northern_lights

8 anni fadiscuss

it's worth noting for others that this was almost certainly a hospital policy violation, not a hipaa violation. There's nothing in hipaa that prevents a person from accessing their own record (though I have heard hospital administrators try to claim otherwise).

northern_lights

9 anni fadiscuss

any MCU can "jam" a GPS receiver if the board is laid out improperly or without enough shielding

northern_lights

9 anni fadiscuss

I think he likely meant "I don't think we will ever see HL7 messages exchanged between organizations [routinely and with little effort]."

"some configuration work is usually needed on each interface" is the key phrase in your response. Just because many organizations have poured cash into yours and your competitors' solutions when the economic stars align does not mean that message passing between organizations is a solved problem.

northern_lights

9 anni fadiscuss

I find Epic to be more horrifying than Meditech, because Epic has somehow managed to convince many healthcare workers that it is a "modern" product worthy of praise, despite all evidence to the contrary. People talk about SmartPhrases like it's some miracle instead of a damn snippets manager (and a bad one at that).

The fact that they're moving away from VB6 to a web-based front-end in 2017 should be reason enough to assume that whatever they come out with is going to be excruciating.

northern_lights

9 anni fadiscuss

I previously used meditech on a daily basis, and good grief is it horrible. I've seen intelligent people spend 45 minutes just trying to figure out how to write a simple progress note before giving up and writing it by hand.

What's very frustrating is that no one - EMR vendors, hospitals, or even doctors - seem to realize just how much of a productivity booster good UX design can be. Even the ability to have multiple windows open at once (i.e. the ability to look at lab results while writing orders or a progress note) would be a breath of fresh air.

northern_lights

10 anni fadiscuss

1.) It's a very time-consuming and hands-on process to train a surgeon. There aren't many other fields that I'm aware of with the same level of intense apprenticeship as surgery (and medicine in general). My first thought after entering medicine was to marvel at how much effort goes into training a single physician. There is a lot of training at between a 1:1 - 1:3 student-preceptor ratio in an effort to produce very high-quality physicians. So, the solution is not exactly as easy as, "well just make more surgeons."

2.) The federal government controls the number of residency slots each year, through Medicare funding for residency programs. I don't pretend to know the details of how it works, but my impression is that to get more residents per year, you need to convince Congress that it's necessary.

3.) Classic chicken-and-egg problem. Any medical student can go into surgery if they want to, unless their performance up till that point is seriously below par. However, there are many other specialties that offer more attractive lifestyles. So to increase the number of students who choose to do surgery, you'd need to find a way of signaling to students that the life of a surgeon isn't all back-to-back divorces, microwave dinners, and 80-90hr work weeks.

northern_lights

10 anni fadiscuss

>If we get a cold and need time off we need to visit a GP, this is rent seeking that could easily be handled by a non doctor for half the price.

I'm not sure where you work, but I have never needed a doctor's note to get off work for a simple cold. That's a company policy issue, not the fault of the medical industry.

As I said, a lot of the front-line work is now handled by NPs and PAs. There are still physicians in primary care, but they spend much of their time handling the more complicated patients.

northern_lights

10 anni fadiscuss

I am nearing the end of medical school now, and I can assure you there are many surgeons who consistently work 80-90 hours/wk. I see it most often in surgeons who have subspecialized and do extremely technical work. Family, social, laundry, food, etc, all become things that you take care of whenever you get a free second. It's very, very difficult to describe the path a person takes to get to that point, but the profession can absolutely be all-consuming. It's one of the reasons surgery is less competitive as a specialty than it used to be - people see the brutal hours and make the choice to pursue options with a more attractive work-life balance.

northern_lights

10 anni fadiscuss

"Most things are simple, and it doesn't require years of school to set a bone or put in some stitches, or even diagnose the flu or pneumonia."

The thing is...when that fracture extends into the joint capsule, or is in multiple pieces and needs a surgical repair, you'll want the doctor around to manage that.

