Fifty Years in Medical Informatics

Morris Frank Collen Director Emeritus, Division of Research, Kaiser Permanente, Oakland, CA, USA

Summary Life has brought me many nice sur- At the end of the war, I stayed with Objectives: An overview of personal experiences in medical prises. One was being invited by my Kaiser Permanente. I enjoyed being in informatics based on Dr. Morris Collen’s 50 years of research in the long-time friends, Reinhold Haux and an organization that allowed me to field. Casimir Kulikowski, to write this article practice medicine, establish a residency Methods: A personal reminiscence and historical overview, focusing for the 2006 IMIA Yearbook and share training program, and do research, just on the first two decades of medical informatics, when Dr. Collen my personal reminiscences. As I reflect as I had hoped to do in academia. began working with Dr. Sidney Garfield, the founder of Kaiser on my 50 years of involvement in medi- Garfield knew that I had training in Permanente, leading to his involvement in computer-based medical cal informatics, a myriad of faces e- electrical engineering, so in 1961 he care, through the development of the pioneering Automated merge, and I recall many people that I asked me to go to a conference on Multiphasic Health Testing (AMHT) system, which they introduced admire and respect for their significant biomedical electronics in New York into Kaiser clinics in Oakland and San Francisco. contributions to the field. My own ca- City. He thought the time had come for Results: Statistical models for medical decision-making based on consultations with Jerzy Neyman and George Dantzig were reer owes much to these worthy people. doctors to use computers in patient incorporated into the AMHT, and tested on a large database of I feel that I was born with an interest care. Of course, he was right; and I cases. Meetings with other pioneers in medical informatics at the in data, beginning with my birth date, found this conference to be very excit-

Karolinska Institute led to the formation of the early society Salutas a series of three consecutive, two-digit ing. On my return, Garfield established Unitas, and the many national and international collaborations numbers: (mo-dd-yr) 11-12-13. As a the Department of Medical Methods which followed during the first two decades helped coalesce the field teen-ager, I enjoyed playing with Research (MMR) in Oakland, Cali- as clinicians and researchers investigated problems of medical data, electric gadgets, so I decided to study fornia, with the primary objective of decision support, and laboratory, hospital, and library information electrical engineering and then go on developing computer-based applica- systems. to graduate school to get a doctorate. tions for patient care. Conclusion: Dr. Collen’s research and his many medical informatics However, my life changed when I met On considering where to start, I decided activities significantly contributed to the growth of the field. The U.S. contributions are covered extensively in his book, A History of and married a nurse, named Bobbie, that it would be easiest and safest to Medical Informatics in the United States, 1950-1990. Washington, who advised me to go to medical school. first use computers in the process of DC: Am Med Informatics Association 1995. Although I planned to end up in aca- examining persons who come in for a Haux R, Kulikowski C, editors. IMIA Yearbook of Medical Informatics demia, my life again changed dramat- health checkup. The traditional health 2006. Methods Inf Med 2006; 45 Suppl 1: S174-9. ically while I was completing my medi- evaluation is a fairly routine and repe- cal residency at the Los Angeles County titive process; and for about 80% of Keywords General Hospital, and Pearl Harbor was Kaiser Permanente health-checkup History of medical informatics, Kaiser Permanente Automated bombed on December 7, 1941. Because examinees we usually did not find any Multiphasic Health Testing System, pioneering research in medical of my bronchial asthma, I did not join significant abnormalities. Furthermore, decision-making, professional organizations and meetings in the group of County Hospital physicians Garfield was committed to preventive medical informatics, evolution of research and leaders in medical sent to India. Instead, I worked for medicine and he advocated periodic Sidney Garfield in the Kaiser shipyards health checkups that could categorize in Richmond, California. Second only examinees as “well”, “worried-well”, to my wife, Garfield had the greatest “asymptomatic sick”, or “sick”[1]. So influence on my career. Trained as a I decided to develop a method for auto- surgeon, he was the visionary who, with mating as much as possible the multiple the support of industrialist Henry J. components of an automated multi- Kaiser, created Kaiser Permanente and phasic health testing (AMHT) system. instilled it with the principles of pre- To develop such a system I needed to paid, group practice, medical care. study some automated clinical labora-

