In (the UK at least) your medical notes follow you as you sign on with a new GP (General Practitioner - first point of medical contact for anything non-urgent). Now knew this theoretically happened, but was quite bemused to see it happen in practice. I rescued a rat from the silken-jaws of my pseudo-homicidal cat, and the ungrateful rodent bit through half of my finger - I thought it would be sensible to have a checkup/shot. I've only got a hazy recollection of what shots I've had when, so my notes were consulted. Seemingly, according to my paper notes produced from the cabinet, 40 years ago "I was an adorable wee thing" (aged 2).

Medical notes are largely fiction IME. You should request all your medical records from any doctor you have seen and start demanding they correct them. You will be shocked at the lies they tell about you.

You will be even more shocked down the road when you find out how these lies can hurt you.

Medicine seems like a technological wasteland. They put "notes" into text boxes and call it "using computers".

I wish I had both CS/SE experience and Medical experience so that I could understand what keeps this field in the 1970s. I have suspicions.

There's a recent New Yorker article by Atul Gawande covering this from a slightly different angle: https://www.newyorker.com/magazine/2018/11/12/why-doctors-ha...

He puts much of the blame on the generalization of computer systems, i.e. that the notes have to be readable by all sorts of staff and need to be systematized to accommodate that.

I recently built my mom a basic web app to automate building patient evaluations. She has been using paper forms with checkboxes for decades and they started requiring the info in digital format over the last few years. She had been copy and pasting from the digital version of the blank form into MS Word. It was time consuming, but still faster than typing it by hand. To be clear, a paragraph containing sentences is the format medical professionals are required to present this information in. Automating the boilerplate stuff actually gives my mom more time to type in the information that the paper forms don't anticipate and provide actual care to patients. The problem is not automation. The problem is unscrupulous executives who maximization profits at the expense of quality of service. The examples provided in this article are unethical and anyone who is caught dumping irrelevant data into important medical records should be held responsible.

My kids' pediatrician was part of a small office, which merged with a larger office that is affiliated with a large hospital and hence uses EPIC. She used to take hand notes on paper and was quiet efficient when she was with the smaller office. After the move I have seen her struggle with EPIC, and then recently hire a medical transcription service and be followed by a person taking notes so that she can focus on the medical stuff. And, of course I have no idea if the quality of her notes has suffered.

I do NLP with medical notes. What I have observed is that the redundancy between the note and information available elsewhere in the EHR in structured formats is pretty high, as is the amount of boilerplate (e.g. section headers and list templates that may not be filled in).

This makes machine learning using the notes difficult since the content is so muddied up. It's far from impossible to do useful things with them but there is a lot of noise. Still, some things require us to look at the notes. For these things we would much rather have them than not.

While it's preferred to have the information entered in a structured way, doctors find that more of a hassle than entering in the data free-text and it's also no good for retrospective analysis where we didn't know several years ago we would be interested in something and so no structured field existed.

Here's a fun thing about our system in the US. If you're taken to the emergency room, they'll ask your medical history. And not just once - they'll ask it in the ambulance, radio it ahead to the hospital, then make you wait while they ask you the same questions again and enter them into their system at the hospitsl. Then the next 3 doctors or nurses who come into your room do the same thing, asking you questions you've already answered. Doesn't seem to matter if it's obvious that speaking is painful for some reason (in a case I'm describing a family member had broken ribs).

This EHR data problem is something I've pondered for a bit.

One "simple" solution is to have departmental standardization of note format with thoughtful inclusion of what fields are typically pertinent. This doesn't solve the problem of care transitions but it might help standardize review in a hospital context.

The other thing that I've been pondering is something resembling a formalized data structure and language for note taking. For example, diagnosis X based on Y Z. Other probabilistic diagnosis A ruled out because not B not C yes D. Reduce free form notes to be as sparse as possible. Also there should be a reference system to point back to other notes / lab values / imaging which when clicked will bring up that data. Finally, a timeline which charts pertinent diagnoses, lab values, and changes over encounters. I'm not sure how viable it would be given the complexity of notes that my physician colleagues have showed me / what I've seen in research, but I'm curious.

I deal with various EHRs every day of my life, and 4-digits-worth of providers. The primary barrier is that practice managers are working to get data standardized, but get pushback from the providers who are busy doing their jobs being doctors and not data scientists.

Some EHRs can streamline via templates and workflow. Others don't. I've literally had practice admins not implement new practices that would document properly and facilitate easy reporting because they would not be able to sell the change to the providers.

