Lawrence Weed Research Articles

For Whom the Note Scrolls: A Brief History of the Medical Record's Role in Education and the Risks It Faces in the Age of OpenNotes.

Dating back to ancient civilizations when records were carefully transcribed onto papyrus, clinical documentation has long served as a cornerstone of medical-and especially neurologic-education. From the case histories of Hippocrates to the diurnal patient logs used by trainees in the 18th and 19th centuries, clinical notes have an extended history as invaluable instruments of pedagogy, scholarly practice, and interprofessional communication. The novel paradigm introduced by Lawrence Weed in the 1950s, advocating for the problem-oriented medical record system, revolutionized the clinical note template and emphasized the need for physicians' carefully considered analyses of a patient's presentation to be clearly reflected in well-organized documentation. In the realm of medical records today, however, a profound shift is underway, largely propelled by the emergence of electronic medical records, the OpenNotes mandate of the federal 21st Century Cures Act, and, most recently, artificial intelligence (AI). Appropriately, patients now have full access to their medical records, but this raises critical questions. Should clinical notes now prioritize patient comprehension over their traditional role as educational instruments, aide-mémoire, and repositories of detailed assessments and insights? What role, if any, should AI have in the creation of physician notes and patient-facing clinical documents? These tensions underscore the delicate balance between transparency and the preservation of notes' clinical integrity and analytical depth. As we navigate the path forward, finding an equilibrium between openness and the continued utility of medical records as tools for education and professional communication will be imperative.

The patient record and the rise of the pediatric EHR

Medical documentation arose as individual case reports written for teaching purposes. Documentation for patient care later occurred in physicians' personal daybooks and only evolved into the individual patient record in the early 20th century. Dr. Lawrence Weed improved the utility of the patient record by introducing a problem-oriented/subject-object-assessment-plan structure and he and other innovators transformed the patient record into electronic form. Pediatricians built on these innovations to create a child health electronic health record (EHR) for primary care. An American Academy of Pediatrics task force formally specified the child-specific needs of the EHR, but much work remains to integrate the EHR into the pediatric primary care of the future.

Registo médico orientado por problemas em medicina geral e familiar: atualização necessária

Medical records are a key component of health care delivery. In family practice, the preferred approach to structure medical records is based on the method proposed by Lawrence Weed’, the ‘Problem-oriented medical record’. It is generally accepted that the ‘Problem-oriented medical record’ comprises three components: baseline data, progressive clinical notes and list of problems. Nevertheless, there is a lack of standards on how to use these sections and, in Portugal, the bibliography on the use of ‘Problem-oriented medical record’ needs updating. This document aims to synthesise and compile the information available, revisiting Weed’s method for practising family physicians and supporting pre- and postgraduate training.

An Alternative Paradigm for Evidence-Based Medicine: Revisiting Lawrence Weed, MD's Systems Approach.

Lawrence Weed, MD, is renowned for being the father of the Problem-Oriented Medical Record (POMR), the medical care standard for collecting, managing, and contextualizing patient data in medical records. What have been consistently overlooked are his teachings on knowledge coupling, which refers to matching patient data with associated medical knowledge. Together, the POMR standard and knowledge coupling are meant to form the basis of a systems approach that enables individualized evidence-based decision making within the context of multimorbidity and patient complexity.The POMR and knowledge coupling tools operationalize a problem-oriented model that reflects a sophisticated general systems theoretical approach to knowledge. This paradigm transcends reductionist approaches to knowledge by depicting how the meaning of specific entities (eg, disease constructs) and their associated probabilities can only be understood within their respective spatiotemporal and biopsychosocial relational contexts. Rigorous POMRs therefore require knowledge inputs from a network of interconnections among specific entities, which Dr Weed enabled through development of the Knowledge Net standard. The Knowledge Net's relational structure determines the applicability of knowledge within specific patient contexts. To enable the linkage of unique combinations of data in individual patient POMRs with existing medical knowledge structured in Knowledge Nets, Dr Weed developed the Knowledge Coupling standard.Dr Weed's standards for record keeping and knowledge coupling form the basis of a combinatorial approach to evidence-based medicine that fulfills Stange's call for a science of connectedness. Ensuing individualized processes of care become the dynamo powering a learning health care system that enables a co-construction of health premised on empowerment and intelligent human decision making, rather than promoting the artificial intelligence of tools. If the value of Engel's biopsychosocial model indeed relates to "guiding the parsimonious application of medical knowledge to the needs of each patient," Dr Weed's approach warrants serious consideration.