IMIA Yearbook of Medical Informatics 2006 175 Fifty Years in Medical Informatics

tory systems. I found to be very help- cal for us to have eight of these ma- at Beth Israel Hospital in Boston, where ful the writings of George Williams and chines running side-by-side to do the Howard Bleich developed his famous his associates at the NIH Clinical Cen- eight chemistry tests I wanted, so I asked acid-base algorithms. Charles Safran ter, who developed one of the earliest Whitehead if he could make me an and Robert Greenes joined them to de- comprehensive laboratory systems. eight-channel, automated chemical ana- velop their impressive Beth Israel Hos- I soon visited Octo Barnett, who had lyzer. After a few moments of thought, pital information system. developed the laboratory system at the he asked me how much was budgeted We initiated the first automated multi- Massachusetts General Hospital for this. I replied only $25,000; to my phasic health testing (AMHT) system (MGH). I heard that the administrator surprise, he agreed to make it. The first in our Oakland medical center in 1962 of MGH found the laboratory system Technicon multichannel AutoAnalyzer [2]. My first encounter with a computer to be so efficient he would never give was delivered several weeks later and was with an IBM 1440 installed in an it up, no matter what happened to their became fully operational in our Oak- air-conditioned basement room with a other computer systems. A brilliant land AMHT system. Soon he delivered myriad of cables on the floor. We gen- informatician, Barnett worked with his a second machine in our San Francisco erated a deck of punched cards for each associates at MGH to develop MUMPS, AMHT system. We used these machines examinee; and as they went from one which became one of the most com- for many years, until Garfield pur- testing station to another, the test re- monly used programming languages; chased an AutoChemist, developed by sults were entered onto the cards. On and COSTAR, a computer-based ambu- Gunnar Jungner in Sweden, that used completing the health checkup, an latory record system for the Harvard piston pumps to keep the serum speci- online printout of a summary report Community Health Plan. Barnett also mens separate; and could do up to 40 listed any abnormal tests found and trained many leaders in medical infor- different chemical analyses. advised secondary follow-up tests to be matics, including Robert Greenes and We tested several modes of conducting performed by using simple decision Jerome Grossman. Octo and I became self-administered patient question- rules: “If this abnormality is present, good friends, who could disagree on naires, and settled on using a sort-box then do this test.” Suggested diagnoses many items, such as the best approach of punched cards with a question on for the physicians to consider were also to developing a medical information sy- each card. In the 1960s, when I was printed on the summary report. Pro- stem. He took a subsystem “modular” visiting my daughter, Roberta, then a fessors George Dantzig (called the “fa- approach, whereas I advocated a “total medical student at the University of ther of linear programming”) and Jerzy systems” approach. History has proven Wisconsin, I met Warner Slack, who Neyman met regularly with us at the his approach was better. I learned from was developing a computer-based, self- University of California at Berkeley him that nurses are the best informa- administered, patient questionnaire us- during the 1960s and helped to develop tion systems analysts, and have ben- ing a LINC computer. The LINC was our approach to providing computer- efited over the years from conversations developed at the Lincoln Laboratory at aided diagnoses [3]. Although most oth- with Rita Zielstorff, Virginia Saba, Judy the Massachusetts Institute of Tech- ers used Bayes’ conditional probability Ozbolt, Patricia Brennan, Kathleen nology by Wesley Clark and Charles theorem, we used a likelihood ratio McCormick, and Susan Grobe. Molner. The LINC computer became approach because we did not always I needed an automated chemical ana- the basis of the PDP minicomputer se- know the prior probability (prevalence) lyzer for the AMHT system being devel- ries that helped to advance medical of a diagnosis Bayes’ theorem required. oped in our Oakland medical center, so informatics. Slack described watching After the completion of the multiphasic I visited Edwin Whitehead, the presi- his secretary fill out an early version health checkup, all of the patient test dent of Technicon Corporation in of the questionnaire. When she came data were stored in the multiphasic da- Tarrytown, New York. Technicon had to questions related to sexual activities, tabase. We collected data from about commercialized Leonard Skeggs’ she asked him to leave the room until 35,000 AMHT examinations each year invention of a single-channel, auto- she had finished. Thus, he learned that in this database that is still used by re- mated chemical analyzer that used a some patients will confide to a com- searchers. I am pleased to have lived peristaltic-pump to push samples of puter personally sensitive information long enough to see Joseph Terdiman, serum, separated by air bubbles, that they would not tell their doctor. whom I called the “czar” of our early through plastic tubes. It was not practi- Slack soon joined the informatics group research databases, now developing a

