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Comment by oomkiller | Hacker News Reader

Unfortunately the problem is much greater than engineers not understanding doctors and other clinical staff, in my experience. For startups that want to sell to health systems and similar-sized/larger entities (really this is the minimum size that can work for most startups, practice sales usually have more friction than value), you unfortunately have to focus on the buyer, which is very rarely someone who is "in the trenches." Best case scenario, having software that is compelling to the end users can help you get your foot in the door early on, but actual adoption will only happen if you can convince the business stakeholders of your value.

In the US healthcare system, clinicians and the business often have opposing objectives and values. This is starting to change with value based care becoming more popular, but it's still all about providing what the business wants, it just happens to align with the clinicians more these days. You'll still need to support IE9 due to that botched Vista upgrade, build out a custom EMR integration, and deliver whatever random feature the sales folks promised (can you automatically fax things?) before you can move on to the features that the clinicians actually want.

The system itself is how we ended up with billing-driven documentation EHRs like Epic. Paradoxically, due to massive adoption, I think Epic and Cerner are some of the only places where real innovation could happen. I think even huge companies like Apple, Amazon, and Google will have a hard time breaking into the space, no matter how much cash they throw at it. For them, the only answer is to go fully vertical like Kaiser-Permanente, but I doubt they have the stomach for this.

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I'm sure I'm being naieve, but could we just get rid of billing altogether if we nationalize the health care system? I have to recount an anecdote. My mom was hiking in a foreign country, and got injured. She hobbled to the next town, and found a clinic. They treated her and were ready to let her go. She said:

Q: Okay, how do I pay?

A: You don't pay for health care.

Q: I'm American. I'm not part of your health care system.

A: That's all well and good, but we have no way of knowing how much to charge you, how to take your money, or where to send it. Have a nice vacation.

The clinic probably maintained some accounting records, but they simply had no billing system.

Somebody will be paying, and will want adequate and auditable documentation about what they are paying for. The potential for fraud is too great. Medicare and states all have to watch for fraud in their claim payments.

Right, but it’s probably done by auditing resources to treatment records. The actual patient needn’t be involved. And in countries like Canada you may end up with multiple operating agencies that are competing for efficiency, such as Coastal Health vs Providence, even though ultimately it’s the government footing the bill.

Providence is under Vancouver Coastal health. The authorities aren’t competing with each other (well, not really) as they have their own geographic catchments.

Right, but they're able to be audited against each other, even though they have separate geographic catchments. Significant discrepancies can be then analyzed.

Folks who view single-payer as a system without checks need to know how those checks do in fact occur.

That's true. But I think the system could be simpler if there were fewer, and possibly just one, entities. I work in a factory, so we live by SAP. And it's complex, typical "enterprise" software, but I don't think it's even within an order of magnitude as complex as Epic.

We want an audit trail, but most of the transactions are made within a single business entity, e.g., from the stockroom to an assembly area. We've had process improvement projects that reduced the number of SAP transactions required to make something.

So maybe the key isn't so much having a government run system, but simply reducing the number of entities. For instance a hospital doesn't have to make a claim to Medicare, if the hospital is Medicare. Also, the game of figuring out how much to bill the patient goes away.

We don't even know how many entities there are in the medical system, or how much money is going to each one. Were I inclined towards cynicism, I'd suspect that this is by design.

If we had a national healthcare system the documentation would consist of proof of citizenship or permanent residency (or guardian's proof of same in the case of minors). That allows spot-checks to validate that fake or deceased people aren't being "treated" to generate fake charges.

Right now even Medicare/Medicaid need lots of process to verify you are eligible and/or enrolled. That wouldn't be a problem if everyone were covered automatically.

Sure, but adequate and auditable documentation need not involve the patient nor money. Just a "here is the medical care we dispersed, on this date, to this person, it took these resources, these people administered the care." No following up every record for payments, no arguing with insurance companies over the price.

And also, what abuse? If medical care is free and drugs are cheap, the only real abuse is drug abuse (by either seekers or medical personnel). With free access to proper care those drug abuse problems will sharply decrease, killing the market (the cause of the other half of drug abuse).

The only reason there is medicare fraud to worry about right now is because not everyone is supposed to be on it, the "fraud" is attempting to get free health care. Which wouldn't exist if everyone had it.