I'm not blaming providers for the data issues. They have a job to do and they do it. It just doesn't always get documented in a reportable manner. There needs to be an easier way to document, or some kind of Middleware that documents for them.

I see people a whole lot smarter than me trying to use ai to interpret notes. I personally think they are just facilitating the ongoing poor documentation problem. And things will slip through the natural language cracks, and it could be a potential health hazard.

My Primary Care Physician is unable to speak coherent sentences.

I'm half-joking, of course. The guy is top-rated, elected head of the state association. He's widely-regarded as a combination of both brilliant with diagnostics and good with people. He just can't complete a sentence when we meet.

Why? Because he's got some pad he carries around that takes up all of his attention span. He comes into the room, sits down -- and there's this struggle for his attention that I watch play out. It usually involves a lot of verbal grunts.

"So we've got this .... er.. .. and it looks .. hmmmm. .... So this is...."

This could go on for a bit. Eventually we get to either a statement or a question.

Frankly I'd think the guy was having some sort of mental issues if it weren't for the facts that 1) he used to be fine before they all started carrying around pads, and 2) he's fine outside the clinic.

I really hope that the tech community has helped make healthcare better. It's certainly had an impact.

I've done a good bit of thinking about medical note taking.

To me it's a little odd that hospitals are the ones who keep this information. I'd think that the records should belong to patients—it's about them after all. And that the patients would provide access to doctors or hospitals.

Right now I've got a personal medical journal that has things like:

* Sickness - Date Range and Notes

* Flu Shots - Date

* Injuries - Date and Notes

* Observations - Date and Notes

* Blood tests - Date and Photos of Tests

Before my yearly checkup (or if I have to visit a clinic) I review the last entries and open them on my phone incase my doctor wants to see any of them.

It works well enough for me, but seems like there could be a ton of opportunity for improvement. I'd love to have a system where my doctor could be notified and comment on new notes or events. Also the ability to bring in my scale, run tracker and other fitness data.

Doc here - spot on. 25% of my day is typing, reading, deciphering, referencing. I waste so much time not providing care.

I strongly agree that EMRs are making this problem worse, not better. And doctors seem to hate quite ubiquitously the extra amount of documentation they have to do. While there is a lot of evidence in some areas that EMRs have improved quality of care and patients' lives, I don't think this is one of them.

I worked at the VA for over 2 decades, including the transition from handwritten to electronic notes. Wow. When I retired, the nursing notes for a patient visit were usually 2-3X longer than the docs note. The nursing note was entirely populated by templated text created by a hierarchy of supervisory staff tasked with satisfying all regulatory requirements. The poor nurses would ask the patient a series of prompted questions, click on the appropriate box, and a page of templated text would emerge. Actually finding useful actionable info in the nursing notes was impossible, or close to impossible. The docs began to demand, reasonably, that actual patient problems identified by the nurse be put in a specific area of the note rather than randomly scattered throughout 4-8 pages of templated text (which without this demand could be randomly intercalated with such useful info as "pt c/o chest pain when walking, much worse", found on page 5 of 8.

The docs notes were, in many ways, even worse. The notes required manual typing, and many docs are not trained skilled touch typists. So the two-fingered part of the note was often very brief and succinct. The templated portions were huge - impressive reviews of systems where you could not really tell if the specific items had actually really been asked or if the template just vomited forth a page full of text for administrative review.

Make a doctor function as a data entry clerk and this is what happens.

The old school method of sticking the charts to the foot of the patient’s bed has the same pleasant properties that using sticky notes on a board for tasks does.

Anyone that’s struggled with JIRA and just said forget this due to tool impedance will have a good idea of how painful this is. In hospitals I almost never see charts pulled up except on daily rounds. Sure nurses are great and smart people and usually remember everything, but they also work hard long hours and the cost of mistakes can be very high.

My favourite citation from the link:

“In fact, across this same EHR, clinical notes in the United States are nearly 4 times longer on average than those in other countries”

It seems that the EHR isn’t the root cause of the problem.

Problem of medical notes have a name: bureaucracy. The hope is leaving it apart, and today it seems a bit utopia...

Also in terms of "numeric/digital" vs "paper" the point is ignorance: how many people outside IT world (and even inside) do actually know enough a desktop to take their own personal notes in an ordered, usable and useful thing?