Determinants of a successful problem list to support the implementation of the problem-oriented medical record according to recent literature.

BackgroundA problem-oriented approach is one of the possibilities to organize a medical record. The problem-oriented medical record (POMR) - a structured organization of patient information per presented medical problem- was introduced at the end of the sixties by Dr. Lawrence Weed to aid dealing with the multiplicity of patient problems. The problem list as a precondition is the centerpiece of the problem-oriented medical record (POMR) also called problem-oriented record (POR).Prior to the digital era, paper records presented a flat list of medical problems to the healthcare professional without the features that are possible with current technology. In modern EHRs a POMR based on a structured problem list can be used for clinical decision support, registries, order management, population health, and potentially other innovative functionality in the future, thereby providing a new incentive to the implementation and use of the POMR.MethodsOn both 12 May 2014 and 1 June 2015 a systematic literature search was conducted. From the retrieved articles statements regarding the POMR and related to successful or non-successful implementation, were categorized. Generic determinants were extracted from these statements.ResultsIn this research 38 articles were included. The literature analysis led to 12 generic determinants: clinical practice/reasoning, complete and accurate problem list, data structure/content, efficiency, functionality, interoperability, multi-disciplinary, overview of patient information, quality of care, system support, training of staff, and usability.ConclusionsTwo main subjects can be distinguished in the determinants: the system that the problem list and POMR is integrated in and the organization using that system. The combination of the two requires a sociotechnical approach and both are equally important for successful implementation of a POMR. All the determinants have to be taken into account, but the weight given to each of the determinants depends on the organizationusing the problem list or POMR.Electronic supplementary materialThe online version of this article (doi:10.1186/s12911-016-0341-0) contains supplementary material, which is available to authorized users.

Development and significance of automated history-taking software for clinical medicine, clinical research and basic medical science.

Development and significance of automated history-taking software for clinical medicine, clinical research and basic medical science.

Reconciling evidence-based medicine and patient-centred care: defining evidence-based inputs to patient-centred decisions.

Evidence‐based and patient‐centred health care movements have each enhanced the discussion of how health care might best be delivered, yet the two have evolved separately and, in some views, remain at odds with each other. No clear model has emerged to enable practitioners to capitalize on the advantages of each so actual practice often becomes, to varying degrees, an undefined mishmash of each. When faced with clinical uncertainty, it becomes easy for practitioners to rely on formulas for care developed explicitly by expert panels, or on the tacit ones developed from experience or habit. Either way, these tendencies towards ‘cookbook’ medicine undermine the view of patients as unique particulars, and diminish what might be considered patient‐centred care. The sequence in which evidence is applied in the care process, however, is critical for developing a model of care that is both evidence based and patient centred. This notion derives from a paradigm for knowledge delivery and patient care developed over decades by Dr. Lawrence Weed. Weed's vision enables us to view evidence‐based and person‐centred medicine as wholly complementary, using computer tools to more fully and reliably exploit the vast body of collective knowledge available to define patients’ uniqueness and identify the options to guide patients. The transparency of the approach to knowledge delivery facilitates meaningful practitioner–patient dialogue in determining the appropriate course of action. Such a model for knowledge delivery and care is essential for integrating evidence‐based and patient‐centred approaches.

