The 'provocative' developer of the problem-oriented medical record, Lawrence Weed believes computerized support tools mean better care
Medicine needs an iconoclast, and few serve better in that role than Lawrence L. Weed, M.D. Over a five-decade career, the Vermont physician has been called many things. Visionary. Controversial. Innovative. Anti-establishment.
"The word 'provocative' is what I would use," says healthcare-quality advocate Ronald Pion, M.D., a UCLA gynecologist and a special adviser on medical information technology to Galen Capital Group, a healthcare merchant bank.
"A lot of people didn't enjoy Larry's provocative style," according to Pion. "Provoking others to think is a laudable, laudable attribute."
As he has been doing for decades, Weed likens a physician without a computer to an astronomer without a telescope. "You use the computer as a reference but mostly as a processing tool," according to Weed.
"The task of knowing every detail is way beyond the human mind," Weed says from the Burlington headquarters of Problem-Knowledge Coupler Corp. (PKC), the company he founded in 1982 to develop clinical decision-support software. "The unaided mind does not know what data to collect, and does not see many of the significant relationships buried in whatever data are collected."
For example, Weed says that diabetes care ought to take into account any of 120 management options and 380 possible patient conditions associated with the disease.
"Needless to say, the unaided mind cannot reliably recall all the causes or management options that should be considered for each patient, nor can it recall all the findings in the patient needed to discriminate among those options, nor can it reliably match findings to options under the time constraints of practice," Weed said in a speech at the TEPR (Towards an Electronic Patient Record) conference in May.
|'It's not sufficient to just know what was done. It's a very incomplete record if we don't know why it was done.'
Â Lawrence Weed, Problem-Knowledge Coupler Corp.
Whatever names he's been called, Weed who created the problem-oriented medical record (POMR) and the subjective, objective, assessment, planning (SOAP) format of progress notes that has become pervasive in medicine remains true to his cause as he approaches his 81st birthday this fall.
Weed began developing the POMR in 1956 as a response to disorder in the myriad work processes in which caregivers find themselves. The SOAP note is the part of the problem-oriented record that helps explain the premise for medical decisions, Weed says. "It's not sufficient to just know what was done. It's a very incomplete record if we don't know why it was done"
Quite the Renaissance man, the learned Weed is fond of citing the work of Tolstoy, Copernicus, Galileo, and other theorists from across the ages, and he is prone to analogy. Drawing from the writings of 17th century philosopher Francis Bacon, Weed says, "You uncover a processing limitation with the human mind before you encounter a memory limitation."
He argues that education and licensing as practiced actually hinder care because physicians are given knowledge while in school and expected to remember it throughout their careers. "The medical schools are still living with the illusion that you can get everything in four years of lectures and four years in residency," he says. Just because a physician passes medical boards and licensing exams does not mean he or she can recall all possible problems associated with a symptom during a patient encounter, then link that information with each patient's unique condition, Weed argues.
Weed also likes to challenge the popular notion that physicians always know what is best for their patients. "It's ridiculous to think, 'That's my doctor. He knows,'" he says. "The patient, when he goes to the doctor, has no idea how many cards the doctor has in his deck."
The solution, according to Weed, is to empower patients with the help of information technology, specifically the electronic "couplers" he began developing in the late 1970s. Couplers essentially are computer-based engines that match specific medical problems to appropriate peer-reviewed medical knowledge.
"The coupler has become the perfect basis for discussion between the patient and the provider," Weed says. Couplers follow the POMR model of physicians interviewing patients and then correlating symptoms with knowledge in order to diagnose and treat the problem.
In other words, it's all about the inputs.
"When you use couplers, no two patients ever answer yes to all the same questions," Weed says.
Weed is a longtime critic of some types of evidence-based medicine because that approach often helps physicians make decisions based on the most probable correlations to a given set of symptoms not the distinct circumstances of each patient. "The unaided mind uses probabilities in direct proportion to its ignorance of the uniqueness of the situation," according to Weed.
PKC updates its software about twice a year. A relatively new release is a Web-based consumer version of couplers so individuals can screen themselves for possible health conditions from home, then discuss the findings with a doctor.
Longtime coupler user Charles Burger, M.D., a Bangor, Maine, internist who is a former student of Weed's, says the technology empowers nurses, physician assistants, and other midlevel providers to develop care plans, freeing up doctors to spend more time with patients. "If you have a nurse spending half an hour with a patient working through a diabetes management coupler, you can bill for that time," Burger says.
"The doctor right now is using up all his time asking questions of the patients," Weed explains. The consumer-focused coupler lets the patients provide the answers before the patient visit. "The dialog starts with all that done."
Weed does not advocate clinical IT just for the sake of automation. "There is no point in automating chaos," he says. "The electronic patient record will never amount to much if cognitive inputs to the record are left uncontrolled."
What is needed, he believes, is a national interconnected network for healthcare information exchange a concept that got a boost this spring when the Bush administration chose David Brailer, M.D., as the first national health-IT czar.
It's about time. Weed has been advocating the idea since Lyndon Johnson occupied the White House.
As Pion puts it, "Being early doesn't make you right. Larry has proven himself early and right many times."