How observations become inventions

Two stories of MDs who turned their ideas into innovations that are helping medical practices.

Software facilitates patient feedback

By John A. Hovanesian, MD

For all of my medical career, I have wondered how we physicians fall into patterns for treating certain diseases. When we recommend warm compresses for dry eye, a medication for allergy or choose a particular lens implant, are we really helping the patient? When we prescribe glaucoma medications, are patients having side effects they don’t report to us, like depression from beta blockers or somnolence from brimonidine? We assume all patients do well unless we hear otherwise, but is “no news is good news” really doing our best? And couldn’t we do better by collecting data on patient perceptions of our treatments?

I started MDbackline to create an automated care system that would reveal how patients were doing after their office visits or surgeries, to ask specific questions about treatment efficacy and to identify those who perceived less-than-ideal results. This, I hoped, would allow me to learn through the patient’s view — the most important of all — which treatments are best. From our data collection, we have learned many lessons, like accommodating lens patients do just as well long-term as those with multifocals. We’ve now published and presented many of our findings, and they’re changing the way we and others practice.


I first had the idea for MDbackline in 2009 when I realized that just a few of our patients with premium lens implants became relatively unhappy in the months after surgery, usually because they needed a YAG laser or a refractive enhancement. Those few unhappy patients rarely called us to tell us they needed our help. Instead they were very vocal among their friends and with their referring doctors, saying that their lens upgrade was a waste of money. I felt guilty that these patients had paid extra, had not received the results they were entitled to and had options for a better result if only we knew which patients they were.

With software, I realized, we could automate the process of following-up through electronic communication and did not have to schedule a separate postop visit for every patient. With the same system, we could deliver much-needed learning material, both before and after surgery. We could also reduce chair time for patients with time-consuming conditions like dry eye. And, we could encourage happy patients to go to online review sites, like HealthGrades, to say positive things about us. Since I built MDbackline, all of these hopes have been fulfilled, though there have been challenges.


Starting a company is incredibly time consuming, requiring knowledge about business structure, patent law and fundraising. It constantly tested my management skills and my commitment to the idea. Along with my colleagues and a team of developers who were recommended to me by a friend who is a successful software entrepreneur, I created and patented complicated branching logic to ask the right patients the right questions at the right time.

For example, after their first diagnosis and treatment recommendations, dry eye patients need follow-up at least twice. First, we contact them just a few days after their visit to check how they’re doing. Then, about two months later, we reach out to determine how long-term treatments like Restasis are helping. Using this branching logic, our platform extends the exam room conversation without using additional resources so patients can learn what they need without a return call or visit to the office.

We’ve created logic so clinical staff are notified of patient outcomes directly in EHR, with greater urgency ascribed to patients who really need attention; a single click can file away a report on a patient who is doing well. The whole idea of MDbackline was to improve on our care while actually saving time for me and my staff.


MDbackline works in the background as an add-on to EHR. It securely sends patients an e-mail from the physician — with a picture and friendly language — asking the patient to report on how he/she is doing. The patient clicks a link and begins a three- to four-minute online “conversation” with the doctor, clicking responses and reading responsive learning material in real time. In our practice, 70% of our patients respond to the system. We’ve learned that the vast majority of patients are happy with our treatments and are very grateful that we care enough to check in.

MDbackline brings value to both doctors and patients from an automated “conversation” between the cloud-based system and the patient.

We’re using these patient response data to meet MACRA and MIPS requirements, and the aggregate satisfaction data have been the key element to securing better payer contracts for 2%-3% better reimbursement on commonly billed codes. The intelligence in the platform even provides a seamless way for happy patients to say good things about us on review sites like Yelp and HealthGrades, which has boosted our online reputation.


Once we proved the concept in my practice, I knew we were ready to share MDbackline with many more practices, so I brought on a wonderful team of professionals to help other practices take advantage of its benefits. Word of mouth was incredibly important. Everyone in our specialty knows each other, so it is important that every user has positive things to say. Thanks to positive recommendations by our users, we’re now linked to hundreds of doctors in large and small practices across the country. The data we’ve collected have been presented and won “best paper of session” at ASCRS two years in a row and led to a growing list of peer-reviewed publications currently in press. Most of all, our docs get a great sense of satisfaction, knowing that most of our patients are very happy with our treatments and surgery — and which few patients need extra attention.

For any of my colleagues who are thinking about following a similar entrepreneurial path, I recommend it highly. However, be prepared to work hard and spend more time and money on pursuing your passion than you ever imagined. It’s wonderful to see an idea turn into reality and to benefit more patients in more places. OM

To learn more about MDbackline and how it can help your practice, contact

About the Author

Tips for the tough and the tenacious

By John P. Berdahl, MD

Ophthalmologists’ involvement with patients and their maladies makes us, unsurprisingly, the best source of ideas for novel treatments and devices. Our job is to recognize unmet need.

But why do so few develop their ideas? That’s easy — because the role of entrepreneur is demanding and foreign to most of us; add to those reasons day jobs that are already plenty demanding. Having jumped into the entrepreneurial world myself five years ago, I have learned about the enormous effort required to turn ideas into products — and products into companies. Making your idea happen requires intensity and commitment: It has to be something you can’t stop thinking about, that you are willing to invest some of your own dollars and lots of your own time in so you can make it a reality.

