🏥 From Scrubs to Startups: Two Doctors taking on Healthcare's Tech Crisis ft. MayJuun | Ep.14

couple of my friends. We were colleagues or partners in crime a couple of years earlier, but we are all members of a flood of community right now and I'm excited to bring to you their story, their mission and vision for something super important in the healthcare world, both in the US as well as the entire world that they're trying to solve, and it is Their company is called May June. So John, doctor John Manning here is the CEO of May June and doctor Gray Fuckinberry is

the CEO of May June. So if about anything, I mean, they always inspire me because both of them are doctors by day and sometimes by night, and then the rest of the twenty four hours, they are technologists and hardcore technologists. I must say so a warm welcome John, and great to startups Bills. Why don't we kick it off maybe with John. You can go first and tell a little bit more about yourself and your journey of how you started off me.

emergency medicine physician by training. I teach medical students and residents how to care for patients in one of the Level one trauma centers in Charlotte, North Carolina, and have done that for almost a decade at this point, getting close to that point right before coming down here, like right around that time, I co founded May June with an interest in building technology solutions that focused on human factors, usability and just trying to make your life easier from

an end user perspective, the kind of short version of it. And we can go in depth if interested. But I used to be ascribed in a medical field in DC. I hand wrote notes helping emergency positions. Was there when we transitioned from paper to electronic saw the equivalent of twenty different health systems across med school, residency, fellowship, etc. And all with different levels of medical record integration and usability.

A lot of them had a lot of usability challenges, and my attempt to give back was in building tech solutions through made focus on that.

that so much of its virtual. You know, you don't have to be in the place where you practice, which is really nice and allows flexibility. And I there's a longer story involved, but I got into this from the global health perspective actually and looking at how you can sort of leverage technology abroad to improve healthcare.

this is a big problem. We've got to do something about it. I mean who started that? I mean, I'm sure both of you have to think about that vision and believe in it saying okay, we can do something to do it. But John, I know you started this and Gray probably joined later. So what did you tell the audience about? I mean, where is it that you noticed this? I mean, I know you said you were ascribed maybe there, but tell us more.

It leads to burnout, so it's everywhere. The specific path that led to May June, interestingly was as a resident in Emergency Medicine, I pitched an idea to the first ever Emergency Medicine hackathon at their national conference. Got the grand prize, got a bonus phase prize, and an opportunity to speak at a public health summit in part of the keynote in Illinois. So we built an app that was based on the hackathon idea. Wrote it in Java's first time that we'd ever written any sort of code.

It was a Java developer friend of mine who had not written anything in Android before, neither had I. He lived a few months away or a few blocks away, and the better part of my final year of residency

training was building this application. All through fellowship, got a lot of opportunities to work with other startups and do a bit of mentoring and working with a group called Matter, a health tech incubator, and time unfortunately broke a little bit of the app, and when we were trying to think through am I going to do this in Cotland? Because Cotland is new. Am I going to switch over? Am I going to just update this in Java? That was almost exactly the time that Flutter was announced, so

December of twenty eighteen. The next month, I was in Boston giving a live coding session, handshaking for five minutes, showing how you can really make this because it just fell in love with Flutter. A few months later, it was a big informatics conference at their annual symposing or their clinical Informatics conference, and in two hours introduced Flutter and live coded how to create the conference's app in

real time while just talking and writing code. And one of Gray's predecessors, his co fellow one year ahead of him, tap through that conference. It was like seventy eighty people in that two hour event. And when he joined Informatic like that Informatic fellowship a few months later, he was interested in global health and maybe Android or you know, trying to build and develop for this, and she looked at him, she was like, well, why don't you just

look into Flutter? And he started looking into this, and there was a shared Slack channel with a lot of Informatic fellows that were going through this new training, and we started collaborating, collaborating every day or slack over years and started building these solutions that would then allow other people that are in and around the health tech space to use the standard for interoperability FIRE within Flutter applications, and much of that goes to Gray and all of

the time and effort that was spent in this, I was I just make apps and Flutter and I live code and I can talk and you know, it's the emergency medicine brain. I can talk and write code at the same time, you know. And that's my thing. But a lot of that underpinning and architecture that's open source and has been used by developers a lot across the world that goes with many things to correct.

