I've worked in the space for a few years and I'd discourage anyone from trying to build a career as a software dev in the Healthcare IT / EMR space. It's extremely sales driven (devs aren't valued at all), code quality is terrible and the systems you write are mostly for the benefit of insurance companies / compliance than doctors or patients.

I think there was a YC funded iPad EMR startup that tried to be cool / hip / provider first until they got smacked in the face by reality.

> It's extremely sales driven... and the systems you write are mostly for the benefit of insurance companies / compliance than doctors or patients.

This.

Once I worked making healthcare software that would basically save costs by avoiding complications. We were bidding into a large hospital network. After the long sales cycle, we checked the most boxes, clinicians liked the feel of ours the best, they said ours was the most intuitive, helped them do their job the fastest, etc.

The clinicians weren't the ones writing the check though.

Our competitor approached the main insurance provider in the area and convinced them they could save x% in additional claims if the hospital network would adopt their software. Competitor's deal was to split the bill between the insurance company and the hospital network. To the admins writing the checks, they had the choice between two vendors that more or less did the same thing but one came in at half the cost. Clinicians' preferences didn't matter, it was a no brainer for them.

No amount of software engineering would have saved that deal.

I have seen in healthcare more "bribery" than in any other industry I've ever worked. Whether quasi-legal in the shape of various kickbacks to outright illegal gifts of cash and goods. It is sadly endemic to the industry.

In part I think it happens more commonly because there is so much "other peoples money" in healthcare. Everyone is spending from someone elses checkbook and so transactions seem very distant.

Accountable care models are the next step now that HMOs are widespread. restoring financial burden to the patient seems backwards when considering systems like universal healthcare, but ends up reducing inefficiency (identifying genuine surplus, not things that end up costing in the end like reducing preventative care)

Not all healthcare systems are beholden to private insurance (my own country's included) and that shows in where these systems are deployed.

Also, compliance doesn't fully explain why competitors are able to convince clinicians to switch systems. Word-of-mouth means that people will know your EMR is a flaming piece of garbage, but (as you noted) companies would much rather cut up-front prices so they can milk an extended contract than improving product quality. All that said, I think there's a bit of a chicken-and-egg thing going on here. Good people don't join the space because the culture sucks and the pay is bad, but those are because those with the talent and drive all self-selected out of it. I get it, health IT is a huge drag and not at all sexy. But just look at how often folks on HN ask about "doing social good" and how many complaints there are about healthcare delivery. Trying to run a "disruptive" VC-backed startup is IMO pretty crazy, but contributing to an OSS project is far less risky and more achievable.

> Word-of-mouth means that people will know your EMR is a flaming piece of garbage

The problem is that the Venn diagram between the people who actually have to use or administer the EMR and the people who decide which EMR to implement is basically two entirely-disconnected circles.

That's often but not always true. With the caveat that is in a non-US country, hospital EHR purchases are usually done the way you describe, while doctors will often personally make EMR purchasing decisions for their own office or private practice. Government procurement and small business sales seem to be two very different beasts in this regard.

Yeah, my experience with healthcare IT was in a two-hospital rural provider in the US, so that definitely colors my observations there.

That said, I don't really recall the doctors themselves using an EMR much, either; they'd usually punt that to assistants and/or nurses. Probably different in smaller practices/clinics.

You're thinking of https://www.drchrono.com/

All these hip, cool EMRs always show a glamour of a patient. I have yet to see a medical practice or health care facility that has a photo studio as a side business!

Maybe not a side business, but it's not as ridiculous as it sounds! A friend of mine was an in-house photographer and graphic designer (I think he had some sort of managerial role, too) for the local hospital network until he got laid off when COVID hit. Basically, in addition to being a good photographer, he had to be aware of the various patient-privacy regulations involved and also have a practical working knowledge of the hospital so he and his team wouldn't be getting in the way.

I think most US hospitals have offer in house newborn photos. I know ours did :)

That's depressing. I feel like the regulatory side needs to be changed so that options like OpenEMR can become viable.

