Sunday, March 06, 2016

Cinders, EHRs, and Other Disappointments

I admit to being addicted to new technology. I love gadgets of all shapes, sizes, and sadly, prices. If there's some technological toy out there I'm missing, let me know and I'll run right out and buy it.

The crowd-funded sites, Kickstarter and Indiegogo, are the perfect trap for suckers people like me. Here, we find a plethora of inventions that one just has to have, requiring only a small investment for a piece of the future. Dangerous places, these.

Sometimes, the invention is so outlandish that it doesn't get funding, but some creations are so tempting and apparently within the realm of possibility that the rubes like me line up to part with their hard-earned cash. I've fortunately only gone down the tubes once, that on a pre-Apple Watch smartwatch wherein the inventor collected funds but never actually made a working copy of his invention. Fortunately, I didn't lose much on that one.

A more frustrating situation arises when the invention sort-of works but doesn't really. Such was my experience with Cinder, a screen protector for the iPhone 6 series.

The enticing property of the Cinder that made me dump a perfectly good Rhino-Shield was the curve...curved edges, that is, as you can sort of make out in the picture above. And why do we need this? Just ask Cupert, the makers of Cinder:
We created CINDER - the picture-perfect, seemingly invisible, ultra-thin glass screen protector with a form-fitting, edge-to-edge wrapped screen design, providing the ultimate user experience.

Unlike dull and ordinary flat screen protectors, CINDER beautifully combines flawless form with practical functionality in a precision-fitted, curved glass screen protector with specially-developed nanotech adhesive to ensure easy installation and reusability.


Engineered to be the most elite, user-sensitive screen safeguarding accessory, CINDER protects your iPhone 6 or iPhone 6s at the highest possible level without compromising design or functionality. Real curved glass edges seamlessly wrap around the iPhone 6 and 6s Series screen - no gaps or hard edges to chip. Just impeccably beautiful, iPhone-flattering protection that’s practically invisible.
Nice idea, but for the majority of users, per reviews, the Cinder just didn't work. It was not washable as claimed, it was very fragile, often breaking when installed, and it was not made from Corning Gorilla Glass as had first been claimed. For me, the problem was that it did not snugly fit around the glass of the screen, and thus, it was dislodged by the iPhone's protective case, and you MUST use a case to cocoon your iPhone should it fall to the floor. When I informed Cupert that every single case I tried knocked their stupid Cinder off the screen, they simply said, "Try another case." No refund, no nothing. So instead of the damnable Cinder, my iPhone now sports a Thule case with built-in screen protector, and I'm pleased with it. But I now have about $100 of unusable protectors and cases sitting in my drawer, thanks to my infatuation with a concept that just wasn't properly produced.

There are probably a million other similar product design missteps like the Cinder. Even Big Companies like Fiat-Chrysler can go down the tubes on a foolish idea. Take something as mundane as a gear-shift lever:
Image courtesy
You would think it hard to bung that up, but you would be wrong. From FoxNews:
Electronic gear shifters on some newer Fiat Chrysler SUVs and cars are so confusing that drivers have exited the vehicles with the engines running and while they are still in gear, causing crashes and serious injuries, U.S. safety investigators have determined...

Agency tests found that operating the center console shift lever "is not intuitive and provides poor tactile and visual feedback to the driver, increasing the potential for unintended gear selection," investigators wrote in the documents. They upgraded the probe to an engineering analysis, which is a step closer to a recall. NHTSA will continue to gather information and seek a recall if necessary, a spokesman said...

In the vehicles, drivers pull the shift lever forward or backward to select gears and the shifter doesn't move along a track like in most cars. A light shows which gear is selected, but to get from Drive to Park, drivers must push the lever forward three times. The gearshift does not have notches that match up with the gear you want to shift into, and it moves back to a centered position after the driver picks a gear.
And so it is with EHR's. These gargantuan and hideously expensive systems have great potential to improve health care, but unless they are well-made, and programmed for success, they can do just the opposite. And they do.

