Pretty simple story: we required and subsidized the adoption of EHRs up to a certain standard that effectively meant it had to be provided by private firms, and then we turned a blind eye and failed to further regulate how those firms exploited the crap out of everyone needing their services, or how they merged and purchased their way into a narrow oligopoly.

There were efforts for open-source alternatives, but from what I've heard they have been abortive (not meeting people's needs; lack of support).

Nationalize or public-utility-ize!

I haven't read it yet, but I'm guessing at some point we get to "hospital administrators are incentivized to be evil."

Total ignorance will not prevent me from speculating that successfully integrating record keeping across so many different organizations would even in the best of circumstances would be a vastly difficult and expensive project.

Having had dealings with UPMC, which is one organization with many branches, suggests that is likely not the root problem.

But the url has "longform" right in it. That's just going to be too much to read.

TBC, I'm not suggesting that US healthcare is the best of circumstances.

It's actually really great as long as you aren't sick or injured.

Wasn't there a law passed in the 1990s mandating interoperability of medical databases?

For all its troubles lately, back when the VA was funded adequately they had a very good medical record system.

I worked briefly on a project to use EHRs to advance drug discovery (eg repurposing) and quickly realized it was such a cluterfuck we had no chance of accomplishing anything.
As far as billing, we're trying a high deductible plan this year for the first time and I'm just waiting for the when I get double billed or the hospital says we owe even though we've met our deductible. Basically I'm almost certain the record system is going to fuck up.

Schneider recalls one episode when his colleagues couldn't understand why chunks of their notes would inexplicably disappear. They figured out the problem weeks later after intense study: Physicians had been inputting squiggly brackets--{}--the use of which, unbeknownst to even vendor representatives, deleted the text between them.

10: Why? I mean, I imagine that your premiums are lower, but I don't think it's worth it.

"The industry was moving along in a natural Darwinist way, and then along came the stimulus," says Frantz [one-time CEO of NextGen], who blames the government's ham-handed approach to regulation. "The software got slammed in, and the software wasn't implemented in a way that supported care," he says. "It was installed in a way that supported stimulus. This company, we were complicit in it too."

[Seema Verna of the CMS:] "Providers developed their own systems that may or may not even have worked well for them," she tells KHN and Fortune in an interview this February, "but we didn't think about how all these systems connect with one another. That was the real missing piece."

It's like no one involved had ever talked to a software architect, UI designer, program manager, or anyone else who had ever done more with a computer than press the power button. Sure, one of the most important goals of the project is interoperability, so let's leave it as something we'll do "later" ("How does 'never' work for you?")

There are many other quotable bits that just reinforce the conclusion that the Obama administration just wanted to dump billions into the problem as a stimulus package (this was 2008), and shockingly, the EHR companies were happy to take the money and produce garbage.

11. The "squiggles" thing is hilarious. I wonder if anyone ever tried entering a patient called Bobby Tables?

The premiums are so much lower that HDHP premiums plus HDHP OOP max is less than the premiums + copays of the full coverage plan. So there's theoretically no downside, at most we pay what we would have paid anyway, and if we manage to have a healthy year we save. That is, unless the records system messes up and we end up paying more than the plan promised we would.

We also went with a HDHP plan this year, for similar reasons. First, we concluded that in a typical year, the cheap plan and expensive plan would be the same and the medium plan would be a little worse. Then, in a bad year, we'd hit our max out of pocket in all three (around 10-12K). In a healthy year, the HDHP could really save us money.

It left me convinced that the three plans are just massive headgames: the worst was the middle plan, which was the most psychologically attractive plan because you felt vaguely like you were hedging your bets, but mostly they were wildly more similar than you might guess.

(IIRC, monthly premiums for a family of six were: $850ish, $650ish, or $250ish. No idea how that compares nationwide.)

I should note that one ER visit for stitches basically means we will hit our max, and there was the added stress of Does it really need stitches I bet I could close it with that skin glue stuff.
I assume that's you're share of premiums not total employee plus employer because that would be insanely low. Our HDHP employee portion is about same as yours $240, employer pays $1700 per month. They also kick us $1k into an HSA.

