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The CMIO Survival Guide
A Handbook for Chief Medical Information Officers
and Those Who Hire Them

Second Edition
The CMIO Survival Guide
A Handbook for Chief Medical Information Officers
and Those Who Hire Them

Second Edition

Richard L. Rydell, MBA, LFHIMSS, FACHE, Editor

Howard M. Landa, MD, Associate Editor
CRC Press
Taylor & Francis Group
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© 2018 by Taylor & Francis Group, LLC

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Contents

Introduction........................................................................ vii
Editors................................................................................... ix
Contributors......................................................................... xi
1 The Evolution of the CMIO in America....................1
RAYMOND ALLER AND RICHARD L. RYDELL

2 A CMIO’s Perspective from 2018 and Beyond........11

PAM ARLOTTO AND HOWARD M. LANDA

3 CMIO, CMIO 2.0, and the CHIO.............................19

PAM ARLOTTO

4 Designing an Effective Informatics

Organizational Structure........................................25
SAMEER BADLANI
5 The CMIO’s Relationship with the Physician
Community.............................................................33
HARRIS R. STUTMAN
6 Healthy Vital Signs: CMIO, CNIO, and Other
Informatics Relationships.......................................49
JOSEPH H. SCHNEIDER
7 Configuration, Workflow, and Document
Standards................................................................59
R. DIRK STANLEY

v
vi ◾ Contents

8 Personal Health Records and Health

Record Banks.........................................................69
RICHARD GIBSON
9 Personal Health Records—A Practical Checklist
for Implementation.................................................89
ALBERT S. CHAN

10 Analytics and Population Health............................99

AMY M. SITAPATI AND CHRISTOPHER LONGHURST

11 Education and Professional Development

for the CMIO......................................................... 111
WILLIAM HERSH

12 The CMIO and Privacy and Security....................123

ERIC M. LIEDERMAN

13 The Role of the CMIO in Small Healthcare

Organizations....................................................... 131
RONALD W. LOUKS

14 Government, Guidance and the CXIO..................139

MICHAEL J. MCCOY AND JACOB REIDER

Index........................................................................... 147
Introduction

The Chief Medical Information Officer (CMIO or CHIO or

whatever new moniker comes into fashion) must have a deep
understanding of both the workflows and the science that
underlies the delivery of healthcare. This, aligned with our
requisite knowledge of healthcare information technology
is the key to the value we provide to our healthcare
organizations.
This book is intended to be a pocket handbook for the
new CMIO. It will be a valued “quick guide” organized by
topics that the CMIO deals with on a regular basis. The key
to the value of this handbook is the accumulated experience
and lessons learned of the Association of Medical Directors
of Information Systems (AMDIS) faculty that contributed to its
content. This book is also a concise guide to picking the right
CMIO job and helping him or her be successful.
It may never be known when the electronic medical record
physician-champion graduated to adopting the title of CMIO,
or where we will go next. We have lived through the years
when discussions about first generation electronic medical
records yielded quizzical at best, or at worst, contemptuous
looks from colleagues. We are now in the era of the nearly
ubiquitous Electronic Health Record (or perhaps moving
towards “Comprehensive Health Records?”) and if anything,
looks are even more polarized than quizzical/contemptuous.
The phenomenon of physician burnout is multifactorial but

vii
viii ◾ Introduction

the EHR has become its lightning rod. Most will admit that an
EHR is truly required to access the information necessary to
provide the best care, but we all acknowledge that the systems
have not kept up with increasingly complicated patients who
expect more and more from modern technology. We are on
the crest of a wave that will leverage AI (artificial intelligence)
and machine learning; advanced imaging; and enhanced
analytics to finally deliver on the promise of improving quality,
efficiency, and both patient and clinician satisfaction. It is these
tools that will be available to the progressively greater number
of young men and women we see extending their training in
medicine to preparation for leadership in medical informatics.
And it is to them that this book is dedicated; and to those who
would seek to understand why they have made this career
choice, to those who hire them in these roles, and hopefully
to assist them in this transformation of healthcare.
The structure of this book is brief, targeted, and to the
point, in keeping with the new literary style that has appeared
in the last decades with the advent of the World Wide Web. It
is our intention to periodically update and revise the contents
of this manual, in keeping with the rapidly changing field of
medical informatics, and the roles of the CMIO.
The authors of this book represent many of the leaders of
AMDIS, but we would be remiss if we did not recognize the
wisdom that is provided by all the members of our esteemed
organization that provided for the core knowledge that we
share with you today.

Richard L. Rydell, MBA, LFHIMSS, FACHE

Howard M. Landa, MD
William F. Bria, MD, FCCP, FHIMSS
Editors

Richard L. Rydell, MBA, LFHIMSS, FACHE, is a founder and

CEO of the Association of Medical Directors of Information
Systems (AMDIS), the premier physician membership
organization dedicated to advancing the field of applied
medical informatics. Mr. Rydell has a distinguished career as
a healthcare executive, serving as a senior vice president and
chief information officer at Memorial Health Services, Long
Beach; Stanford University Medical Center; and Baystate Health
Services. He is a fellow in the American College of Healthcare
Executives and a fellow and life member of the Healthcare
Information and Management Systems Society (HIMSS). He
served as national president of HIMSS and was a founding
board member and vice chairman of the College of Healthcare
Information Management Executives (CHIME). Mr. Rydell is
the coauthor of the popular books, The Physician-Computer
Connection and The Physician-Computer Conundrum (Taylor
and Francis, 2004) and coeditor of the first edition of The
CMIO Survival Guide (Jossey-Bass, 1996). Mr. Rydell serves as
an elected board member of the Seneca Healthcare District,
Chester, California. He was recognized as one of the “HIMSS
50 in 50,” a recognition of 50 individuals who contributed
significantly to the field of healthcare information technology
and the improvement of healthcare through technology, in the
50 years since HIMSS was founded.

ix
x ◾ Editors

Howard M. Landa, MD, did two years of surgical residency

1983–85 at NYU and Bellevue. He trained in urology at the
University of California-San Diego and completed a fellowship
in pediatric urology at Texas Children’s Hospital, Houston,
Texas.
After training, Dr. Landa joined the Loma Linda University,
Loma Linda, California to practice pediatric urology and
during his first year he built a document management system
to help the practice manage transcribed documents and he
became the director of Medical Informatics for Loma Linda
University Medical Center in 1996. He joined Kaiser Hawaii
in 2001 to practice pediatric urology and act as one of their
physician IT champions, and became their chief medical
information officer (CMIO) in 2005. He was the physician lead
for both Kaiser’s national downtime project and the operating
room software; and under his leadership Kaiser Hawaii
completed the EHR implementation, attaining HIMSS level 6
two months after inpatient go-live and Level 7 in 2012. From
2009–2017 he was the CMIO of the Alameda Health System
and led multiple EHR implementations and optimizations.
In 2017, he joined Sutter Health as their vice president
of Clinical Informatics and EHR. He has been the program
director and vice-chair of the Association of Medical Directors
of Information Systems (AMDIS) since 1997; the chair of the
HIMSS/AMDIS Physician Community 2011–2013; and was
named one of the top 25 clinical informaticists in 2010–12.
Contributors

Raymond Aller. Dr. Aller has devoted his career to

advancing and teaching clinical informatics. His MD thesis
at Harvard Medical School entailed design and deployment
of the first online surgical pathology information system,
which has served as the prototype for most of today’s
commercially available systems. He has guided hospitals in
the implementation of diverse healthcare information systems,
in several cases functioning as CMIO long before the word
had been invented. He helped to develop the first edition of
SNOMED, the concepts of HL7, and later, the LOINC system
for exchanging laboratory and pathology results. For over 30
years, he has edited Newsbytes, one of the most widely read
columns on healthcare informatics. In 1991, he launched the
proposal to create an ABMS-endorsed board certification
in clinical informatics – this reached fruition with the first
certification examination in 2013. He has championed many
other forward-looking initiatives in clinical informatics,
including the early-1990’s campaign to identify all blood
specimens with a barcoded wristband, and more recently, the
use of positive biometric identifiers in every healthcare venue.
Most recently, he has focused his attention on strengthening
laboratory information systems in low-income countries.

