Getting Into Dr. Weed

B. Dale Magee, MD Curator

Lawrence Weed, MD (1923-2017) was ahead of his time and set the table for the development of the Electronic Health Records that we are still perfecting today. The clinician-researcher noted in the 1960s that the medical record could become a vital tool in improving medical care rather than the burdensome afterthought it was treated as.(1) At the time, medical records were not created with an eye towards communicating details of clinical care and the thought process behind them. Rather, they often only included a notation that an encounter occurred, a notation of a diagnosis or procedure, a charge and whether or not the charge had been paid. Even with additional information , the handwritten records were often difficult to read (Figure 1). Weed also noted that for chronic conditions, a means of tracking the course of a condition was needed. He recognized that problems were often multiple, leading to complex decision making, remarking that having bright, hardworking, well educated doctors on staff was not adequate for delivering the best patient care in the modern era. Doctors also needed data specific to their patients combined with decision support to enhance their ability to provide care.

Starting in the 1960s Weed began a campaign to revolutionize medical records that was remarkably successful, particularly given the general lack of enthusiasm about the subject by rank-and-file clinicians. It began with the S.O.A.P. (subjective, objective, assessment, plan) format to progress notes and expanded to the Problem Oriented Medical Record (POMR), which added the structure of tying the elements of a note to

each patient problem and, in turn, tying the note to a problem list through a note title. With these innovations he enabled the linking of history, physical, lab data, plans and orders to a particular problem. This allowed for tracking outcomes as well as contributing to the knowledge base of clinical medicine. He eloquently presented this in an historic grand rounds in 1971 (https://youtu.be/qMsPXSMTpFI?t=1). Next in Weed’s evolution was the development of Problem-Knowledge Couplers—an early form of artificial intelligence that allowed clinicians to access up-to-date medical knowledge specific to patients (Figure 2).

Figure 1

All of this was initiated before personal computers, the Internet or widely available databases. Indeed, if we look at Weed through the lens of traditional academics, he accomplished a transformation with fewer than three-dozen articles published over fifty years, many of which appeared in second-tier journals or were interviews. (Weed preferred traveling to medical centers and delivering his message in person.) His publications and presentations were characterized by a crystal clear explanation of the problem with current records and the advantages of his proposed format, as well as a rather searing critique of the state of medical practice and education.

A quote from one of Weed’s interviews provides a look into his perspective and style. His emphasis on data collection and analytics was combined with an insistence that care be customized for the individual patient and that “one size fits all” guidelines did not work:

“EBM (Evidence Based Medicine) is based on a misguided use of statistical knowledge instead of the unique set of details from a given patient. A truly

EBM system could develop if evidence would be used to individualize care rather than standardize it.

Physicians are increasingly expected to apply knowledge derived from large population studies and clinical trials. Referred to as evidence-based medicine, this approach is rightly intended to prevent physicians from following arbitrary local practices and unsupported personal judgments. But this approach systematically excludes the individualized knowledge and data essential to patient care.” (2)

This perspective remains true today and shows how much further we have to go along the path that he started us on 60 years ago.

References

1. Weed, L.L. Medical records, patient care, and medical education. Ir J Med Sci 39, 271–282 (1964).

2. Jacobs L. Interview with Lawrence Weed, MD- The Father of the Problem-Oriented Medical Record Looks Ahead. Perm J. 2009 Summer;13(3):84-9.

Figure 2: Diagram of individualized Health Care Delivery and KnowledgeDevelopment Systems from Medicine in Denial by Dr. LawrenceL. Weed and Lincoln Weed.