I hope you are already a fan of ZDoggMD, a physician-rapper (much funnier than a physician-blogger). ZDogg has encapsulated the frustrations with today's EHR's in this painfully hilarious video:

You will find the lyrics and background information on ZDogg's website.

His bottom line is this:
Simply put, the Tower of Babel of existing EHRs may not ever talk to one another, but they do share one thing: they come between us and our patients. Staring at a screen to click boxes and satisfy quality measures while figuring out the seventeenth digit for an ICD-10 code—this nonsense robs us of precious time and attention that should be spent on and with patients. I would never advocate going back to paper. Ever. But we need to demand technology that binds us closer to those we care for, technology that lets doctors be doctors. And nurses, and RTs, and case managers, and dietitians, and scrub techs—[insert crucial care team member here].
Which is what I've been saying for YEARS about PACS. The damn things work just enough to justify their existence, barely. They are clearly designed by people who do NOT understand our workflow, and they get between us and our patients, or their images, anyway. This is not how it should be. So why are EHR's so hard to use? Easy. Poor design, poor testing, and no real incentive to change.

As with PACS, EHR's are sold not to the end-users, but to the IT department and the CTO/CIO, who probably have absolutely no idea how it should work. Their criteria will be some combination of the following:

  1. Which product is cheapest?
  2. Which product is most expensive? (If it costs more it must be better!)
  3. Which is the Big Name Company that everyone thinks you have to have?
  4. Which company will do the maintenance and let IT off the hook?
Notice that having the thing actually work in the hands of those who use it is not on the list. 

A comment on ZDogg's page from someone who claims to work for THE Big Name in the EHR business is quite revealing:
People wonder, "why aren't EHRs designed with providers in mind?" I've worked at Epic and can tell you why not:
  1. Physicians were on staff, but hard to reach. They were technophiles and barely practicing as others mentioned.
  2. It really is a billing platform with some patient stuff tacked on. Everything useful you see is probably a workaround and one level away from not working at all.
  3. Quality Assurance (manual testers) are supposed to be a surrogate for users, as there is no beta testing. They are intentionally hired without CS background and maintained as laymen with a very lite, monkey-see-monkey-do training. However if they are not lickety-split quick to master the software, they are fired. Quality Assurance ends up being more like Self-Reassurance.
  4. There is absolutely no testing of interoperability. There is however plenty of testing for the several convoluted ways of sharing data between Epic servers.
And in fact, interoperability is another HUGE bugaboo with EHR's. As ZDogg rapped, er, said in the video, "Bought the new software, and though we use it here, I can’t use it over there, different systems everywhere!" In fact, Epic has been charged with overtly blocking data from other systems. Rather ominously, the original piece from has been taken down, or at least yields a 404 error. But what happens in Vegas stays on the internet, and so the cached version is still accessible:

Thursday, November 5, 2015

Connecticut reportedly has launched an investigation into several hospital networks and Epic Systems over their information sharing practices after a state law (S 811) took effect last month, prohibiting the use of electronic health records to block the flow of health data, Politico reports.

Background on Law

The law, which was passed in June and took effect Oct. 1, makes information blocking an unfair trade practice and subjects violators to penalties. According to Politico, the law based its definition of information blocking on the one used in the Office of the National Coordinator for Health IT's April information blocking report.

In addition, the law aims to slow the rate of health care network consolidation.

State Investigating Complaints

According to Politico, the Connecticut Attorney General's Office is reportedly investigating complaints under the law, including those against Epic and health systems in the state (Allen, Politico, 10/30).

The investigation stems from independent medical groups' allegations that hospital networks are using EHRs to dictate patient referrals and bring patients back to their networks (Walsh, CMIO, 11/3).

Critics allege that Epic -- which holds more than 50% of the state's hospital EHR market -- is unfairly collaborating with certain health networks against smaller physician practices.

For example, state Sen. Len Fasano (R), who co-sponsored the new law, said he heard anecdotes about physicians struggling to access patient information recorded at large hospitals, in particular Yale-New Haven Health System.

He said, "It was impossible for them to gain access to a patient's full medical record unless they were associated with the hospital," adding, "Independent doctors cannot properly care for their patients if they are denied access to full medical histories."