Pam Arlotto, President & CEO, Maestro Strategies. Pam

Arlotto works with CEOs, Boards and the C-Suite to develop
strategies for high-value healthcare. She is President and
xi
xii ◾ Contributors

CEO of Maestro Strategies an Atlanta-based healthcare

management consulting firm. She is a former National Chair
of the Healthcare Information & Management Systems Society
(HIMSS). She has worked with AMDIS to develop the CMIO
Crash Course: A Survival Guide and wrote the white paper
“From the Playing Field to the Press Box: The Emerging Role
of the Chief Health Information Officer. She is well known for
the award-winning book series, Beyond Return on Investment:
Expanding the Value of Healthcare Information Technology.
She was the founding Chair of the Center for Healthcare
Information Management and has served on the Boards
of The Georgia Tech Foundation, The Wallace H. Coulter
Department of Biomedical Engineering at the Georgia Institute
of Technology & Emory University School of Medicine, the
Scheller School of Business, and the Georgia Tech Alumni
Association. She currently serves on advisory boards for
several privately held healthcare companies.

Sameer Badlani, MD, FACP, is the Chief Health Information

Officer & System Vice-President for Sutter Health. His areas
of accountability include clinical informatics, digital health,
enterprise analytics and data management. His areas of
interest include the potential use of behavioral psychology in
the delivery of health care, engaging clinical providers and
translating the value of analytics and informatics in the clinical
and business domains. As an advisor to startups in various
stages, he supports their journey to value creation and product
delivery, while engaging with VCs on portfolio and investment
thesis.
Dr. Badlani speaks nationally, educates and consults on
topics in digital medicine, clinical informatics, analytics, and
innovation. In 2013, he was recognized in Crain’s Chicago
2013: 40 under 40 and nominated to the board of AMDIS, the
premier international organization of CMIOs and executive
physician leaders in Informatics. Recently, he was nominated
to the Becker’s 2017 list of top 50 Health System CMIOs.
 Contributors ◾ xiii

He received his medical degree from the University of Delhi

in India. After completing his internal medicine residency
training, Dr. Badlani served as chief resident at the University
of Oklahoma in Tulsa. He also received training in bio-medical
informatics at the University of Utah in Salt Lake City. At the
University of Chicago, his clinical practice was focused on solid
organ transplant and oncology in the inpatient setting.
Previous roles include faculty and CMIO at the University of
Chicago Medicine and Biological Sciences followed by CHIO
for Intermountain Healthcare.

Albert S. Chan, MD, MS, serves as Chief of Digital Patient

Experience at Sutter Health, leading the digital transformation
of one of the largest integrated health systems in the
United States. In this interdisciplinary role, Dr. Chan leads
an omni-channel patient engagement strategy that spans
patient outreach via the patient portal My Health Online,
telemedicine, and tech-forward customer support via online
chat and artificial intelligence-powered solutions. He is also
the executive pacesetter for patient access, leading Sutter’s
modernization of its scheduling practices and navigation of
healthcare services. In addition, Dr. Chan provides leadership
for the development and scaling of innovative partnerships,
spearheading translation of innovation into his own clinical
practice and those of his colleagues.
Dedicated to physician and patient empowerment through
health information technology in his current role and
previously as CMIO of the Palo Alto Medical Foundation, Albert
was awarded the fourth Epic PAC Academy Award (2014) by
his peers for contributions to the Epic Systems Corporation
community. In 2017, Dr. Chan was named to the Fulbright
Specialist Roster and awarded an Eisenhower Fellowship.
Dr. Chan earned a B.S. in Biological Sciences from
Stanford University and M.D. from the University of California,
San Diego. After completing residency and chief residency in
family medicine, Albert concurrently completed fellowships
xiv ◾ Contributors

in Biomedical Informatics at Stanford University School of

Medicine and family medicine research at the University
of California, San Francisco School of Medicine. During
fellowship, he joined the team that launched PAMFOnline, one
of the first linked personal health records in the United States.

Richard Gibson, MD, PhD, is the Executive Director

of the Health Record Banking Alliance (http://www.
healthbanking.org/), a non-profit organization founded in
2006 to promote consumer-centered, consumer-controlled,
comprehensive, lifetime health records. Dr. Gibson comes to
HRBA from Gartner, Inc., where he was a Research Director.
Previously, he held roles as Chief of Healthcare Intelligence
at Providence Health & Services, Chief Information Officer
at Legacy Health in Portland, and Chief Medical Information
Officer at Providence Health System, Oregon Region. He
is an Affiliate Assistant Professor in the Department of
Medical Informatics and Clinical Epidemiology at Oregon
Health and Science University. Dr. Gibson’s educational
background includes a BS from Stanford University, an MD
from Case Western Reserve University, a PhD in Medical
Informatics from the University of Utah with a fellowship at
Intermountain Health Care in Salt Lake City, and an MBA
from the Wharton School. Dr. Gibson is a retired family
physician and emergency physician.

William Hersh, MD, FACMI, FACP, is professor and chair

of the Department of Medical Informatics and Clinical
Epidemiology in the School of Medicine at Oregon Health
and Science University (OHSU) in Portland, Oregon. Dr. Hersh
is a leader and innovator in biomedical informatics both in
education and research. He serves as director of the OHSU
Biomedical Informatics Graduate Program, which includes two
masters degrees (research and professional), a PhD degree,
and graduate certificate. Dr. Hersh has won numerous awards
for his innovations. These include the OHSU Faculty Senate
 Contributors ◾ xv

Distinguished Faculty Award for outstanding teaching in 2007;

the 2008 AMIA Donald A.B. Lindberg Award for Innovation
in Informatics; one of the Modern Healthcare Top 25 Clinical
Informaticists in 2010, 2011, and 2012; and the HIMSS
Physician Leadership Award in 2015. He is an elected fellow of
the American College of Medical Informatics and the American
College of Physicians. Dr. Hersh also maintains a web site
(http://www.billhersh.info) and the Informatics Professor blog
(http://informaticsprofessor.blogspot.com/).

Dr. Eric M. Liederman, MD, serves as director of Medical

Informatics for The Permanente Medical Group and National
Leader of Privacy, Security and IT Infrastructure for The
Permanente Federation, of Kaiser Permanente, which serves
over 12 million members across the United States. In these
roles, Dr. Liederman is accountable for privacy and security, IT
investment, large program governance, and IT infrastructure
delivery and resilience.
Prior to joining TPMG in 2005, Dr. Liederman served
as medical director of Clinical Information Systems for the
University of California Davis Health System, where he led the
successful transition from paper medical records to a vendor
electronic health record (EHR) and patient portal. Earlier, Dr.
Liederman served as medical director of Information Systems
for Mercy Healthcare Sacramento and MedClinic Medical Group.
Dr. Liederman served as a Lieutenant Commander in the
U.S. Navy, where, as squadron flight surgeon, he ensured the
medical readiness of a Marine Corps Expeditionary Force with
which he deployed to the Persian Gulf for Operation Desert
Storm.
Dr. Liederman has published, and speaks internationally
on topics including knowledge management, patient
e-connectivity, collaboration with IT, and privacy and security.
He earned his Bachelor’s degree from Dartmouth College, his
MD from Tufts University, and his MPH from the University of
Massachusetts, Amherst.
xvi ◾ Contributors

Christopher Longhurst. As Chief Information Officer

of UC San Diego Health, Dr. Longhurst is responsible for
all operations and strategic planning for information and
communications technology across the multiple hospitals,
clinics, and professional schools. Dr. Longhurst is also a
Clinical Professor of Biomedical Informatics and Pediatrics
at UC San Diego School of Medicine, and continues to see
patients. He previously served as Chief Medical Information
Officer for Stanford Children’s Health and Clinical Professor
at the Stanford University School of Medicine, where he
helped to lead the organization through the implementation
of a comprehensive electronic medical record (EMR) for over
a decade. This work culminated in HIMSS stage 7 awards
for both Lucile Packard Children’s Hospital and 167 network
practices in Stanford Children’s Health.
Dr. Longhurst has published dozens of scientific articles
in peer-reviewed journals on how technology and data
can improve patient care and outcomes and was elected
as a fellow in the prestigious American College of Medical
Informatics, among other distinctions. He is a board-certified
pediatrician and clinical informaticist, and founded Stanford’s
fellowship in clinical informatics, first in the nation to
receive accreditation. Described as a pragmatic academician,
Dr. Longhurst serves as an advisor to several companies and
speaks internationally on a wide gamut of healthcare IT topics.