Defining the Process of Medical Care to Include Dual Situation Awareness between Patient and Clinician

Directing design of information & communication system in healthcare according to the workflow in the doctor patient relationship might follow established concepts from the field of Human Factors. The Endsley model of Situation Awareness is modified to accommodate both physician and patient, and recalls the Problem Oriented Medical Record of Lawrence Weed. Although the original purpose of computer health applications was documentation, the goal of shared Dual Situation Awareness and improved shared decisions is offered as an alternative to record-keeping. Also, design with these concepts may provide a pathway to enhanced patient engagement in their health care.

The Use of Problem-Knowledge Couplers in a Primary Care Practice

In the Summer 2009 issue of The Permanente Journal, Lawrence Weed, MD,1 outlined the philosophy behind the development of the problem-oriented medical record and the subsequent development of the clinical decision tool called problem knowledge couplers. In this article, I describe how my associates and I have integrated the use of problem knowledge couplers into our Internal Medicine practice.

Interview with Lawrence Weed, MD- The Father of the Problem-Oriented Medical Record Looks Ahead.

I first met Lawrence Weed, MD, in 1972 when I was a third-year medical student at the University of Vermont. To this day I remember his passion for a disciplined approach to medical record documentation to optimize the care provided to each individual patient.Now, 35 years later, I was privileged to meet with Dr Weed at his home in Vermont. We discussed when he first was alerted to the nonscientific approach clinicians use to make decisions on patients. The rest of the interview time was spent with Dr Weed teaching me about the solution that he has spent the last 30 years designing and implementing.This interview is published to complement the editorial in the most recent issue of The Permanente Journal (Spring 2009;13[2]:85-7). We believe that in the era of health care reform and quality improvement initiatives, it is important that the medical community take a close look at Dr Weed's total approach decision-making information support defined in this interview.- Lee Jacobs, MD.

Attaining Comprehensive Health Care Improvement is Imperative

How about sitting with Lawrence Weed, MD, and Donald Berwick, MD, in the same week? Granted my time with Dr Weed was one-on-one for three hours in his living room in Vermont and my time “with” Dr Berwick was as part of an audience of 6000 attendees at his National Forum on Quality Improvement in Heatlh Care in Nashville, TN (December, 2008). I felt privileged to listen to the journeys of these two men who have had such a dramatic effect on how medicine is practiced today. Dr Weed and Dr Berwick have much in common. Both have a passion for and a vision of how to improve health care. Both have played major roles in improving health care over the past few decades. Both are pioneers and as such have for years endured the criticism of their skeptics and the accolades of their followers. Both are leaders of significant movements that have and will continue to affect health care in the US and around the world. Both provide real solutions to waste in health care. And, most importantly, both want to increase the likelihood of a positive outcome for each individual patient encountering the health care system while at the same time lessening the chances of being harmed. During my time with these two physicians, I heard both describe with similar language the state of disrepair of our present health care system; however, I found neither was pessimistic about the future. I was struck by the can-do attitude voiced by both—the problem is huge but there is a solution and they optimistically believe it can be attained. In leaving their mark on how health care is practiced, however, these two physicians have taken two very distinct paths on their journey.

The Electronic Medical Record: Medical Records That Teach Communication Skills

In 1985 we began developing a hospital information system (HIS) at the Veterinary Medical Teaching Hospital (VMTH) at University of California, Davis. We wanted to provide easy and timely access to medical, surgical, laboratory, radiographic, demographic, and financial information in a patient-oriented, integrated format. In the course of its development, the HIS expanded to include pharmaceutical and supply information as well as images, clinic schedules, and evaluations. The HIS has become a management tool for hospital services such as pharmacy and central supply and a support tool for administrative functions, including clinical service schedules and performance evaluations of students and residents. The HIS is now a comprehensive computerbased system that provides the information we use to care for patients; teach students and residents and evaluate their skills, knowledge, and professional attributes; perform clinical research; support continuing education and service to the community; and administer the hospital. The core of the HIS is the patient-oriented electronic medical record (EMR). Besides serving the traditional function of the patient record as a repository for all-important patient information, the EMR is now a primary tool for teaching critical thinking and communication skills to students and residents. Evoking the vision of Lawrence Weed, it has become a medical record that teaches.