IMIA Yearbook of Medical Informatics 2006 1. Introduction

176 Collen

much larger research database for Kai- pleased to see that he had also insti- Victoria, played an important role in ser Permanente’s national membership tuted a multiphasic screening program. editing papers published in Methods of of more than eight million. Charles I have always regarded Homer Warner Information in Medicine. Flagle, then Professor of Operations as a model informatician. His hospital In the late 1960s, Kaiser Permanente Research at Johns Hopkins University, information system, with its clinical- in the San Francisco Bay area decided visited us several times to help conduct decision support program called HELP, to use the AMHT system as a proto- cost-effectiveness analyses. which I observed operating at LDS type medical information system be- In the 1970s, “stand-alone” AMHT sys- Hospital, continues to be one of the best cause it had given us some experience tems expanded rapidly in the United in the United States. The only problem with a computer-based patient record States and in several other countries. that I ever had with Homer was when and with many of the subsystem com- Today, due in part to the advent of large, we were together at a meeting in Ger- ponents of a medical information sys- computer-based, hospital information many. As I guzzled the delicious local tem. Under the leadership of Edmund systems capable of absorbing a health- draft beer, I learned that he would not (Ted) van Brunt, we developed and checkup subsystem, and in part to the join me in drinking any alcoholic bever- operated a pilot medical information general lack of support by American ages. Warner established the first system in our San Francisco medical physicians, AMHT systems operate Department of Medical Informatics in center, with a computer-based patient mainly in Japan and in Taiwan. the United States at the University of record that had been developed by the On studying computer-aided diagnosis Utah, where he trained several giants manager of our computer center, Lou programs and clinical decision-support in the field of medical informatics, in- Davis [6]. However, due to lack of ad- systems, I was most impressed by cluding Alan Pryor, Paul Clayton; and equate funding in 1973, further devel- Ledley and Lusted’s landmark paper also Reed Gardner who continued to opment of Kaiser Permanente’s medi- [4]. I consider this to be the most im- expand the LDS System in Salt Lake cal information systems was delayed for portant medical informatics paper I City and also made many important some years. have ever read since it had such a great contributions to the field of medical When I read Paul Starr’s book on “The influence on stimulating the develop- informatics. In the 1960s, Homer Social Transformation of American ment of computer-based, clinical-deci- Warner chaired the National Institutes Medicine” [7], I was impressed by his sion support that should be a major goal of Health (NIH) Computer Study Sec- characterization of the hospital as the of every comprehensive medical infor- tion. About the same time, I chaired most complicated organizational struc- mation system. Robert Ledley, a den- the National Center for Health Services ture made by man. It was evident that tist by training, was a quiet person, a Research and Development (NCHSR& the computer-based systems used by brilliant thinker, and a remarkable in- D) Health Care Systems Study Section. banks and many industries would be ventor honored by a Presidential Inven- Being a member of one of these study inadequate to meet the functional and tor Award. While Professor of Radiol- sections provided an extraordinary op- technical requirements of a medical ogy, Physiology, and Physics at portunity to observe first-hand the de- information system (MIS) and that it Georgetown University, Ledley began velopment of informatics technology. would take a team, led by physicians to conduct research and development This Yearbook’s theme, “Assessing In- and supported by engineers, to develop on computer applications to dental formation Technologies for Health”, a successful MIS. projects at the National Bureau of Stan- brought back memories of the 1960s To acquaint myself with evolving com- dards; and there he developed in 1973 and 1970s when AMHT was popular puter applications in medicine, I vis- the first whole body scanner, that he internationally. The International ited several people who were already called the Automated Computerized Health Evaluation Association (IHEA) recognized leaders in the field. To be- Transverse Axial (ACTA) scanner. was launched by Fred Gilbert, at the gin, I visited James Sweeney at Tulane I was also impressed by Homer Warner’s University of Hawaii. IHEA held peri- Medical School, who with Joseph early article on computer-aided diagno- odic meetings on advances in health Schenthal, a clinician, had already be- sis that applied Bayes’ theorem to cor- screening in London, San Diego, To- gun to use a computer to process data rectly diagnose 95% of patients with kyo, and in Vancouver, British Colum- with mark-sense cards for clinic patients congenital heart disease [5]. When I bia. IHEA published selected papers; [8]. Sweenney became the first Pro- visited Warner in Salt Lake City, I was and Jochen Moehr, at the University of fessor of Computer Medicine in the