I mean you are perfect examples for that, right. But how did that love for even technology come in to both of you? I mean, obviously you need a spark within you, you need that push within you to say, Okay, this is not something that I can outsource to a company and say build it. I want to do this myself, right, I mean, how did you sort of make that choice great to say okay, I mean, you guys want to be you know, getting your hands and feed wet with building this whole thing.

the time it was exciting. I was looking forward to it because again I like technology, and at the time it seemed mostly good you know, the not having to fight for the chart, having one chart for a patient, having eight people trying to look at it. You know, you didn't have to worry about that anymore, having to walk across or down fifteen floors and across campus to write an order and a chart. You could just put

it into the computer. So there were some really nice things about it, and then there were a lot of not nice things about it. It was obvious that, as John said, the usability was not a sort of forefront in anyone's mind. You know, with the design of these and any sort of study or survey done on physicians

now you'll see that. You know that there is burnout, and so you work with that long enough and it becomes a source of frustration because it really felt like the people who designed it hadn't ever seen a patient. And that was probably true, you know they and you really need to understand the workflow. You need to understand how it feels and what you need and how it should be organized to take care of, you know, a patient.

And I think what drove a lot of us into informatics is the feeling that we want to be involved in this, We want to help make this better. This is something. This is a skill set that we feel like we have and we can develop and we can actually contribute and sort of change things for the better. So much of medicine is already sort of set in place, and there's there's so little opportunity to sort of change any of it. But informatics, I think is different. It

is still new, it is still changing. It is a lot of it is sort of set, but a lot of it's not, I think enough of it's not that we can sort of affect that change. And I think that's what's exciting about it is the feeling that I actually have the ability to hopefully, you know, help medicine and healthcare be provided in a better way through technology, you know. And that was sort of how informatics I think, came into my life. Yeah.

a thirteen, but you're missing a whole number. And since we've all learned it this way, I'm sorry you have to learn it that way too, even though it makes no sense. Welcome to healthcare. Here's a chance where we can actually build things that match the workfload that's there. To Gray's point, if you don't see it, if your brain isn't literally into the weeds, and it's not there's one thing to be shadowing somebody who was doing this, there's another where you were putting all of your cognitive

effort and load into the care of a person. So you don't make those mistakes, and so that you know, medicine always has mistakes, but so that you minimize that and yet you allow for the right processes and everything to help. Well, if you have a very expert, complex system that's pulling all of your attention away, you're gonna get distracted and things will happen, and it's you know, it can lead to it can lead to harm.

room with a fifteen year old by himself, with mom or dad not nearby, as he is individually swallowing almost forty pills. There's a lot to it. So any ways that we can improve that medical perspective I think is helpful.

extremely hard. You have to fill out release sheets and they have to often fax them over the fact that facts comes into conversation at all anymore is ridiculous, but it does in medicine all the time. You know, I regularly get two hundred pages of faxes of someone's medical record from another hospital, you know, trying to take care of it, because medical records don't share data very well.

And then about not quite fifteen years ago now, there was a standard that started being developed called fire Fast Healthcare Interoperability Resources in order to share it. And again that's a big deal because just having that information is so important. So the ability to easily share healthcare data you know can is not just a convenience issue, it's it's a safety issue. If I don't know what medications someone's taking and I give them something that interacts that

obviously can be incredibly dangerous. You know, I don't need to do certain tests if I know that they were just done somewhere else. And so having the ability to more easily share that data from place to place is incredibly important. And I think it helps both from sort of again a frustration and a time sort of commitment, as well as a pure safety issue. And that's something

that again we've we've sort of touched on. As John pointed out, we both sort of lean slightly different directions on this, but again trying to make electronic records that work better for the people involved. So we want to be able to share data, We want it to work well, we want it to be easy to use, you know. And and so I think both the sharing of the data and the usability can't be overstated about sort of how important those aspects are.