Ronald W. Louks, MD, MBA, is the Medical Director of CPSI

(a publicly traded company), a leading provider of healthcare
IT solutions and services for community hospitals and post-
acute care facilities. CPSI offers acute care EHR solutions from
its Evident and Healthland companies, and a post-acute care
EHR solution from American HealthTech.
With his background as a practicing Internal Medicine
specialist and Healthcare Administrator for 27 years prior to
joining CPSI in 2012, Dr. Louks is frequently sought out by
executive and physician leaders to help develop and advocate
 Contributors ◾ xvii

strategies for physician EHR adoption and optimization

that include improving proficiency, reduction of error rates,
increasing accuracy of clinical documentation, and enhancing
patient safety measures. He also works internally with the CPSI
family of companies to develop and improve policies related
to patient care products, and provides physician leadership for
EHR product development, implementation, and adoption.
Dr. Louks was awarded the degree of Bachelor of Science
from the College of Science at Purdue University in West
Lafayette, IN, where he was inducted into Phi Beta Kappa,
Zeta chapter, as an undergraduate. After earning his MD from
Indiana University School of Medicine in Indianapolis, IN, he
completed a residency in Internal Medicine at Ball Memorial
Hospital in Muncie, IN, followed by an additional year there
as Chief Resident of Internal Medicine. He later received
an MBA from Ball State University in Muncie, IN, where he
was inducted into the honorary management society, Sigma
Iota Epsilon. Dr. Louks maintains active membership in the
Phi Beta Kappa Society and is a lifetime member of the
President’s Council of Purdue University. He is also a member of
the American College of Physicians (ACP), the Association
of Medical Directors of Information Systems (AMDIS) and in
2005 was named a Vanguard member of the American College
of Physician Executives (ACPE). He has practiced and held
several administrative positions in Indiana and Idaho, including
successful entrepreneurial ventures as well as employed
positions with both small and large healthcare systems.

Dr. Michael J. McCoy, MD, has diverse experiences as a

practicing clinician, a physician executive in the electronic
health record vendor community, a national consultant, and as
the first chief health information officer for The Office of the
National Coordinator for Health Information Technology (ONC).
He previously served as the first chief medical information
officer for a large faith-based Integrated Delivery Network (IDN).
Trained as an OB/GYN, he was chief of the OB/GYN department
xviii ◾ Contributors

for Noble Army Hospital post residency. He had a collaborative

solo private practice of obstetrics and gynecology for more than
20 years, and was an early adopter of EMR systems.
He served as The American College/Congress of
Obstetricians and Gynecologists’ national health information
technology strategist, participating in Certification Commission
for Healthcare Information Technology (CCHIT), Integrating
the Healthcare Enterprise (IHE), Healthcare Information
Technology Standards Panel (HITSP) and other Standards
Development Organizations (SDOs) involved in healthcare
information technology and interoperability. He held executive
roles at both ambulatory and enterprise vendors. He currently
is co-chair of the Board for Integrating the Healthcare
Enterprise (IHE) International, representing HIMSS.
In addition to special interests in interoperability, he is
passionate about consumer engagement, person-centered care,
quality/safety, public policy, and privacy/security.

Dr. Jacob Reider, MD, is the Chief Executive officer at

Alliance for Better Health and has led a number of Healthcare
Information Technology start-ups aimed at improving health
outcomes with better data. He served in the Office of the
National Coordinator of Health IT as both Chief Medical Officer
and Deputy National Coordinator 2011–2014 and previously
was the Chief Medical Informatics Officer for Allscripts. He
received his MD from Albany Medical College and did his
Family Medicine Residency at St. Clare’s Hospital.

Dr. Joseph H. Schneider, MD, is a retired CMIO who consults

in informatics and provides care for newborns as a clinical
assistant professor with the University of Texas Southwestern
in Dallas. He serves on the Child Health Informatics Advisory
Committee for the American Academy of Pediatrics (AAP)
and is a founding member of the Texas Medical Association’s
Healthcare Information Technology (HIT) Committee, known
for its involvement in promoting usability and safety.
 Contributors ◾ xix

He was co-author of the 2003 Continuity of Care Record

standard, an early interoperability approach. He also
coauthored the AAP policy on Personal Health Records
and authored the #1 AAP Chapter Resolution of 2003,
recommending that the AAP take a leadership position in the
development of pediatric EHRs.
Dr. Schneider graduated summa cum laude from Emory
and has an MBA from Columbia with 15 years of business
experience, including managing a startup medical device
company. In 2014, he became board certified in Clinical
Informatics.
Dr. Schneider is a competitive racewalker but he loves to
go on slow walks with his wife and dog. His passions are
the families he cares for and the quality, safety, security, and
usability of the technology used to help them have healthy lives.

Dr. Amy M. Sitapati, MD, is the chief medical information

officer of Population Health at the University of California
San Diego Health. She is clinical professor in the Department of
Medicine, Division of General Internal Medicine and Department
of Biomedical Informatics. Dr. Sitapati is board certified in
internal medicine and clinical informatics. She has oversight
of analytics and population health initiatives related to UC San
Diego’s 49 active patient registries which support bulk activities,
care management, care gap closure, and identification of risk.
Dr. Sitapati’s expertise supports the design and creation of
systems that deliver improved care, support pay for performance
programs, risk contracts, and CMS innovation initiatives.

R. Dirk Stanley, MD, MPH, is a hospitalist, physician

informaticist, and CMIO. Originally from Hartsdale, NY,
he started working professionally in the software industry
during high school and college. After graduating from
University of Massachusetts at Amherst, he earned his MPH
in epidemiology at New York Medical College and worked
for five years as medical data analyst in the QA department
xx ◾ Contributors

at Westchester Medical Center in Valhalla, NY before starting

medical school at St. George’s University in Grenada. After an
Internal Medicine residency in Albany, NY, his IT and data
analysis background led him to Cooley Dickinson Hospital in
Northampton, MA where he served for eight years as CMIO
and practicing hospitalist. In 2010, he won New England
HIMSS Physician-of-the-Year; in 2014, he was ABPM board-
certified in clinical informatics, and in 2016, he accepted a
position as the first CMIO at University of Connecticut Health
in Farmington, CT.

Dr. Harris R. Stutman, MD, serves as the chief medical

informatics officer at MemorialCare Health System in southern
California. He trained as a pediatric infectious disease
physician at the Children’s Hospitals of Pittsburgh and
Oklahoma and has held full-time academic appointments
at the Universities of Pittsburgh, Oklahoma and California-
Irvine. His research activity focused on the microbiology
of cystic fibrosis-related infections and novel antimicrobial
chemotherapy. He has authored more than 50 peer-reviewed
articles, 40 book chapters, and two handbooks in the fields of
infectious disease and informatics. He also served as chief of
staff at Miller Children’s Hospital in Long Beach.
His career in medical informatics spans 25+ years, including
leadership positions with the Medical Information Systems
Physician Society, the Computer-based Patient Record Institute
and the Association of Medical Directors of Information Systems.
He is a long-time member of the American Medical Informatics
Association and HIMSS. In addition to current and previous
CMIO positions, he worked for six years on the “vendor side,” in
product management and clinical system design.
His major responsibilities at MemorialCare focus on EHR
implementation and optimization as well as addressing
clinical decision support, controlled clinical vocabularies
and analytical strategies, and leading their meaningful use
initiatives.
Chapter 1

The Evolution of the

CMIO in America
Raymond Aller and Richard L. Rydell

Contents
Bibliography................................................................................. 9

