Comment by dlitz | Hacker News Reader

Comment by dlitz | Hacker News Reader

Seriously, the tech startup model isn't always the best one. Here are some more points:

11. If hospitals were run like startups, 10% of emergency patients would be turned away ('not the target audience'), and any medical staff who complained would be labeled "insufficiently pragmatic".

12. If hospitals were run like startups, 90% of them would close their doors within the first year of opening.

13. If hospitals were run like startups, patients' medical information would be used to sell them ads. The databases storing this information would also be leaked within the first 10 years of opening, since details like security are rarely a priority in a startup.

14. If hospitals were run like startups, junior medical staff would be overworked, underpaid, and burnt out. Actually, this is already the norm (at least in Canada).

15. If hospitals were run like startups, patients who went in to have their appendix removed would find that their tonsils and wisdom teeth had also been removed, and an RFID chip with their patient ID had been implanted "to serve them better". This would be OK because it would be covered by the blanket consent form referred to by the sign at the entrance that reads "by using this facility, you agree to its terms and conditions (available upon request; may change at any time)". Patients who had read it would know that they could opt out.

16. If hospitals were run like startups, ER patients would be treated by college dropouts who taught themselves surgery by watching videos of mom's stitching their kid's dolls together.

I have worked IT in hospitals. I agree with the actual point the original article is trying to make - hospitals are not doing technology well at all. I don't want to bash the article too much, because that point is correct.

But there is an extremely important factor here - patient health. No technological improvement is worth risking the health of a patient.

This is a core business principle at work - the point of most businesses is not to have the best technology. Technology is a tool that often helps them achieve their actual goals better. Just a tool. Technology for its own sake is usually a mistake, and very much a mistake if it risks the health or life of any person.

I think the best point the article makes is regarding the patient records systems. It sounds like the "best" systems out there were developed with the same sensibilities that leads to Enterprise and QA tracking systems with more than 100 fields per screen, 90% of which are useless in any given installation.

Basically there's a ton of room for improvement, and the reason the improvement never happens is that the people who evaluate the systems are never the same people as the users. Moreover, the people who evaluate the system have no idea how to do anyone else's job, and so they have no idea how much inefficiency they're saddling their underlings with.

They probably also don't care.

> No technological improvement is worth risking the health of a patient.

What about the time spent on 350 clicks? Do that 20 times a day. How many hours of sleep did that intern lose to clicks?

As a physician who writes code, and is on the hospital's informatics board, his main point is a massive drag on medicine. And the problem is very much on the IT side. The hundreds of clicks are the problem.

People who write this code really should be made to write that code, at least sometimes, maybe one day a week, on the floors. Just sit at the nurse's station and try to do abstract, thoughtful work in a near panic. Oh, sounds terrible? Yes, yes it is.

The people who buy this software, quite frankly, I have no idea what to do about them. It makes me sick.

No technological improvement is worth risking the health of a patient.

I disagree, least of all because the health of the patients should be put ahead of the health of a patient.

The fact is that this unreasonable fear of harming patients has caused everyone to be completely blind to the routine fuckups and inefficiencies which, when taken together, doom the industry and patients as a whole.

Let's look at EMRs. Epic, for example. Integrating with Epic is pretty hard--unless the client really twists their arm, they basically won't say anything to help you with their software or access their piles of shitty databases (mumps lol). They get paid tens or hundreds of millions of dollars a year (per hospital!) to handle the task of not losing patient records, a task at which they semi-succeed. They have no incentive to change. Oh, and one more thing...hospitals are deathly afraid of having data duplication anywhere, so they freak out if you start looking like you're a sibling system to their EMR instead of just blindly consuming it.

Moreover, they--like many smaller vendors--do extreme customization work that basically guarantees a new learning curve everytime somebody moves to a new system. And the software looks like garbage, and is hard to use, but at least lives aren't on the line and nobody was risked being harmed by some ~crazy new startup EMR~. Hah, oh wait, they are on the line, and people die due to bad medication decisions that aren't flagged or are flagged and ignored by the system.

And this whole system? Most of the mess is geared towards solving the billing problem. It isn't geared towards the patients records problem, towards the "what did this patient's body do at this time" problem. It isn't geared towards the "hey, that's odd, all my lab messages have the same jank-ass free-text formatting instead of an interface from the 90s".

The fact is that the vendors and hospitals have conspired in their fear and greed to basically raise the barrier to entry so high that iterating on new designs to help is quite hard, and instead just a good way of giving yourself an aneurysm. And you don't want that, because by that time you'll want to step nowhere near a hospital.

The state of ERP and MES systems is very similar to what you describe. I had a brief chance to work with a few of them, and between the bugs, unimplemented features and the UI design straight from Necronomicon, I have no idea how factories even work, much less are able to produce and deliver quality goods reliably.

Wow. Talk about missing the point. He's obviously not talking about how the whole hospital is run. He's talking about using selective technology to make certain things run better.

15. happens more and more often too. I know at least two different docs who "overdiagnosed" or were force to overdiagnose in order to rush people to unnessary surgeries, i.e. fill the op calendar.

Sad, but true.

That's insane.

Forced by who? The management? Or did they do it themselves for their own benefit?

Actually both, one was forced by the lead doc and the other was the lead doc himself.

The turn away happens already.

It's literally illegal in an emergency for a US hospital to deny treatment (EMTLA, 1986), so if what you say is true, it's actionable.

> It's literally illegal in an emergency for a US hospital to deny treatment (EMTLA, 1986),

It is illegal because it was a frequent occurrence, and, while less frequent, it (patient dumping) remains a serious problem.

Saying "the turn away happens already" has quite a different implication from saying, for example, "29 years ago, this was a major problem."

It happens today.

It is a major problem (both independently, and as a symptom of other major problems) today.

Its less of a major problem today than it was before it was outlawed.

It is a serious problem because of the degree of awfulness of the act, not because of its present-day frequency. See also https://oig.hhs.gov/fraud/enforcement/cmp/patient_dumping.as...

It's also an unfunded mandate. The government declared that all patients must be seen, but did not provide a mechanism to pay physicians, nurses, and hospitals for their services to care for those patients. They also did not shield the clinicians from liability. Hell, in order to perform a "medical screening exam" that EMTALA mandates, you have to do everything required to determine there is no true emergency. If you determine there is no emergency and discharge the patient (with no compensation), then the patient has something happen in the parking lot, you are 100% liable. As a result, people get these frighteningly expensive workups in the ED out of fear for litigation. People should get turned away if they don't have an emergency, but the fact is, no one turns anyone away, because there is no incentive to.

Now you can trace a direct link between passage of EMTALA to the over utilization of the Emergency Department.

Thanks. I replaced "patients" with "emergency patients" to clarify and to avoid derailing the topic.

Happens also. Granted, the reason is not the wrong target audience but there are other issues.

http://www.dispatch.com/content/stories/local/2014/12/30/ohi...

Reply on news.ycombinator.com