From the article:......and considered by some to be the Cadillac of medical software.....

So something that's bloated, wasteful and ridiculously overpriced is the standard of excellence for EHR systems. Seems about right.

This article exposes so many things that are wrong with our healthcare system and really pretty much the way we do all public things in this country that it's almost impossible to figure out where to even start.

Moby's probably referring to VISTA, which was a big part of why the VA delivered excellent value-for-dollar to its patients (of course, they were underfunded, but they weren't wasting the money). The Obama admin could have mandated that all the EHR systems it subsidized be based on VISTA, and OSS (like VISTA -- b/c it was FOIAed *grin*) but they didn't. Sigh.

The problem with VISTA is if you ever had a login to use VISTA and then stopped renewing it because you didn't have a reason to use it anymore, you keep getting reminders to reset your VISTA password every so many months until you lose that email account.

13 is truth. As time goes by ISTM that more and more instances of startling incompetence dribble out of the Obama administration.

11/13: My guess is that the text input fields were based on some open-source software--say, MediaWiki or Confluence wiki--in whose syntax braces denote formatting, and nobody bothered to look up how formatting in them worked. Which implies an embarrassing lack of testing.

21 sounds plausible.

My basic perspective is (1) software projects are difficult, and many software projects fail. (2) IIRC, there isn't any silver bullet; there's no industry or set of practices which significantly reduces the failure rate (which isn't to say that there aren't better or worse approaches to software development; just that even if you do things right you still can't start a project and know that you're have a functional software at the end of it) (3) The lowest-risk projects start with something that works and extend it or modify it in mostly predictable ways, or projects in which there's flexibility about outcomes -- where you go into it with 6 goals but knowing that if you can achieve any 3 of those goals you'll have something that adds value. (4) In general it's better to have fewer layers of bureaucracy and some open communication between end users and developers.

By those standard the inability to produce a solid system of EMR is an embarrassing failure (whoever was actually spending the money or receiving the money clearly did not do their job) but not exactly a surprising failure.

Tim's employer offers a high-deductible plan. My out-of-network deductible is $1500. In-network is 0. There are only 2 options to choose from. Neither is a high-deductible. PCP visits and Behavioral health are $10 co-pays. Unfortunately, because we changed insurers, it's harder to find a behavioral health provider who will take the insurance. The one that costs more has a lower out-of-pocket maximum . And the co-pays are higher if you go outside our system with the cheaper plan but the same within our system. It used to be a higher out-of-pocket with the cheaper plan.

If you stay within our system, it's a good deal. Would still prefer to have Medicare.

My plus 1 plan after 1 year of emplyment was $45/week a couple of years ago but is up to $60. So $320. The goal is to get employees to cover 20%. Previously it was only 10%. Old-timers remember extremely generous benefits.

Can't add $240 a month. When I started as a new employee it was $90/week ($360/month). One thing I like is that in addition to family, they have 1 plus kids which is way cheaper than family plan. Other places single parents get screwed.

How did you people fuck up so badly? My most recent monthly health contribution, ~1USD.

Other places single parents get screwed.

It's either than or in vitro.

Anyway, it's very clear that a large portion of America's employers either think their mid-level jobs are so horrible that nobody will do them if they could provide health care for family otherwise or really wants to make them that bad. For the lower-level jobs where most people don't get insurance, they have to go through all the trouble of trying to destroy the entire social welfare system.

Interoperability! Ha! I found that Cedars and MGH, although both using EPIC, had no way of transferring any data. This nearly caused redundant testing, but I was able to get (with a lot of luck and help) the imaging files sent to my laptop so the attending physician could review the previous tests.

29: They do for text results, but Epic requires that you give consent during a current visit. It's called Care Everywhere.

That reminds me that the radiologist gave me the film of my ankles on a DVD. Very handy because the doctor who was supposed to be able to access it on the system could not in fact access it. Also, I have a picture of my ankle that makes me look extremely hard core for even walking around with a bone spear digging into my soft tissues.

in a natural Darwinist way

I don't think it's a stretch to say that someone who uses that phrase as a positive may also be inclined to pass off responsibility onto government regulation when it seem pretty clear that there was a lot of blame to go around. Ultimately, the government shouldn't have been certifying shitty systems, which amounted to an incentive to create shitty systems. So maybe I agree with the guy anyway.