Resistance to computer innovation

Dr. Lawrence Weed's "knowledge coupling" (KC) computer innovation (Weed, 1991; 1997; 2000) is designed to overcome the widely documented limitations of the human mind. By linking (or "coupling") patient-specific findings with relevant medical knowledge, KC tools exploit the power of the computer to reliably recall, process, and organize vast quantities of medical knowledge and information that would otherwise be missed during the clinical encounter. Further, KC tools offer an alternative strategy for managing clinical uncertainty, which also entails relinquishing personal responsibility for patients and decision making. Previously-learned orientations toward uncertainty and responsibility predispose physicians to resist this alternative strategy. Existing orientations are sustained by the broader institutional framework medicine. Nonetheless, changes in the institutional framework --- namely, greater patient participation in decision making and growing interest among third-parties to regulate medical care costs and quality --- will likely make it more difficult to sustain current orientations to clinical practice and will instead produce conditions that are more favorable to the widespread use of KC tools.

What has Changed after Dr. Lawrence Weed’s paper in 1968?

What has Changed after Dr. Lawrence Weed’s paper in 1968?

Rationalizing Medical Work: Decision-Support Techniques and Medical Practices

Reviewed by: Rationalizing Medical Work: Decision-Support Techniques and Medical Practices* Marcia L. Meldrum (bio) Rationalizing Medical Work: Decision-Support Techniques and Medical Practices. By Marc Berg. Cambridge, Mass.: MIT Press, 1997. Pp. x+238; illustrations, figures, notes, bibliography, index. $30. Marc Berg undertakes in this very interesting volume to analyze the application of decision-support tools—computer-based support systems, protocols, and clinical decision analysis—to medical practice. In doing so he raises several interesting questions about the nature of medical diagnostic and therapeutic practice and about the use of computer-based and other “rationalizing” technologies in contemporary work and culture. Berg begins with an incisive discussion of the post-World War II medical literature, tracing how arguments for the use of decision-support tools were developed, supported, and critiqued. His demonstration that each tool was shaped by a particular concept of what “science-based medicine” is, or should be, is well reasoned and provocative, and prompts the reader to reexamine what we understand by scientific practice. The central section of the book considers the construction and implementation of several decision-support tools: a triage aid to help nurses decide which chest pain patients should be admitted to the coronary care unit, a computer program for the diagnosis of abdominal pain, a research protocol for an experimental breast cancer treatment. Based on these examples, Berg argues that structured, rationalized aids are usually transformed in practice by a variety of logistical, organizational, and value-based factors—staff skills and hierarchies, variations in patient presentation financial criteria, ethical questions, among many others; that where decision-support tools succeed, it is after the practice site is “disciplined to a formalism” (p. 79), that is, where structures are introduced or reinforced to support the tool’s operation; that this mutual transformation of tool and practice site by each other is highly localized in space and scope—and must be replicated and readjusted if the tool is introduced in another setting; finally, that even where the tool is successfully adapted for regular use, doctors and other staff routinely support, adjust, and retransform its operation. The tool and the practice in this way “co-produce” each other to form a new adaptive hybrid. In Berg’s view, both advocates and critics, wedded to prescriptive views of how decision-support tools “are supposed to work” or not to work, fail to understand the nature and potential of the way they actually do work. Berg’s argument is intelligent and well researched through interviews, practice observations, and reading of the literature. It is probably my historian’s bias, but I think the book might have been stronger if he had placed more emphasis on his unique material and slightly less on the theoretical discussion, which, as he notes, complements and extends analyses of scientific [End Page 719] practice and work by contemporary anthropologists and other scholars—Bruno Latour, Donna Haraway, Susan Leigh Star. His many interesting statements about the flow of medical practice, its embedded assumptions, and the work done to incorporate tools are supported with concise observations drawn rather disjointedly from his several cases, supplemented by only a few complete narratives showing us the internal processes. Particularly after the author tells us that very few tools have been introduced in more than a single site, or remained in permanent use, the reader is forced to question whether his model has reality only in localized instances. One tool that might have received more intensive analysis is the use of the problem-oriented medical record introduced by Lawrence Weed, which has been almost universally instituted, at least in the United States, and which Berg discusses in his review of the literature, but to which he fails to return. One of the principal technologies examined is the breast cancer research protocol. As Berg points out, research protocols are widely used and highly structured. But they also present a different rationale from decision tools introduced into established clinical practice. A research protocol carries with it the implication, often the promise, that existing rules and routines will change. This implicit assumption does not invalidate Berg’s model of “co-production,” but its operation will be different than in the other examples...

