Death by a Thousand Clicks: Where Electronic Health Records Went Wrong
Y Combinator Posting, Death by a 1000 Clicks<p>Fair warning: put on your flame-retardant suits; the following rant contains adult content and is for mature audiences only.<p>I started my career as a professional software engineer, where I worked on porting the UNIX kernel to an SMP machine, then I went to grad school in CS, with a focus on database theory and AI, back when AI was unfashionable and NOT funded by the NSF or DARPA, and then I went on to medical school.<p>I&#x27;m also an industry insider, having worked for one of the larger (marketshare-wise) EMR companies.<p>So I&#x27;m a doc. A real one. As in I spent 4 years busting my ass at a top college, where I graduated phi beta kappa, while all the privileged white frat boys spent most of their college time getting drunk and fucking all the cheerleaders. Then I spent another five sleep-deprived years as an underpaid resident.
Now that you know my credentials, let&#x27;s get a few things straight:<p>1. Physicians HATE Epic. It&#x27;s responsible for an epidemic of physician burnout. I personally know physicians who have refused to work for the companies that acquired their practices because they were told they&#x27;d have to use Epic after the acquisition was finalized. And I personally know physicians who have left the practice of medicine AFTER being forced to use Epic. It just wasn&#x27;t worth it to them.<p>2. The non-disparagement clauses are true. I&#x27;ve seen then. You are not allowed to talk about the very real patient harm and threats to patient safety that Epic has caused. Epic&#x27;s CareEverywhere merges the wrong patient data across health systems way too often. These are HIPAA violations. But the health systems refuse to report the HIPAA violations because of the civil and criminal fines they would face, not to mention the violation of the non-disparagement clauses. I&#x27;ve seen it first-hand. It&#x27;s all too real. And patients have been harmed. But no one has ever outed this problem.<p>3. You remember the old trope: &quot;No one gets fired for buying IBM&quot;? The modern equivalent is &quot;No one gets fired for buying Epic.&quot; In reality, the health systems&#x27; C-Suites are clueless; they don&#x27;t listen to their physicians. Their only concern is their job security; not their patient&#x27;s welfare, and not the mental health of the physicians that they employ. To them, physicians are replaceable commodities.<p>4. Health systems purchased Epic in the FALSE belief that it would pay for itself via Medicare bonus payments. Bullshit. It never did, and it never will. Magical thinking is too fucking prevalent in the health systems&#x27; C-Suites. And there&#x27;s no sign of it ending.<p>5. It&#x27;s an EMR stupid. Not an EHR. When we stared automating the paper chart (medical record), we called it an ELECTRONIC MEDICAL RECORD. Then some suit -- a non-clinically-trained MBA&#x2F;marketing bozo -- came along and decided to rebrand it as an EHR (Electronic Health Record). Guess what. It&#x27;s an ELECTRONIC version of the MEDICAL RECORD. I really don&#x27;t give a shit if some magical-thinking homeopathy-prescribing naturopath, or some nurse practitioner who wants to play doctor, is offended because we are using the term MEDICAL rather than HEALTH. It&#x27;s an electronic version of the fucking medical record. Get fucking used to it.<p>6. You ever heard of MUMPS, as in the Multi-User Medical Information System? It&#x27;s what Epic is based on.<p>MUMPS was designed in 1966 at the MGH Laboratory for Computer Science by a team working under the direction of Dr. Octo Barnett, a physician&#x2F;computer scientist. Dr. Barnett is (was) a fucking genius. He figured out how to build a database-enabled multi-user OS and run it on a DEC PDP 6 with only 128K of RAM and 5MB of disk storage. Think about it. That&#x27;s K, as 128x1024 bytes of RAM. And 5MB, not 5GB, not 5TB, but 5MB of disk storage. Way the hell less RAM and non-volatile storage than in that computer in your pocket that wants you to think it&#x27;s nothing more than a phone on steroids. Could you write a multi-user OS with persistent storage that run in 128K RAM? I didn&#x27;t think so.<p>A few fun facts about MUMPS, the engine that powers Epic:
a) MUMPS uses a hierarchical database design, and was developed four years before Dr. Edgar Codd published his seminal paper on the set-theoretical relational model for data. No self-respecting professional software engineer uses a hierarchical database.
b) MUMPS variable names are&#x2F;were limited to three characters in length. Imagine writing a complex piece of software where your variable naming scheme is limited to three-character variable names. But remember, this had to run within 128K of RAM.
c) All variables are global in scope. There is no encapsulation. Um. Ever tried to implement recursion where all variable are global in scope? Or how about RPN notation, as in the shunting yard algorithm? Not happening.
d) All character data values are limited in length to 1024 Bytes. So a text note that is 1500 characters has to be stored in a linked list. Or not. Epic just truncates long notes to 1K.
e) All variable are persistent. As in -- they represent data storage elements on the disk. Huh? Again, this was a great design for a PDP 6 with 128K RAM and 5MB disk. But not for today&#x27;s architectures.
f) No such thing as a transaction. So no commit or rollback or ACID compliance.
g) None of the first tier computer science programs teach their students how to program in MUMPs. Why would they? But I&#x27;ll bet you can find an open-enrollment &quot;university&quot; -- a diploma mill where your ability to pay tuition is the only requirement for matriculation -- that is willing to teach MUMPS programming skills.
Bottom line: Epic is the technological equivalent of the 1966 Corvair. Advanced for its time. But that was more than 50 years ago. Wouldn’t you rather own and drive a 2019 Tesla Model S?<p>Flame off...