Meanwhile, state Senate President Martin Looney (D) said Epic was being used "as both a coercive tool to shut out nonparticipating practices and, in some cases, force them to be sold to larger health care networks."

Epic's Response

Epic spokesperson Eric Helsher said the vendor is not responsible for creating the conditions that led to such complaints, noting that the health care landscape is changing.

He said, "Physicians are aligning with health systems to reduce costs and improve patient outcomes," adding, "Epic enables this alignment by providing deep integration around a single patient record, a robust patient portal to increase patient engagement, and population health management and analytics tools that drive coordinated care" (Politico, 10/30).
So...Epic admits no responsibility although it created a proprietary system in a space that should be trying to integrate. Heck, even the majority of dysfunctional PACS can talk to each other, at least to some degree. Epic's stance is tantamount to Apple saying that from now on, an iPhone can only call other iPhones, but why would you want to communicate with a filthy, stinkin' Android anyway? Not cool, and at least in Connecticut, not legal.

And this unbelievable combination of hubris, arrogance, and indifference to the real needs of the patients, let alone those of us striving to take care of them, sets a rather nasty tone for the future.

I have said repeatedly on this blog and elsewhere for the past eleven years that PACS is a critical, life-saving creation. Dalai's First Law, in fact, states that PACS IS the Radiology Department. And as it is used today, the EHR the patient's entire record, and his connection to healthcare. Nothing happens in an electrified hospital that doesn't pass through the EHR. If it works, great. If it fails, people die. You might recall the little Ebola episode in Dallas from 18 months ago, and the Epic Fail that contributed to the near-disaster. (I say "near" because "only" one person died that time.) What I said then is still true:

Do you sense a familiar refrain? (Lawyers please note...THIS IS ALL MY VERY OWN HUMBLE OPINION, as is every other word that I have ever written or ever will write, unless quoted from someone else, and worth every cent my dear readers paid for it.) Once again, here in the Health Care Field of Dreams, we have badly written, badly designed software, created with minimal input from those who have to use it, selected and then implemented by IT types who also don't have to use it and don't understand enough about those who do to get it done right. This has to stop. Right. Bloody. Now. Hit CNTL-ALT-Delete and start over.

With Epic and the government having their hands deep inside each others' panties, we may well be stuck with these unusable systems for the foreseeable future. (And as an aside, if you deconstruct the Meaningful Use rewards and penalties, doctors are being bribed to buy EHR's that have the certified and confirmed ability to transmit data to Washington, D.C., so again, we won't expect the government to do anything about anything.) But, the demise of Mr. Duncan, and no doubt dozens if not hundreds more that he inadvertently infected between his two ER visits may level the playing field.

It is clear that Epic's epic Dallas fail (which might not really be totally attributable to Epic per se, but rather to the way the product was set up in the field, not passing that one lil' bitty critical entry to where it should go), contributed to Mr. Duncan's being released when he should have been locked up in the local version of Wildfire. It is possible, just barely possible, that this tragic episode will awaken the public to the dangers inherent in the IT-controlled medical software industry and its acronymbysmal spawn, EHR's, CPOE's, and the occasional unruly PACS. Get enough people upset about this, and they will call their congressmen, and more importantly their lawyers. (I would submit that more gets done by class-action suit in this country than by Congress.)

I realize that replacing these huge legacy systems which were outdated before they were even conceived would cost somewhere in the trillions of dollars, and so I'm not holding my breath that this will ever happen. But maybe a few million and billion dollar suits and fines would get the attention of the Epics, the Cerners, McKessons, and all the others who create these nightmares. Or maybe, just maybe, the execs will read this, and the other rebellious propaganda we are starting to see online, and realize that they are causing damage rather than progress, and be inspired to turn it all around. I'm a staunch believer in the electronic record, PACS, computers, iPhones, Apple Watches, and anything else technical. This is the future, without question. But it has to be done right, and so far that hasn't happened.
And don't underestimate the power of the individuals. Go to ZDogg's site,, and express your opinion about EHR's. It's a start.

This sorry state of medical software cannot go on. The time has come to fix it. Now.

No comments :