I actually did read the whole article, because I actually like longform journalism even if I don't always have the attention span anymore. I'd be interested in a follow-up that focused more closely on the stimulus and the early implementation. I can imagine there were other ways to spend $36 billion on health records, and given the existence of lobbying, a look at how the policy was made might be revealing. Or maybe it all happened in back rooms and no one wrote down notes.

There was a great deal of continuous work in the several years following the stimulus of implementation, as they continually upped the standards for EHR capability and use. I suspect the original bill was pretty vague and most of the flaws were down to the implementation process.

There was recently a Vox podcast looking at a clinic and the person there who spends hours a day faxing results because no systems are interoperable. At the end they interviewed someone in the Office of the National Coordinator, the only office theoretically empowered to fix this, and under Trump his response to everything was "We think it will fix things if we further empower the free market."

Why not try Christian Science?

A joke about an electronic health records systems free market and appendicitis.

(IIRC, monthly premiums for a family of six were: $850ish, $650ish, or $250ish. No idea how that compares nationwide.)

Sounds a lot better than our bronze plan. We are currently at $950 a month for a family of three, down from $1150 last year.

I think mine was close to $900/month with my previous work, but my employer paid half. Now my employer pays it all, which is both kind of great and part of the problem.

This part seems especially bizarre:

Doctors could shop for bargain-price software packages at Costco and Walmart's Sam's Club--where eClinicalWorks sold a "turnkey" system for $11,925--and cash in on the government's adoption incentives.

Plus the annual membership.

I wonder if anyone bought at Costco with a plan to return it after getting the stimulus money.

31- we had a similar situation but they knew they wouldn't be able to transfer it, they just gave us a dvd and said we had to bring it to the doctor ourselves to analyze.

I'm technically a state employee, which means I have access to (IME) really decent health insurance. We can choose between Aetna and BCBS. The university pays 95% of the cost of the worst plan, and 86.75% of the cost of the best plan (which is what I have). I pay $110/month to cover just myself (if I covered a spouse and children, it would be $286). The university pays $723/month. No deductible, $20 co-pays for standard care. The network is very large, so I don't have to worry much about staying in it. The coverage for physical therapy and chiropractic care isn't as generous, but it's still ok.

To the OP, I really learned the benefit of EMR when I had cancer. Almost all of the doctors I saw were somehow connected to the main hospital system, and so they all had immediate access to my labs, imaging, visit notes, etc. The difference between that, and my experience trying to coordinate between my gynecologist and my GP regarding my osteoporosis, was huge.

For health nerds, apparently in the last two years my hospital system has moved from GEMMS and Centricity to Cerner's integrated PowerChart platform.

42: our state employees get not great insurance now. $300 per day co-pay for high cost imaging or something like that.

Our teachers get pretty shitty healthcare although not the worst I've ever heard of. Once we were comparing whose employer had a better deal and they looked similar on premiums the we realized mine was monthly cost and hers every two weeks.

||

NMM to Larry Cohen, king of the horror B-movie: Q, It's Alive, The Stuff, Black Caesar.... RIP.

|>

And I'll add one of the great NYC filmmakers who really used city to great effect.

||

Cheng Pui Chee's Thailand-registered company Thai Sawat, led by his brother, was one of only five companies whose 1989-granted permission to log in Myanmar was renewed in 1993, gifted penguins to Myanmar's forestry department in 1990 and Northwood donated zebras and giraffes to Naypyitaw Zoo in 2011

A phyaician friend who has only practiced in the military health system routinely talks about catching stuff that would only be possible because of their systemwide patient records (this is true for service members and for dependents). I remind him that he's going to be so frustrated when he leaves the service. He reminds me that every time he deals with someone who has gone outside the system, such as to a civilian emergency department, he experiences it.

$36B over ten years is about 0.1% of all medical spending. That's not a lot of money. Odds are doctors offices have been spending that much stocking up on magazines.

