Commencement Address – U Texas at Houston School of Biomedical Informatics

U Texas Houston

School of Biomedical Informatics Commencement Address 2015

Blackford Middleton, M.D., M.P.H., M.Sc.


Thank you Dean Jiajie Zhang! It is a great pleasure, honor, and a privilege for me to be here with you, the Faculty and Staff of the School of Biomedical Informatics, and most importantly: this year’s graduating class of newly minted biomedical informaticians! And, of course, their family, friends, and hopefully anyone else who helped these new graduates make it to this significant milestone in their lives!! Congratulations to you all!

Graduates: You have good reason to be proud of yourselves, each other, your school and it’s Faculty and staff, but most importantly you should be thankful as well… to all of those who helped you get to this incredible milestone.

Long ago when I was in a similar position, ending one era of study in my life and preparing for the next, I penned the following poem to express my thanks to my parents for getting me to my graduation day. I’d like to share it with you now, and you may use it as you wish to say thanks to your parents (or anyone else who is deserving of your thanks!):

Graduation Poem

On this day, glad tidings bearing

Thanks are wont for parents unerring,

Well, mostly so if truth be told

For want I not gray hairs of old.

The future unfolds, mysteries revealing

God is good after some appealing.

Now I ask for strength and stamina

To help me learn all biomedical informatica!

But thanks are due before going on

For a good life, childhood, Dad and Mom

Their dynamic balance, and how I was raised

Earns my humble respect and profound praise!

Though dote I not in approbation

On the attributes of close relations

They should know without my telling

And thus avoid a fearful head swelling!

So it seems life, change, unchanging

Starts anew with every morning.

With glad heart, free spirit, and clear mind

I pray I make it through the daily grind.

God give me insight myself to know,

And honesty to see where I may go

And strength enduring to get me there

With happy heart, and gay countenance to bear!

So thanks to all the parents and other supporters out there!!!

But now, let me turn to the graduates: I’d like to share with you what I feel is the true and essential promise of biomedical informatics: it is to help fix what ails US healthcare…

I will start with an overview of what I see as the “vital signs” of US healthcare – while we have the best healthcare system in the world still we fail in many ways to deliver to all US citizens the benefits of modern health care, health maintenance and prevention, and optimal public health.

Next, I will highlight a few of the many ways Biomedical informatics can come to the rescue!, through continuous improvement of care delivery, discovery, and learning in our health system. And I will close with a personal request of all of the graduates, and in honor of David Letterman retiring this year, I will share with you my Top Ten Reasons to be a Biomedical Informatician!

So let’s turn to the Vital Signs of US Healthcare:…

Let me share with you some statistics from the Commonwealth Fund (and I encourage you to visit their amazing website which is chock full of data at

What are we spending on US healthcare?

  • The US spends more per capita on healthcare than any other country, in 2014: $8745/person
  • Healthcare spending as a percent of GDP is 16.9% – also the highest
  • Out of pocket expenditure on health is $1045 per person, second only to Switzerland

Is this due to oversupply of physicians? Probably not.

  • In the US we have 2.5 physicians practicing per citizen, second lowest after Japan… in fact we have a shortage of physicians, and a mal-distribution problem

Is this due to overutilization? Well partly yes and partly no:

  • No, because we are 2d lowest after New Zealand in the average annual number of physician visits per capita at 4.0 visits/year
  • No, because we are ranked 4th lowest in hospital discharges at 125/1000 population, with only Canada, Japan, and the Netherlands having fewer hospital discharges per capita
  • But yes because we have more MRI machines per capita than any other nation except Japan, and we spend more on all modalities of diagnostic imaging than any other country
  • And, yes because we spend a LOT more on drugs in this country, well ahead of the next highest of Canada, Japan, and Germany, at $1010 Per person, per year on average

So we might ask: What are we getting for this high expenditure in terms of access, quality care, safety, and public health?

  • We know that the uninsured, and the under-insured have extraordinary difficulty seeing a physician when appropriate: 69% of the uninsured have not seen the doctor when they needed to, compared to just 22% of those with insurance
  • Yet, We are the best in the world at cervical cancer screening, second best at flu immunization, have the third lowest adult smoking rates, the best 5-year breast cancer survival rates
  • But we provide procedures too many times when the appropriateness may be questioned, or viewed as completely inappropriate,
    • for example in cataract surgery (9% inappropriate or questionably appropriate),
    • angioplasty (4% inappropriate, and 38% questionably appropriate), and the worst is
    • bypass surgery (14% inappropriate, and 30% questionably appropriate),

So… What is the perception of US Health care among US citizens, and US Physicians?

