorite]

I design and code for our regional integration engine. I live in EDI/HL7/XML/X12 all day long. AMA about wanting to shrivel up into a ball and roll myself off a cliff.
posted by WinnipegDragon at 10:57 AM on November 14, 2018 [5 favorites]

Why don't more places use it if it is free?

There's a bunch of modules that need FDA certification ( imaging, IIRC is one ) so there's a bit gap between "download it and figure out how to spin up a VPS/Container to hold it" and "ready for production use."

So you can't really just install and go.

I have to limit the attention I pay to the implementation and coding issues on the Hardhats Mailing List beacuse it really does drive me nuts, the untapped potential.

(Oh, and M is just the backend. The Frontend IIRC is still written in Delphi .
posted by mikelieman at 10:58 AM on November 14, 2018

Holy balls. MUMPS is like if someone looked at brainfuck and thought "well, it's a good idea it just needs some quasi-English words to make it easier to use!"

I think burning it all down and starting from scratch using a real programming language instead of a bad joke invented by some sadists would be a good start.
posted by sotonohito at 11:18 AM on November 14, 2018 [3 favorites]

BungaDunga, how do you maintain a thing like that? It seems ... difficult.

As far as I can tell, Epic simply shovels manpower at the problem. They have a voracious appetite for software developers and quality assurance testers.

I've no idea how the VA does it.
posted by BungaDunga at 11:19 AM on November 14, 2018 [3 favorites]

QUIT:$QUIT QUIT QUIT ; (quit)

Imagine looking at that on your work screen
posted by thelonius at 11:23 AM on November 14, 2018 [23 favorites]

Oh, and the other other fun part about MUMPS is the database. It's so old that it's prerelational. Everything's done with B-trees, that are transparently pulled off disk when you ask for them and put back when you write to them. So that's sort of cool, for 1970's technology, but it means that pulling data out requires writing MUMPS. No SQL joins for you. It means some things are quite fast, if there's an index; everything else is slow, and adding a new index is approximately impossible.

Epic tried to build a declarative DSL for queries- implemented by a little interpreter coded in MUMPS- but it's worse than MUMPS. There's a flowchart, which looks like something out of cstross' Laundry books, and probably could be used to summon demons.
posted by BungaDunga at 11:24 AM on November 14, 2018 [3 favorites]

That's just a new user of vi
posted by advicepig at 11:24 AM on November 14, 2018 [11 favorites]

...There is no way to highlight the eight I want, or hide the rest...
posted by basalganglia at 10:00 AM on November 14

The most annoying thing about Epic is that everybody's version of it is different. Like, not "everybody" as in "every hospital" (though that's true too) but "everybody" as in "every user". I'm an administrative assistant, non-clinical, and I think this ought to mean that I see what my doctors see when I log in (but without permissions to e.g. sign orders) so I can help them like I do with literally all other software in the world. But no.

So, I know how to customize my Epic screen (click the Epic logo, then Personalize, then Customize Your Toolbar) but I don't know how to tell you to customize yours, except that it can, probably maybe, be done.
posted by joannemerriam at 11:24 AM on November 14, 2018 [4 favorites]

How much would it cost to develop a replacement for Epic?

Epic is getting a lot of hate in this thread because it was the one mentioned in the article, but having worked with a few others EHRs -- including Cerner, McKesson, and (shudder) MediTech -- Epic is actually the most user-friendly. I'm speaking as an ED RN, so YMMV.

I've not used VistA so unfortunately I can't comment on that system, but compared to the other systems I've used, Epic does a decent job at the two core concerns of any EHR, specifically about how easy it is to find the stuff I need to document, and then actually complete that documentation. The most cumbersome systems I've used tend to fail at the first concern less by making stuff hard to find, than by giving the user a half-dozen different ways to get to whatever form needs to be filled out, leading the overall user experience to be one of constantly feeling like you're muddling through and never really being sure if you're doing something the correct or optimal way. The desire to be able to get to anything from anywhere also tends to lead to a confused mess of icons/links which end up just being clutter.