> I wish more FAANG-calibre devs would look into contributing to and evangelizing these platforms rather than writing yet another note-taking/"productivity management" app.

I would like to see the US Digital Service continue to task technologists with improving EMR systems at CMS (Centers for Medicare and Medicaid Services), but made free to use by all practitioners and citizens (and of course, open sourcing the resulting codebase). It seems sort of inefficient we keep reinventing the wheel (Epic and the like, which are crazy expensive, or self hosted solutions, when practitioners should not be spending time maintaining EMRs), when your records should be stored for your benefit by your government over the course of your life. This is where, imho, high calibre engineers provide the most leverage (one way ratchets on public goods at scale).

[1] https://www.usds.gov/resources/USDS-Impact-Report-2020.pdf

[2] https://www.va.gov/health-care/get-medical-records/

The VA sort-of does this, at least when I worked for them. The issue they had when I was there was depending on where you went, you may or may not have access to the record, because the VA didn't use a central system, it used many systems across the country, each with their own records(basically their own mainframe). We once added a hospital to our system, and had to have dual workstations because the systems couldn't be easily merged, and they had to look up patients in both systems.

Also, with Veterans Choice, I don't know how much there was an effort to bring this data back. Same thing with the DoD, for a while there was an agreement to send medical records for active duty to the VA, but then that got pulled for a time.

I believe there was a huge undertaking to consolidate these to fewer systems in the last few years, but Vista[0] (the VA's EMR) is pretty scary. I wouldn't wish it on anyone.

https://en.wikipedia.org/wiki/VistA

The VA has something called BlueButton that looks really cool (https://www.va.gov/bluebutton/) and I think should be standard practice across all EMS systems (one click export of all a patient's data to a single text file).

The file format itself seems like a bit tough to parse, but the concept I love.

Blue Button technically is an industry-wide standard though its origins were indeed in the government. I've seen it supported in a couple of the private healthcare systems I've used (though I haven't ever used the resulting data download unfortunately!).

https://en.wikipedia.org/wiki/Blue_Button

There's a pretty good library that helps parse those bluebutton documents:

https://github.com/amida-tech/blue-button

> Vista[0] (the VA's EMR) is pretty scary. I wouldn't wish it on anyone.

why do you say that? From a doctor's perspective, Vista is one of the more user friendly EMRs.

The US government has a public domain EMR system which they are in the process of replacing with a commercial system.

https://news.ycombinator.com/item?id=25042125

TIL that the new system is Cerner. That's depressing. Thanks.

EDIT: Still a win I suppose if it improves care delivery over the status quo. Nice to know there's still some progress on this front [1] [2]. Looks like I owe OpenEMR a financial contribution.

[1] https://news.ycombinator.com/item?id=25040076

[2] https://playbook.cio.gov/#play13 (Digital services playbook: Default to open)

I hope like hell “FAANG caliber devs” never take an interest in this space. Or at least not until the culture changes substantially.

There are just some things that “throw devs (of any quality) at it” just doesn’t work. The health care industry is one of them.

That's imprecise shorthand on my part. s/"FANG Calibre"/"objectively talented and used to/capable of negotiating good compensation"/. There's a degree of Stockholm Syndrome in healthcare tech where people don't know what a well-developed product or codebase looks like. It's unlikely to change from the top, so getting more technical folks with higher leverage into the field is IMO the next-best option.

And yes things are changing at a glacial pace, but they are changing. For example, my province is developing a new patient portal [1] out in the open. AFAICT, they seem to be doing everything aboveboard: CI, code quality standards, documentation and proper testing, etc. Yet if you look at another team in the same org (ministry of health), you'll find non-existent dev practices, oodles of VBA, or (even worse) some slow+buggy third party system put in place by one of the procurement vampires (IBM, CGI, Deloitte, you know the bunch). The biggest difference? The former project has a dedicated, US Digital Service-style team of skilled and hopefully better-compensated dev(ops) people who know how to deliver good software.

[1] https://github.com/bcgov/healthgateway

I think, in fact, you have it exactly backwards. You are very unlikely to find a decision making authority (person or committee) in a medical practice who gives the slightest bit of consideration for the development practices or code quality of software they're considering.