The CMIO position is one of the newest executive positions

in American healthcare. The creation of this role can be
understood as a maturing of the healthcare industry in the
United States, especially in the application of IT in the practice
of medicine.
Although the term CMIO was not widely used until the
late 1990s, and most institutions did not formally appoint
anyone to such a post until early 2000, some physicians
were performing this role in the 1970s and 1980s, and even
in the 1960s. This chapter focuses on those individuals,
some of whom are identified, and others who are more
generally described, as they wish to remain anonymous.
Some institutions achieved success in relying on such talents.
Others took them for granted, and suffered a series of failures
after driving them away. We cite those examples with which
we are most familiar; there are numerous others who could

1
2 ◾ The CMIO Survival Guide

be discussed, but we lack the knowledge and space to do

so here.
Those who have practiced the CMIO role have depended
heavily on the historic development of clinical informatics
as a discipline by such renowned individuals as Lawrence
L. Weed, MD, at the University of Vermont in Burlington,
who conceived of the problem-oriented medical record, a
way of looking at medical information that has provided
the underpinnings for all of our work in electronic medical
records (EMRs). Similarly, Octo Barnett, MD, and his team
at Massachusetts General Hospital (MGH) in Boston had the
brilliant insight to understand that medical data had unique
characteristics and to conceive the MUMPS (Massachusetts
General Hospital Utility Multi-programming System) database
structure, alternatively known as M, and related tools
(sometimes called associative databases), which have served
as the underpinnings for the most successful and widely
deployed large-scale medical software programs, such as
Veterans Administration’s Decentralized Hospital Computer
Program (DHCP), Veterans Health Information Systems and
Technology Architecture (VistA), EPIC, Sunquest, Medical
Information Technology (Meditech), and many others. The
most widely installed and successful EMR system in the United
States, EPIC, is built on associative database architecture, as
it the most long-lasting governmental system, VA’s VISTA.
Donald W. Simborg, MD, of the University of California at San
Francisco, envisioned the need for peer-based communications
protocols such as Health Level 7 (HL7), and built early tools
to support hospital-wide communication. Roger A. Cote, MD,
DSc (Hon), with the SNOMED Committee, developed multiple
editions of the Systematized Nomenclature of Medicine
beginning in 1976. Thirty years later, this was amalgamated
with the British READ codes, and is now SNOMED-CT,
the worldwide lingua franca of medical information.
Clem McDonald, MD, led the development of real-world
interoperability, through protocols (lab communications),
 The Evolution of the CMIO in America ◾ 3

semantics (the Logical Observation Identifiers Names and

Codes [LOINC] database and universal standard), and reality
(the Indiana Health Information Network). We could list
dozens more. But these are the subject pioneers—the CMIOs
who have created or taken these tools and made them real in
their own institutions.
The earliest creation of an organization-wide EMR system
was a 1968–1972 experiment funded by the U.S. Department
of Health, Education, and Welfare—a collaboration between
the Lockheed Corporation, many of whose engineers
and programmers had created the U.S. Gemini space
program—and El Camino Hospital in Mountain View, CA.
Particularly important to the implementation of this EMR tool
at El Camino was Dr. Ralph Watson, who truly embodied the
position of CMIO decades before anyone used the term.
In order to better understand how physicians, nurses, and
others in healthcare were actually using the medical chart
and communications tools, a young hospital administrator,
Richard L. Rydell, MBA, set up super-eight movie film with
a time code at a busy nursing station at El Camino Hospital.
With time-lapse recordings, this pioneer was able to discover
what clinicians’ communications entailed in the daily process
of care and, importantly, how long they took in each of the
activities. In retrospect, it is remarkable to realize that they
were focused on the improvement of the process of workflow
and provider communications, which remains to this day one
of the most elusive aspects of EMR implementation.
Although the Lockheed (later Technicon) system
implemented in El Camino was implemented in several other
hospitals over the next two decades (including the Clinical
Centers of the National Institutes of Health [NIH]), the time
wasn’t yet ripe for the widespread deployment of clinical
information systems (CISs).
Another example of physician leadership of hospital
informatics unfolded beginning in 1980, when a hospital-based
physician arrived at a respected 400-bed community hospital
4 ◾ The CMIO Survival Guide

in a coastal California community, and began functioning as

CMIO (without that formal title). He immediately tackled the
challenge of bringing the hospital from a punch-card-based
Burroughs billing system (the only computer in the hospital)
to an array of badly needed clinical and ancillary systems.
Interestingly, his medical and residency training had included
mentoring by Drs. Roger Cote, Octo Barnett, and Don
Simborg, and his early practice was influenced by the work
of Dr. Clem McDonald, such that he had an uncommonly
deep knowledge of clinical informatics. Beginning in 1980,
he organized site visits, and encouraged system evaluations.
From 1983 to 1985, he guided the technical and clinical
staff of the hospital to selection and installation of several
clinical information systems, including laboratory, radiology,
pharmacy, and patient care/clinical. By 1985, the hospital
was nationally recognized for the excellence of its array of
clinical information systems. Baxter Corporation pointed out
to hospital administrators that the hospital now had the most
complete clinical implementation of the Dynamic Control/
Delta order entry/results reporting system in the United States.
Unfortunately, hospital administration repeatedly refused to
reflect any compensation for the time of their de facto CMIO
in their regular (management-fee) payments to his medical
group. Although his partners made it clear that they couldn’t
continue to permit him to work on tasks “that we are not
being paid for,” hospital administration obstinately refused to
designate a portion of that payment for clinical informatics,
steadfastly insisting that it wasn’t necessary to pay, and they
weren’t required to pay for informatics services.
Subsequently, the physician moved his practice to another
city. The community hospital, lacking physician informatics
guidance, went on to purchase a costly and disastrous failure
of a system for physician outreach. A few years later, the
hospital was a major participant in one of the most notable
and spectacular regional health information organization
(RHIO) failures on record.
 The Evolution of the CMIO in America ◾ 5

Decades later, the hospital has recognized that physician

informatics expertise is valuable, and they have begun paying
a medical staff member as CMIO.
A year after leaving the community hospital, this
informaticist realized that a major factor in the hospital’s
failure to consider payment was that informatics was not an
ABMS-recognized (and therefore reimbursable) specialty. He
presented the need of certification in clinical informatics as a
medical specialty to the American Board of Pathology (ABP),
and in 1991 the ABP proposed to the American Board of
Medical Specialties that a Speciality Certification in Clinical
Informatics be established.1 The ABP then appointed a test
committee to create a certification examination. This task
proved exceedingly difficult, and it was not until 2005, when
other specialities of medicine joined the work of defining the
scope and creating the questions that the exam began to take
shape. The first certification examination in clinical informatics
was administered in 2013, and has been administered yearly
since then. Practitioners who can show experience in clinical
informatics will be grandfathered into be exam-eligible for a
few more years. The primary mode of certification will be via
a 2-year ACGME-approved fellowship.
Fortunately, other community hospitals took an opposite
approach. In 1982, Bill Bria, MD, a pulmonary specialist
who had trained at MGH, joined the pulmonary division at
Baystate Medical Center in Springfield, MA. Finding that the
mainframe computer used there was useless—five years after
implementation, its only clinical function was to order chest
x-rays—Bria introduced the subject of its inefficiency, with
indignation, at a medical staff meeting, putting into motion
the dynamic that when one brings up issues, he or she is then
charged with finding the solution.
News of his criticism reached the new Chief Information
Officer (CIO) at Baystate, Richard Rydell, who also learned of
Bria’s (successful) Apple II programming course for physicians.
At their first meeting, Rydell’s opener to Bria was “Would you
6 ◾ The CMIO Survival Guide