For the second concern, EHRs are infamous for their "death by a 1000 clicks" interfaces. Cerner, for instance, is notorious for this. If I want to document a required assessment (e.g., a GI assessment) on a patient, one way I can do this is to find the patient on my "dashboard" list of patients I've sign up for. Then go to an icon for pending tasks, clicking on that opens up a list of uncompleted tasks, from which I can then select the "document" icon for that assessment (or any other task I want to queue up to complete), then click the "document" button to actually go fill out the assessment. This pops up the form to fill out (which is basically just a fancy spreadsheet, all EHRs are, at their heart, fancy spreadsheets). I then double click the column header to open up a new assessment at the current time. This is an example of what I'm seeing at this point, from a Cerner training module. Each one of the column cells will pop-up a new window of check boxes. Once, I'm done filling out whatever cells are required and/or relevant, I can click a tiny check-mark up in the left hand corner to "sign" my documentation. I then need to refresh manually.

That's a bunch of fucking clicks just to say that my patient feels nauseous and has vomited twice today, but is otherwise within normal limits for GI status (soft, non-tender, non-distended, passing normal stool, etc.). In Epic, for comparison, I can open the patient chart from a similar dashboard, click the "GI Assessment" on my quicklist of most used assessments, which then automatically opens a new window with the current time/date auto-filled and presents the same sort of assessment options in a single window, which autosaves when ever I click out of it.

So yeah, EHRs are awful, but some are more awful than others, and all are superior to paper. I know some MDs seem pine for the Good Old Days when they could just focus on patient care, but scratch the surface and they too will agree that paper charting was a nightmare of inefficiency. I think there may be an element of MDs having the mythology of their profession being wise sages whose handcrafted, personalized, small-batch, organic, artisanal patient notes reflect the summation of their sagacity punctured by a brute uncaring computer system which only cares about standardized measures comparable across thousands, if not millions, of interactions. Realizing you're just a cog in the machine is not pleasant. Younger/Newer physicians who have only ever used EHRs tend navigate them better and with less stress and grousing.

Better customization can help solve some of these problems. The thing I always hear about VistA is that its was built by clinicians, for clinicians, and thus is very intuitive for them. I'm lucky enough at the facility where I use Epic to have a team of designated RN superusers who can quickly make changes on a non-systemic level (e.g., change the layout of a page, rewording an item, etc.), AND are good about showing people how to customize their interfaces. I work at a large, well-funded hospital with more resources than most though. So when basalganglia complains about how "there are THIRTY-EIGHT different tabs in the sidebar" I understand, but I also know that I customized my view to collapse the ones I don't use (or use infrequently) under a "more..." option and then re-ordered the rest to reflect my workflow. The problem is that every single version of Epic or Cerner or whatever, is specifically tailored to each institution with myriad little changes and permissions, so my experience may not be reflective of others. VistA, if rolled out on the same scale as Epic or Cerner to the disjointed, idiosyncratic mass of health systems, might also end up with the same non-optimized experience for clinicians.

Then, of course, there's this passage:

In building a given function—say, an order form for a brain MRI—the design choices were more political than technical: administrative staff and doctors had different views about what should be included. The doctors were used to having all the votes. But Epic had arranged meetings to try to adjudicate these differences. Now the staff had a say (and sometimes the doctors didn’t even show), and they added questions that made their jobs easier but other jobs more time-consuming. Questions that doctors had routinely skipped now stopped them short, with “field required” alerts. A simple request might now involve filling out a detailed form that took away precious minutes of time with patients.

I've highlighted the absentee-ism of the physicians from this process because it reflects in many ways my own experiences with physicians being absent from a lot of the administrative humdrum background stuff, which, in this case, has come to bite them in the ass. Collaboration and customization can go a long way towards building a system that makes clinical work easier, more accountable, and more accessible, but that only works if everyone feels they have equal investment in building the system. There's really no way to smoothly integrate doing an abdominal exam with tapping away on a computer, but the charting still needs to be done. The stereotype of the physician saying that "all this paperwork just gets in the way of me doing my job," is fairly shortsighted; that paperwork is your job. Nurses have it drilled into them from Day 1 that "if you haven't charted it, it wasn't done," and while I'm sure physicians get the same mantra thrown at them, it does always seem they take that part of the job -- the boring, mundane administrative work -- less seriously and see it as an impediment to their "real" work.
posted by Panjandrum at 11:41 AM on November 14, 2018 [21 favorites]

Oh, and the other other fun part about MUMPS is the database. It's so old that it's prerelational. Everything's done with B-trees, that are transparently pulled off disk when you ask for them and put back when you write to them. So that's sort of cool, for 1970's technology, but it means that pulling data out requires writing MUMPS. No SQL joins for you. It means some things are quite fast, if there's an index; everything else is slow, and adding a new index is approximately impossible.

