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Comment by FwarkALark | Hacker News Reader

Is this something where a public competitor might help? It surely can't be worse than private industry.

In Swedens capital region they failed with this too. It's dominated by a system that is largely quite well polished but has some scaling issues that has lead to down times. The region decided to develop their own in cooperation with other regions, but instead of just hiring two-three developers and putting them in a room inside some small hospital, they decided to make a Grand Political Project out of it.

Billions of Swedish crowns later, having written ZERO lines of code, they quietly cancelled the entire thing. This enormous boondoggle didn't even make the news because the waste was all man-hours and consultancy, and not a building or something the media found sexy.

I think a big problem is that politicians need Grand Political Projects to get reelected, but that's not how you build software. Or make meaningful small incremental improvements to science, infrastructure, schools, etc. The incentives are wrong...

Interesting, what was this project called?

The UK government tried this, wasted 12.4 billion pounds over 10 years, and ultimately wrote most the project off. The dream of an EHR is just deceptively tricky, so many smart, well-funded, well-connected teams have tried and failed.

ref: https://barnett.surge.sh/welcome/intro.html

Again, this can't be worse than private industry—that profit margin will guarantee this. I guarantee there is some other disease to blame for the waste—probably politicians of some sort invested in industry.

Of course, this does demand citizens give a shit, which seems hopeless at this point.

If I’m not mistaken, the Spanish healthcare system has a fully electronic medical record.

Germany too

hahahahahahahahahahahahahahahaha

This is a joke. We want to have this but its like everything in germany if its about something digital. Its a fucking mess. Everyone can read it. Most doctors dont use it and even many insurance dont use it... its a fucking mess

Ok, but it’s digitalized, I didn’t say it was good. You can now directly go to an Apotheke with your insurance card and get your medication, even the prescription is digitalized.

ok thats true and that does work. But the system in the background is a mess.

In reality it has several

I have a friend that has worked on this project for over a very long time and the issue is not that the UK tried to implement EHR records from scratch but rather that GPs (General Practitioner, think local doctors surgeries) had mostly all implemented EHR systems already. The issue is that these systems are created by several (6-8 if memory serves) different private companies and the UK Government can't force the GP to change or adopt a standard system.

The different GP EHR systems record patient information in their own ways. Think of a database entry for chemo medication, one EHR provider having a db column labeled "Drug X" with the patient entry listed as "Yes" with separate columns for dosage, frequency etc. Another will list the drug, dosage and frequency in the same field. Even if they have the same column e.g. frequency, different EHR's may list "5d" or "5 Days". There are also spelling errors, doctor's personal shorthand abbreviations etc.

The problem is that the UK interoperability system has is to implement a safe translation layer that will allow records to be transmitted between these systems that doesn't kill anyone. The astonishing amount of different types of information that are used and all the oversight needed to ensure that information is accurately transferred has made this project way more costly and time consuming that originally thought.

There is, of course, waste and profiteering, both internally to the Government project (huge contract salaries) and also with the private EHR companies (overruns and re-builds are all handsomely paid for).

> The issue is that these systems are created by several (6-8 if memory serves) different private companies and the UK Government can't force the GP to change or adopt a standard system.

Yeah, the UK healthcare system is only mostly nationalized.

I do think these IT issues could be fixed, but only if there was someone at Cabinet level who knew what operations management was, which we're unlikely to get in the forseeable future.

Following the sources listed there, "wrote most of the project off" seems like an overstatement.

> The MPA found that there have been substantial achievements which are now firmly established, such as the Spine, N3 Network, NHSmail, Choose and Book, Secondary Uses Service and Picture Archiving and Communications Service. Their delivery accounts for around two thirds of the £6.4bn money spent so far and they will continue to provide vital support to the NHS. However, the review reported the National Programme for IT has not and cannot deliver to its original intent.

Of the rest of the £12.4bn, £3.4bn is "expenditure by local NHS organisations, for example on local IT and training and ensuring compliance of local systems with Programme delivered systems", which probably isn't entirely wasted either.