like to do something about the problem you’ve identified, or

do you want to just continue to complain?”
After consultation with the Chief of Staff and Chief of
Pulmonary, Bria accepted Rydell’s challenge to dedicate
25 percent of his work time and salary in order to take on the
challenge as a physician champion in the information services
department. Within a year, this dedicated time increased
to 50 percent, and under Rydell’s direction, Bria traveled
throughout the United States, speaking about and beginning
to understand what this task was really about.
Needless to say, Baystate has had far greater and sustained
success than the shortsighted hospital discussed in the
previous example.
1n 1990, the Chief Executive Officer (CEO) of Long Beach
Memorial Medical Center (Long Beach, CA) had decided to
bring in the Technicon system (described earlier) because
of its emphasis on the value of direct physician order entry
(a dozen years before this became fashionable). He brought
in Rich Rydell as CIO, because of Mr. Rydell’s experience in
that deployment, who in turn identified a highly respected
member of the medical staff, Harris Stutman, MD, to serve as
CMIO (although the term wasn’t in use at that time). Additional
physicians were recruited, all on a part-time basis (including
the informaticist from the first hospital above), and within a
few years the hospital had launched TDS7000, with a rate
of computerized physician order entry (CPOE) as high as
80 percent in some specialties.
There are a number of examples of academics heavily
involved in medical informatics in the 1970s and 1980s. In a
few cases, they functioned as CMIOs, guiding hospital efforts
in systems deployment, and in other instances, they focused
on research and had little or no contact with the clinical side.
Most notable are those who stepped forward and
developed clinical systems that became the core applications
in their academic medical centers. One of the first was
Octo Barnett, MD, founder and Senior Scientific Director
 The Evolution of the CMIO in America ◾ 7

of the Laboratory for Computer Science for over 40 years

(retired in 2012). As mentioned earlier, his most far-reaching
innovation was to lead the invention in the late 1960s of the
MUMPS programming language, which was used to create
a clinical laboratory information system, a radiology system,
a medication ordering system (decades before its time), a
surgical pathology system (that served as a prototype for many
of the systems popular today),2 a Computer Stored Ambulatory
Record (precursor of today’s EHRs), and many other clinically
relevant tools.
At Indiana University’s Regenstrief Institute, Clem
McDonald, MD, and his team began creating the EHR tool
that became the core application for the Wishard Hospital
and many other applications. An even more important part
of Dr. McDonald’s role was in his creation and championing
of standards crucial for our interconnected world—the
ASTM/HL7 (American Society for Testing and Materials and
Health Level 7) standard for reporting observations, and the
LOINC standard for naming lab results. Since 2007, he has
been leading the Lister Hill Center of the National Library of
Medicine.
At the University of Utah LDS Hospital, Homer Warner,
MD, PhD, and his team built a series of clinical tools,
encapsulated in the HELP system, that became the beacon
for such understanding (and application) as how to improve
patient outcomes with informatics tools. In the early 1970s,
they also constructed the Medlab laboratory information
system, one of the first widely installed (and highly functional)
laboratory information systems. Unfortunately, the adage that
“a prophet is without honor only in his own country” applied
to that team. For all the success they had at LDS Hospital (and
subsequently at Intermountain Health Care), their opinions and
guidance were often disregarded at the “official” University
Hospital across town.
At another Harvard Hospital, Beth Israel, Warner Slack and
Howard Bleich, both MDs, led their team to create a complete
8 ◾ The CMIO Survival Guide

suite of clinical applications, initially deployed in the early

1980s and still in use today. These served as models for the
clinical applications subsequently developed at Brigham and
Women’s Hospital that served for some years as the primary
system for Partner’s Healthcare.
In 1976, the University of California, San Francisco (UCSF)
hired Donald W. Simborg, MD, as their CIO. Not only was
it highly unusual to hire a physician for such a post, but
this appointment occurred in what proved to be a highly
propitious time. Dr. Simborg proceeded to develop a series
of applications for important clinical functions (such as
patient master index, surgical pathology, etc.) but also came
to recognize the most fundamental needs for technical
interoperability. It was out of this experience that he founded
Simborg Systems and developed the first set of tools to freely
interchange clinical data among disparate systems. Simborg’s
experience was one of the most important factors leading
to the creation of the HL7 data interchange standard. In this
instance, not only did Dr. Simborg’s contributions benefit the
patients at UCSF, but UCSF contributed to all of our ability to
interchange clinical data.
So, several academic informatics programs became
involved clinically, or built applications that became core to
their medical center, while others remained preoccupied with
academic research projects and largely oblivious to the mission
of the medical center they inhabited. To differentiate these two
tendencies, one need only consider how many applications
developed by that group are being widely applied for patient
care in their own institution, or in others.
In other academic institutions, physicians sometimes
took the lead in acquiring and implementing commercial
systems. One of the most notable was Mel Bernstein, MD’s
comprehensive installation of Meditech applications in 1980 at
the University of British Columbia at Vancouver. Dr. Bernstein’s
vision of an integrated solution serving multiple departments
off a single database was an inspiration to many.
Another random document with
no related content on Scribd:
based on space experiments to the extent that they affected national
security. But even he could not find a means to extend a security
blanket to cover a theory of extra-galactic origin of the moon.
He raged at Jim, however. "You'll make a laughing stock of us in
every scientific center of the world! You can't publish a ridiculous
thing like this!"
"No one will laugh if he reads the data I've got to present," said Jim.
"Every member of our staff who knows the subject has verified that
the data are correct. The conclusion is inescapable."
"I can't forbid publication, Cochran," said Hennesey, "but I think it is
very unwise for you to go ahead. Very unwise."
"I'll take that risk," said Jim.
He sent the paper to the Journal of Astro-physics. At the same time
he sent an announcement to the major news services.
He had expected some sensationalism in the reporting. There was
more than he bargained for. Some of the headlines that followed
were:
"Savant Says Moon is Messenger from Outer Space."
"Moon Will Poison Earth."
"Moon Trip—One Way only."
The reactions in the upper echelons of NASA were almost as bad—in
their own way. No thought had ever been given to a need for
complete decontamination of astronauts and equipment after
exposure on the moon. The requirement, if admitted, would threaten
the entire program in the minds of some of the engineers. Others
admitted it was tough, but thought they could solve it in an extra year
or so. Rumblings were heard echoing down from Congressional halls.
Why hadn't the stupid scientists known in the beginning that this was
necessary? Always bungling things—
In the end, it was Alan himself who came up with a proposal that kept
the project from bogging down and still provided some measure of
protection against the possible menace. He suggested a plastic outer
suit to be fitted over the space-suit and discarded as the astronaut re-
entered the space vehicle. With care, such a procedure could prevent
direct contact with moondust. In the meantime, it was hoped that
robot vehicles could bring back moon samples before the Apollo was
sent out.
This rather mild proposal did much to calm the furor in NASA and
contractor engineering circles and soon the press had abandoned it
for other, more sensational stories. But Hennesey and a number of
other officials didn't forget. Some of them believed Jim Cochran was
a charlatan at worse and an incompetent at best. They considered he
had degraded American science with his fantastic theory.
Scientific judgement was being held in abeyance until actual moon
samples were available on earth. For the present, at least one of
Jim's predictions had come true. The hypothesis was becoming
known as Cochran's Theory. That it was also called Cochran's Idiocy
by a few didn't matter.
Jim continued his own sixteen-hour stints at the analyzer controls,
probing in a wide pattern over the floor of the Sea of Rains, and
striking deeper toward the heart of the moon with each probe.
Probing to such great depths was made possible by a development
that didn't even exist when the Prospector design was begun. Then, it
was hoped that penetration to a foot and a half of the moon's surface
might be possible. Five-hundred-foot holes were only a madman's
nightmare. How could you carry such drilling equipment all the way to
the moon?
Then, in the last months of Prospector design, laser devices had
been produced, capable of burning holes in a diamond. It was only a
small step, then, to the design of a drilling head which mounted a
cluster of laser beams. These would literally burn their way toward
the heart of the moon.