You have no restrictions; you don’t have to wait for industry to recognize a need and do something about it. You just have to be up for the challenge. Here’s a guide for navigating the product development maze, based on my own experiences.


My own entry into the world of innovation and product development was atypically easy.

It is a classic story of finding an unmet need: the way to address it then getting that solution to its potential audience, which turned it into a product with a modest amount of value. But, more importantly, it’s an example of helping surgeons and patients who don’t have a good solution to their problem.

At the time, I was a fellow with David Hardten, MD. We had a patient who still had a bunch of astigmatism after having a toric lens placed. Dr. Hardten said, “You used to teach math. Why don’t you figure out how to do the vector analysis on this?” So I did. We created a spreadsheet that could do all the trigonometric calculations, then other surgeons heard about it and wanted the spreadsheet too. I began e-mailing it to them individually and ultimately made a free website for surgeons to visit ( About 1,000 surgeons a month visit the website to figure out what to do in patients who still have astigmatism after a toric lens implant.

We’ve analyzed that data and published a number of papers about residual astigmatism after cataract surgery, and it will likely get directly incorporated into outcomes-based technologies.


With that experience under my belt, I addressed another need: a sublingual sedative for cataract surgery to get around the IV needles that many patients dislike and can cause OR delays.

We had traditionally used IV sedation for most of our patients, but we heard that a number of surgeons used sublingual Versed (midazolam, Roche) instead, so we tried that. We liked it but felt the sedation was not what we wanted. We also heard that some surgeons liked using IV ketamine because of the analgesic effect, but we didn’t want to go back to the IV. So we did sublingual Versed and sublingual ketamine together in a liquid form. Although we really liked the sedation the combination provided, it was too much fluid to put under the tongue.

This time, my experience was more typical to that of other innovators: I had to reach out to a company to partner with me in developing my idea further. I knew Imprimis had a track record of being able to safely compound medications, as well as treating surgeon-innovators fairly, and our partnership resulted in the MKO Melt, an IV-free conscious sedation compounded formulation. The 3 mg of midazolam, 25 mg of ketamine HCl, and 2 mg of ondansetron (Zofran, GSK) fits under the tongue and is delivered as a single-use prescription for each patient.

Despite this successful experience with an industry partner, my next project was to found my own company in 2014 to develop and commercialize my newest project — Balance Goggles, eyewear that helps regulate IOP. I chose to take on this formidable task — in addition to practicing medicine full time and working on my own innovations — because my mind wouldn’t let the idea go, and observations taught me that companies aren’t interested in ideas still in their infancy; they are looking for more developed “adolescents.” So Equinox was born ( ).


It’s understandable that industry is reluctant to consider concepts still in their infancy. Interesting ideas, after all, are a dime a dozen; getting an idea executed is a lot of work. And no one is looking for extra work. But for those of you interested in turning your idea into a product, here are my tips for navigating the path to product development.

1. Explore back channels. One of the challenges for the entrepreneur is, “I’ve got a great idea. I know I can’t make it reach reality by myself, but I don’t want anybody to steal it.” I advise you to reach out to any physician-innovators you know and ask them how to go through the process. Physician-innovators will have great insights and certainly aren’t going to steal your idea. Also, consider attending the Ophthalmic Innovation Summit where you will see 40 companies try to tell their best story. If you feel like you could be up there sharing that story like they are, then you may have a product and a company. If not, your one day at the meeting just saved you a whole lot of time and money and effort.

2. Get ready to risk — and work. There’s no way around it: You will have to risk on your own before you can even hope to partner with a company. If after your exploration you are convinced you have an idea that’s worth pursuing, the next step is to apply for a patent for your product or method.

Then it’s time to do some proof of concept work. For that, you will likely need the help of an engineer. You want to test your idea as quickly as possible, because the goal at this stage is to fail fast, and cheap. In this case, failure is a success because you didn’t dedicate years of your life to an unsuccessful idea. If it succeeds, you get confirmatory evidence to move to a bigger stage. Because if you’ve got proof of concept, you’ve got something worth talking about — you’ve got an “adolescent” that industry or investors may be interested in.

3. Time to seek financing. Once you have proof of concept, you have something solid to put in front of an investor or a strategic partner. Doctors undervalue how difficult it is to get other people to put their hard-earned dollars into you and your idea — plan on putting a lot of time and effort into persuading them. Partner with reputable surgeons who recognize the value in it. Realize that you will give up significant portions of your company to investors. Also, realize that there is an enormous responsibility in being entrusted with other people’s money.

4. Eat, sleep and breathe your idea. It has to be something that you wake up every morning thinking about, and can’t stop thinking about, and something that you are willing to invest some of your own dollars and a significant amount of your own time into taking it from an idea to an early reality. If you are not sufficiently excited about your own idea to spend some of your own time and money on it, you can’t expect anybody else to.


Mark Twain said, “I love progress. It’s change I don’t like.” That’s me. But, as physicians, we need to embrace change in order to get progress.

So, if you have an idea you just can’t get out of your head, reach out to an experienced entrepreneur and go for it — because that’s the kind of lasting change that our profession requires for the long term. OM

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