[submain]

As someone who worked at a fortune 500 company making such EMR software:

There's no incentive to make the UI or workflows better. They don't pay the bills. Software is sold to the suits during dinners and baseball games, not doctors or nurses.

Besides, a great portion of the development is outsourced chasing lower costs. The code reviews were so bad that a coworker used to joke that "we'd get more stuff done if we just fired the overseas team".

The biggest and most well funded dev team was the one that worked on Revenue Cycle.

I quit a few years ago and haven't looked back.

[moribvndvs]

I worked on EMRs for 20 years. I recently quit that sector completely, and I wish I would have done it sooner.

Almost all of the features/fixes customers are actually begging for (the most popular categories being speed, reliability, reduced cognitive load and UI/UX streamlining) get dumped into the bottom of the backlog to languish. All the board and leadership care about is RCM, stupid ancillary services that patients do not give a shit about but look good in a sales brochure and have a high margin, chasing incentives from insurance and pharmaceuticals, cost cutting, and last minute, bare minimum regulatory/interop work necessary to not lose our ONC certification or violate HIPAA. Patient care and staff happiness just don’t rate that high. EMRs and the people who buy them are purely profit motivated.

It was humiliating watching how angry our customers rightfully have been and knowing there was nothing I could do about it. Now that almost all of our founders, product owners, and SMEs are gone and they just fired all but 7 engineers so they could offshore development to a company we haven’t worked with before and who has no experience with healthcare, our customers are going to be in absolute hell. The sad part is we don’t seem to be an exceptionally incompetent outlier but fairly typical of the industry.

[Nemi]

I agree. I also worked on EHR software and what people don’t realize is that the “customer” isn’t the doctor. Not to be disparaging, but the doctor is “just” an employee.

The purchaser of the software is the administrator. And because of harsh regulations and legal liabilities in their industry, they need software that is compliant with regulations and limits legal liability on the institution. Full stop. If they can get that with a good UI/UX, then great! But in the end, this is just another case of “No one ever got fired for buying IBM”. It is all about incentives.

Companies like Epic could make their UX better, but that costs money. And what drives sales is being regulations compliant, and that is hard. It takes a ton of time. There is little time left over to make something work well considering no other software is challenging them on that front. It really is a situation of regulatory capture.

[threatofrain]

I think the tides have been shifting for years but the medical industry is rare in that a substantial portion of “employees” are interest owners.

[karmajunkie]

100% this.

EHRs almost universally suffer from usability problems. people actually love having their medical records available. They hate the UX they have to go through to see them.

The source of the problem is that the people deciding which EHR to use are almost never the people using it. it’s ultimately the CFO or CEO who’s ultimately going to make the call, and they do it based on metrics like price tag or how many accreditation checkboxes it fills, not on user satisfaction scores. Until those user satisfaction numbers make it into CMS guidelines for reimbursement, the situation’s never going to change.

[hyponatremia121]

"The source of the problem is that the people deciding which EHR to use are almost never the people using it. "

Yes, this. We are a Cerner (now Oracle, yaaaaa) site, not Epic. The Cerner folks I've met in smallish meetings are nice/great on the front lines. However, the deal that our CEO/CFO/COO/CMIO made with Cerner was years ago and, per rumor, involved large financial penalties for early cancellation. Subsequent people in those roles have chosen to uphold the contract. The local management and healthcare teams in my particular facility are great but I take a dim view of our c-suite as do the majority of the work force. Things are reasonable locally for most people, I think, except for the EHR.

So, I would plead with leadership teams of EMRs, EHRs, healthcare systems, and shareholders of these entities to do the right thing and give healthcare workers working in high-risk settings the proper tools they need. You are currently failing us. No one wants unreliable, difficult software installed in critical settings such as ICUs.

I've submitted tickets, emailed leadership and had conversations with the CMIO. If there is improvement it is so slow that I cannot discern it.

In anecdotal conversations over the years I've observed that the vast majority of healthcare workers hate all EMRs but give Epic the nod because it is the least worst, and for some, reasonable. I have met a few Epic users that are enthusiastic about the software but that is after they arrived at our Cerner site and were in shock.

@duffpkg - my original comment was under yours and I wasn't intending to malign your project. I'm not familiar with it but do like that it is open source.

Respect to the developers that work on EHRs. I recognize you are held down by management.

I'm perplexed by UX/UI problems in EMRs. This must cost more to fix than I suspect. It seems to be the easiest of the issues from my layperson/healthcareworker/tech-enthusiast viewpoint.

One more thing to add: an effect of bad EHR is healthcare worker burnout. Bad EHR is a known contributor. Burned out healthcare workers are at increased risk to make medical errors. Bad EHR -> burnout -> errors -> adverse outcomes. This is a well known flow to us in the clinical setting that we attempt to mitigate. The executive teams of orgs that produce or purchase EHRs are never held accountable for bad outcomes even though, to my view, they share responsibility.

Edit: government regulators (CMS, etc) also share in the blame for bad EHR and outcomes.

[duffpkg]

This is a much easier fix in Cerner. I would guess based on the limited information at hand there is something wrong in the setup of the order release rules. IT should hire a Cerner specialist and the problem should be able to be resolved in days/weeks.

[DANmode]

You one of their phone sales people?

[DANmode]

Usability wasn't on the feature list.

That's $10M extra.

[npteljes]

As someone with a similar working background, I agree, in fact, I wanted to share this same exact sentiment. The software is shit, and everyone knows it how it's shit, and the reason is that the incentive is not there to make it not-shit. The main users, and the people who they record, are not the main concern in these systems. That is why everyone feels bad while using the software. It's not about them, it's not for them. It's not even against them - it just doesn't care. And this really radiates from the UX.