  • 53% of citizens rate US healthcare as excellent or good, but 44% rate it as only fair or poor
  • And among physicians who rated their ability to provide quality healthcare data from 2000 suggest 15% of physicians believe their ability to provide quality healthcare has improved, 25% believe there ability has stayed about the same, 57% state it has gotten worse…

So US Healthcare is technically best in the world perhaps, but we do not provide access across the board to health maintenance, prevention, diagnostic, or therapeutic services. We do not provide the appropriate care, or use tests and procedures appropriately, in all cases. We some times provide care which is not known to be effective, and thus is wasteful, and potentially dangerous. We are not efficient in providing care – wait times may be long, and there are many inefficiencies in the care processes that could be improved. It often may take years to decades for new discoveries in care and therapeutics to be universally adopted, and our potential for making new discoveries with ‘big data’ is exploding. We also don’t always do all that we can do to prevent disease and maintain the public health. And, lastly we are not always engaged as patients, empowered with healthcare maintenance and management tools, and participating in making our healthcare decisions – shared decision-making – in an optimal way.

So HOW CAN BIOMEDICAL INFORMATICS COME to the rescue???   And that means YOU – the newly minted biomedical informaticians from U Texas at Houston!

I believe that biomedical informatics is the key to curing what ails US healthcare.

So where does biomedical informatics fit in?


Certainly, the evidence is clear: we can improve the safety of care provided in hospitals and clinics with a wide variety interventions. From the simplest checklists of Atul Gawande, to the most sophisticated informatics interventions, such as the adverse drug event monitor in CPOE (computer-based provider order entry) systems.

For Timely Care

We can ensure with clinical decision support alerts and reminders that patients are kept up to date on care guidelines, health care maintenance screening, and care management. Clinical decision support now a days comes in the form of alerts and reminders to doctors and nurses, and other members of the care team, but also to the patient him or herself with apps on the smartphone and the like engaging patients in their own care. The advent of the quantified self and the proliferation of ‘wearable’ technologies that will provide many new data and signals will help us detect when to intervene for a patient, to fine-tune and adjust care.

For Effective Care

Increasingly we can enhance our ability to do comparative effectiveness research given the large data sets arising from the installed base of EMRs – we can help to augment the evidence-base in medicine with more and larger randomized clinical trials, but also so called pragmatic clinical trials that may be run across patients in clinical data networks, or practice-based networks, such as those being created in the PCORI work (Patient Centered Outcomes Research Institute). In addition, where knowledge may be missing or absent from traditional evidence-based medicine, we can examine the outcomes of patients and the experience of practitioners by mining their EHR databases to create so-called practice-based medicine. This can be done in near real time as was done at Stanford recently to make a therapeutic decision for a pediatric patient with SLE (system lupus erythematosus), and is central to creating the “Learning Health System” as described by Chuck Friedman and others.

Efficient Care

We can use our informatics tools to fundamentally improve the value of care we provide, or even more generally the value of care and preventive services, so that the patient experience is optimized, and we increase the quality and safety of care provided, while minimizing the cost. This is critical to healthcare reform efforts in this country, and to get us out of the high cost bubble we are in and move toward a more sustainable payment model for healthcare, as we move from episodic care toward a continuous care model.

Efficiency also applies to our experimental and discovery process, however: we need to accelerate the translation of new knowledge (once validated), into routine care, to shorten the time it takes for all patients to benefit from this country’s remarkable innovation and discovery engine. This is another central component of the Learning Health System.

Equitable Care

We are increasingly able to improve the access to health care knowledge and services for patients themselves without the need for a healthcare intermediary – the internet is chock full of excellent resources, and many apps now exist, to assist with patient self management. The key here will be to ensure that internet access is universal (whether it is a desktop and a browser, or a smartphone app), and that we weed out the garbage from the high-quality content on the web. This will help change information asymmetry between provider and patient toward information symmetry – and thereby improve shared-decision making. At the same time we can improve access by bringing the health care provider and team to remote locations such as critical access hospitals, or even to bring a provider to the patient/consumer himself with a virtual visit on their smartphone! These are truly remarkable times – advances in technology are creating many new avenues for connected care.