IMIA Yearbook of Medical Informatics 2006 177 Fifty Years in Medical Informatics

United States; when I asked him what Health Services Research Centers. In low at the Center for the Studies of the his title meant, he said that he took care the 1970s, Lindberg developed several Behavioral Sciences (CASBS) located of sick computers. clinical decision-support programs. His on the Stanford University campus. I It was very helpful for me to study the CONSIDER program helped physicians had the help of librarians there to find remarkable accomplishments of William analyze and treat patients with blood a large number of early publications, Stead, a physician, and Ed Hammond, electrolyte problems. AI-RHEUM, including one on a bottom shelf in the an engineer, who developed TMR (The which he developed with Lawrence Stanford Engineering Library, printed Medical Record) at Duke University. Kingsland, was one of the earliest clini- in the purple ink of an old ditto ma- TMR was so well designed that it was cal decision-support systems using an chine, but still readable. Also of help soon readily transferred to a medical artificial intelligence approach to help were the many copies of their publica- group in California. I was also very physicians manage patients with rheu- tions sent to me by fellows in the Ameri- impressed with the important accom- matic diseases. can College of Medical Informatics. My plishments of Clement McDonald, at the In 1984, Lindberg became the Direc- book was published by the American Regenstrief Institute in Indianapolis, tor of the National Library of Medi- Medical Informatics Association who with Marc Overhage and associ- cine (NLM), where he established the (AMIA), thanks in large part to the ef- ates developed the Regenstrief Medi- National Center for Biotechnology In- forts of Clement McDonald, then chair cal Record (RMR) and a clinical deci- formation. From 1992 to 1995, he also of AMIA’s publications committee. sion support program called CARE. I served as the first Director of the Na- While at the Stanford University, I had also visited Lawrence Weed, who de- tional Coordination Office for High the opportunity to visit the University veloped his problem-oriented medical Performance Computing and Commu- libraries and browse through the files record system (PROMIS) at the Uni- nications. At NLM, Lindberg initiated of Joshua Lederberg’s work with Ed versity of Vermont, and was a brilliant the Integrated Advanced Information Feigenbaum in developing DENDRAL. and entertaining banquet speaker. My Management System (IAIMS) program I was also impressed by the work done most admired and respected leader in to transform health care institutions, in the 1970s by Edward (Ted) medical informatics is Donald and the Unified Medical Language Shortliffe who developed MYCIN; by Lindberg. When Lindberg was at the System (UMLS) Project to facilitate Casimir Kulikowski who developed University of Missouri-Columbia, he access to machine-readable information CASNET; by Jack Myers and Randolph began in 1964 to develop one of the located in various sources, including Miller who developed INTERNIST; by earliest computer-based systems for the the scientific literature, factual data Octo Barnett who developed DXplain; reporting of clinical laboratory deter- banks, and knowledge-based expert sys- and by Gwilym Lodwick who devel- minations, using punched cards to en- tems. Under his direction, NLM insti- oped computer-aided diagnosis of bone ter clinical laboratory data into the com- tuted MEDLINEplus and PubMed, da- tumors and the Missouri Automated puter. In 1965, he expanded his tabases widely used by health care Radiology System (MARS) as early as laboratory information system into a professionals and the general public; the 1960s. comprehensive computerized hospital and supported a host of innovative In 1974, I was invited by Maurice system. By 1970, he was operating a projects including the Human Genome Sedouilh, Director of the European Re- multi-facility medical information sys- Project and the Visible Human Project. gion of the World Health Organization tem in the state of Missouri, using long- In my estimation, Lindberg is equal in (WHO), to go with him to Moscow, distance telephone lines. He also pro- stature to John Shaw Billings, who was Kiev, and Tbilisi to study and report to vided communication and technology Director of the Army Surgeon General’s WHO on medical uses of computers in services to a unique AMHT system in a Library that was the forerunner of NLM. Russia. Although I was informed that solo-practice physician’s office 90 miles I was surprised and honored when their Minsk computers were merely outside Columbia, that I was privileged Lindberg suggested I write a history of copies of IBM computers, I was very to visit and observe in full operation medical informatics, “before all of you impressed by M. L. Bykovskiy’s pre- while processing patients. old fogies in the field have died.” I sentation of an enhanced application of I visited Lindberg at the University on began working on the book, “History the Bayesian approach to computer- several occasions during the 1970s, of Medical Informatics in the United aided diagnosis. Sedouilh invited John when we each had federally funded States” [9] in 1986, when I was a Fel- Anderson from London, Peter Reichertz