When that flu weakens your immune system and causes you to get a superimposed bacterial pneumonia, you'll want the doctor around to manage that.

The days when a doctor could make a living managing only simple problems are long gone, if they ever existed. These days, PAs and NPs handle the majority of healthcare's equivalent to CRUD applications, and physicians handle the complicated cases.

I have noticed that it's become popular on HN to refer to parts of the healthcare industry as "rent seeking," and while I agree to some extent, I haven't seen much evidence that doctors or medical schools themselves are rent seeking.

northern_lights

10 anni fadiscuss

To address your example directly - we already have holter monitors that would show a case of atrial fibrillation quite easily. They aren't terribly expensive, at least for something that has to have FDA approval, and they are frequently used. Heck, you don't even need "AI," in the sense of neural networks/machine learning/some other buzzword. Current systems will review a strip collected over several days and flag any abnormal rhythms.

The problem comes with determining who to put on a monitor. In the case of the patients you described, it's actually quite likely that the doctors seeing these patients considered the possibility of afib. The symptoms, though, can be very vague, and they are seen nearly every day in the doctor's office. It's simply too expensive to put every patient on a holter monitor - the doc's office has to be paid to maintain the monitors (which people abuse at home), the nurses have to be paid to teach patients how to correctly wear them, the monitor company has to be paid for whatever absurdly expensive and proprietary review software they supply, and the prescribing doctor (oftentimes the prescribing cardiologist) has to be paid to review and confirm the machine's interpretation.

All of this for a transient rhythm which any second year medical student would easily recognize if presented the EKG from across the room.

The sad reality is that the patients you described were experiencing the system as it is "designed" (I use the term loosely) to work. The fact that someone is persistently seeking help for their problem dramatically raises the probability that something is truly wrong, and doctors actually recognize this and take it into account. This is one of the reasons it's considered best practice to establish a long term relationship with one doctor who knows you well, but it's harder and harder to do with insurance companies only reimbursing for 15 minute visits.

northern_lights

10 anni fadiscuss

One of the challenges of medicine is that the information is gathered from so many sources and is so "fuzzy" in quality.

Building a "database" of information from which to make a diagnosis is unlikely to be easily automated. Take a straightforward case of a patient who comes to the emergency department after "fainting". Did they slowly kind of "melt" to the ground, or did they just BOOM fall? Were they confused after they woke up, or just a little sleepy? Was it a hot day or is it wintertime? Were they wearing a shirt and tie, or a t-shirt? Different answers to each of these questions will change the probability of each potential diagnosis. The signal:noise ratio is frequently very low, and there's not a great way to improve it without adding an extremely large amount of cost and time to an already expensive and slow healthcare system.

Good clinicians already have an idea of the top 2-3 most likely possibilities before they walk into a patient's room, based on epidemiology and a quick review of a patient's chart, but we try to be flexible enough to discard those preconceptions if new info becomes available. Sometimes clinicians fail to fully investigate what a patient is telling them, and that's where the real mistakes get made.

northern_lights

10 anni fadiscuss

Many people might not understand just how busy physicians are, and how difficult it can be to integrate a new product into the clinical workflow.

The most pressing thing to understand is that clinicians spend the VAST majority of their time gathering all of the necessary information to make a diagnosis. In other words, they aren't puzzling over how to diagnose about 85% (made that up) of their patients.

Once the necessary information is gathered, an experienced doc doesn't usually spend more than about 10-15 seconds debating different diagnoses. Therefore, if your tool takes more than 10-15 seconds to launch, enter any necessary data, and get a result, you are slowing the clinician down and they won't use it. This is why automated EKG interpretations (which are very much a real thing used at hospitals across the country) print directly on the EKG printout - it doesn't cost the clinician more than about 2 seconds to read what the machine thinks and adjust their interpretation accordingly[1].

