When I started my practice in 1980, the word digitalization had not yet been invented or at least not firmly established in language. While letters for GPs these days are typed on computers and sent directly to GPs via mail or some other means, in those days they were typed on a typewriter and sent as physical letter. The typewriter had just become electric, i.e., you no longer had to hit the keys as hard as you did on the mechanical machines (which I still used in the beginning to type letters for GPs myself at home on weekends), but there were no screens on the machines yet. Secretaries, no matter how good they could type, naturally made mistakes. Because I wanted the letters to be sent error-free, they could correct errors by going back 1 letter on the typewriter, then push a piece of paper with Type-ex into the machine, hit the wrong letter again (which then turned white) and type the correct letter over it. What they also sometimes did was to whiten a letter with liquid Type-ex and then write over it with a pen. We kept our own carbon paper copies of the letters and they were often riddled with errors.

After a number of years, machines came out with a small screen on which you could see what you had typed. But there was some delay between typing and it being printed as single letters on paper. If you made a mistake and you saw it on the screen, you could go back something like 12 characters to still correct it. The first real personal computers didn't appear in hospitals until sometime in the first half of the 1990s, if I remember correctly.

Financial administration

The financial administration was also performed manually in the beginning. Back then there were 2 categories of patients: 'health insurance patients' and 'private patients'. For the first category, we sent the referral cards and completed forms for diagnostic and therapeutic procedures (mole removal, radiation treatments, allergy tests, etc.) in large envelopes to the various health insurance companies monthly. But we had to send our own invoices to private patients (the rates for 'private' at the time were much higher than those for 'health insurance'). During and after a consultation, I would write codes for procedures performed in the margin of the patients' medical files. Once every 3 months, we took all their statuses home over the weekend. There I would write the names and addresses of the patients and all financial data on a pre-printed invoice form, my father added up the amounts and wrote down all the data (patient information, invoice number, date, total amount) in a large cash book. Here it was also recorded who had paid their bill and when. When no payment was received after 4 weeks, we sent a reminder invoice, all manually, you will understand. If only automation had started a little earlier!

In 1984, the arrival of a first 'real' Personal Computer (PC) became reality and I bought an IBM-XT that year, one of the first 10 to arrive in the Netherlands. At that time, of course, I was much more youthful (33) and still modern.......

IBM-XT (image originating from Wikipedia)

With the computer, I also bought an A3 printer (for large sheets) and some software from Grote Beer ('Big Bear') company. All in all, it cost 18,000 guilders, equivalent to almost 8150 euros. So I had to reach into my pocket to be modern. The computer had a hard disk of, don't be chocked, 5 Mb, with you can't even fart digitally from nowadays. That hard disk cost five thousand guilders (2300 euro) so if you were unlucky enough to have it crash after a year and a day (which was not unthinkable at the time), you could put 5,000 guilders on the table. I had bought the computer mainly for printing out the invoices. It came with a financial program from Grote Beer and one could enter patient name, address, financial and other data into it and then everything was printed out on command (back then it had to be done with MS-DOS commands, whizzkid Bill Gates had not yet invented Windows) and we no longer had to write invoices. As an aside, it was a huge investment, but I quickly recouped the amount by printing out my book Patch testing. I suggest you read the amusing story about that.

Chain forms with a tear-off edge (sorry, this section is in poor English, I'm afraid)

Printing the invoices back then was done on chain forms, A4-sized papers that were joined together with a tear-off edge and that had a tear-off strip on both sides with holes in it. Those holes fit into protrusions on a spool in the printer, so the forms were propelled while printing. So there was a stack of blank forms on one side of the printer, which were then pulled to the printer, printed, and then pushed out again. Thus, on the other side of the printer there was an ever-growing pile of printed invoices. Next, we would then separate individual bills at the tear-off edge and then remove the

side edges. Now it was of the utmost importance to position the first form very precisely, in that the holes would fit  exactly over the protrusions of the spools, allowing the forms to be pulled and pushed in a 100% straigh line. If there was any deviation, however slight, the papers would run off the spools. And therefore I always had to stay with the printer during the printing process (which could take 7-8 hours), because if I noticed that the forms were skewing even a tiny bit, I had to try like hell to straighten things out, without tearing the paper, of course. Now you will say, 'then shut the case down, when you see this happening.' Logical thinking, but this was not possible: turning off the printer would mean having to start the procedure all over again, with invoice number 1, that is. Why? Well, back then we were only at the beginning of the computer and software age and it was all still very primitive. I can assure you that I had an awful lot of misery with Big Bear's software (I had several programs), sometimes I had to write them desperate letters begging them to help me!

Putting the invoices in envelopes

Well, when printing was completed, we still had to fold the invoices, put them in envelopes and lick them closed (well, we mostly used a moistened sponge). So still a lot of work. We had envelopes with windows, below which the address on the invoices wer visible. For a certain period of time, I don't remember when, the specialists had a quarrel with the health insurance companies, and then we had to make our own invoices for the 'health insurance patients' also and send them to these individuals, as we were used to do with the 'private patients'. As a consequence, sometimes we had as many as 1500 invoices every 3 months. Then I would take a Friday afternoon off and from about 2:30 p.m. or so started printing all invoices. The printer usually rattled on until about 1:30 in the morning before everything was redy. And all the while I had to stay with it to make sure the chain forms would not run off the printer. A nerve-wracking situation, I can assure you. Alas, on 2 occasions, after 5-6 hours or so, the paper did indeed run off the printer despite my efforts to control the situation and I had to start printing all over again. Horror. The next day, Saturday, my secretary and assistant would come to our house for the better tearing, folding and pasting, and on Monday we would take everything to the postal department of the hospital(s) for postage.

Sometime between 1990 and 1992, I think, the computer made its appearance in the hospital, automation came into play, and administration became a lot easier for us.

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