> And also, what abuse?

a clinic could mis-report (over-report?) how many patients they treated, and/or the procedure. They can then claim back more money than they actually spent, netting easy profit.

Solved by not allowing money to enter the circle. Results in you needing to sell the drugs/things you overcount on, which is rather easy to track and find out.

> Solved by not allowing money to enter the circle.

This is not possible without socializing the entire economy. At some point, you have to pay doctors, nurses, staff, equipment manufacturers, etc.

If they are public employees, they have sort of a standardized salary coming straight from the healthcare ministry/department/whatever where the specific hospital just administer the HR part. You still think in a for profit manner, where healthcare in most countries is not a for-profit endeavour. As long as it works, it's fine, even if it's a net negative. You try to limit the money you waste and inefficiencies, but not by pulling levers on the staff salaries.

>You still think in a for profit manner, where healthcare in most countries is not a for-profit endeavour.

And in the US it's not.

Assuming that you can simply remake a massive chunk of the economy (hospitals, doctors, nurses, clinics, etc, etc) to be government owned is silly. People will protest, lobbyists will be paid and it won't happen. If your only solution to the problems people point out is essentially magic then, no, it's not a valid solution.

Audits. Monitoring of anomalies. Multiple traps.

That happens with the current system

Some years ago, I met a doctor on vacation - bit of an ass, but whatever

Last year, I found out he’d gone to prison for “performing procedures” that he was mot present for, including some whilst he was on the beach in Fiji with me!

So, the federal government already has procedures to catch cheats at every level.

This happened to me. When I first moved to Boston I went to a new dentist who kept remarking how great my dental insurance coverage was. It turned out I had a cavity which was fully covered by my insurance so I went to his office, got the novocaine shot and spent an hour with the guy supposedly drilling in my mouth. I saw the dentist for about a year and had three cavities. The only three I'd ever had in my life.

A year or so later I switched to a dentist who was closer to my office. I told him I had had three cavities but they weren't showing up on the x-rays he took. We did two or three sets of x-rays before we figured out they were never going to show up because he had just been billing my great insurance for work he didn't actually do.

> If medical care is free

It is never "free" (almost nothing is). Costs are usually covered through (forced) mutualization (usually through taxes).

If you are that strong a believer in the evils of socialism do you avoid Freeways, airports and the internet?

All of which depend on public subsidy.

1. Noone said anything about the evils of socialism.

2. Why do you expect people to refrain from using services they've been forced to pay for?

Generally because stating it as "being forced to pay" often comes with a hint of it being wrong.

So the question could have been: do you think we should have free/socialized streets/hospitals? If not how do you think they are different?

I'm not the GP and think we probably should have more socialized hospitals.

But suggesting people who oppose publicly funded freeways should boycott publicly funded freeways is silly.

Imagine an office Christmas party where everyone is told to chip in for refreshments and then the refreshments will be whatever the boss ends up buying with that money. I may not like that arrangement, and may prefer to keep my money and bring my own food for myself. But, given that I have to pay in, I feel no need to abstain from eating the salad that the boss ends up providing using everyone's money.

Right, indeed I think that in this situation eating the salad does not prevent you from criticizing the party.

But this is the point, you were "forced" to pay for something and you would be okay with not getting it. If only the people who paid for the Christmas party were invited that would be okay.

Do you think this reasoning should also apply to streets and hospitals?

(I am specifically referring to using the word "forced" and the moral implication of using it)

> Do you think this reasoning should also apply to streets and hospitals?

Probably not.

But neither do I find it hypocritical to utilize publicly funded medicine (since you already paid in) while also opposing it (because you would be willing to forgo it to avoid paying in). The opposition is perhaps cruel or inconsiderate of others, but certainly not hypocritical. People who construe it as such are either confused or intellectually dishonest.

The forced was a parenthesis, you're focusing on the wrong aspect of the message.

> If you are that strong a believer in the evils of socialism do you avoid Freeways, airports and the internet?

Well you are conflating a few things here, it not black and white. It is funny to see how stating something that seems obvious to me gets me downvoted and categorized as an extremist anti-socialism...