There is (or was) a public competitor. VistA was largely developed by the federal government. Some organizations still use it and it's available for free, but independent reviews have generally rated it as worse than the private industry products.

https://worldvista.org/AboutVistA

Interestingly the linked article seems to be singing praises of VistA, though it's unclear whether the author has actually used the system themselves. They link to an unsourced article with that claims it tops reviews, but clicking through to the various related articles seems to have a consistent theme of people not liking VistA all that much.

I have to wonder how independent those reviews are when medical staff consistently rate it higher than commercial products, the system has won multiple awards, and when the VA tried to implement a commercial replacement it failed.

Vista is public domain, so there’s no money in it and no-one to take management out for expensive lunches.

People generally like VistA a lot more than what the DoD has been pushing the VA to replace it with: EHRM.

https://www.gao.gov/products/gao-23-106685

https://www.moaa.org/content/publications-and-media/news-art...

VA is moving to Oracle Cerner.

https://fedscoop.com/va-still-has-significant-concerns-as-or...

Oh it could be much worse. You should see how bad government run HIE’s are.

To back you up. They are profoundly worse. It’s an area where private dominates entirely, as the government HIEs are almost unusable.

Again, I don't see how a private industry per se could even possibly be worse given the demand for a profit margin. Your beef is with some other aspect of this process.

the same higher-level forces shape the public project's fate into certain doom that led to hospitals buying the absolutely shittiest tech.

because there's no clear signal (in the private sector there's some drive for sales, market share, profit), only made-up hyperpoliticized bullshit requirements and maybe some barely coherent vision.

as long as there's not a clear technocratic organization with sufficient independence and competence these projects are rudderless yellow duckies on the sea of tragisocial medicine mismanagement madness.

no party involved really has enough resources to deliver something nice. it's like high speed rail in the UK or the US. as a public project it's already stillborn, because it's too expensive to do it right (or if it would get the right amount of funding it immediately attracts unlimited scope creep, and the usual vultures show up, it becomes a typical everything bagel project, solve EMR but also education and childcare and whatnot), and to do it efficiently it would require draconian standardization and heroic amount of data migration work.

and on top it gets over promised and under staffed and so on

I believe the Estonian government has long had at least a basic EHR that they use across their public and private medical facilities that is part of their larger e-government system

https://e-estonia.com/solutions/healthcare/e-health-records/

Private industry is already worse than the older system of keeping notes with pen and paper. (Source: my mother operated her own medical practice and applied for a government subsidy to switch over to electronic medical records, then complained about how it reduced the functioning of her practice.)

Why was the government subsidizing that?

They decided that medical records should be electronic rather than paper. Why do they do the other things they do?

Probably as part of the meaningful use policy in the US. Early adaptors were initially incentivized to move to EMRs off paper charts.

Today the incentive no longer exists. Instead theres a penalty in the form of reduced Medicare/medicaid reimbursement for practices that don’t comply.

Great answer. Thanks for not just downvoting me.

In what sense is that an answer to "why were they doing that?" The entirety of the answer does nothing but give a name to the policy. "Why" would usually be understood as a question about the reasons behind the policy.

"The government was subsidizing the abandonment of paper medical records because they had a program in place to do that" is something you knew before you asked the question.

Is it? There's trade-offs of course with everything. There's certainly many aspects in which a medical practice only using pen and paper is worse. How about transferring records to other institutions? Or taking your work home with you? Do you want to lug boxes of records home which may get lost (HIPAA breach) so that you can finish up your notes at home? What about making copies for a patients right to access? What about auditing changes or access to the record to enforce data security, integrity, and compliance?

What's the timeline of evaluation of reducing the functioning of her practice? If it was just a recent change then I would expect growing pains. I have many close personal relationships with healthcare workers and when their electronic health record system is down, having to use pen and paper leads to drastically worse functioning within their job. So the same claim but in the opposite direction. The reality is doing something you're not used to is harder.

Is there any industry in which public competitor is better than private one?

I mean, all industries? The profit margin guarantees this. Anyone who has worked in private industry will verify its utter incompetence in the long term.

Can we talk about particular examples? I know for a fact that in my area private train ticket booking app is vastly better than government one. So at least there is an exception.

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