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Maxander is correct. As they say, "Don't judge a person till you've walk a mile in his shoes." As a someone who has been writing healthcare software (not EPIC but close enough) for nearly 10 years I can tell you it's not the software engineers. The regulations (often vague and open to interpretation by the customer) often play a part in creating the monstrosities that power our healthcare systems. Because of the subject to interpretation aspect customers often say, "No. This is how it has to work because our processes say this is what we do to meet the regulation." Inevitably it's implemented to be configurable because that's what's required. Another culprit is the institutions and lack of standards surrounding process. There's a reason EPIC software is customized for every institution it is installed in. It's because every institution wants to do things differently. Even in the space which I work, it's the same. Every institution wants "some specific change" that they can't live without and won't go live until it's available. I'm saying this is neither a good nor a bad thing. It's just a reality. And the ever present legacy, take EPIC as the example, it was founded in 1979. I'm not saying that their code is all from 1979 but there's definitely a fingerprint of what was in their modern day applications. There are layers upon layers of data from mergers and acquisitions translated into various codes and mapped to various databases for any number of uses. Any day of the week your state code may be two letters, three letters, full name, a custom internal legacy code, you name it you'll see it. Spend a year working for a company with a regulated legacy healthcare product and significant user base. You'll have to become proficient at security, regulations, data standards (HL7, FHIR, etc), legacy data migration, and any other number of skills. If you're lucky enough to have all of those in place then you're still going to spend time coming up to speed within the specific healthcare domain you're working in and where it touches other healthcare (and non-healthcare eg financials) domains. Oh, and often you won't be allowed access to production instances to troubleshoot issues and a copy of the production instance isn't available because HIPPA and the customer is uncomfortable giving access to engineers. You get really good recreating problems purely via error logs and staring at the code where the issue "might" have occurred. |
My sense is that EHR mandates were colossal screwup. They should have never happened. No matter how good they seem in the ideal, mandating them should have never been the case.
The reason why is because each hospital had a very well-tuned staff with a system that was designed for that hospital, in-house, over years. Implementation of EHRs should have been done the same way, ground-up, on a site-by-site basis, in a way that allowed for more gradual, flexible adoption with complete autonomy by each site. If they wanted to buy into something like EPIC, great. If they wanted to develop something in-house, great. If they wanted to contribute to an open source project, great. That sort of system would have been much better in the long run.
As it happened, EHRs were just sort of slapped on, top down, with the providers being forced to adapt to them rather than vice versa. It was horrible, and a perfect example of government regulations fucking things up. I'm very pro-public sector, nonprofit, etc. but also think that regulations (in terms of restrictive licensing laws, FDA nonsense, things like EHR mandates, etc.) are the unrecognized disease in American healthcare systems.
EHR mandates at each hospital system I or my spouse worked at to resulted in cost overruns of billions of dollars. Those are just two systems in the US, and believe me, neither of those hospital systems--which were very successful, well-run enterprises, without EHRs--would have never implemented them when they did without the mandates.
The most egregiously stupid thing about the mandate is that EHRs would have been implemented in both these hospitals relatively soon anyway, but it would have happened on a much better timeline, in a much more sane way.