One of the major problems limiting adoption of "expert" computer systems is the amount of (very expensive) integration it takes to get them under that 10-15 second limit. One of the big reasons radiology is seeing a lot of buzz around machine learning and automated interpretation is that integration becomes a lot easier when you can just feed in an image and maybe 5 words about the indication for the study.

I would love to go on for a while about this stuff, but I'll stop there for now :)

[1] Some people here might be interested to learn that non-cardiologists generally don't have negative views about automated EKG interpretations. But we are also very well-aware that when we make decisions about a patient, those decisions have to be anchored to something a lot more substantial than "the machine told me to do it."

northern_lights

10 anni fadiscuss

I honestly cannot understand why anyone would call Altium an "overpriced piece of technical debt." It's an extremely powerful piece of software, and fantastically easy to use (especially compared to some of the crap out there, cough OrCADcough). Perfect? Of course not, but it's not bad.

northern_lights

10 anni fadiscuss

The regulations only look like they're in favor of the doctors to those completely unfamiliar with the field. But who keeps the money from that $8000/night hospital stay? It certainly isn't the internal medicine doc making $200k/year (admittedly a great salary, but not at all out of line with the requirements of the job). I'm an advocate for less regulation in the healthcare industry, but it's not as simple as just throwing away all barriers and allowing the free market to solve everything.

Nurse practitioners and physician assistants are new entrants in the healthcare marketplace, and they are absolutely a "disruptive force" in the healthcare market, in the original Clayton Christensen-sense of the term. In fact, these professions were even called out as such in The Innovator's Dilemma. So your argument that new entrants to the market will somehow magically make prices lower doesn't hold much water (and for those who think that these entities should be freed from the regulations which require them to be supervised by a physician...that's like advocating for a large bridge to be designed and signed off by a civil engineer 2 years out of undergrad).

As for Certificate of Need laws, which limit the amount of hospitals and sophisticated equipment that can exist in any given area...certainly most doctors I know don't love these laws. It's the hospital associations (made up of many, many people other than doctors) which continually fight to keep them on the books.

northern_lights

11 anni fadiscuss

Obviously. This one doctor erring on the conservative side and not immediately taking a sharp instrument to your friend's eyelid proves that all doctors are corrupt and/or stupid, and the whole system is a scam.

Or maybe doctors generally know what they're doing and can, on average, perform their profession better than a random guy on the internet.

northern_lights

11 anni fadiscuss

You can argue all you want about whether it's a good metric for surgery quality or not, but if you're being discharged soon after surgery, the idea is that your surgery went well enough that you don't need to be around $50mil worth of life-saving equipment 24/7. It has a valid place in the system, with pros and cons like any other metric.

Hospitals are full of all kinds of hard-to-kill microorganisms. They really are not good places to stay after a major traumatic event (e.g. surgery) if you don't need the resources of the system; staying will only increase your chances of getting a life-threatening infection. When I get home from the hospital, I try to change out of my clothes as soon as possible for this very reason.

As for pain medication, well...one only needs to look at the enormous rise of opioid addiction and prescription medicine abuse in the USA to see that moderation of these very dangerous medications is in the patient's best interest.

The medical system is far from perfect, but don't operate on the assumption that the people working in the field are ignorant of the problems you're pointing out. There are many things we could be doing better, especially on the transparency and patient education side of things, but it's a huge industry and big ships turn slowly.

northern_lights

11 anni fadiscuss

What's this? A medical device company that publishes prices and actually tries to make low-cost, high-value products?? I will be watching this very closely!

I am in medical school now, but I used to be an EE in the medical device space; my experience was that so many device makers sell through one or several layers of intermediaries that prices have to be jacked up substantially to make any money at all. We're talking selling products with a BOM <$150 for $3000+ (these weren't highly specialized med products either - you'd find similar devices in practically every doc's office). As a result, the companies never moved enough units to justify a refresh of the design more than once every 10-15 years.

I'm very happy to see someone trying a leaner approach, and I hope you guys do well! Sell me some cool stuff in a few years :)

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