The laser drilling head was lowered on five hundred feet of minute
cable, which had tremendous tensile strength. The vaporized moon
substance boiled out of the hole and condensed above the surface,
settling as fine dust. As the hole deepened, the condensation
products coated the upper portions of the hole and the cable. To keep
the hole from thus being closed, the cable was vibrated at a
frequency that shook loose the condensing rock products, and the
laser head was raised with beams shooting upward to clear the hole.
Jim found that a very special technique was required to raise and
lower the head at the proper intervals to keep the hole clear and
prevent loss of the drilling head. A spare was carried, but he didn't
want to face the loss of even one. After three weeks, he felt confident
in his operation and began lowering the drilling head to depths of two
hundred and three hundred feet.
As he had expected, along with the lunar geologists who were
participating, the moon showed a definite pattern of stratification. But
the differences between the layers seemed slight. Chalky, calcium
compounds were abundant. Some were powdery; others were
pressed into brittle limestone formations. No really hard rocks such as
granite were encountered, however. The boundaries between layers
were ill-defined. No one knew what to make of it. The observations
were interesting. Explanations were wholly lacking.
Then, after five weeks of probing, on the edge of the four-hundred-
foot level, Jim found something new. He sought out Sam at the end of
the day.
"A few years ago," he said, "scientists were startled to find chemicals
that were the product of life, inside meteors from outer space."
"I understand they've even found bacteria which they have been able
to bring to life," said Sam.
Jim nodded. "More than four hundred feet deep on the moon I've
found the same kind of chemicals—hydrocarbons that must be the
product of living cells."
"Four hundred feet deep on the moon—" said Sam musingly. "And
maybe the moon came from billions of billions of light years across
space. So wherever it came from there was something living. What is
it? Traces of bacteria, or chemical remains of plant life like our coal
mines?"
Jim shook his head. "I don't know yet. I'm not sure we can find out
until we go there. But, as you say, it means the moon was once the
scene of life—wherever it came from."
"One thing I haven't understood," said Sam, "is why the moon
stopped here if it had been traveling through space for so long. Why
didn't it keep on going?"
"It was just a combination of factors," said Jim. "The moon happened
to be traveling at just the right speed. The earth was in just the right
place at the right time. As a result, the moon fell into an orbit around
the earth. Pure accident."
"A lucky accident!" said Sam.
Jim looked up at the pale moon above their heads as they walked
toward the parking lot. "I hope so," he said. "We will soon know
whether it was a lucky or an unlucky accident."

The moon laboratory had not been designed for extensive organic
chemical analysis. There were only a few things it could do with
organic compounds. But these were sufficient to convince Jim that
the moon had once been the scene of life.
Why so deep? he wondered. Nothing had been found in the upper
levels, unless he had missed it—he would have to check that out
later.
As the drilling head moved slowly downward, the evidence of fossil
hydrocarbons increased. There seemed to be an almost geometric
increase in concentration after he passed the four-hundred-foot level.
He was certain the drill was penetrating a bed of fossil remains of
some form of life that flourished the little planet that the moon must
have been incalculable eons ago.
The more he thought about his theory, however, the more difficult it
became to explain all the factors. If the moon had actually been a
planet of some far distant system, what had torn it loose from its
parent sun and sent it careening through space? Had its sun
exploded, blasting whatever planets the system held into the depths
of space? Such an occurrence might explain the sterility of the
moon's surface, but why was the evidence of life buried so deep?
Perhaps the upper layers of the moon's surface consisted of debris
blasted from the exploding sun. Such debris would have been molten,
flowing about the moon's surface, cremating everything living. Finally,
it would have shrunk in the cold depths of space and wrinkled into the
vast mountains and cracks that laced the moon's surface.
It was one way it could have happened, but it seemed so fantastic
that Jim had difficulty in convincing himself that it was true.
He doubted the accuracy of his analyses. There were so many
tenuous links between the substance on the moon and his own
senses that an error in any one of them could destroy the accuracy of
the results. But he had no reason to doubt.
He began making calibration checks before and after every analysis.
It added scores of hours to his work. Sam sat beside him, checking
and verifying the accuracy of the telemetering circuits constantly. The
operation was as foolproof as their science could make it.
"You've got to believe what you find," said Sam. "There's no other
answer."
And then, one day, Jim found an answer that was utterly impossible
to believe. His mind balked and closed up completely at the thought.
Sam had been watching him for almost three hours, aware that
something had perturbed Jim exceedingly. Sam kept his mouth shut
and leaned quietly against the desk of his own console, keeping
check on the circuits while he watched Jim grow more and more
distressed. Sam didn't understand the processes, but he was aware
that Jim had been going over and over the same analysis for almost
two hours. At last Jim's face seemed to go utterly white, and his
hands became motionless on the console.
Sam waited a long time. Then he asked, "What is it, Jim? What's the
matter?"
Jim continued to stare at the panels of the console, then answered as
if from some far nightmare distance. "Two chemicals, Sam," he said.
"One of them a big molecule, something like hemoglobin. And neither
of them could exist as fossils. Their structure would have broken
down long ago. They could exist only in live tissue!"
He continued staring. Neither of them moved. Sam felt as if he had
just heard something in a nightmare and had only to wait a minute
until he woke up. Then it would be gone.
Jim turned his head at last and faced Sam. He gave a short, harsh
bark of a laugh that sounded half-hysterical.
"We'd be off our rockers, wouldn't we Sam? Clear off our rockers to
believe there could be something alive five hundred feet inside the
moon!"
"Sure—and if it were alive, it wouldn't be sitting still while the laser
beams drilled a hole into it. Besides, we just couldn't be lucky enough
to lower the drill right smack into some cave where a moon bear was
hibernating. All the circuits must have busted down at the same time.
We'll fix it tomorrow. Let's get the girls and have a night on the town."

It was a very unsuccessful night on the town. Jim and Mary, and Sam
and his wife went to a show and a nightclub.
"You're moving like a zombie. What's the matter?" said Mary as she
and Jim danced together.
"Feel like a zombie. Why don't we give it up and go home? I want to
get down to the lab by five in the morning."
"That's the trouble. You've done nothing but live in the lab since the
Prospector landed. So we're not going home. Sam and Alice are
having a good time. You dance with Alice next, and make her think
you're enjoying it!"
So Jim didn't go to bed at all, but he was at the lab by five in the
morning. The night crew were still at work. He had steered them
away from the analyses he was doing so they were unaware of the
shattering results he had found.
He took over the controls, and resumed work alone.
There was no doubt about it. If any of the methods they were using
were accurate, then he had discovered almost indisputable proof that
some living tissue existed five hundred feet below the surface of the
moon.
Since the laser drilling head sealed the walls of the hole with a
coating of frozen lava, it was necessary to probe horizontally for
samples. Small extension drills, capable of reaching five feet on
either side of the hole, were carried in the head for this purpose.
Jim lowered the head through the last twenty feet of its drilling limit.
Every six inches he sent the horizontal probes to their limits. The tell-
tale chemicals existed at every point. He computed the volume he
had probed, and felt numb.
By the time Sam had shown up, Jim had withdrawn the probe to the
surface and was moving the Prospector slowly across the moon's
surface.
Sam saw the motion on the television screen. "Where are you going?
I thought we were going to check out the hole we were in."
"It's been checked," said Jim. He hesitated. His original plan had
been to move the Prospector a distance of fifty feet and probe again
to the five-hundred-foot level. Then, decisively, he pressed the control
that kept the Prospector moving. He stopped it a hundred feet from
the previous hole and began the long, tedious job of drilling again to
the limits of the Prospector's equipment.

Sam spelled him off during the day. By evening, they had hit the four-
hundred-and-fifty-foot level. Jim took his first analysis in this hole. The
chemicals were there. In greater concentration than at the same level
in the previous hole.
Jim turned to Sam. "We have circuits for measuring potential
differences on the lunar landscape. Could we make a reading at the
bottom of this hole?"
Sam considered. "It'll take some doing, but I think we can manage it.
What do you expect to find from that?"
Jim didn't dare tell him what was in his mind. "I don't know," he said.
"But it might be worth trying—if there is anything living down there—"
By the following afternoon, Sam had made the necessary equipment
arrangements so that potential readings could be obtained in the
mass from which the chemical samples were being removed. The
telemetered report was connected to a recorder that plotted the
variations against a time scale.
As soon as the circuit was set up and calibrated, the recording meter
showed a response. A very slow, rhythmic pulsation showed in the
inked line on the paper.
Jim felt as if his breathing must have stopped for an infinite length of
time. "That's what I thought we'd find," he said at last.
"What?" said Sam. "I don't understand what you're talking about.
What do you think those pulsations mean?"
"Did you ever hear of an electroencephalograph?" said Jim, gravely.
"Electro—Sure, brain wave recordings. Jim! You don't think these
waves—!"
In silence, the two men stared at the wavering pen and the sheet of
recording paper that slowly unrolled beneath it.