IMIA Yearbook of Medical Informatics 2006 178 Collen

from Germany, Paul Hall from Stock- achievement led to the development of AMIA delegate to the International Medi- holm, Ezio Mase from Italy, Sudarikov the Internet; and one of its developers, cal Informatics Association (IMIA); and from Russia, and me to assemble peri- Vinton Cerf, gave a memorable key- in a few years she became the first odically to advise him about computer note talk at a SCAMC conference, de- American and the first woman to lead developments that might be useful for scribing his landmark contributions to IMIA, where she efficiently imple- the WHO. developing the Internet. mented organizational changes needed Paul Hall had implemented, as early as I soon became convinced that profes- to move into the new millennium. 1967, an information system on the sional meetings on medical informatics The MEDINFO conferences IMIA held hospital wards of the Karolinska Insti- are the best way to learn about inno- every three years, offered me a place tute in Stockholm, and had instituted a vations, and maintain relationships with to renew friendships with people from multiphasic health testing system in colleagues who have similar interests. other nations who were also working Sweden. I well remember one of his In the United States the annual Sympo- in medical informatics. The first lectures in which he eloquently de- sium on Computer Applications in MEDINFO was held in Stockholm in scribed how data is collected to form Medical Care (SCAMC) were clearly 1974; and it was a pleasant surprise for information which can be further ag- the best conferences on medical me to be invited by Werner Schneider, gregated to become knowledge, from informatics. It was at one of my earli- a member of the Program Committee which one can develop an expertise, and est meetings that I met the remarkable chaired by Francois Gremy, to moder- finally acquire the wisdom to make Marion Ball. Marion is one of the most ate one of the sessions. It was at the good judgments between available al- charming and smartest people I know. first MEDINFO that Joe Terdiman de- ternatives. Paul Hall was a charmer. She meets her friends with warm and scribed our pilot medical information One evening, when we were at his effusive greetings, yet I have seen her system and Sidney Garfield presented home in Stockholm, he played the pi- chair international meetings where she his vision of a new medical delivery ano and then danced with my wife, very efficiently carried on with the system. It was there that I first learned Bobbie. I realized it was time for us to agenda by gently but firmly adjudi- the new term, informatics, and its deri- leave Sweden. cating strong international differences. vation from the Russian and German In our zeal, this harmonious group Marion is a natural leader and organizer. informatik and the French informatique. formed an international organization, She was instrumental in merging the Another pleasant surprise occurred Salutas Unitas (Unity for Health), with Society for Computer Medicine (SCM) when I was invited by the Organizing Ezio Mase, as president. William Spen- with the Society for Advanced Medi- Committee for MEDINFO ‘80 in To- cer and Carlos Valbonna from Baylor cal Systems (SAMS) to form the Ameri- kyo, to chair the Program Committee. University, Donald Lindberg, and can Association for Medical Systems I enjoyed the planning trips in Japan, Sidney Garfield also became members. and Informatics (AAMSI). This merger where I became friends with M. Since Mase was the medical officer was so successful, that Thomas Piemme, Oshima, chair of the Organizing Com- responsible for supervising health spas who had very successfully managed the mittee; with S. Kaihara who co-edited in Italy, each year he arranged for us to SCAMC conference for many years, the Proceedings with Donald Lindberg; have a meeting at a different spa. We agreed to merge SCAMC with AAMSI. and with Gustav Wagner from Heidel- gave talks and published papers from The American College of Medical berg, one of the early developers of these delightful meetings that contin- Informatics (ACMI), that had been disease registries. It was at MEDINFO ued until, regrettably, Ezio Mase died. formed with Marsden Scott Blois as its ’80 that their medical information sys- I can recall the national excitement cre- first president, also agreed to join in tems were described by Peter Reichertz ated by the Russian launching of Sput- while I was the second president of in Hannover, Germany; by John Ander- nik in 1957. That remarkable event ACMI. Thus the American Medical son in London; by Jan van Bemmel in stimulated the United States to create Informatics Association (AMIA) was Amsterdam; and by William Spencer in the Department of Defense (DoD) born, with Donald Lindberg as its first and Carlos Vallbona at the Texas Insti- an Applied Research Project Agency president. In my opinion, the birth of tute for Rehabilitation and Research. (ARPA), that developed ARPANET in AMIA was the most significant medical There I met A. M. Cormack, Professor 1969 to link computers of different informatics organizational development of Physics at Tufts University, who pre- types located in various institutions. This in the Americas. Marion Ball became the sented a keynote paper describing his