[dickersnoodle]

This is the sad tale of enterprise software.

[elevaet]

This is so broken and depressing. I had a tour of the EMR system being used in my jurisdiction and it was shocking how bad the UI/UX was. The scenario you describe is exactly what I imagined.

As a software developer I feel so motivated to fix it, I know a small team could do a better job. But I don't even know where to begin to try to enter that industry.

[nothercastle]

You don’t. It’s a regulated industry that regulated competition out

[mike503]

It's not just EMR, it's just capitalism in general. Everything is about squeezing the most value out of the least budget.

If there was a way to factor in costs due to downtime, poor usability, anything like that, might be able to push back and bake some of that in to begin with... but even that is a can they'd kick.

[scrubs]

I totally disagree except to the degree the provider is broke, close to broke in which case capitalism can yet help. When you're worried about money one may manage for money the exclusion of all else. It's a distortion only not a counter argument for capitalism.

The issue, ultimately, is crappy management. The need for, the good outcomes that could be achieved profitably, are insane in possibilities. Many country's demographics now include a lot of retiring people.

I continue to think basic TQM (which has gone out of vouge unfortunately) would help a lot.

Look at psychology in the US: a lot of providers will not even get involved in the insurance side of the equation. Patients pay cash. The patient is stuck with the insurance and re-imbursement, if they can figure it out.

The supplier side --- medicine and insurance and to some degree politicians --- made the paperwork system extremely bad. Simplification and elimination have got to be on the table.

Part of the problem is the patient is dis-intermediated The supplier deals with insurance directly --- hospitals in the main:

* the supplier can bill the patient's insurance wrong, for the wrong procedure, for stupid high amounts, and so on. The patient is not empowered to push back on that because the patient doesn't hold the checkbook

* hospitals and outpatient stuff like MRIs etc. don't publish a price list for the patient. Granted this is changing slowly. But why has that taken so long? Because the patient doesn't have the checkbook so why bother? Payment is done out of sight between the supplier and insurance company. It doesn't matter what the customer thinks.

The stuff where capitalism works better is when the customer knows the price, the supplier has no choice but to be upfront about it, and the customer will fire the supplier, refuse payment, or dispute payment for crappy supplier quality. The supplier can't get payment no matter what if the customer isn't going to provide it. Conversely, the supplier can refuse service for bad customers. This way both parties are encouraged to act smartly.

If I could wave my magic want I'd like to see a scenario in which,

* Customers pay insurance premiums to insurance companies in return for a bounded amount of access to a cash account.

* The customer must deal with out-of-pocket and co-insurance to eschew abusing the insurance company, fraud, and feckless spending. There must be bounded access to cash so the customer prioritizes what needs work and what doesn't.

* The supplier presents the customer with an itemized bill

* The customer --- and only the customer --- pays the bill electronically to the supplier through the insurance company's B2B payment system.

* Patients must get involved in, and start owning up the fact they can't refuse to take a zero on the dollars and cents of the care they're getting.

[scrubs]

See also the current HR story on Intel [1].

>biggest and most well funded dev team was the one that worked on Revenue Cycle

> no incentive to...

I am working hard to not build and fuel a fully loaded Boeing 787 into high-earth orbit and crash land it on the not-my-problem, told'ya, it's all corrupt-all-the-time, MONEY! money-is-the-measurement-of-all-things, it's bad-here-so-I-left city center fecklessness of it all.

Toyota at its peek performance (say late 1980s) was making king-kong sized money top and bottom line. No manager would ever say their only incentive or even primary care is cash. "Our only incentive is walk around with cash. Cash in the hand, cash in the brief-case, cash in the pocket, cash on the boss' desk. Show me the cash." has never spoken in companies knowing about TQM.

Instead there were aware of the numerous cross-cutting factors that, in net, determine what kind the money the company can make

Maybe medicine cares about cash so much, because it's broke or close to broke all the time. Hmmmm.

There are ton's of great incentives for the docs, the nurses, the customers, and the company's top/bottom-line to name just a few.

Somehow, someway, one day, one time management will have to get sick and tired of the on-going mediocracy. And until then I guess medicine doesn't suck hard enough. Eventually, like in Voltaire's Candide, they'll have to get into lockup, when the lady in the other cell says (paraphrasing): "You think that's bad? Big deal. I only have one ass-cheek" and goes on to tell a serious tale of woe. We're not sure yet if medicine is the one-cheeked lady, our Candide and his charges in the other cell. Only time will tell!

My extended family:

* runs several hospitals in the US

* owned a radiology business w/ multiple branches for a while

* worked at major city trauma care university hospitals that eventually went bust and had to stop operating

A few things I can tell you about them when we spoke about how the US does 16% of GDP on medicine with its high costs, and sometimes poor outcomes in what should be routine stuff,

- On the people: doctors, and nurses love to help and can be counted on same. Wonderful people.

- They did not tolerate quitters

- Good incentives (carrots) and incentives for dumb (sticks) are not per-se key, but rank in the top 10 with several other things to right the ship.

- Crummy hospitals run by crummy people (esp admin, senior staff, and management) that can't even break even can't help patients, because the unit has to close. There was serious contempt for anything contributing to that eventuality

- They tried in some cases to focus on process improvement, and process simplification instead of more automation for crummy processes.

- They were at times despondent about the sectionalism and the fact that software is too compartmentalized by discipline because the IT stuff often came from vendors that could have some integration but certainly not enterprise integration.

[1] https://stratechery.com/2024/intels-humbling/