I see some evils in socialism, but probably not the one you believe. For instance claiming that healthcare is free in a socialist country is one of the most evil aspect of it. My main grief is that people treats it as something that they can waste and don't need to be careful about. Same for "free" universities: student thinking it is "free" don't have much pressure to actually take the most of it and be careful about their choice (let's do a first year of sociology studies after high school because I don't know what I really want to do, and then I can still do a first year of psychology studies, and I'll figure later what I'll do with all this...).

On the other hand, after growing up in France and now living in the US, I learnt that this is all not free and I consider this very previous for the French society. I won't advocate against these welfare benefits, on the opposite I think they should reinforced in many ways however I would like the state of mind of people to change with respect to these "free" benefits, starting by stopping to use the word "free".

As a concrete action, I would send the full healthcare statements to patients, showing how much it costs and how much the taxpayers money is offsetting. I was in the hospital in France multiple times, I have no idea how much it costs, I didn't pay anything as far as I remember, and didn't have a statement. The same approach can be used for University and other welfare benefit.

To me, this just sounds like something normal and beneficial, described in scary-sounding words.

I don't say it isn't beneficial (actually I agree with this, but I consider this more an opinion than a fact), the notion of "normal" is a bit subjective so I won't comment on this, but what did you feel was "scary-sounding"? I thought this was fairly stating something that should be obvious.

> Sure, but adequate and auditable documentation need not involve the patient nor money. Just a "here is the medical care we dispersed, on this date, to this person, it took these resources, these people administered the care." No following up every record for payments, no arguing with insurance companies over the price.

This is naive. The source of income (whether it's insurance companies, the government, patients) are not the people who actually buy medical supplies for the hospitals. The simplest way to commit fraud is to charge the insurance company (in a privatized system) or the government (in a public system) for large amounts of care for fake patients in fake cases, which is only caught if an audit shows a mismatch between claims and supply, e.g. a hospital claims that it dispensed 5,000 doses of a $10,000 drug but can only show a purchase order for 100 doses (leading the hospital to fraudulently get $499 million).

You would think that the way to deal with that issue is to vertically integrate, i.e. the hospital issues orders for medical supplies which it doesn't pay for directly, and the medical supply company is compensated in some other way, probably by government funding. But this turns into a government-run market and it has all kinds of issues. Without pricing as a guide, hospital doctors over-prescribe supplies whose real price is far higher than older but similarly effective alternatives. Drugs which the hospital didn't order, but are absolutely crucial for patient X, are either completely unavailable (if the official supplier doesn't stock it) or tied up in medical bureaucracy (to get a special exemption for a special delivery of the drug). The quality of patient care suffers as a result.

You know there are a hundred countries where this is a solved problem, right?

> The simplest way to commit fraud is to charge the insurance company (in a privatized system) or the government (in a public system) for large amounts of care for fake patients in fake cases

Insurance fraud is a problem for the insurance company. They deal with that already so it's not relevant here. And a govt hospital can be audited just like any other govt entity.

>Sure, but adequate and auditable documentation need not involve the patient nor money.

Since almost all healthcare in the US is private (hospitals, doctors, clinics, etc.) then, yes, it needs to involve money since all those entities will want to get paid. And, no, the government can't take it all over since everyone will fight it (and win).

>Just a "here is the medical care we dispersed, on this date, to this person, it took these resources, these people administered the care." No following up every record for payments, no arguing with insurance companies over the price.

This is basically existing medical billing without the follow through (what was done, why, when and by whom). Not sure why you think money (ie: paying hospitals, doctors, etc.) needs to be removed from the equation for it to work.

>The only reason there is medicare fraud to worry about right now is because not everyone is supposed to be on it, the "fraud" is attempting to get free health care. Which wouldn't exist if everyone had it.

Fraud is also doctors, hospitals, etc. billing for things they didn't do or didn't need to do.

From my Spanish Perspective.

What fraud? Going to the doctor is literally useless unless you're ill.

They will literally send you away home if they find you to be fine. The doctors and nurses and personnel and what have you will also get mad at you for wasting their time unjustifiably (and I've done this myself and oh boy they left an impression on me).

If you mean Government fraud, from the ones planning the system yes, indeed, all documentation about how much a healthcare center "costs", how their location and capacity is decided, and etc... should be open and easily accessible to the public.

