1980s – Mark Leavitt

Mark Leavitt In 1980s, Doctor, Doctor!, Grand Tour, Health Informatics

Electronic Medical Records: 2nd Generation

1986-1992

By the mid-80’s, PC hardware and software had advanced enough to put a networked workstation in every room of the medical office, sharing data from a relational database stored on a centralized hard disk drive. So I set out to write the next generation of my EMR software.

GUIs (graphical user interfaces) weren’t yet in wide use, and many experts argued that doctors would never use keyboards, but I rejected that opinion. I figured that doctors resisted keyboards more because of “secretarial stigma” than from an inability to learn touch-typing; and since any clinician using an EMR regularly would soon become an expert user, an efficient keyboard command interface would serve them well.

After creating and using the 2nd generation EMR in my own office, it attracted the attention of my educational software customer, Eli Lilly. With two new recombinant DNA drugs on the market, they asked me to create EMR software to support specialists using those products. Over the next several years, I developed Humabase for doctors treating diabetes, and Growthbase for pediatric endocrinologists treating growth hormone deficiencies. Specialized features included the ability to print Lilly’s educational handouts on demand, upload and analyze data from home glucose meters, calculate dosages, and create individualized children’s growth charts. Lilly distributed the software gratis to doctors as an educational service (though that might not be acceptable today) and it was warmly embraced. A handful of doctors became so attached to it that I found copies still in use 30 years later!

While Lilly was distributing its specialized versions of the EMR for free, I built a more general-purpose version for my own office, which became a kind of showplace for computer applications in ambulatory care. Among its off-the-wall features:

Tracking and analysis of patient waiting times at every step by tapping into the chart holders and room signal lights
Nurse and assistant call buttons with escalating alerts designed to minimize patient waiting times
Background music in exam rooms that faded in/out automatically on my arrival, with music selections tailored to the patient’s age cohort
After-hours dial-in chart access; using an early cell phone, I could enter touchtones and the computer would read out my patient’s problems, medications, and allergies

When I demonstrated this at conventions, it generated so much interest I decided to try marketing the EMR myself. It soon became clear that my marketing, sales and implementation skills were woefully inadequate. The product name kept changing (Mark-20, System II, ClinicaLogic) as did the sales model (software-only? software-hardware bundles? fully-installed turnkey?). I needed help.

By 1993 two founders of Mentor Graphics — Rick Samco and David Moffenbeier — offered to join, fund, and help grow MedicaLogic, but I’d have to leave medical practice and become a full-time CEO. Once again I left a comfortable career behind for a riskier path. It would prove to be the adventure of a lifetime.

Mark Leavitt In 1980s, Doctor, Doctor!, Grand Tour, Health Informatics, Inventions and Patents, Wearables for Health

Desperation is the Mother of Invention

1983-1985

While I was busy building up my internal medicine practice and side business in clinical software, my wife Susie’s health was deteriorating as the complications from 20 years of Type I (insulin-dependent) diabetes accumulated. Home blood glucose monitoring was becoming available, and it was hoped that more precise control of insulin dosage could forestall complications, but data management remained primitive and paper logbook-based.

In hopes of helping Susie record and visualize her blood glucose data, I added a remote terminal to my Apple II+, consisting of a TV set mounted into the wall of the kitchen and a light pen built from plans in Byte Magazine. The built-in TV made the kitchen look high-tech, and the light pen let her enter her blood glucose without using a keyboard. The software could print out a log for visits to her physician, who found the graphs printed on curly thermal paper occasionally helpful.

Despite attempts at careful glucose control, the complications accelerated, eventually leading to end-stage kidney failure, treated with at-home peritoneal dialysis. There was no invention I could come up with to overcome this setback. All I could do was help manage the thrice-daily sterile drain/refill procedures and make sure the required medical supplies were always on hand.