IMVHO a so small percentage that we can probably know them all by name. Just take a look at a "common" mailbox: most of them are an utter pile of data, few with some incoherent taxonomies, few even with the sole inbox as an archival place. Than take a look a common "home directories": the very same mess. And if this is for personal and generic data do you think that those people are able to properly not only manage but share helpful information with digital systems?!

The medical journal is one of, if not the most, important inventions of modern medicine. I'm an MD and work with them every day.

But yes, the current infrastructure is not good.

1. Money

2. Legal liability (CYA)

3. We don't use outcome-based medicine

I refuse to believe (beyond a bad email notification , which is not acceptable for medical information) that being elaborate or non-concise is a problem. Why is 4x more medical density a bragging point , in other words?

One "solution" is sometimes to use speech-to-text. The mangled results would be hilarious if they weren't frightening.

I read number 1 —- “money” — as “doctors lie about what they are doing to get paid more by your insurance company”. Is that unfair?

Spec. Off's [1]

  - Doctor enters your visit (encounter), cross your fingers that his system has the most up-to-date medical codes (e.g. snomed, cpt, icd, etc)  
  - Doctors notes for that encounter are potentially entered as a text area in one system (u/petermcneeley). Can be notes at the encounter level or for a specific diagnosis/lab result/etc.
  - The codes vs free text, is what we refer to as discreet and narrative/free text.
  - The current IHE spec. [2] (last updated in 2015?), allows for codes to be interpreted from narrative text if a valid code is not provided. I think there are a few startups that have popped up here that are trying to make sense of the narrative text.
  - That same spec would be great if everyone followed it but they have to get their system to bend a little bit or throw an integration engine in front of the problem to play nicely with others. (u/nradov)
  - Start sending those back and forth and you either end up losing those notes or butchering them up.


  - There are some orgs (e.g. DoD, VA, Sequoia, etc) that have everyone follow the basic requirements but then add their own flavor on top. [3]
  - FHIR [4] is here, but I think everyone is already scrambling or haven't had the need to make the cut over to it until its government mandated. I have to say this has been the easiest spec. to grok, but it is still way too flexible for these companies to mess up. A cut over to FHIR for everyone should ideally be that you have to use the Hapi FHIR models [5]. Maybe have a way for Hapi to sign the models on their way out?

Sorry, this turned out to be more of a rant, but I stare at this stuff everyday. There are a few other folks on the thread that know the industry as well that have some good info too.

[1] https://media1.tenor.com/images/af0c71048d5a130cefc335423c59...

[2] http://www.hl7.org/implement/standards/product_brief.cfm?pro...

[3] https://xkcd.com/927/

[4] https://www.hl7.org/fhir/

[5] http://hapifhir.io/

"how these lies can hurt you"

True story, I had a major illness in my late 20s. And apparently I have a high tolerance for pain, so the nurses and doctors repeatedly underestimated how much pain I was in. I can be in incredible pain and still hold it together and answer questions in a calm and rational manner. This made one doctor suspicious that I was faking the whole thing. So then I tried to adjust my behavior. I started deliberately giving more outward signs of the pain I was in. And then the another doctor accused me of exaggerating or being a hypochondriac.

I was not able to find a level of external performance that kept all of my doctors happy. If I was too restrained, then they had trouble believing I was really feeling the pain that I described with my words. But if I tried to act the pain I felt, then I was accused of being a hypochondriac.

I should add that most of my doctors were great. In my whole life, I've only had 2 negative experiences with a doctor, the two that I just mentioned.

I found omissions to be particularly interesting too.

For example, I once declined to take a shot after the doctor explicitly told me that it would most likely not yield any benefit, given the response I had from other treatments.

The medical record simply shows that I declined the shot, but not that this was upon strong recommendation from the doctor.

This became an issue later when the provider went back to the records and stated "you were offered this shot and declined". It is technically true of course, but context would tell a slightly different story, and would definitely shift more responsibility towards the doctor.

The doctor was probably right to make this recommendation, but the fact that it is not captured in the records makes me uncomfortable.

A while back I had a doctor where you could access everything via the online portal. I don't think some of the employees there realized that as there was some truly shocking stuff in there. One thing I learned was that anything I said which could possibly be misconstrued in a negative light was noted in my record as if the negative connotation was accurate.

In the US you're legally entitled to your medical records too but every time I've done it the response is always defensive, ie "why do you need them", "send me the doctors information and I'll fax it to them myself".