These people have three things on their mind (in no particular order): 1) does this product meet this organization's requirements under our regulatory compliance policies; 2) does this product (including installation, maintenance, and training costs) fit within my budget; 3) is this product widely known and trusted by my peers at other medical practices.

Notice something? The word "software" doesn't appear in that even once. They literally don't care. The result is that companies develop products (software) on the cheap, and that results in the quality issues that exist.

Improving the quality of the code base and development practices is solving a problem the purse-holders (customers) don't have.

I agree that all the factors you've listed are in play, but they are far from the only ones involved in decision making. Perhaps this is a regional thing, I've never experienced (and have no wish to) what the US EMR market is like.

Some complaints/feedback I did receive from doctors and clinic admins while working for an EMR vendor:

1. Your system is buggy/unintuitive and we hate using it.

2. We're not upgrading or moving to your new system because of 1).

3. We're moving to competitor X because they have Y feature.

4. [conversely] We came from competitor X because their EMR is slow/buggy/lacks features.

5. We signed up because the docs/office assistants liked [hero feature] in the sales demo.

So yes, 0 mentions of the word "software". However, all of these are directly related to the software itself. There's a reason flashy new companies can swoop in and steal some market share (at least where I am). Even more importantly, there are many tech-related reasons why some companies start floundering and drop out of the market:

- bad foundations (most EMRs were created by doctors with limited dev experience)

- rampant tech debt driven by feature-driven development

- lack of knowledge about testing/CI

These are not theoretical problems. More than once, we incurred regulatory fines and SLA penalties in excess of the "cost of doing business" threshold. After a pretty major patient data screw-up, upper management even relented and gave the dev(ops) team time/money to clean up their act. Regulatory and bureaucratic inertia may insulate health IT companies from software engineering issues, but there's a limit to everything and they can sure as hell bleed.

Believe it or not, there are some engineers that have worked at faang companies that are not sloppy and I work with a few of them.

It’s not about being sloppy. It’s about ego and hubris.

Just want to add: I work with (ex-)FAANG folks on a daily basis, too. Not all of them have egos bigger than their britches. But the ones who think “this industry just needs better software, and I can write it” sure as hell do.

I work in the medical research space and we have to integrate with EMR systems to get our data. I don't think software is the root problem, but rather the root problem is "there aren't incentives for good CMSes"--namely, there's no incentive for systems that talk to each other because healthcare consumers don't think about this when choosing a hospital and hospitals don't have any incentive to make it easier for their customers to leave their system (and EMS vendors certainly don't have that incentive). Ultimately the question is "why do we believe EMSes are valuable, but no one can figure out how to make money from making them better?".

I used to work in Bioinformatics. Getting Epic and Cerner to flow into our i2b2 or REDCap was a mess. Epic was a real disappointment in terms of their willingness to implement simple features that would have truly helped researchers analyze more specific outcomes. But I guess you gotta make money some how.

Hospitals are liable for data breaches and leaks, they have a direct incentive in making data as hard to access as possible.

Eh, as someone who deals with EPIC, ESO, and a few others... that's not the real motivation.

Epic will _happily_ interconnect with other systems for data sharing.

I mean Epic will happily _sell_ you interconnects with other systems, and will generally bill you on top a per patient, per export fee.

Yes, I absolutely agree that there is a problem with greed, ego and hubris in sillicon valley. Just wanted to point out that not all engineers fall in that category. I think that confidence in writing solid software when paired with humility can lead to good outcomes. To me, it seems like the ego and hubris issue can cause the most amount of problems when an individual (e.g. zuckerberg) takes on a savior and machiavellian complex. It seems like most of them actually believe that they are making the world better and they don't see the harm that their self interested blood thirsty capitalist side does at all.

I love this space—mostly because I loathe the absolutely awful American EMR systems— and intermittently have been working on some ideas with a few people (https://github.com/treenotation/pau) (here are some fugly notes/links to EMS systems for anyone interested in the space: https://github.com/treenotation/pau/tree/master/paudb)