When severe hyperparathyroidism then developed as a complication of the renal failure, Susie underwent surgery on her neck to remove the overactive glands, but the outcome was disastrous. She was left with vocal cord paralysis requiring a permanent tracheostomy, taking away her ability to speak while recovering. Finally, this was something I could help with. I put a 555 oscillator and small speaker into a brass tube, directing the sound output through a smaller soft rubber tube. With the tube in the corner of her mouth, she could create speech with a fairly intelligible albeit robotic-sounding voice. I found the gadget still in my “junk box” 35 years later.

Complications continued to set in, and she passed away in 1985.

Mark Leavitt In 1980s, Doctor, Doctor!, Goodies for Oldies, Grand Tour, Inventions and Patents, Wearables for Health

I’m (Not) Falling For This

1983

The Ambularm – an ambulation alarm

At St. Vincent Hospital, word spread quickly about the quirky new hybrid doctor/engineer down in the basement, and one of the senior physicians soon wondered if I could help him solve a big problem: patient falls. Despite instructions not to do so, patients would get out of bed and fall down on the way to the bathroom. Even the best hospitals experienced hundreds of these events per year, causing everything from bruises to hip fractures to head injuries and deaths. Bedside rails didn’t reliably prevent this, and restraining the patient in bed wasn’t acceptable either.

Weight sensors in the bed had been tried, but they didn’t activate until the patient had left the bed, and they didn’t protect a patient who was sitting in a wheelchair either. So we hit on the idea of a battery-powered tilt sensor that would be worn in the thigh, and would sound an alarm as soon as the femur (thigh bone) angled downward more than 30 degrees.

I built a crude prototype with Radio Shack parts in a plastic box with an elastic strap to hold it on the thigh. It looked promising so we had a PCB and molded case professionally designed, and eventually received a patent. The Ambularm made a distinctive bell-like sound that brought a nurse running before the patient got to his/her feet, and fall rates were cut in half. I wasn’t involved in the later stages, but apparently the Ambularm stayed on the market until 2015.

Mark Leavitt In 1980s, Doctor, Doctor!, Grand Tour, Health Informatics

Electronic Medical Records: 1st Generation

1982-1985

With residency complete, I rented space in the basement of St. Vincent Hospital to launch a solo practice in Internal Medicine. I’d been pondering how to program the Apple II+ to improve practice efficiency and patient satisfaction. Three needs stood out: problem list maintenance, medication/prescription management, and customized info printouts for the patient. During those early months, the appointment book had plenty of gaps, and I spent them writing code in Apple Basic.

I had wide printer paper manufactured with perforations; it would tear apart into a letter-sized page and 3 prescription slips. As each visit ended, I updated the patient’s problem and medication lists, checked off any necessary refills, and selected from a list of information handouts for various conditions. Zing, zing went the Epson dot matrix printer. Then I handed the patient a summary of their diagnoses and medications, educational information, follow-up instructions, and a stack of neatly printed prescriptions.

Patients loved these handouts, and my practice grew as they showed their friends what a modern doctor they had! But of course there were limitations. A floppy disk could only hold about 100 patient records, so it required disk swapping (e.g. A-E, F-J, K-O, P-T, U-Z) as the practice grew. Text notes were typed on a word processor, but there wasn’t room to store them on floppy disks, so they were printed out and kept in conventional paper charts. At best this was a computer-assisted, but not fully digital, record system.

So I had to wait for technology to catch up to my dreams. I bought a Kaypro-10, the first hard-disk PC, but it proved a dead end. When the IBM-PC/XT arrived, I abandoned Apple Basic in favor of dBase II, a high-level relational database language. Finally, low-cost networking arrived, supporting data-sharing between PCs installed at the front desk, in exam rooms, and in my office. It was time to create the next generation EMR.

Mark Leavitt In 1980s, Doctor, Doctor!, Grand Tour, Health Informatics

Docs just wanna have fun

1981-1989

Clinical Simulations on the Apple ][+

The Apple II+ personal computer appeared during my residency (1979-1982) and I wanted one badly. Susie feared it was just an expensive toy ($1200 was more than a month’s pay for a resident) but gave in, bless her soul. After playing with the Flight Simulator program, I became convinced that clinical simulators could be useful — and even fun — in medical education. So off I went on this side project during any spare time I could scrape together.