Support the OpenNotes movement. Patients have a legal right to view their records (with some limited exceptions). But it needs to be easy and happen by default rather than as a special request.

https://www.opennotes.org/

At one point recently someone noted on a X Ray that I had hepatitis. I asked my PCP; he said don’t worry, we don’t diagnose that with radiology.

I asked that it be removed.

No can do.

AFAIK I’ll go to the grave with a note from a random radiologist that I have hepatitis.

Your comment reminds me of a series of Seinfeld scenes [0] which honestly scares me to death as I'm pretty sure all my doctors have labeled me as a hypochondriac.

[0] https://www.youtube.com/watch?v=ZJ2msARQsKU

Yes at least with paper they were typically tied to one hospital. Now with Epic they are basically automatically pulled over.

In my experience, it's a combination of a couple of things. First off, the field is heavily regulated (in the US anyway) and the penalties for violating regulations like HIPAA are incredibly high. Second, the field is currently dominated by major players such as Epic, so its pretty important to be compatible with them, but they don't really have an incentive to open up their ecosystem since they have such a stranglehold on the market. Finally, a lot of medical folks have been burned by technology in the past, and, in my experience, often view a lot of the tech they have to use as an insurance and government mandated evil, rather than a way to make their lives better.

Not to say things can't be improved, but there are a lot of factors that make it more difficult than a traditional B2B or B2C product.

The regulations are outdated (fax is considered secure communication, as I've harped on before.) There's no patient visibility into these systems, so they don't see just how outdated and broken they are. I think that the biggest problem is this relentless focus on the short term-upgrading systems will cause problems now even if in the long run they'll pay huge dividends. Sort of similar to how medical professionals work extremely long hours with inadequate sleep.

I used to work at Epic as a software developer. My take on it is that the key explanation for why medical software is so bad is that it is so hard to even attempt to compete with established EMR's.

I could go on at length about this but I'll try to keep it short. Basically, imagine that you're a startup and you want to compete with Epic in providing a comprehensive IT solution to health systems. You will _at least_ need to:

1. Write software for every major medical specialty that is comprehensive enough to satisfy the specialists' expectations of domain-specific tailoring

2. Also ensure that these modules are flexible to accommodate intra-specialty variation (for example, oncologists vary a lot in how they divide stages of cancer)

3. Ensure that your software will comply with and help your customers perform well financially with federal, state, local, and program-specific (Medicaid, Medicare...) regulations

4. Go into a room full of health executives who are deeply weary and suspicious of health IT people (for better and worse reasons) and convince them they're better off risking a multi-year, extremely expensive transition project on your startup, which might not be around in a few years, instead of going to an EMR vendor that's almost-not-even-mediocre but stable like Cerner or Epic. (The "nobody gets fired for buying IBM" effect here is real.)

Clearly all of this requires a lot of work, and would require millions of dollars in funding and the poaching of some top talent in healthcare IT who know the lay of the regulatory land. As a result, most HIT startups (that I know of, at least) target something less ambitious than an enterprise EMR. Some target only a specific specialty (like home health or care management), others target small family practices (which are becoming increasingly rare as they are bought out by major health systems).

This is in a way bad for everyone except the software vendors, though, because without a competitive threat, there is little incentive for companies like Epic to undertake the risky, major rewrites which are vital for the company's long-term technical health. Epic still uses a typeless, (almost) data structure-less language called MUMPS for its server and DB code, and on the client side, all of it is still either in VB6 (yes, 6, not .NET) or a quite spartan home-grown JavaScript framework. The result is that bad code never gets totally thrown out, and Epic's developers are not able to benefit from the productivity-multiply amenities of modern languages, which include type systems and abstractions more powerful than subroutines and goto statements. Development then takes an order of magnitude longer than it might have, and the feedback cycle continues.

It seems like most of these articles focus on the documentation side.

There are other elements, like med/consult/lab/diagnostic imaging orders going to the relevant person/department instantly. With a handy interface for following them along, cancelling or re-scheduling them at any time.

A nurse doesn’t need to follow a provider around to find out what the new orders are, they show up automatically on their own task scheduler.

Providers can enter orders remotely.

Or allergies just getting verified instead of collected from scratch each visit.

Or billing/appointments happening electronically instead of manually completing forms.

There is a lot of copying and pasting data from one system (i.e. lab results) into the other. This is probably rooted in distrust of the system and fear that the lab results will become unavailable combined with a healthy amount of "cover-your-ass" syndrome.

https://www.newyorker.com/magazine/2018/11/12/why-doctors-ha...