I believe that issue was fixed, but using InterSystem's db. The underlying structures are B-trees still, but you need never think about that and even use JDBC from a java app.
posted by mikelieman at 11:48 AM on November 14, 2018

Panjandrum, I hear you. I agree that clinicians are often not part of the decision-making (usually because we're trying to see patients), and that has come to hurt us in the end. Those 38 tabs I mentioned, for instance? They are not the actual sidebar (which yes, I've customized to just the top 5 with the rest hidden under "other") They are the 38 tabs/quicklinks/whatever they are called within the Visit Navigator, which best I can tell is not customizable.

I got pretty worked up in my last comment and never finished the thought about having used computers since preschool. Point is, I'm supposedly a "digital native" and I find Epic frustrating because it is not designed with the end user in mind. I didn't mind it all that much in residency, but whatever version of it my current hospital has bought is actively terrible. I want to look at and speak to my patient, not a damn screen.

I've used CPRS (the GUI version of VistA) and while it is not pretty the way Epic is (and sounds like MUMPS, which I legit thought was a joke when it first came up in this thread, is even uglier), it allows me to write a meaningful note and place orders with a minimum of fuss, which Epic definitely does not. But yes, Cerner and Eclipsys (which my medical school used, I think it was homegrown) were worse.

that paperwork is your job
Nope. My job is to diagnose and treat. The paperwork is a means to the end, not an end in itself.
posted by basalganglia at 11:56 AM on November 14, 2018 [8 favorites]

To jump WAY back to the comment about designing Alexa skills for physicians:

This is useful but ONLY if significant improvements are made to voice recognition systems, specifically with respect to female voices, more specifically with accented female voices.

My mom is a retired radiologist with a mild Southern accent. Back in the day they used to dictate case reports to mini audiotape and an army of transcriptionists would type them up. Then the hospital got rid of all the transcriptionists and replaced them with an automated voice to text software program. The radiologists dictated their reports and were then responsible for correcting all errors in the interpreted text. You will be shocked, SHOCKED, I tell you, to know that her transcripts had 4-5 times as many errors as the transcripts of her male colleagues. She had to spend hours more per day correcting transcripts than they did. Because the software was trained on many fewer female voices.

Even now, the Echo in her house misunderstands her more than anyone else in the family. It understands me pretty well, but I've been out of the South for long enough that I've lost the accent. When we visit, my mom is apoplectic on a regular basis that the Echo understands my 4 year old better than it understands her.

It's not like she has a particularly thick accent, or uses strange grammatical constructions, or anything. She's just a lady with a specific voice that voice recognition systems aren't trained for.

So this is definitely a thing that needs addressing before unleashing a fully voice-recognition based medical record system on the world.
posted by telepanda at 12:36 PM on November 14, 2018 [14 favorites]

I used to work as an audio typist for the NHS and we basically have a system where electronic stuff on a database is duplicated in paper notes. I used to spend ages filing in the massive health records room in our hospital which had all the living patients' notes, great big bulging folders stuffed with letters from appointments, nursing notes, pages fluttering with stuck on lab results, multiple volumes for the very ill or old which were rubber banded together. When someone dies you stamp DECEASED on the cover of the notes with a great big red stamp which, if you're a band 2 audio typist, is pretty much the biggest power trip you will ever get. The dead people's records are sent to a special off site storage room.

.... So yes I was a typist, which is a job you might think wouldn't exist now but which was and indeed is the NHS's way of getting around the doctor screen time conundrum. After every appointment they dictate a letter which is uploaded to the typing queue which you, invariably a woman, open, your headphones stuck in and a foot pedal stopping and starting the recording, listening to a dr's mumbled account of an appointment while an 80s radio station blasts in the background. After you click finish, the Dr checks verifies what you typed, a copy of the verified letter is uploaded to the online system, then you file the printed letter in the notes if you still have them. If not you track down wherever the notes are, and phone and put on your best polite voice in the hope that the clerical officer on the other end of the line will take mercy on you and send the notes back.