Dr. Thomas Banning had been a class mate of Jim Cochran when
they were both in their first couple of years of college. Banning had
gone on into medicine, specializing in brain studies, while Jim had
turned to chemistry. The two had been out of touch for several years.
Tom Banning was the first one Jim thought of, not only because of
their old friendship, but because he had read recent papers
describing some of Tom's new work on the frontier of
electroencephalography. He called first on the phone, then arranged
for a personal visit. Sam went with him. They had closed down all
Prospector work while they were to be away.

Tom met them and was introduced to Sam as he ushered them into
his own modest laboratory. "This isn't the plush sort of surroundings
you've become used to," he said as he showed them around. "The
Government isn't spending billions these days trying to find out how
the human mind works."
Jim could well understand Tom's bitterness. Doing research on the
frontiers of the mind, he was forced to spend his own money for much
of his laboratory equipment.
"I can sympathize, but that's about all," said Jim. "I just work here
myself."
"Tell me about your problem. On the phone, that sounded interesting
enough to make a man's day brighter. You said something about an
unknown life form with electrical pulses that might be related to brain
waves?"
Jim nodded. "That's the way it looks to me."
"But where does this life form exist? Surely it can be identified!"
"If I told you, you'd throw me out or call the paddy wagon. Look at
these, first."
Jim and Sam spread out the long folds of chart they had accumulated
through days of recording. "Does it look like anything to you?" asked
Jim.
Tom Banning frowned. "Well, it certainly could be an EEG record of
some kind. The apparatus—"
"The apparatus was nothing but a single electrical probe, and the
signal was transmitted under very unsatisfactory conditions."
"Signal transmitted, you say? Just where did this come from, Jim?
You didn't come all this way just to pull my leg."
"No," said Jim wearily. "If anybody's leg is being pulled, it's mine. I
wanted to see if you could recognize it as having any similarity to an
EEG. Then I wanted to ask about your work you reported in your last
paper. The one on 'EEG as a Brain Stimulus and Communication
Medium'."
"Yes? What did you want to know about that?"
"You've had some success in taking the EEG waves of one person
and applying them to the brain of another person so that the latter
understood some of the thoughts of the first person while being
stimulated by his brain waves."
"Yes."
"Would it be possible to do that with this record?"
Tom studied the record silently. "Any cyclic electric impulse can be
applied as a stimulus to the brain. Certainly, this one can. My
question still remains, however, what kind of a creature generated
these pulses? If it is so alien you can't even identify it, we can't really
be sure that these are brain waves. I can only say they may be."
"That's good enough for me," said Jim. "How about setting it up so
that we can see if these tell us anything."
"I think I ought to make you tell me where you got these, first."
"Afterwards, please, Tom."

It took the rest of the day to transcribe the record to the format
required by Tom's light-intensity reader. They set the following day for
the experiment.
Both Sam and Jim were to participate. Tom applied eight electrodes
to the skull of each man. They reclined in deep sleep-back chairs,
and Tom suggested they close their eyes.
Jim began to feel a sense of apprehension as he heard the first faint
whine of the equipment. He knew the transcribed tape was unreeling
slowly beneath the photo-electric scanner. The resulting fluctuating
current was being amplified, filtered, gated to the proper level, and
applied to the electrodes on his skull. He felt nothing.
"Just like a ride on the merry-go-round," he said in disappointment.
Then it struck.
Like a fearful, billowing blackness rising out of the depths of Hell
itself, it washed over him. It sucked at his very soul, corroding,
destroying, a wind of darkness where the very concept of light was
unknown.
He was not conscious of his screaming until he heard his own dying
voice and grew slowly aware of the sudden rawness of his throat. He
heard another screaming and it sounded like Sam. Dimly, he
wondered what had happened to Sam.
Tom was bending over him, patting his face with a cold towel and
murmuring, "Wake up, Jim! You're all right now. You're all right."
He opened his eyes and saw Tom, white-faced. He turned and looked
at Sam, whose head lolled sluggishly while a low whimpering came
from his lips.
"I'm all right," said Jim weakly. "Take care of Sam."
Exhausted, he leaned back and closed his eyes another moment.
Sweat oozed from every pore of his skin, cold, fear-inspired sweat.

An hour later, he felt completely recovered from the experience,

except that his knees were still a little wobbly when he tried his legs.
"We've got to try it again," Jim said. "Can you cut down the intensity a
little? Better still, how about rigging up an intensity control that we can
operate for ourselves?"
"Nobody is trying that thing again in my lab," said Tom Banning. "Do
you think I want a couple of corpses on my hands? Not to mention
the droves of police that your screaming will bring down."
"We've got to know," Jim said. "Listen, Tom, I'll tell you where we got
this record. Then you can judge for yourself."
Rapidly, he told Tom all that had happened since their first experience
with the Prospector. The brain specialist listened impassively until the
end of the story.
"So you conclude there's something monstrous on the moon, and this
experience you've just had would indicate that it's highly inimical to
human life," said Tom.
"That's about it," said Jim.
"What do you expect to do about it?"
"I want to finish what we started here. Then I've got to show the
authorities that the moon project has got to stop. We can't go ahead
with our moon landings now. If we do, that thing will be stirred out of
dormancy into life—and, somehow, it will make its way to earth. I
wouldn't be surprised if it could navigate space alone, its own naked
being."
Tom turned back to his equipment. "All right, let's go. I want to get a
sampling of that before we're through, too."
With a control that he could operate himself, Jim found it endurable.
With the control at minimum intensity, he tensed for that first terrible
impact of the alien impulses pouring into his own mind.
They were weaker, but still he felt as if the shroud of death had
settled over him. He heard a moan from Sam and knew his
companion was experiencing the same sensations.
The impulses of evil poured on through the electrodes into his mind.
He sensed the immensity and purpose of the thing that had
generated them. He sensed that out of some far reach of space,
where time and dimension were not the same, the thing had acquired
an eternal nature of a kind that knew no birth and could experience
no death in the dimensions of man.
He sensed that its nature and its purpose were pure destruction.
Destruction of life in any form. It was a thing of death, and life and it
could not exist in the same universe.
He sensed how it had come and why it had come, and the partial
defeat that had sent it into dormancy because there was no life of the
kind it knew in the universe through which it hurtled.
Now—it was once again aware of life.

The three of them went back to the tracking station laboratory

together. Jim managed to obtain a clearance for Tom to see what
they were doing. "I want to move the Prospector a long distance and
try one more hole," he told Sam.
"What do you mean by a long distance?"
"A hundred miles."
"A hun—! You think you'll still find this thing that far away?"
"We'll find out. Can the Prospector travel that far?"
"Sure. If you wait long enough. Its maximum speed is two miles an
hour."
"A little better than two days. Let's pick the direction of the flattest and
lowest terrain. I don't want to get it up into the mountains."
During the following two days, Jim considered what his next move
should be. He had to present his data and evidence to a conference
of men who mattered, who could make the necessary decisions. It
had to be brought to the attention of the top levels of NASA. The
Department of Defense and the Presidential advisors should be in on
it, too.
His thoughts came to a stop and he felt more than a little hysterical.
Who was he? A third-string chemical researcher on one of dozens of
current NASA projects. Who was going to let him call a conference of
the nation's brass and instruct them to close down the moon
program?
Nobody.
In the Civil Service hierarchy to which he belonged there was
absolutely no way on earth by which he could bring his story to the
attention of the people who could act on it.
No way at all. But he had to try.
He tried to reach the Director of NASA. The Director's secretary told
Jim the Director was out of town and could not be reached except for
emergency or other top-priority communications. Jim said that was
exactly the nature of his message. The Secretary told him to get his
Project Director to approve the message and an effort could be made
to get it through.
That meant Hennesey.
Hennesey laughed in his face, and told him that one more fantasy like
that would get him fired.
Jim had known that's the way it would be, but he had to try.
By this time, the Prospector had traveled more than ninety miles from
the last probe. It was far enough, Jim decided. They'd put down one
more probe, then—he didn't know where he'd go from there.
Sam saw the bleakness and bitterness on his face when he came
into the tracking station. "No luck?" said Sam.
"What do you think? Have you ever realized that there is no way
whatever for the ordinary citizen to get through with a message that
requires action at the top? Channels, supervisors' approvals, okays
by supervisors' supervisors—the only communication the top level
has is with itself; generals talk to other generals, Bureau Directors
talk to generals and other Bureau Directors, the President talks to his
advisors who talk only to each other. The communication barrier is
complete and absolute."
"I could have told you that," said Sam. "I've been here longer than
you have. But some of them may still read a newspaper now and
then."
"What do you mean by that?"
"Call a news conference of the science editors and reporters of the
major press services and big-city newspapers. Your reputation is big
enough that they'll listen to you."
"You saw what they did to me last time!"
Sam shrugged. "Maybe you know a better way."