beyond what was there before before the Fire standard. What kind of happened through all of this sorefly Fire with Flutter Library Integration FLI, where the packages that Gray had developed over the course of his fellowship, which is about ten million lines of code total three million lines of dart. A lot of it's auto generated, but in a way that allows you to use any published version of fire that also goes through all its test cases and then

directly put this into your Flutter application. And that Android equivalent of this is open heal Stack by Google for Flutter. If you're building a Flutter app, you should use the Firefly packages. So you know. To Gray's point, so he's a medicine pedes trained hospitalist, so he cares for patients

when they're admitted to the hospital, adults and children. Practiced in eight countries, spend a year in Uganda, wrote the textbook on pediatric care in that setting, and has a very high global health focus of trying to help in areas that are very resource limited. My background is emergencies.

I care for emergencies. I did MS things and a lot of the things that come around me as an emergencies and disasters, and how can we improve in those cares, those care settings that are unscheduled and where a lot of people are afraid, And both of them have opportunities to improve in rural areas as well as global. So to your point that you had mentioned earlier, Anthony, of what was our story, well, we both had a shared interest of building things to help in healthcare from usability

perspect with a mobile first approach. Then collaborated on the Firefly packages, reached out to the Office of the National Coordinator. The actual National Coordinator at the time was Don Rucker,

who we got through other members of Nyjune. They had connections and here we are in front of the ONC talking about Firefly and how cool this is, and they said, look into social help like social care areas, and so that is where we built screening tools to help with social need and multiple states and multiple languages, and we're still on the Gravity Projects. Main page is their success story,

which is wonderful and cool. But you know, as clinicians, we're always trying to see how best we can apply this in a way that helps in rural, underserved and in global areas.

do with data collection. You know, they are validating it behind the scenes, so you know, just as a patient myself or you know somebody who I've seen, even in the children's hospitals, great, right, I mean when my daughter was young, I mean, you know, she'd be running very high temperature and you go there, they make your sit for forty five minutes, right, I mean why because you're still collecting data. So in that sort of a let's say, I mean you don't want to call it life threatening,

but it's still an emergency. Is there something that you know? Using fire in May June, I mean you can simplify that process to accelerate the time to which by the time you walk in through that door, a doctor is able to see you at least within fifteen minutes or so. I mean, you know, if sixty minutes is too much, at least cut that down by yeah, you know, seventy five percent.

But trust me, the very very like near death patients and severe traumas and medical and traumatic resuscitations, they're seen really fast. It's not sixty minutes. And there are workflow tools where you can even register a patient without any information quickly, be it medical or trauma, so that you can give them medication and treat them and get do an ultrasound or get some X rays or something at

the bedside to help them. All of that stuff has its own workflow in American medicine that uses the electronic medical record and the use of majune technology probably isn't as relevant there if you look in resource limited scenarios. So another example, I helped with some of the hurricane relief efforts in western North Carolina where it was multiple groups together and some of us were using paper and

some of us were using another technically medical record. That will also wasn't really designed by a clinician, and it was clear that there were a lot of opportunities to improve with that. That's a place where we can inject and help and where we have the skill set and the expertise and the domain knowledge to improve in those settings. And we've had conversations with groups that were interested and

our services from there. So from the over arching perspective of you know, just emergency medicine care, usually it's going to be in the low resource or disaster response or international area where we can improve rather than the traditional brick and mortar emergency department. But medicine always changes, you know, if we build something and then it expands and then

it continues to expand. And that's right up both Gray and my alley of ways that we can improve in areas that also build on the background expertise that we have.