The systems are built to serve administrators, not practitioners.

Some industries require higher table stakes than others, in the form of a defensive patent portfolio.

A principal of a failed medical records startup described it to me as an incumbent coming to them and saying basically "You have a nice disruptive startup. But we don't want to be disrupted. We have some patents. Their details don't matter. Our <unit of time> legal budget is greater than your last round of funding. End of game."

A blend of regulation and complex sensitive domain.. the medical field tried a few time going computerized, it failed badly. Half because of project management issue, half because of the field itself .. I think there should be a dedicated CS staff to grow solution cheap and on the fly rather than large upfront monolith that will fail to actually deliver value to patients and employees

There are multiple reasons for this, in no small part because what people think EMR's are and what they really are is very different.

Medical tech has the seemingly simple barriers voting has, but that once you incorporate it into a system they because heavily limiting and expensive.

I'm a Dr who has just quit my specialist job for the 2nd time to pursue a startup.

You'd think I'd do something medical - I've been in the field 10 years, I should have been able to find a problem IT can address?

To be honest the thought of doing a health IT startup just fills me with dread.

Many departments do standardize their note formats. The problem is that the note is directly connected to billing, and the billing requirements are absurd. I'm a medical student, and I recently visited my PCP for a medication refill. I have no significant medical history whatsoever, and the visit took no more than 15 minutes as expected. A month later, I was given a bill for $330 stating my hospital visit was level 4 acuity (there are 5 levels, with level 5 being ICU-like care). I looked into how the billing level is determined, and I found this article explaining how components of the notes are tied to billing levels [1]. Basically, by including 6 elements to the physical exam rather than 5, you can bill at a higher tier. There are several other areas that are tied to billing like this, including the family history, social history, etc. My PCP had completely filled out her standardized note to include every little detail I had mentioned—many of which were totally irrelevant to my current issue.

I talked to some other physicians about this, and I learned that hospital departments use their standardized notes to include as much detail (i.e. bloat) as possible so that physicians can bill at higher tiers since billing is tied to the number of details included in the note.

[1] https://www.aafp.org/fpm/2003/0100/p29.html#fpm20030100p29-b...

All large hospitals and clinics already have standardized note formats.

For care transitions the HL7 C-CDA 2.1 Continuity of Care Document (CCD) format works pretty well. Modern EHRs can export a summary of a patient's chart in that format. Some data may be lost in translation but usually it works fine. But there are often still technical obstacles to transporting a CCD from one provider to another.

There are existing formal code systems for notes: CPT, ICD-10-CM, RxNorm, CVX, SNOMED-CT, etc. Those are helpful for billing and analysis purposes, but they can't replace free form narrative text for most clinical use cases.

Epic provides progress note templates:

http://ist.jefferson.edu/content/dam/ist/epic/SmartList.PNG

http://3.bp.blogspot.com/-13TVMTrcPkA/UPWKAB_rTGI/AAAAAAAABD...

The problem with this is that a very small minority of patients are that diligent or reliable, for various reasons (dementia, forgetfulness, disinterest, mental illness, low IQ, substance abuse, not realising the information is required, brought in by ambulance unconscious and peri-arrest, etc.).

Here in the UK patients do have responsibility for some records - notably anticoagulation records and maternity / child health records.

I have seen literally one patient present with their anticoagulation record. I have lost count of the number of patients who come to appointments without their maternity notes or child health notes.

Even trying to get an accurate medication history from a patient is near impossible and we end up having to look at past hospital discharge letters, call their GP, or look on shared record systems to try and piece together what they are taking.

I'm all for patients "owning" their records but they must be held in a way that is accessible when needed regardless of human variabilities.

Notes intended for patients would have a different form than notes intended for doctors. Unfortunately medical records achieve neither. My notes are bloated with information needed to bill the maximum amount from the center of Medicare services, which ultimately hurts all parties.

The bloat obscures critical information from other doctors. Patients are unable to read a meaningful account of their care, and are charged more for worse services.

One thing I like about Japan, where I live now, is that every time I get a test done (and unfortunately I've had a lot of them recently), they send a copy of the results to me. I have everything my doctor has. He also writes personal notes for himself, but usually they are descriptions of symptoms when I complain about stuff. I could write them down too (and maybe I should), but those are his personal notes just to remind him what was going one when I visited him. I don't need access to that, as far as I'm concerned (although he shows me what he's writing and sometimes I even ask him to show me what he's written on a previous page).