Medication is partially subsidized and never given for free at a medical center or hospital unless it's an emergency, older than 65+, disabled, etc...

Recently, the government ordered to make like 1200 common meds cheaper (link in Spanish) https://cadenaser.com/ser/2018/12/29/sociedad/1546084258_187...

You're right that "patient"-doctor fraud is unlikely, but receiving unnecessary medication (addictive/fun/valuable drugs) or medical people overcharging or charging for unperformed or unnecessary procedures is a possibility for fraud.

But the personnel are salaried, not paid per procedure.

Most hospitals have on-call work, overtime, outsourced work, consumables that can be billed for etc. Pay cheques vary a huge amount depending on work done, and as a radiographer in a regional hospital my yearly wage was more than half made up by penal rates and overtime.

There's a balance though. A huge bureaucracy to stop all fraud is expensive and cumbersome. There's going to be an acceptable level of fraud in order to keep the administration costs of the system in check.

Other countries have figured this out. The US could use the experience of our allies that already have systems that are working to design a system for us.

I will see your anecdote and raise you one. :)

When I was an American military wife, I mostly just flashed my military ID, made an appointment, picked up my meds, etc.

I was diagnosed with atypical CF in my mid thirties and some of the things I was prescribed were not on the formulary of the military hospital. I went in town and had a co-pay of (IIRC) $13 per prescription. One day, I tripped across an old receipt: More than $1200 worth of pills with a $39 co-pay. Probably three months worth of digestive enzymes.

I was also seeing a specialist at a clinic at UC Davis Medical Center in Sacramento. I had been a few times when I noticed a sign prominently displayed on the front desk announcing that they would not see you if you owed money. I asked the person at the desk if I owed anything as I had never paid them anything at all. Surely, I owed some co-pays.

She checked my records. Nope, I didn't owe anything. I was all good.

Well, that was weird. But I was fighting for my life, so I shrugged and moved on with my life. I didn't have the energy to figure out what had happened.

Some years later, I was talking with folks on a CF email list and, silly me, I remarked that "I guess the CF Foundation picked up the co-pays or something." People vociferously informed me that, oh, no, that is not what happened. That's not something they do.

No clue why I was never billed at all by UC Davis Medical Center. But I (apparently* ) wasn't.

I don't know how the military handles it. But when I was a military wife, no, I generally did not see medical bills of any kind.

* I was extremely sick. It's possible my husband paid the bills and I just didn't realize it. But I don't think that's what happened.

Sorry, how is this relevant to what the OP comment posted? I don't follow...

We already have a healthcare system within the US where billing seems to mostly not happen. So, presumably, it isn't completely alien and foreign and something America would need to steal from elsewhere.

Billing definitely happens. And one procedure can trigger billing from multiple different providers. I had my appendix out a few years ago and received separate bills from the hospital, the surgeon, the anesthesiologist, and possibly something else (nursing?). I was able to get the hospitals portion written off ($~20,000 and I was unemployed and uninsured at the time) but no such luck with the other providers, and those bills and the collections agencies followed me for years until I could get them paid off.

That’s decidedly not my experience. I’ve certainly been presented with bills for every single thing I’ve done at a hospital, including visits that I was assured I would not be billed for. I’ve even spent months trying to work out arrangements with hospitals and insurance only to have my bills sent to collections. The thousands of people who file bankruptcy each year for medical bills would likely wonder what you mean, too.

Note the part where she said she was a military wife.

That is, the healthcare system she's talking about is the one provided to members of the military.

I see. I may as well add now, that’s roughly the experience I have receiving care in my home state with Medicaid. The people at the state even said I should never be presented with any sort of bill. Out of state, though, it’s been more difficult to arrange as hospitals in other states may or may not be able to bill my Medicaid, restricted either by lack of agreements or competence.

I find your anecdote a little difficult to balance with the stories of all the vets who need medical treatment but can't get it.

I'm not up on what you are referencing.

I can tell you active duty is different from what retirees deal with. Also "vets" doesn't necessarily mean they are retirees. If they didn't serve long enough to qualify for retirement, it's possible to be a veteran without still being part of the military benefits system.

You actually have insurance in the military. When my husband was on recruiting duty, we did not live near a military base. I had to deal with insurance at that time.

But when you get treated at a military facility, you show your ID and there is no bill -- at least, this was true back when I was a military wife.