it is actually spent talking to a patient. And so I think using technology, including some of the June you know, questionnaire data gathering, structured data capture sort of stuff, a

lot of that could be done beforehand. And so if you have a fifteen or a twenty minute appointment, or you know, whatever John has available to be able to see you in the emergency room before the next trauma, you know, instead of spending all that time or the bulk of it trying to gather all your information, make sure that we have all of your medications correct, that

we know all of your history. If that can all be shared or gathered more efficiently ahead of time, then we can sort of review it quickly and then we can spend more time talking to you. We can spend more time ensuring that we didn't miss anything that's important. We can ensure that you understand the plan, and so the time that we do spend with you can be actually spent with you and so sort of caring about what the problem is instead of just asking you a

whole lot of questions. And so I think there are some ways, even in sort of a traditional setting where you know, we could be beneficial that. Again, I think there's lots of opportunities to sort of improve that.

literacy and then help explain and work through that. And the other point from Gray is if you've ever seen there's a twenty twelve article in Jamma called the Cost of Technology by Toll and it was a drawing of a seven year old in their pediatricians clinic where you know, they're smiling, Mom's smiling, big sisters holding baby child like baby sibling. Everybody's smiling. Then the doctor is smiling but has their back turn and a staring at a computer.

And this is over thirteen years years ago when that was done, and it's still relevant today.

And that's sort of what sold me on Flutter because, as John said, one of my colleagues said, well, she had seen this talk about Flutter. Maybe I should look into it. So I did, and I got on Slack and I started working with John. And the punchline to his story was that it was about two years later when I realized that the speech my colleague had seen was given by John that then got that, then got the end of flu. So it was yeah, it's a full circle.

that part is super helpful. So shifting years a little bit, John and Greg, obviously you started May June with a vision, right, how much of that have you achieved? And what are the next couple of years looking like for you? Guys with May June, either of you can take it.

So a good example of the first thing we built was for any MS agency that had protocols to help in rural areas that the initial the content was excellent, that was something they built and curated, but the delivery needed help, and so we helped and you know, we

continue to help and support them for years. We're always building, and we're always doing this in a way that can scale into other solutions and can apply some of the backgrounds and experiences that we have as as practicing clinicians and informatis and we have other informatics clinicians that are a part of MADE as well, and in addition to

more tech first people as well. I think for us, we're always trying to find that best opportunity where we can have the biggest impact on the broadest scale in a way that pushes things forward in a good way. And I think that's always where we've strived. And so are we there yet? I'll say no, Are we always going down that path?

sort of finding where we wanted to be. You know, We've done you know a number of different projects in a number of different places, sort of in and sort of slightly out of healthcare, always intertwined, you know, And so I think we're we've sort of found our niche and sort of where we want to be. And I think that's again it's sort of exciting, and a lot of times it's places that other you know, groups don't

want to go. And again, sometimes there's a lot of times there's a monetary barrier to it, you know, whether it's sort of rural areas or low resource settings or disaster relief one of the ones that that again John brought up earlier. You know, these are all really important to have good health tack tech stacks for if you're going to actually collect data and be able to show what you're doing, you know, who you're treating. You know,

it's important to be able to record all that. It's really hard, though, but I think you know a lot of that fit what our interests and what our passions are and our knowledge and our expertise, and so I think we're sort of excited and looking forward to being able to use you know, who we are and what we want to do it, you know, even more effectively as we move forward.

Or the other trend I've been hearing about is you know, taking the hospital to the home, right, I mean, if there's critically ill patients, I mean, you're moving a lot of equipment into the patient's house and still collecting data and things like that. Are there's a lot of you know, devices that the patients can carry home, but as a doctor,

you still want to collect all that information. So looking at some of these new trends, I mean, what are your thoughts on you know, how May June will evolve. Obviously you would have given that thought. I mean I second, maybe a second part of the question is, I mean, how much of AI have you actually tried to bring into the whole tech stack and try to do something with it.

they're totally different buckets. So let's take the first bucket. So, first one, I've given local talks, given talks at Amya about this, and I've tested this and I also co chair our service line Innovation and Informatics group with an Atrium, and we've tested this from the very beginning and with frequency, there is a difference between So as a scribe, you mentioned this, there's a difference between a good scribe and a bad scribe, and a good scribe speeds you up.

