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Med School in Miami

1977-1979

On Old Olympus’ Towering Top…

Just how did the University of Miami magically compress the usual four years of medical school into just two? Well, if you taught beginner swimming by throwing everyone into the deepest end of the pool, then awarding diplomas to any survivors, you’d have the basic idea.

While the “basic sciences” would normally be covered in two years of lectures and labs, we had them crammed into 9 months. For the PhD-to-MD students with doctorates in the biologic sciences, it was intense but doable. But for those from pure engineering backgrounds  — bereft of pre-med courses such as organic chemistry — the only way to survive was with intensive memorization. Mnemonics — unforgettable sayings whose first letters correspond to the names you’re trying to memorize — were key. And I created over 1500 flash cards, flipping through them late into every night.

Pocketing my first medical informatics invention

Emerging from the 9 month onslaught of lectures, it was time for clinical rotations, in which the junior medical student’s role is to gather all the data  surrounding every patient, and be able to instantly and flawlessly report it to the more senior residents and attending physicians – any time, any place.

Scribbled index cards were in common use, but I wanted something more compact and organized. So I designed and built the custom plexiglas pocket clipboard, shown here. I had index cards printed with a grid and punched in the 4 corners, to keep penciled-in data organized in rows and columns. Each patient had a problem list, med list, history and physical, and lab flowsheet all on a single card.

With the clipboard back transparent, I kept critical info (drug doses, telephone extensions, etc) on the back of the bottom card for instant access. Those two plastic arches had a thin gap at the top, letting me insert or remove any card in the stack with the flick of one hand. There was one side effect: notoriety. Whenever the attending doc asked for more detailed patient data, the ward team just turned to me, “the clipboard guy”.

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.

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.

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.

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.

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.

The Accidental CEO

1993-2003

In 1993, Rick Samco and David Moffenbeier, two of the early founders of Mentor Graphics, joined me. At Mentor, they had been through all phases of a fast-growing business, but my only experience was managing a handful of staff in my medical office. With physicians being the key customers for our EMR, they insisted I leave my medical practice and be MedicaLogic’s full-time CEO. Thus began my 10 year on-the-job learning experience.

My comfort zone had been as a solo programmer writing software. Now that was over, because we needed a larger team to move quickly, upgrading from a character-based program in MS-DOS to a more modern graphical user interface. By 1994 this team had created Logician, a fully-featured EMR running on Microsoft Windows. Records were securely stored on an Oracle database back-end.

It was the CEO’s job to articulate the company’s vision to potential investors — a big change from writing code in my basement at night. I had to go from being a reluctant public speaker to a confidence-inspiring leader. Thanks to Dave and Rick’s track records, by 1995 we were pitching to the venture capital firms of Silicon Valley. Sequoia Capital and other firms were sufficiently convinced to plunk down several million dollars for our first round. Later rounds brought in even more capital.

What next? Well, of all the careers I’d ever dreamed of, “salesperson” was never one of them, but now I was needed as a key sales asset. Doctors, nurses, and healthcare leaders wanted to hear a physician explain the benefits of an EMR. I morphed into a road warrior, delivering conference presentations, EMR seminars, and outright sales pitches to prospects across the country.

Going Public

Our sales kept doubling every year, putting us on the Inc 500’s list of the fastest growing companies for 3 years in a row while we acquired marquee customers, even including the NASA astronaut program. But the late 90’s dot-com boom drove the expectations for startup companies even higher. “Get big and go public, or go home” was the challenge, and we accepted it, joining the parade of companies preparing for an IPO in 1999.

While the IPO may be considered the holy grail by many entrepreneurs, for me it just felt like a necessity of the moment we lived in, and it was exhilarating and terrifying in equal measures. Once public, we joined the frantic wave of mergers and acquisitions underway, buying Medscape, which operated both physician- and consumer-facing medical news websites, a digital records transcription firm, and smaller companies with technologies (such as electronic prescribing) that rounded out our offerings.

Within months, the dot-com bubble popped, dragging the NASDAQ market — and all newly public companies — down with it. Customer confidence and sales deflated along with the stock price. We sold off Medscape and slashed expenses while we searched for a corporate buyer that might recognize the value of our product and customer base, if not our stock certificates.

On the morning of September 11, 2001, as I drove to the Portland airport to fly to a meeting with General Electric executives about an acquisition, the news came on the radio. The staff at our Medscape office in New York were shell-shocked but unhurt. Beyond that, time just stopped.

GE did eventually acquire MedicaLogic in 2002, but by then it required going through a bankruptcy proceeding to clear up various liabilities. The acquisition restored customer confidence, and the EMR product, renamed Centricity, remained one of the leading products in the ambulatory care market for many years to come.

My personal fit with the customs of a huge corporation was not ideal, but I was intrigued when serving as GE’s representative on various healthcare IT policy initiatives. So after 18 months with GE, I departed for the nonprofit healthcare IT sector, thinking it would provide a relatively calm respite after my saga as CEO of a publicly held company. Instead, yet another adventure lay ahead.

Nonprofit (not necessarily nonstressful)

2004-2014

Certification Commission for Health Information Technology

In 2003, I became Medical Director at HIMSS, the Health Information Management Systems Society, a nonprofit trade and educational association. In this role I organized various committees and events to spread the word about the benefits of electronic medical records. But in 2004, things became more serious: a National Coordinator for Health IT (informallly called the Health IT Czar) was appointed by then-President Bush. The first National Coordinator, David Brailer, MD, PhD, immediately published a strategic plan for speeding up health IT adoption, with a key element: government-approved testing and certification of EHRs (renaming EMRs to EHRs was another thing he did).

HIMSS and other health IT organizations felt strongly that any such effort should come from the private sector, so we quickly recruited a blue-ribbon panel to demonstrate our readiness, and somehow I was named Chairman. Simultaneously, the Federal government announced a Request for Proposal for an organization to develop standards and processes for testing and certification. We called our panel the Certification Commission for Health Information Technology (with the acronym CCHIT), drafted a proposal, and won a three-year federal contract beginning in 2005.

Leading CCHIT to execute a federal contract was the complete mirror-image to presiding over a for-profit company. Every step and relationship had to be completely transparent. The work of drafting our standards was done by over 300 volunteer subject matter experts, in a multi-stage process with opportunities for public comment at every step. We held Town Halls at conferences, and Town Calls online, to communicate with all stakeholders many times each year.

Once CCHIT’s first Ambulatory EHR certification program was Federally approved in 2006, every medical setting and specialty clamored for an extension to their domain, keeping us very busy and raising our visibility. I provided testimony at Congressional hearings to report on our progress, and appeared on the list of the “Most Powerful Executives in Health Care”. It was not the low-key respite I had expected from my transfer to the nonprofit sector, and the intense travel (I’d hit the million-mile flyer mark) adversely impacted my health. So I promised my wife Carolyn that I’d retire in 2010.

Under newly-elected President Obama, legislation was drafted offering $30 billion in incentives to healthcare providers adopting EHRs — providing they were certified. CCHIT had a front-row seat to this legislative process, being experts on certification, but with so much money on the table, competition appeared for the work of setting standards and doing the testing. Our mission had been to demonstrate that it could be done, not to compete in a marketplace. I retired as full-time Chair in 2010, though I continued to consult for CCHIT until 2014, when it wrapped up its work and closed its doors.