[duffpkg]

I am frequently asked about why systems in institutional healthcare are so hard to modernize, this has come up a lot related to pricing transparency. While HL7 is in theory a standard, in practice it is a semi-parseable "email" between two parties that know each other.

Widely used systems like EPIC have bugs and quirks that have existed so long that the bugs themselves have become their own standard. Because HL7 relationships typically happen between longterm consistent partners both parties tend to evolve the format to suit localized needs and this business logic and the reasons for it are lost to time. It isn't that rare to find HL7 interfaces that have been in use for 20+ years that have become vital black boxes. HL7 2.x, still widely used, was originated in 1989.

In a lot of case modernization like FHIR is nothing more than taking the old garbage and putting it in a new fancier bag.

As whacky as HL7 may seem it is really nothing compared to its much bigger uglier older brother, X12 837/835, used for communication of billing information from performing entity to insurer.

[ethbr0]

I don't have enough fingers to count the times I was doing automation in healthcare, implemented the process to spec, and then had a bunch of test cases flagged as failing.

Turns out, for large known counterparties, there are indeed de facto processes that incorporate each party's eccentricities and are "known" on the floor (processors typically have long tenures in their jobs) but unknown above a certain level of management.

E.g. a large children's hospital that reliably spit out misformatted requests to the local payer, but which the payer papered over on their side by converting them to payable requests (naughty, but kept them from bouncing back and requiring resubmission)... and had been doing so for 10+ years.

[ArtWomb]

Bizarro-world that doctors actually defend EPIC! They all complain about the ASP.NET 1.0 UI. It's just the convenience of viewing all patients from all hospitals in one virtual "chart" ;)

[devilbunny]

As a doctor, Epic is mediocre software that just happens to be less mediocre than most of the alternatives.

My biggest problem with Epic is that things are so heavily silo'ed by your job description (RN, MD, PharmD, etc.) and job context (without getting too deep into the weeds, it is a fact that the Epic implementation at my hospital does not allow anyone other than anesthesia personnel to see an intraoperative anesthetic record - not even the surgeon who performed the surgery (!); and that certain contexts do not allow a nurse who is running the schedule in one area to edit their case status board, which is a view of all cases in that area that allows them to see what's been done, what's left to be done, etc., - but if they switch context, they can change things, make their own boards, and then change back to the "proper" one and use the ones they've made).

[cmiles74]

It's more than just the job description, I believe many EHR vendors require people who use particular modules to be "certified" for that module. Obviously this leads to a silo effect where the information is available but one clinician may need to request another clinician to actually read the data to them.

[devilbunny]

Which is beyond moronic.

If you need the anesthesiologist on call to come back to the hospital just so the surgeon can see what drugs were given during the case and what the vital signs looked like, your EMR is less useful than paper.

[Spooky23]

A loved one was inpatient for a few weeks at a local epic hospital/medical system and then a more specialized/academic hospital with a federated collection of cerner systems.

It’s a night and day difference. The GUI may be ugly, but the Epic implementations tend to be soup to nuts. Everyone, from the transporters moving patients to the doctors to the primary care providers to the patients know what’s going on in real time.

At the teaching hospital, they had awesome medical capability, but nobody had a clue what was going on. That leads to risks if you need care from multiple specialties.

I’m sure that it’s garbage enterprise software of course.

[noelsusman]

Epic is the worst EMR system, except for all the others.

[nradov]

The baseline HL7 V2 Messaging standard is really intended as more of a toolkit. It's very generalized to allow for a wide range of uses anywhere in the world.

In order to establish real interesting between two organizations you generally need to follow an Implementation Guide which constrains and profiles the baseline standard. HL7 publishes some IGs itself and others are available from organizations like the CDC and DirectTrust.

[cmiles74]

Agreed. While FHIR is clearly more modern, in my experience it's the same data I'm seeing provided over HL7v2. It's easier to parse JSON and it's nice having the data labeled but values are still inconsistent.

[robertlagrant]

It's worse than this. EPIC will have its own conventions, but then each hospital system will have its as well. It is the least rigorous data environment I've ever worked in.