A bad scribe has things interjected that gives you almost twice the amount of time that you would be using otherwise. Tech always changes. Even a year ago, there were a lot of bad scribe ambient dictation tools out that a lot of it's improved even in the last eight months.

And if you want something to look at, there was a AI tech sprint from the VA, the Veterans Administration that was hosted at the start of this year and then announced early Q two, and if you just search for the AI tech sprint within the VA, you can see some of the companies that were well embedded in that perspective. I think ambient dictation is going to have a high opportunity to help clinicians caring for patients, albeit

in limited resource settings. That's going to be a challenge still, just because all of these need a lot more cloud services of a level to them, So that's going to be your mileage made very depending on where you practice, but there's definitely opportunity. The other aspect for decision support

from the clinician's perspective, I think is great. What used to be called clinical decision support is now being rebranded by the ONC as a decision support Instrument, which includes AI and also requires you to have to get past that black box of where did this algorithm come from? Is this actually a hallucination?

essentially your own personalized pair programmer. I think is really useful if you have at least a basic understanding of the tech that you're trying to build in. It's not going to supplant your knowledge and information, and you have to work through some of the suggestions that are high confidence and low accuracy, otherwise your code will suffer from that.

But there's really a lot of opportunities as you're building to help speed that up, and time has shown us that as well as from the perspective of the clinician as you're caring for patients of the bedside.

the world doesn't speak English as their first language. And so if you can't write a research paper in the proper pros, your research is not going to be a to it, just even if it's high quality and so, but having AI help you write a research paper, you know where your research and your methods are sound, but because you may struggle with English, you can't get it published. That's a barrier to entry that shouldn't be there, and AI might be really helpful for, you know, to help

you with that. One of the ones we were actually looking at was sort of what John was talking about, where you teach people some basic data science and then use AI to help you know, analyze your data. You know, there's lots of places where they don't have people that can do it themselves, and sort of AI can help with that. And so I certainly think AI has a good role to play. I think you have to be really careful with it. I think that most AI, especially

in a healthcare setting, is untested. I think implementing a technology, you should study it. We do with all the rest of the technology, and yet AI I don't think is undergoing the same sort of you know, scrutiny, which again I think is going to have some difficulty and some problems that it's going to introduce. It has to be

trained on something. Lots of the old healthcare data is not great and a lot of it's biased, and I think that's the other thing to really be cautious about is that if you're going to train on it, we know AI tends to amplify sort of biases and data, and so you have to be really cautious. I think using AI for especially for decision making.

How much of adoption have you seen here? And I know for a fact that, I mean, you've tried to take this outside of the Americas as well to some of the countries. Who is using whether it's Firefly or the overall stack in general, who is using it today?

we always want to move the needle forward. We're not trying to train up other people that then immediately directly compete with us. But for Firefly, we want this to be useful for everyone. That is a core package that everybody needs to have and that will always be open source, you know, through the duration that we're supporting, and it needs to be like that.

Now it's actually the WHO is creating smart guidelines that it's going to be used sort of around the world, which is based on Open Health Stack and Android SDK, And again we're not competing with them where there's no reason too, there's lots of work, but we want sort of a parallel option because again we see the value in Flutter and being able to create something that could then be used and implemented again sort of based on

WHO guidelines. And that's again the sort of thing where we're not We don't want to keep it to ourselves. We want to share it. We want anyone who's interested or available or wants to try it or or you know, work with it, develop, you know with it. We we want to encourage that.

the next, one year to the next. We're always happy to work work together and to collaborate.

a bunch of questions I'm sure you can answer. But thanks so much for taking the time amidst your busy schedules, lovely to speak to both of you, and I learned a lot. Hopefully everyone listening in and tuning in learns a bunch as well. Thank you so much.