The most stressful part of my job was sorting the post, which included all our lab results, colour coded: red (haematology), green (biochemical medicine), purple (biopsy results). I should say that the results are also electronically uploaded to a database - but requesting drs might not be alerted/ignored alerts, as I understood it. There is a lot of room for human error in this sort of thing. I always felt like I was one stupid filing error from someone not finding out they had cancer. I should emphasise that I was objectively not good at my job - I worked with women who'd been there for decades, they knew the ins and outs of the hospital and knew exactly who dealt with what. Experienced typists know the way round all the incomprehensible medical jargon in their specialty and are familiar with the names of medications etc. I was just guessing, or I'd stop the recording and ask my (v experienced) office mate to listen.

The whole time I worked there I kept thinking - surely this is a job which should be computerised out of existence? But until transcription software is better at dealing with accents and terminology it's work that needs to be done, and if you don't want clinicians doing clerical work (and you don't, I certainly don't want my doctor stuffing envelopes or typing, or my nurse worrying about filing) then someone has to do it, so you employ a clerical officer earning 17k/year rather than an expensive consultant who has other things to do.
posted by the cat's pyjamas at 12:48 PM on November 14, 2018 [7 favorites]

I believe that issue was fixed, but using InterSystem's db. The underlying structures are B-trees still, but you need never think about that and even use JDBC from a java app.

Epic has its own in-house database organization layered over the raw B-trees, and definitely has some bindings. But that's only good for the x% of the frontend that's been developed in C#, the rest is VB6 calling stored procedures. It also supports read-only SQL mappings, so you technically can write reports in SQL, but it's only external reports that do that, nothing displayed in the system uses it, because it's not live data.
posted by BungaDunga at 12:56 PM on November 14, 2018

and at some point a "MUMPS Server Language" was considered

It shall not be spoken of! We cast thee out for mentioning the Beast!
posted by Abehammerb Lincoln at 1:17 PM on November 14, 2018

Fancy sales lunches with executives can only explain so much.

Oh, I don't know. That can explain a lot. Not well, mind you, but accurately.
posted by Abehammerb Lincoln at 1:19 PM on November 14, 2018 [5 favorites]

Fancy sales lunches with executives can only explain so much.

Well there's probably golf games involved too.
posted by octothorpe at 1:21 PM on November 14, 2018 [3 favorites]

Also -- sorry I can't let this go apparently -- in addition to the cluttered interface and "death by a thousand clicks" of Epic, it actively hinders medical student and resident education. I don't do inpatient medicine anymore, but when I used to round in the hospital with the team, no one ever makes eye contact, because all eyes are on screens. I was guilty of this too, when I was in training. A presentation is less a presentation and more a recitation of various pieces of information spat out by the computer, with little to no effort to integrate into something meaningful. It's become less of a tool and more of a crutch.

Example: I recently did mock orals for my institution's neurology residency program. (Oral boards don't exist any more for neurology, but it's a good way to present a hypothetical case to the resident and see how they would approach it as if they were in practice.) If a resident says they would start Medication X, I ask "OK, so how would you tell the patient to take it?" And one resident -- about to graduate our program in June -- said, "Oh, I'd just do whatever Epic told me."

Reader, I failed him.
posted by basalganglia at 2:08 PM on November 14, 2018 [10 favorites]

Going back to your previous comments, *basalganglia*, any given EHR can be hard to judge on its merits given that different roles, and even different departments, can have radically different views. This makes it difficult to discern whether any given shitty interface is intrinsic and immutable, or just the result of poor optimization for a specific role.

I very much do not agree that documenting is not your job though. I may have a couple great story ideas floating around in my head, but until I right them down, I'm not a novelist. You may have the world's most accurate diagnosis and genius plan of care, but they're nothing until you write them down and support them with assessment data. EHRs are tools for doing that, and imperfect as they are, it's still work that needs to be done. It's work I do while still seeing and caring for patients (which is also my job).

Saying it's not your job just means it's going to become someone else's job and then we end up with physicians complaining about poorly designed systems that they didn't bother to show up at the design meetings for. You would, presumably, want to have maximal input about any other tool used in your practice.
posted by Panjandrum at 2:26 PM on November 14, 2018 [8 favorites]

Panjandrum, for sure accurate and meaningful documentation is part of my job. I need to be able to summarize and synthesize my thought process and recommendations for the patient, for the referring doc, and for myself when I see the patient in follow-up.