By the time I finished residency, I had created HeartSim, a cardiac electrophysiology simulation, and Condition Critical, an intensive care case simulation. I installed them on a computer in the ICU’s call room so fellow residents could try them out, but they attracted even more attention from sales reps of medical device and pharmaceutical companies. They wanted customized, trademarked versions for use at convention booths.

MedicaLogic is born

I created the customized program, adding a scoring system based on the player’s treatment efficacy: student, intern, resident, attending, and so on. Viewing this as a fun educational project, I offered the Eli Lilly reps the software on cassette tape (as a floppy disk drive was beyond my budget) for free. But they needed multiple copies, on diskettes, so we turned it into a barter deal: they bought me a disk drive, and I delivered the program on floppy disks.

After the convention, I heard that the convention organizers had asked Lilly to close down the simulation games during presentation hours, because attendees were lining up to play these games instead of going to the presentations. Apparently, when experienced physicians received a “student” rating, they kept coming back to play until they could level-up to the status they deserved!

I incorporated MedicaLogic in 1985 to put this activity on a more robust business footing. Eventually there were simulations for diabetes, cardiac transplantation, infectious disease, and other clinical scenarios. When Lilly learned I was working on Electronic Medical Record software, a new chapter would begin.

Mark Leavitt In 1980s, Doctor, Doctor!, Grand Tour, Health Informatics, Inventions and Patents, Radio Daze

A Medical Residency in Portland

1979-1982

How I learned to hate paper medical charts…

I chose Oregon Health & Science University for my residency. Susie’s health was declining so we chose Portland to be near her family.

A few weeks into internship at the Portland VA, I was summoned at 2 AM to “pronounce” a patient. Being my first time, I was very careful to check for vital signs and confirm the chart matched the patient bracelet before signing the certificate. Paged again at 3 AM, I was told it was also my responsibility to call the family. Trudging back to the ward, I took the chart handed to me and called the number on the next-of-kin form. The daughter was shocked, but I did my best to console her. After another fitful hour of sleep, I was paged again to find the daughter had arrived and now confronted me with her declaration that “my father’s not dead!” My own heart stopped — had I missed a faint heartbeat? She led me to a different patient room, where a father wondered why his daughter seemed so surprised to see him.

At my 3 AM call, I’d been handed the wrong chart, with the same, common last name. The daughter was so happy to find her Dad alive, she didn’t lodge a complaint, but I was deeply mortified. I already disliked the messiness of paper medical charts, but this took my aversion to a new level. It probably set the stage for my 30-year career endeavor to bring medical charts into the computer age.

A novel form of doctor/patient communication

In my senior residency year, we had a patient in the VA ICU with Guillain-Barre Syndrome, a rapidly progressive paralysis that ascends from the legs upward through the body. With meticulous care there can be a full recovery over many weeks, but the “locked-in” phase of complete paralysis can be psychological torture. We could only guess at what he wanted or needed and his suffering was undeniable.

When his family visited, I asked them about his experience as a WW II veteran. When they reported he was a submarine radio operator, a light bulb blinked on in my brain. I asked him if he knew Morse code, and he blinked once for yes, but trying to blink his eyes in Morse code quickly exhausted him. So I examined him to see what other muscle strength he had left, and found he could still clench his jaw slightly. I donned a glove, put one finger between his teeth, and asked him to try sending Morse code that way. Immediately he squeezed out HOW DO YOU DO. THANK YOU !

I built a crude Morse code key using tongue depressor sticks, a switch, and buzzer. With this he could send clean Morse code, and became quite chatty with me! A Morse code chart over the bed helped the nurses understand him, though he had to send very slowly. Finally able to express his needs, he made it through the locked-in phase to a full recovery.