Lastly, President Obama has confirmed we are entering the era of ‘precision medicine’ – formerly known as personalized medicine, among other names. Usually this refers to taking advantage of our better understanding of the relationship between the human genome and individual diseases. Such ‘genotyping’ allows us to much better target therapies to an individual’s unique nature. It also means, however, being sensitive to the patient’s priorities, or their values and preferences for care, and their life plans (perhaps we should call this ‘life-typing’). It also means empowering the patient with knowledge, tools, and technologies that enhance their understanding and ability to self-manage, or participate in their care management actively. As a patient, I would like to have a road map for my care to help me better navigate healthcare services, and keep on the path toward a healthy life!

The Promise of Biomedical Informatics:

So, the promise of biomedical informatics is central to the future of US healthcare, and potentially healthcare around the globe.

Thus, it is truly an exciting time to be a Biomedical Informatician! Congratulations again on your foresight to see the opportunities here, and to pursue and obtain your graduation goal.

[Famous Graduation speech quotes]

No commencement address would be complete without a few quotes. I’ve scanned the web of course, and will share three with you that stand out to me as apropos (two from tech giants and one from a comedian):

Your time is limited, so don’t waste it living someone else’s life. Don’t let the noise of others’ opinions drown out your own inner voice. And most important, have the courage to follow your heart and intuition.”               – Steve Jobs

From another tech giant:

“I think it is often easier to make progress on mega-ambitious dreams. I know that sounds completely nuts. But, since no one else is crazy enough to do it, you have little competition. There are so few people this crazy that I feel like I know them all by first name. They all travel as if they are pack dogs and stick to each other like glue. The best people want to work the big challenges.”

Larry Page

And, from a timeless comedian:

“If opportunity doesn’t knock, build a door.”                              – Milton Bearle

So in closing, and finally, as promised, here are My Top Ten Reasons to be a biomedical informatician, and I will close with my personal request:

#10.    To make it fun to practice medicine

#9.       To help people get better

#8.       To make the patient care experience better

#7.       To improve the quality of care

#6.       To lower the costs of care

#5.       To learn every day

#4.       To work with smart, dedicated, and caring people

#3.       To discover something new, bright, and shiny

#2.       To take delight in seeing a new idea come to life

#1.       To leave the world a better place

So I invite you to follow your passion in biomedical informatics, pursue it empowered with your new knowledge-base and growing experience, and to find like-minded folks to work with, to make the new discoveries, implement new technologies, and fundamentally transform our healthcare delivery system for the better…

Now here is my personal request: Please, get busy NOW, change healthcare for the better!!!   I’m not getting any younger!…. 😉

Thank you for this honor to be your commencement speaker! I wish you all the very best in these exciting times and all your future endeavors!!!   Thank you.

BusyContacts and academic networking

Academic workflows on a Mac

Three months ago, I started using BusyContacts, which a reader suggested in a comment to the post on organising academic contacts. Last week this software (developed by the maker of my favorite BusyCal) released the first official version. I have really enjoyed BusyContacts, which not only can replace Apple’s Contacts but can even compete with large CRMs such as Daylite.

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An Early Introduction to EMR from the Stanford Informatics Short Course circa 2001

Folks, Trying something a bit new here — uploading some of the old lectures I have done with Powerpoint to get them off my computer and more importantly start to think about the history of what has happened in clinical informatics over the years, and with which I’ve been directly involved. Should be fun, enjoy!

Part 1:

Part 2:

“The Why” to be a Clinical Informaticist

Recently, at an informatics meeting it was suggested by a colleague that we all watch a recent TedTalk. I was moved by Simon Sinek’s talk on “The Why” — he eloquently discusses leading with ‘the why’, and not overly focusing on ‘the how’, or ‘the what’.

I suggest you take 8.5′ to watch Sinek’s video on ‘The Why’. See, and ask yourself are you focusing on the why, the how, or the what. All are important, but in different, sometimes not well understood, ways.

So I asked myself: Why do I do what I do?

Here’s the answer today:

To make it fun to practice medicine

To help people get better

To make the patient care experience better

To improve the quality of care

To lower the costs of care

To learn every day

To work with smart, dedicated, and caring people

To discover something new, bright, and shiny

To take delight in seeing a new idea come to life

To leave the world a better place

I’d like to suggest we all think about why we do what we do, which effectively guides the how and the what.