Thing is, Epic doesn't prioritize any of that. 90% of any given note in Epic is regurgitated information that is only thrown in for the purposes of bean-counting. That's not accounting for the scourge of copy-paste; that's just the way templates are structured. For instance, if I write out family history in narrative format without clicking through the badly designed family history matrix in Epic, that "doesn't count." If I don't review a problem list bloated with junk like the UTI you had in 2004, that "doesn't count." And because it's harder to remove things like the 2004 UTI than to just hit the "reviewed" button, the problem list gets obnoxiously long to the point where it's meaningless rather than meaningful. Med lists are ridiculous and frequently inaccurate, particularly in my specialty where people might take 2 pills at 7, 1 pill at noon, 2.5 pills at 5, and 0.5 pills at bed, but the med list just says "1 pill six times a day" because that's the only way Epic knows how to do it/it's quicker for the prescribing doc to click off the 1 and 6 boxes than to actually write out what the patient is taking and when.

I honestly didn't mind Epic when I was a resident -- maybe because I was just trying to keep myself afloat and barely had time or mental energy to think about how fucked up it was that I spent 5x more time interacting with a computer as with a patient. But now that I'm an attending and the buck stops with me, I really care about accurate, timely documentation that actually communicates in a way people can understand. If you can give me an electronic medical record system that will let me do that, I will shower you with rainbows and puppies.
posted by basalganglia at 2:50 PM on November 14, 2018 [6 favorites]

Ugh. I spent a year working at hospitals and clinics in NY as a dietetic intern, and I came away with the assumption that hospital EMRs are sold on the golf course, EMR executive to hospital executive. You can't make me believe that anyone who has to actually use the systems is ever part of the decision process. And from what I understand, since the EMR companies can charge to train staff on the software, there's no incentive to make it intuitive.

It couldn't even do simple stuff -- you want to see a patient's cholesterol levels over time? Wouldn't that be nice in a chart, a line graph or something? Sorry, here's long list of numbers.

At one site for every visit we had to fill in a patient's height and weight, and then pull out a calculator and calculate their BMI and ideal body weight. Like, it's a computer! Its basic function is to compute! And how about the computer show me % change in body weight from last visit rather than making me look it up and pull that calculator out again?

Everything about those systems seemed designed to make our work harder.
posted by antinomia at 3:37 PM on November 14, 2018 [6 favorites]

I had to get my latest prescription from a pharmacy that I no longer use because the doctor couldn't get the computer to fill it at my preferred pharmacy.

I can't stress enough how much the US has the greatest healthcare system in the world - until you actually try to use it.
posted by dances with hamsters at 3:52 PM on November 14, 2018 [1 favorite]

What the hell is an LDA?

Lines, drains, airways. I use this tab daily, but I work in an ICU. (It frequently contains interesting info like that a patient has a peripheral IV that's 1043 days old because no one removed it from the list.)
posted by obfuscation at 4:29 PM on November 14, 2018 [5 favorites]

It frequently contains interesting info like that a patient has a peripheral IV that's 1043 days old because no one removed it from the list.

But everyone who opens the chart probably gets a popup to remind them to document why the patient needs an IV after 1043 days; that is promptly ignored because no one actually reads it, they assume it is a bug of some sort, or they know it needs to be removed but they don't have the time to go back 1043 days in the chart and fix it (which is not likely to be a trivial task; at the very least they would have to figure out when the IV was actually removed).
posted by TedW at 5:08 PM on November 14, 2018 [5 favorites]

I'm also a nurse and I've used both Cerner and Epic. Epic is way better than Cerner. And Epic has training for physicians so they can make their own changes to the EHR.

Hospitals don't have money to put into big IT staff so changes get made slowly. And no two cardiologists can agree on how they want things, so they end up making twice as many changes. EHRs work best in hospitals that have standard procedures for things. Then hospitals cheap out on training at go live giving the shortest possible training with temporary employees who don't know your workflow and are not nurses or doctors.