IMIA Yearbook of Medical Informatics 2006 179 Fifty Years in Medical Informatics

early work with a computer-aided to- on an elephant. Bruce Blum, from enthusiasm for one’s work, preferably mography (CAT) scanner, that led to Johns Hopkins University, described the within a supportive organization; and his sharing of a Nobel Prize in 1979 evolution of their oncology clinical in- of having respected colleagues, warm for the development of one of the first formation system. Susan Grobe, from friends, and loving family; and the need imaging machines. The advances in the University of Texas, presented a for boundless optimism and good hu- imaging that followed were among the paper on nursing informatics. Vimla mor; and the remarkable stimulation most important technologies developed Patel, from McGill University, gave an from greeting each morning with „It’s in the first five decades of medical illuminating paper on the relationship going to be a great day today!“, fol- informatics. between medical informatics and cog- lowed by having a good cup of coffee. Some of the other MEDINFOs and some nitive psychology. MEDINFO ‘95 was of the presented papers I found memo- held in Vancouver, British Columbia. rable included MEDINFO ‘83, gra- Jochen Moehr, from the University of References ciously hosted in Amsterdam by Jan van Victoria, with Vimla Patel, gave an in- 1. Garfield SR. The delivery of medical care. Scientific Bemmel. Here, Hans Peterson described sightful paper describing some prob- Am 1970; 222: 15-23. his Stockholm County Health Informa- lems associated with the newly devel- 2. Collen, MF. Periodic health examinations using an automated multitest laboratory. JAMA 195: 1966; tion System; and Jean-Raoul Scherrer, oping patient information systems. 830-33. from the University Hospital in Geneva, Moehr graciously hosted some of us at 3. Collen MF, Rubin L, Neyman J, et al. Automated described his approach to developing a his home. screening and diagnosis. Am J Pub Health 54: 1964; 741-50. medical information system. MEDINFO In writing my reminiscences, I make 4. Ledley RS, Lusted LB. Reasoning foundations of ‘86 was held in Washington, D.C., and this disclaimer: I have mentioned those medical diagnosis. Science 130: 1959: 9-21. Donald Lindberg very efficiently chaired who most affected my personal career. 5. Warner HR, Toronto AF, Veasy LG, Stephenson R. A mathematical approach to medical diagnosis. the Organizing Committee. I am not claiming that the persons or Application to congenital heart disease. JAMA 177: MEDINFO ‘89 had been scheduled to events mentioned were the best of the 1961; 177-83. be held in Beijing. However, after the best, but they contributed to, and had 6. Davis LS, Terdiman JF. The medical database. Chap 4, in: Collen, MF (ed). Hospital Computer Sy- Tianamen Square disaster, many physi- attributes that greatly influenced my stems. New York: John Wiley; 1974. p. 52-79. cians declined to go to China. The chair life; so I consider them to be memo- 7. Starr P. The Social Transformation of American of the Program Committee, Phil Man- rable for me. Furthermore, I confess Medicine. New York: Basic Books, Inc.; 1982. 8. Schenthal JE, Sweeeney JW, Nettleton W. Clinical ning from the University of Southern that when one is trying to recall events application of large-scale electronic data processing California, rose to meet this quandary that happened 40 or 50 years ago, it is apparatus. I. New concepts in clinical use of the and developed a complete program for sometimes difficult to separate fact electronic digital computer. JAMA 173: 1960; 6-11. 9. Collen MF. A History of Medical Informatics in a second conference in Singapore. Since from fantasy; so others who may have the United States, 1950-1990. Washington, DC: I personally feel that physicians should shared some of my memories may dif- American Medical Informatics Association; 1995. provide their services regardless of po- fer with my reminiscences. litical strife, I gave a keynote paper at Yes, indeed, my life has brought me Beijing and learned more than I ever many surprises, mostly good ones. At would need to know about traditional my age of 92 years, I now appreciate Correspondence to: Morris F. Collen, MD., Director Emeritus Chinese medicine. how one’s plans must adjust to un- Division of Research MEDINFO ‘92 was held in Geneva, planned surprises that often bring new Kaiser Permanente and the opening ceremony was a great problems, which can, however, create 2000 Broadway Oakland, CA 94612 surprise when Scherrer, chair of the opportunities that may be exploited. I USA organizing committee, entered riding have learned the importance of having E-mail: [email protected]

IMIA Yearbook of Medical Informatics 2006