Jim took his seat at the console and watched the slow progress of the
Prospector across the moon's surface. It was winding its way through
an area of small, low crags. Ahead was a smooth, level plain. Jim
determined to halt there and make the next probe.
Out of the corner of his eye he saw Hennesey moving toward them.
He could think of nothing that would make the day more unpleasant
than Hennesey's presence.
The Project Director scanned the panels and the meters that showed
the distance traveled by the Prospector.
"Why have you moved the machine so far?" Hennesey demanded.
"You've used up valuable machine time that could have been used in
additional probes. We may be approaching the end of the useful life
of the Prospector very rapidly."
"I am aware of that," said Jim icily. "The stock of reagents aboard is
nearly exhausted. I wanted to make at least one comparison probe at
a considerable distance from our original site."
Hennesey grunted and remained silent, watching. Then, suddenly he
cried out, "Look out! You fool—!"
Jim had seen it, too. At the edge of the crags was a ten-foot wide
fissure spreading darkly on either side of the Prospector. The drives
of the machine were upon it before he realized it was there. In fact,
the crazy thought echoed in the back of his mind that it wasn't there
an instant before.
He slammed his hand against the switches that sent out a reversing
signal to the drives of the Prospector. But it was too late. The worm
drives bit into nothingness as the machine toppled slowly at the edge
of the crevasse. And in that moment, as the image on the television
screen teetered crazily, Jim had the impression that he was looking
into the black depths of utter horror. There was a blackness oozing
and writhing faintly in the depths—that could have been thirty or a
hundred feet deep. But he had seen just such a black horror once
before.
When the EEG signals from the moon first smashed into his brain!
He glanced at Sam. Sam was staring in a kind of intense horror that
told Jim he recognized it, too.
The image tilted abruptly against the black moon sky. Then the
screen went dark. And Jim had the feeling that the blackness had
closed over him.
But Hennesey had sensed nothing of this. He was cursing and raging
beside Jim. "You blind, brainless fool! You wiped out a billion-dollar
experiment because you weren't looking! You're through, Cochran!
Get everything that's yours and be out of here in ten minutes!"
Hennesey whirled and strode away, his rage reeking through the
atmosphere of the room.
Jim stood up and moved to the back of the panel. He opened the
plastic doors and clipped the last ten feet from the spool of TV
recording tape and slipped it in his pocket. When he returned to the
other side of the console, Sam was waiting for him.
"Where are you going?" said Jim.
"With you."
"Where's that?"
"I don't think you know, but I do. I'll tag along and see if I'm right."
"You're crazy. Didn't you just hear Hennesey fire me?"
"Yeah. I quit at the same time."
"You're really crazy."
Jim had a few textbooks and scientific papers in his desk. He
arranged for one of his men to clean them out. He didn't feel that he
could endure remaining in the station any longer.
Tom Banning followed them out into the sunshine of the parking lot.
"I'm sorry," he said, "but it looked as if what happened back there was
rather inevitable."
"It was," said Jim. "I'd have kicked his teeth in sooner or later. It's
better this way."
"What will you do now?"
"Ask Sam. He seems to think he has some crazy idea of what I'm
going to do next. I sure don't."
"The news conference," said Sam. "You'd better call it right away
before news of your dismissal gets out. They may think you just want
to unload some sour grapes if they hear of that first."
"Yeah, I guess you're right. Will you back me up in the conference,
Tom?"
The doctor nodded. "Gladly. It's pretty hard to believe, but you've got
me believing."

Jim was personally acquainted with most of the newsmen who

showed up for his conference. He had met them and helped them get
stories on the Prospector during the past two years. They were
sympathetic toward him.
He began his story by reviewing his initial discovery of the difference
in moon elements. He explained the analysis and showed them
samples of the telemetry record. Then he eased slowly into his
discovery of fossil hydrocarbons and finally the living hydrocarbons.
He watched carefully as he moved deeper into the story. He didn't
want to lose them here.
They stayed with him, incredulous but confident that he knew what he
was talking about. It was when he spoke of the fluctuating potential
measurements, that proved to be interpretable as EEG recordings
that he almost lost them. But he introduced Tom Banning quickly to
verify his statements. And Tom introduced the EEG machine itself. He
offered to demonstrate. A half dozen of the reporters tried it. They
had no doubts, afterward.
"You can almost draw your own conclusions," said Jim in winding up
the conference. "That thing is out there in our sky. There's no doubt
about it. I've shown you what we know. Now let me tell you what I
believe:
"There is some form of life in the moon. It is not merely in the moon. It
is the moon. I believe its bulk occupies almost the entire volume of
the moon. I believe this nemesis was spawned incalculable eons ago
in a time and a space that is literally outside our own. It was driven
out of that time and space by intelligent beings who could not destroy
it, but who could at least exile it in a state of dormancy. Or perhaps
they thought they had destroyed it and wanted not even the remains
in their own domain. Perhaps the craters of the moon were caused by
bombardment intended to destroy the thing.
"But it is not dead. It was dormant. Now, our laser probings have
stirred it to feeble life. It made a deliberate effort to capture or destroy
the Prospector by opening a fissure beneath it. My TV film recording
proves that the fissure was not there previously.
"What are we to do about it? That is why I have called you here.
Consider that the science of the intelligences in the domain that
spawned this thing could not destroy it. What chance has our feeble
science and powers against such a force? Hydrogen bombs would
probably serve only to feed it the energy for which it is starved.
"We must cease our lunar exploration program at once. We can hope
that it is not too late. If it is not, this thing may relapse into the
dormancy from which it has been shaken. We can only hope.
"But if we persist in our explorations and our probings of the moon we
are certain to loose upon ourselves a living force that our entire world
of science will be helpless to overcome.
"We must stop the moon program now!"

They kept him for another two hours with questions and demands for
further information. He gave them everything he knew, and when they
finally left, he felt that a sane and correct story of his findings would
be published. He waited for whatever results would be published by
the news services the following morning.
He waited.
There was nothing.
Eddie Fry called him two days later. Eddie was the reporter who knew
him best. "They killed the story," said Eddie. "We had to clear it with
government sources, and they persuaded every press association
and newspaper that knew about it to kill it. They said it would destroy
the national economy that was being built up on the space program.
We tried to make them believe it, Jim, but we couldn't do it. It was
hard enough to be convinced when we were listening to you. Second
hand, it just wouldn't go over. You really can't blame them.
"They're doing something else, too. They're really going to nail you for
this thing. A story is being released about your dismissal. It is said
that you were released for fantastic and unreliable theories and for
incompetence that resulted in the loss of the Prospector. I'm sorry as
hell, Jim. I wish we could kill that one, but there's not a thing we can
do for you."
"It's o.k., Eddie," said Jim. "I know how it is."
Crackpot. He was finished.
He called Allan at his base that night. His brother-in-law's voice was
icy as he answered. "What do you want, Jim?"
"Come down over the weekend, can you, Allan? I've got something
important I want to talk to you about."
"Listen, Jim. Stay away from me! Don't call; don't try to see me. Don't
send me letters or telegrams. Nothing! Do you understand that?"
"What the devil—?"
"They're investigating me. Because of you. They want to know how
much I've been listening to your crackpot notions. They're afraid
maybe it will produce an instability that will make me unfit for the
moon trip. If I lose out, it will be because of you!"
"That's what I want to talk to you about. Allan, you've got to listen to
me! You won't get off the moon alive—"
The phone went dead. Jim hung up slowly and went back to the living
room where Mary sat in tense, white fear. She had heard Jim's side of
the conversation. She guessed what Allan had said.
"It's no use," said Jim. "Don't try to reach him. He'll hate you forever."