I'm pretty damn upper class culturally. I'm just broke.

Ha! Try that scenario again with cheap or no insurance. That’s the reality for many

I'm well aware that's the reality for many. My awareness of that is the reason I commented on the fact that the US already has one very well-developed and well-established medical system that works much like socialized medicine: The military medical system.

We don't need to look to other countries at all to try to figure out how that's done. It's done right here on American soil every single day for military members, military retirees and their dependents.

All we need to do is figure out how to expand on that existing system. And perhaps one first step would be to change the rules such that anyone who serves in the military gets medical benefits for life, even if they don't stay long enough to retire and get all those other benefits.

It's never sat well with me that it is possible to be a veteran and have no benefits at all. Giving all veterans medical benefits would begin expanding coverage in the US under a system where billing is the exception, not the rule.

I hate the civilian US medical care system and it's fucked up coverage. I've been a military dependent basically my entire life. My experience of medical care is vastly different from that of most Americans and it's a crying shame we don't do more for our citizens in that regard.

The military healthcare system proscribed Naproxen for my broken wrist. Not a win.

As an Australian I always struggle with the idea that healthcare would cost money above a couple of dollars for things that aren't essential.

But almost every American I've ever spoken to who hasn't experienced decent national healthcare seem to have a bizzare view that "if it's free then obviously it will be abused", not realising that it's just as open to abuse as a system where end customer are also involved because shockingly customers arent usually the ones committing the fraud.

It genuinely feels like theres a view that some people might not "deserve" healthcare, and the way we determine who "deserves" healthcare is not the very humane "well they need it, therefore they deserve it" but rather "capitalism. Definitely the answer."

Makes me a little sad, but I guess when you have nothing else to compare it to...

Also Australian.

The concept of abuse seems hilarious. What abuse? That people might visit their local doctor more frequently? That's a good thing! Many ailments get more expensive to treat the longer they are left untreated.

Once you come to terms with the fact it's permanently cheap/free, the psychological incentive to be wasteful ("use it or lose it") disappears completely. By comparison the American capitalist health system continually reinforces the notion that healthcare has monetary value, which means failing to take advantage of it feels wasteful.

The concept of abuse seems hilarious. What abuse? That people might visit their local doctor more frequently? That's a good thing!

In the UK A&E is flooded with people with minor ailments that could have been treated at home with a first aid kit, or people who are just drunk. The system is definitely taken for granted. People even call ambulances for a ride to an appointment, not even an emergency.

Source: once spent 5 hours waiting to be seen in A&E, sitting on a plastic chair with a broken leg, while kids with grazed knees and people with minor colds were seen before me. If I needed the bathroom or a glass of water, I had to get up and hobble there on my broken leg. The NHS were great once I actually got seen, but they are swamped with idiots demanding unnecessary medical attention, because it's free.

Also UK. Some 'abuse' of A&E happens because people cannot alway get access to a local surgery as opposed to driving to a nearby hospital, especially at weekends.

This.

I had half of my face stop working and had recently moved (and not yet registered with a new GP.)

I went to my previous GP and they turned me away (no longer in the catchment area) so I eventually ended up in A&E.

It doesn't help that the local ones near me at the time seem to live in the past... No call queuing or online scheduling, have to call within a 1 hour slot for appointments (so that's an hour of busy tones, oh well let's try again tomorrow)

Why does the NHS have catchment areas? Surely you should be allowed to visit any GP anywhere. People do travel after all.

Surely you should be allowed to visit any GP anywhere

A GP practice is a private business, usually all the GPs are partners just as lawyers or accountants would be, and the staff such as receptionists are not NHS employees, they work for the practice. If they can't bill the NHS for their services because you're not on their books, they aren't interested. It is surprising perhaps, but many people in the UK are unaware of this, they think the GPs surgery is directly a branch of the main NHS, and get angry about "privatisation" without realising that GPs have always been private.

Right, but why are private practices artificially limited for whom they can bill the NHS? That seems like pointless, unnecessary bureaucracy that comes back to bite them with more A&E visits.

I'm guessing because each one is only set up to bill a particular NHS Trust? But you're right, it should be possible keyed just off an NI number or something.