Unfortunately EHRs are not built for physicians or nurses or for the patients. They are built for billing and for meeting regulatory requirements. Doctors notes need templates so we can prove we can bill for that level of office visit. Nurses have to chart for hours every little detail of care to prove we met CMS requirements and DOH requirements and JCAH requirements and hospital policy etc... until we change the way billing is done and change unneeded regulations EHRs will be a mess.

But I never want to go back to the days of paper charts, trying to read people's scribbles and running around asking who has Mr Diego's chart?! Back then we wrote one paragraph per shift about the patient, instead of five pages we do now.
posted by SyraCarol at 5:09 PM on November 14, 2018 [7 favorites]

I just came to the realization that this has become the venting thread for medical people. Maybe we should move it to MeTa?
posted by TedW at 5:10 PM on November 14, 2018 [2 favorites]

I guess I will be one of the very few health care people who feels that Epic is fine. I use it every day. Yes it's a lot of clicks, yes it can be annoying, but I find EMR system vastly superior to the confounded paper charts that we used in my residency. Gone are the days when you have to try to decipher the inscrutable handwritings of the previous doctors as the patient is crashing next to you. One HUGE advantage is that all the patient databases of the major hospitals in my city are linked and records are available at a click (okay, a few clicks) of a button. Want to know what surgery was done two months ago and what was found there at outside hospital and the patient doesn't remember? Click, and you shall know. As someone who works in inpatient settings instead of clinics, I never use computers during patient encounters and can avoid the dehumanizing aspect of divided attention between screen and the human being in front of me. And to be honest, the documentation requirements are not that onerous and I find that the processing of typing my thoughts out is a good opportunity to think through the plan for the patient and make sure nothing else is missed. Just my two cents.
posted by Pantalaimon at 8:39 PM on November 14, 2018 [3 favorites]

Guys, the problem must be with the doctors, because I know for a fact that everyone at EPIC is really smart. I know this because when I interviewed with them, the first step was an online IQ test.
posted by qxntpqbbbqxl at 12:05 AM on November 15, 2018 [8 favorites]

I've no idea how the VA [maintains VistA].

In my case it was with a lot of weeping and cursing and moving over to the Java/Oracle side of things as fast as was humanly possible.^*

It was a bad sign when on my very first day I was sitting next to one of the veteran MUMPS programmers who couldn't figure out why his code was only affecting every other record. I--the brand-new guy who hadn't seen MUMPS before, mind you--pointed out to him that he was incrementing a counter twice in the loop he'd written.

^*Of course, that project wound up getting so behind schedule and over-budget that I eventually snapped and quit to go back to school for a BA in theatre because that's where the money is cue laughter and bitter weeping. I spent two and a half years at that job and wrote maybe two hundred lines of code.
posted by Mr. Bad Example at 2:04 AM on November 15, 2018 [2 favorites]

I've had several biology students who worked as scribes in Atlanta hospitals. They tend to enjoy the work and get great exposure to the ins and outs of various healthcare careers, which is really good experience for students. It pays well and the scheduling tends to be very compatible with going to school. The only downside is it has to pay well so you get people who do a good job, and obviously that eats into the profits of our for-profit healthcare system. There is no possible solution to this.
posted by hydropsyche at 6:44 AM on November 15, 2018 [5 favorites]

just a week ago I had an appointment with my doctor for a check-up. She has been my doctor for years, and I really appreciated her and her ethic. I tried many doctors in the past but most of them were only interested in my money. But SHE would give me the time and all her attention.

The other doctors didn't use a computer, so each time I visited they wouldn't remember me, and the first thing they used to do was to prescribe unecessary medicine. SHE used a computer which helped her have my health history and accompany me through different health issues.

Well, last week, she told me she will be quitting and that the reason is the unmanageable stress. She spends hours each night on her computer to get everything prepared for the next day patients, and she was exhausted.