I've already benefited from the new records system. I have doctors at different facilities including a couple of independents, and they can just pull up each others' records. (I have to give proper permission, but that's a good thing.) It also means I can look up my own medical records to keep track of things. Throw in email and online appointments, and I'll say it has been a win.

The software, of course, is terrible, but large organizations almost always have crappy software. It's rolled out form the top down with million word contracts and billion word requirements documents. There might be a million ways to die, but there are more than a trillion ways to get sick. If you compare the software a typical employee has to use just about anywhere, any airline, Home Depot, Walmart, or where ever, with the typical corporate web site, it's like comparing a floor of glass knives with a plush carpet. And, some of those web sites are pretty awful.

XI JINPING THOUGHT CRUSHES AFRICAN SWINE FEVER!

China's Ministry of Agriculture, the authority in charge of virus control, has announced 113 reported cases of the disease so far, including two in March, seven in February and five in January, a significant fall from 21 in December and 25 in November.
[...]
Sun Dawu, the chairman of Hebei Dawu Agriculture Group, a company that operates pig farms in the province [...] said, about 15,000 pigs had died from the fever in Xushui County in Hebei province but the local authority had covered it up.
[...]
one editor working in online media said [...] he has received several orders - both verbal and written - banning him from covering related stories.

How do they calculate the amount of money spent? A major install here was hugely expensive, but part of what they were including in the price tag was the cost of trainers and lost physician productivity.

You count the the pig skulls in the ashes and multiply by the market price.

re: 21

Or Jinja or Twig templates, or something of that ilk.

How do they calculate the amount of money spent?

professional grade software does the calculation!!

55 was me, not exactly spam but not exactly not either.

51. In many countries, potentially contagious animal or crop disease create conflict between ministries of health and agriculture.

Under especially unfortunate circumstances, health authorities don't really have freedom of action if there are economic consequences. https://www.fda.gov/Food/NewsEvents/ConstituentUpdates/ucm633483.htm

The stimulus act alone allocated 25 billion. I think the ACA might have added on to that.

We actually tried to do this within the NHS and it was a disaster for a whole range of reasons and in a whole lot of different horrible ways. £12bn and bugger all to show for it.

Blogging about it, I came to learn about VISTA as mentioned above, so why the fuck didn't you just deploy that?

Expanding VISTA, the system used for the VA, sure would make sense. Unfortunately the VA has been targeted as a house of bureaucratic horrors for its entire existence. This is because it's our one socialized system and conservatives have been trying to use it to discredit socialized medicine, doing their usual thing of identifying local instances of corruption or long waiting lists and saying "Of course this is typical of the VA", with zero pushback ever from the Democrats or even from people who might like to defend the VA for its own sake.

Speaking of, the Justice Department is now calling in the court to rule all of Obamacare unconstitutional. The number of huge stories barely getting attention because of the shitshow keeps growing.

Link please!

It's too hard to do that on the phone.

62: https://www.motherjones.com/kevin-drum/2019/03/justice-department-urges-court-to-kill-obamacare/

Thanks.

Thanks.
57: I think the conflict in this case is between the ministries of agriculture and health on the one hand and the ministry of truth on the other.

I know of a hospital that tried to implement an open-source version of VistA. They apparently found it ill-supported and ended up switching to one of the biguns. (Of course the government could have added that support for little outlay, made it the public option.)

For at least one (very) large HCP based in MN, the scale of the problem is just mind-boggling because there are so many different organizations (some acquired, some developed internally) with so many competing priorities paired with executive powerplays at the highest level (some trying to acquire power, some trying to defend power, others trying to hide the pile of dogshit they staked their professional future on in the last iteration of standardization efforts)...getting things done is nigh impossible and penny-pinching comes in play in the oddest ways.

As an example, this organization has over 10,000 different APIs. The organization charged with streamlining and standardizing data transfer so that querys would take under a second instead of (in some cases) hours can't even get the funding approved to hire a contract communications person to help promote alignment with the initiative because "that's something an admin could do." (3 guesses as to why I'm bitter, and the first 2 don't count.)

I honestly don't see how it gets fixed beyond finding something that mostly works and a mandate from the government that that's the system that gets used by everyone.

The billing system for Medicaid for All.