> To me it's a little odd that hospitals are the ones who keep this information. I'd think that the records should belong to patients—it's about them after all. And that the patients would provide access to doctors or hospitals.

This is absolutely the future, with the ubiquitous devices and cloud-like infrastructure. But we are decades away from with with entire segments of the population not even having an email account.

I was working for a large multi-state HMO during their transition to a major EHR (I'll let you guess, since I do not speak for either). I have a background in IT and was a systems consultant for a number of years.

On paper, I could get a relatively uncomplicated chest pain case from the ER to the hospital unit with all the orders for workup ready in 45 minutes.

With the EHR, we had abominations like double medication reconciliation and poorly customized order sets that ballooned my average admit time to almost two hours. And I was among the fastest. (I should note I am told these issues have improved, but it took years.)

Given that there was so much other stuff to do now and that ordering had become a nightmare of lookups and checkboxes, physicians under time pressure are going to economize where they can. Where they do is in the documentation, which is not generally reviewed and won't by itself prevent the patient from getting where they're going.

Now move this to an outpatient office where patient loads have not lightened and it becomes magnified.

It's a point of pride that I don't copy-paste my notes, but I have the luxury of being mostly administrative these days and most of my patient contacts are in a hyperspecialized clinic where I can do things like prewrite most of the note even before I go in a room. But it's killing primary care and it's probably making things worse at the very point where it needs to be made better.

The fundamental problem in my opinion is that these EMRs were forced on providers and hospitals rather than emerging organically by choice.

I fully support the use of EMRs as some ideal, but it should emerge as the best option not as something that was forced. The result was a lot of EMR systems that would have never been adopted if there wasn't added pressure from government regulations. I strongly believe that EMRs would look pretty different if they were adopted organically without regulation.

It's really astounding to me that the elephant in the room of healthcare regulation isn't discussed more in public discussions of cost. As a result we end up with EMRs where the tail wags the dog, lack of transparency, lack of competition, lack of choice, etc. etc. etc.

I keep hoping the weight of the edifice will cause the thing to implode as it becomes so obviously unsustainable, but it's as if more regulation just births more regulation.

I’ll shoot: what extra documentation has to be done on an EMR that isn’t necessary on paper?

Has the “standard” been to document X, Y and Z, but providers felt (rightly or wrongly) that documenting those things is unnecessary, so they didn’t, but now they have to and it’s easily auditable?

Is the problem the medium or the implementation?

> It’s not uncommon for teenagers to be misdiagnosed with mental illness or ADHD and either of those are disqualifiers for FAA medical certification, military pilot careers, and likely many other military, law enforcement, and intelligence careers. IIRC, a prolonged history of ADHD treatment is enough to disqualify military entrance for any MOS without waiver. Waivering prior ADHD diagnosis requires a costly and difficult process to undiagnose the patient and prove that he or she no longer has the condition and was incorrectly diagnosed in the first place, at least if you are trying to get FAA certified for a Class 1.

How do you feel about the (I presume underlying notion, at least when it comes to programming jobs) that a "bad" hire is costly and we'd rather let ten potentially great candidates go rather than accidentally hire one very bad candidate?

The relative risk of driving while having ADD/ADHD (accidents/km with / accidents/km without) is around 1.54 [1]. This isn't horrible, of course, but it's still bad.

Non-disqualifying visual impairments have a relative risk down around 1.2, implying a surprisingly low cutoff for a visual impairment being disqualifying. "Severe behavioral problems due to ageing (dementia)" have a RR 1.45. A category covering epilepsy, narcolepsy, and other conditions causing sudden interruptions/disturbances in consciousness is at 1.84, and those conditions require medical sign-off in every country I checked. Diagnosed alcoholism amortizes to around 2, and that'll get you a breathalyzer or suspended license right quick.

The cutoff for being ticketed is is observed to lie around a relative risk of 4, which is where cell phones come in. The cutoff for being arrested on the spot, being legally drunk, is a relative risk well above 10 and probably up around 40.

Interestingly, almost nothing is as bad as being a teenage male, which carries a relative risk around 7. Teenage females are around 5.5.

That all said... while we can certainly complain about rampant misdiagnosis - I wish I had a dollar for every time someone told me that I'm just addicted to stimulants - my opinion is that this particular rationale for disqualification is absolutely justified. There's a reason I don't drive.

[1] https://www.toi.no/getfile.php/Publikasjoner/T%C3%98I%20rapp...