There is a hospital in my town but it's A&E was closed in 2007 IIRC, so if you can't see a GP you can't even go there, you have to drive a couple of towns over.

> why are private practices artificially limited for whom they can bill the NHS?

I'm not sure they are. Here's the (admittedly complex) book: https://www.england.nhs.uk/publication/primary-medical-care-...

Note this is only for England. I have no idea about the rest of the UK.

If you're inside the catchment area it's very difficult for the GP to not register you. GPs are expected to provide service to almost anyone living in their region.

If you're outside the catchment area the GP can chose to offer full service; offer limited service; or offer no service.

The full service includes things like home visits, so it's not surprising that GPs seek to limit that to patients who live far away.

For people who are travelling there are temporary registrations, but also GP walk in centres and GP out-of-hours services.

I also recall that a lot of local clinics one would normally go to end up closing thanks to lower funding... so, let's fund more walk-in clinics around?

I once did an experiment: I tried to get an appointment at a local clinic.

(Note: This anecdote was ~15 years ago. Things seem better now.)

Having failed to get an appointment the normal way, because they didn't have any slots available, I decided to test a theory.

I woke before 8pm and continuously dialled during the time slot from 8am-9am when it was, theoretically, possible to book an appointment. I'd wait for the busy tone, then immediately hang up and dial again. For an hour.

I did not get past the busy tone for the first 2 weeks.

After 9am I'd get through, and they told me there we no bookings available and I would need to call back the next day, and they recommended I call between 8am-9am...

In the end I got an appointment but it took 2 weeks and literally hundreds of call attempts to get one.

Apparently this was because the clinics keep statistics on how long people have to wait between making an appointment and attending.

To keep this number down, they set a limit on how far an advance it's possible to book an appointment.

Unfortunately, it had the side effect of preventing people from making appointments when all slots within the limit were filled.

The _true_ waiting time was therefore grossly hidden from reported statistics. And for many, it was enough to make them give up trying to get an appointment at all, further distorting the reported figures.

It took quite a long time before government, which had set the reporting requirements, learned how they were having the opposite of the intended effect.

Sounds like NHS could open more local surgeries and save a lot of money. Or at the very least, add a wing to every A&E to allow stupid stuff to be handled by nurses and trainees.

In Australia, ambulance rides are not free unless you have a membership plan or private insurance.

It is absurd that the UK could not at minimum issue fines against abuse of ambulances. (Not to mention abuse of 999 calls!) The fact that this was an issue for more than five minutes is absurd and cannot be used as an indictment against public systems.

And even if the ambulance issue was unsolvable (ha!) it would still represent a fraction of a percentage of the waste occurring in the American system.

he fact that this was an issue for more than five minutes is absurd and cannot be used as an indictment against public systems.

We also have issues with prescription abuse, such as people getting prescriptions filled who no longer need them, and don't take them anyway. The NHS tried to fix this by printing the real cost of the drug on the label, so people would be aware of the waste. But they had to stop because it was making people who genuinely needed the drugs feel guilty about how much it was costing. No easy answers to this, but something will need to happen because as I say, it is simply taken for granted by so many people.

Unfortunately, the NHS is something of a "sacred cow", any criticism no matter how evidence based of it is seen as a heinous blasphemy. Which means its problems are always brushed under the carpet and will never be fixed. "The envy of the world", we're told, but I doubt the French or the Germans or the Canadians or the Japanese or any number of other nations are envious of it!

There is a massive propaganda machine pushing against any sort of universal health care here. The idea that not everyone deserves care is definitely one of the angles they push. Another angle is that socialized medicine is garbage, a view which tends to confuse people who have lived with it.

which country?

This is very misleading.

In single payer systems, doctors and hospitals bill someone for their service, it's just that the 'insurance company' is the government.

Someone 'out of system' cannot provide the health/ID necessary, ergo, no way for them to bill. But otherwise they do bill.

Epic is often compared to Salesforce, which is to say even if there is a better localized app for a specialty (of which there are many in healthcare), the next questions are: How do integrate this into the other apps, how does it get into the record, how can people in other specialties receive information downstream to act appropriately from medical side to billing side. Then there's the last non-app part, what is the cost structure, what are the hardware requirements, who's going to watch it when it goes down, what disaster recovery strategies are available, what downtime-protocols should be followed when it goes down and up, who can I call when there's a problem I need fixed now, and finally who out there is already using it and demonstrated success with it?