That made me really sad, because I like her a lot, and I don't know if I can find a good doctor like her. With all the technology,softwares, automation algorithms and health startups out there, I am a little bit shocked doctors have to still spend a lot of time on their computers. A real waste!
posted by sophieJu at 7:47 AM on November 15, 2018 [2 favorites]

Where I work we have Cerner rather than Epic, though I used Epic as a fellow. I found the Epic templated notes impossible to deal with, for reasons others have already mentioned (too much info, impossible to find what you actually need). Cerner has plenty of issues, but we currently have the option to dictate our notes, which most (older) doctors do faster than type, though this leads to less uniformity in data presentation, and I think this means we don't spend time staring at the computer rather than the patient. I dislike Cerner but it doesn't take up all that much of my time, possibly because I'm a surgeon. I don't find Cerner's presentation intuitive but I certainly don't hate it enough to spend time going to meetings to address it rather than seeing patients or operating.
posted by n. moon at 10:20 AM on November 16, 2018 [1 favorite]

I feel very mixed about this article. I work in a public hospital that currently utilizes 4 different EHR systems AND still uses paper in some clinics, as well as a sort of informal para-EHR for some programs connected to the hospital. Some of the EHRs we use really suck (NextGen which I guess is designed for clinics but seems to mostly be for safety net clinics is the most piece of shit cobbled together un-usable, un-readable garbage, for one example). Some systems are good (the Wellsoft ED software is really simple and super easy to use for that fast paced environment but wouldn't work in any other department). Using several different incompatible systems is a nightmare. We're in the process of moving everything to Epic, at great expense, and although there's lots to fear, I can't wait.

I see EHR software as serving multiple intentional and unintentional functions. Some of these suck, some are good.:

- It make care more uniform & makes evidence based practice easier and quirky out-of-step practice harder
- It forces you to complete certain functions you may prefer to outsource (for docs that includes administrative functions once pushed to admin staff or nurses).
- It is a CYA for our litigation culture (nursing documentation seems to mostly be this)
- It is a tool for surveillance and discipline from the managerial class to the workers
- It allows patients much better access to their own information, and facilitates communication between healthcare providers across and between systems

The final point is a very big deal. I can easily support the complex healthcare needs of my two elderly parents and my teen daughter because of the ease of the Epic patient interface - checking test results, emailing doctors, scheduling appointments. For medically complex patients, it's a huge boon to safety. This story is right on: “The care of the homeless population of Boston took a quantum leap,” he said. With just a few clicks, “we can see the fact that they had three TB rule-outs”—three negative test results for tuberculosis—“someplace else in town, which means, O.K., I don’t have to put him in an isolation room.” It also means we can find out if the patient has a social worker somewhere. If he's got untreated hep C or if she is taking long acting medications that may interact with something we're going to give in our ER. This aspect can't be appreciated enough.

I think Gawande puts a bit too much blame on the EHR that should fall on absurdly short appointment times and a medical culture focused on billing and avoidance of lawsuits. But indeed, I agree that there are inherent aspects of EHR use, especially Epic which is massively focused on tracking, monitoring, quantifying, and metric-izing every aspect of health but also every aspect of performance of the user, that is just a really problematic amplification of a culture of managerialism. It makes us miserable and it should. Even as I recognize there are benefits to knowing quickly if one doctor kills more patients, or if one nurse never does his charting on time.

But I think the sort of biggest resentment expressed in this article which I find problematic is that what's sort of being discussed without being said is that in the past, doctors could use nurses as secretaries, and no longer. The boring work is shared more equally. Sure, I want a scribe too. But now everyone must experience the drudgery of tedious tasks. I'm all for removing unnecessary tasks, but if we need them, I say let us share them. Put in your own orders doc - I'm a nurse not a typist.

In our Epic build, I've been really appreciative of their implementation process: we all sit in a room together, doctors, clerks, billers, nurses, and hash out what the software should look like. That's not a weakness, that's a strength. To the extent that they let middle managers make calls in that room, it fails, but when you have the person who has to schedule appointments getting equal voice with the chief of surgery, that's a Good Thing. We all work in this organization together, and you better believe the place will fall apart if the clerk can't do her job because the software is designed badly for her needs.

To me, this article is most compelling where he focuses on the existential problems with software that are not specific to medicine in particular. Typing everything is slow. Clicking is slow. Copy/paste is terrible in this context. These are new kinds of work created in the software age that make all workers who have to use computers lives' harder. Surveillance is inherent in software as everything you do is recorded.

Anyway, I'm glad this article was printed, but I think there's more to EHRs than what he says here.
posted by latkes at 10:12 PM on November 16, 2018 [6 favorites]

Oh one huge ticking time bomb for EHRs is the potential for massive data breaches and the already realized possiblity of extorting hospitals financially by stealing our medical history.
posted by latkes at 10:27 PM on November 16, 2018

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