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Comment by killjoywashere | Hacker News Reader

The cancer reporting protocols from the College of American Pathologists are available in structured format (1). No major laboratory information system vendor properly implements them, properly, and their implementation errors cause some not-insignificant problems with patient care (oncologists calling the lab asking for clarification, etc). This has pushed labs to make policies disallowing the use of those modules and individual pathologists reverting to their own non-portable templates in Word documents.

The medical information systems vendors are right up there with health insurance companies in terms of their investment in ensuring patient deaths. Ensuring. With an E.

(1) https://www.cap.org/protocols-and-guidelines/electronic-canc...

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People could potentially properly implement them if they were open and available:

"Contact the CAP for more information about licensing and using the CAP electronic Cancer Protocols for cancer reporting at your institution."

This stinks of the same gate-keeping that places like NIST and ISO do, charging you for access to their "standards".

For liability reasons alone, you cannot just have random people working on health/lab stuff and the requisite vendors have access to these standards.

According to what killjoywashere said, the vendors do not want to implement these standards. So if CAP wants the standards to be relevant, they should release them for random people to implement.

Aren’t all NIST standards free as they are a government body?

> The medical information systems vendors are right up there with health insurance companies in terms of their investment in ensuring patient deaths. Ensuring. With an E.

Can you expand on this?

Medical information system vendors only care about making a profit, not implementing actual solutions. The discrepancies between systems can lead to bad information which can cost people their life.

As an analogy, imagine if the consequence of Oracle doing Oracle-as-usual things was worse medical outcomes. But they did them anyway for profit.

That's basically medical information system vendors.

The fact that the US hasn't pushed open source EMRs through CMS is insane. It's literally the perfect problem for an open solution.

It's worse than that. VistA is a world-class open source EMR that the VA has been trying to kill for decades.

VistA was useful in it's time but it's hardly world class anymore. There were fundamental problems with the platform stack and data model which made it effectively impossible to keep moving forward.

I love open source EMRs, but has any major country adopted open source EMRs?

I know OpenMRS exists but is mainly used within developing nations.

The US has Vista, made by VA, and it is a beast and no one really wants to use it.

If I understand correctly, Estonia made their own EMR/EHR from scratch. The government produced (and commissioned?) software is all open source. https://koodivaramu.eesti.ee/explore

EMR software seems like something that shouldn't be that hard. It's fundamentally a CRUD. Sure, there's a lot of legacy to interface with, but medical software seems like a deeply dysfunctional and probably corrupt industry.

It’s a famous “should be easy” use case. I think this is wrong only because no one does it.

I'm sure there's a lot of work, but hundreds of millions per deployment is not justifiable. The Finnish EPIC deployment has cost almost a billion euros.

Estonia's from-scratch system was reportedly about 10 million euros.

It wouldn't be appropriate for the federal government to push any particular product. They have certified open source EHRs. It's not at all clear that increased adoption of those would improve patient outcomes.

https://chpl.healthit.gov/#/search

Since Oracle bought Cerner a few years ago, no imagination needed. Sadly, since Cerner has lots of good people who want to make good products.

>The fact that the US hasn't pushed open source EMRs through CMS is insane. It's literally the perfect problem for an open solution.

It's not insane, it's because the US is an oligarchy. And it's about to go even more oligarchy on steroids in the next year.

What explains most other democracies not doing it?

Is Sweden an oligarchy, too? Or France? Etc etc

It doesn't look like the XML data is freely accessible.

If I could get access to this data as a random student on the internet, I'd love to create an open source tool that generates an interactive visualization.

The problem is that a bug could kill people.

I mean, you're attributing malice, but it could just be that reliably implementing the formats is a really really hard problem?

How about fixing the format? Something that is obviously broken and resulting in patient deaths should really be considered a top priority. It's either malice or masskve incompetence. If these protocols were open there would definitely be volunteers willing to help fix it.

Incompetence at this level is intentional, it means someone doesn't think they'll see RoI from investing resources into improving it. Calling it malice is appropriate I feel.

If there is no ROI, investing further resources would be charity work. I don’t think it’s accurate to call a company not doing so malicious.

Not actively malicious perhaps, but prioritising profits over lives is evil. Either you take care to make sure the systems you sell lead to the best possible outcomes, or you get out of the sector.

The company not existing at all might be worse though? I think it’s too easy to make blanket judgments like that from the outside, and it would be the job of regulation to counteract adverse incentives in the field.

Agree that most companies prioritize profits over lives in an unconscionable manner, but there's a point of diminishing returns where eventually you can save a few more lives, but at an astronomical cost. Auto manufacturers have the same dilemma: spend a few hundred million dollars adding safety features, or nix the features and hope to lose less than that in lawsuits?

Eventually the question will be, how far do we really need to go, i.e. how much profit do we allow ourselves before it's morally untenable and we should plow it back into R&D? Unfortunately, as long as health care is for-profit, and absent effective regulation, companies will always err on the side of profit.

You seem to think that the default assumption is that fixing the format is easy/feasible, and I don't see why. Do you have domain knowledge pointing that way?

It's a truism in machine learning that curating and massaging your dataset is the most labor-intensive and error-prone part of any project. I don't why that would stop being true in healthcare just because lives are on the line.

I think there are more options than malice or incompetence. My theory is difficulty.

There’s multiple countries with socialized medicine and no profit motive and it’s still not solved.

I think it’s just really complex with high negative consequences from a mistake. It takes lots of investment with good coordination to solve and there’s an “easy workaround” with pdfs that distributes liability to practitioners.

Healthcare suffers from strict regulatory requirements, underinvestment in organic IT capabilities, and huge integration challenges (system-to-system).

Layering any sort of data standard into that environment (and evolving it in a timely manner!) is nigh impossible without an external impetus forcing action (read: government payer mandate).

You're making a lot of unsupported assumptions. There's no reliable evidence that this is causing patient deaths, or that a different format would reduce the death rate.

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