I used to work at Epic and have seen in the field the requirements the immediate people need as I listed above. Billing driven documentation is an accurate way to label it. The software is implemented to maximize revenue for the hospitals and organizations, without reliable targeted information coverage agencies won't pay for what was supposedly done. There are whole teams in health care and applications from suites like Epic for such teams just for refining billing. A physician knows what they are ordering for a patient, a temp worker downstream refining billing data doesn't, therefore prioritizing accurate data from the physician will result in better likelihood of obtaining claims downstream. That however competes with the immediate need of the patient.

> There are whole teams in health care and applications from suites like Epic ... just for refining billing.

To anyone interested in AI in healthcare, I suspect that datasets of procedure and diagnosis billing codes could be some of the most accurate and immediately usable of their size.

Standards like SMART-on-FHIR [1] and CDS Hooks [2] have the potential to allow innovation developed outside of Epic and Cerner inside of those products. Both of those vendors even have "App Stores" [3] [4]. So far, though, there aren't a lot of apps in these stores, and none of my doctors (all of whom work for large academic medical centers and use Epic) have access to any third-party apps - so I do wonder whether the vendors (or their customers) may be putting up roadblocks that are slowing adoption.

[1] http://docs.smarthealthit.org/ [2] https://cds-hooks.org/ [3] https://apporchard.epic.com/ [4] https://code.cerner.com/apps

Epic, Cerner, and their major competitors are actually a lot more open now and no longer putting up major roadblocks. The real roadblocks appear to be in the hospital and clinic IT departments. They have to upgrade to a current version of the EHR which supports SMART on FHIR (many organizations are several versions behind) and then enable the app store feature. Some organizations have concerns about using third-party apps due to training requirements, security, and malpractice liability.

I do think that SMART on FHIR makes it easier to turn clinicians into software developers, so hopefully that will spur some innovative apps.

We solved it by having a doctor on our team. In fact, not sure how you could solve any healthcare issues without it.

I work in the public sector of Denmark, and I’d recommend doing this. The companies who hire actual domain knowledge and listens to it are simply miles ahead on making software that doesn’t suck for the end-users.

It would be better if we allowed departments to build their own software, because our in-house software is honestly the only stuff that truly does the job right, but I don’t see that being prioritised. So having contractors hire a few doctors is probably the best we get.

It also helps to have them as a conduit for your communications to other doctors. It’s sad that you have to pay someone a lot to (partly) forward your emails, but it works.

If responding to internal emails had a billing code, I think they would fight over who gets to respond.

Exactly.. short of the parent company of a hospital also owning a software company for the software this likely won't happen. Even then, software engineers RARELY get to interact with the people using said software for any meaningful time... It's usually meetings with your PM, Manager, their manager, and maybe the same on the other side. That's like 3-6 layers of separation in this telephone game.

Didn’t Massachusetts General develop MUMPS in-house?

> For startups that want to sell to health systems and similar-sized/larger entities (...), you unfortunately have to focus on the buyer, which is very rarely someone who is "in the trenches."

This is my current experience. The person bankrolling the project delivers lists of requirements, and nearly half of them end up being removed later when someone "in the trenches" either says they don't need/want it or it's too confusing of a feature.

Another part of the problem? "Confusing features" for doctors includes some very standard app features, like back buttons and refresh buttons. This honestly frightens me. We had to remove the back button -- which was requested by the buyer -- because it became a patient safety issue.

At least we don't have to target IE9.

It’s true that Epic and Cerner are the dominant players when it comes to hospital EMRs, but they have less of an influence in outpatient settings outside of academic medical centers.

For larger outpatient practices that are participating in value based programs (ACOs, care bundles, etc.), such as the type apple amazon or google may choose to work with or, less likely, build, there’s less of a need to rely existing EHR vendors and a greater likelihood to rely on a variety of tools that are able to interact with each other.

The trend is for more and more care to move outpatient. There’s opportunity for innovation there.

Cerner and Epic are billing driven because that is priority 1 for hospitals.

Not a surprise. Overbilling Medicare is a huge Nono.

Having a nice audit trail of who gave that Tylenol and when makes life a lot easier.

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