Gene Therapy and Pharmacy Practice: Part 1

The holy grail of clinical medicine is the ability to assimilate the ever-increasing volume of medical knowledge and apply that knowledge to detailed patient data without error or omission. But can even the best of us achieve that goal with consistency? Dr. Lawrence Weed argues that all of us can by rigorous use of properly designed software tools. Those tools identify detailed patient data for a given medical problem, and then couple the data with comprehensive medical knowledge. The tools developed as an outgrowth of his earlier development of the electronic problem-oriented medical record. He believes it can transform not only medical decision making but also medical education, credentialing, and the development of medical knowledge itself. Some of us will disagree with the scope of Dr. Weed’s vision for the information tools that he has developed. Most of us, however, will agree with his premise that reliance on the physician’s unaided mind is imperfect. Read on for a medical odyssey into the future of computers in medicine.—Editorial Comment by Machelle Seibel, M.D.Caregivers are constantly trying to organize their collective efforts in a way that serves the needs of individual patients. And patients themselves seek active involvement and control in their own care. Disorder in medical practice frustrates achievement of all of these goals. Escaping that disorder requires using information tools designed for two purposes: (A) combining patient data with medical knowledge more effectively than the unaided human mind permits, and (B) organizing the multiple processes involved in patient care.

Why SOAP Is Good for the Medical Record?: Another View-Reply

<h3>In Reply.—</h3> We thank Manning, Di Poala, Payne, and Singer for their comments. Their negative reactions to our proposal¹are not surprising. The problem-oriented medical record (POMR) has become something of a sacred cow in academic medicine. Proposals for substantive changes in the POMR are thus likely to elicit strong reactions. Lawrence Weed's original proposal for reform of the medical record also encountered vociferous objections. The medical record is already changing in subtle ways that few people are objecting to or even noticing. Much of the record now functions as an annotated bill prepared for third-party payers. This can have the chilling effect of making our patients appear sicker than they are, as physicians strive to add enough pathologies (and ICD-9 codes) to justify the hospital and physician services the patient is receiving. We need to think about ways to reclaim the chart for the patient. Calling what the

The Computer-Stored Medical Record

To the Editor. — The article by McDonald and Tierney 1 concerning computer-stored medical records has a significant omission. Nowhere is mentioned the philosophical and technological landmark effort of Dr Lawrence Weed with the computerized problem-oriented medical information system (PROMIS). Under the leadership of Dr Weed at the University of Vermont from 1969 through 1981, PROMIS demonstrated the prototype integrated computer-stored medical record. 2,3 It was funded primarily by the federal government, to the tune of more than $10 million. The PROMIS system was developed from the perspective of the patient, focusing on medical care delivery problems in coordination, logic, memory, and feedback, problems that still remain basically unsolved today. The entire medical record was on-line, most of it as coded text entered through branched logic pathways, using a defined, unified medical vocabulary. The system provided guidance to users both in the form of the pathways and with online information

A Manual of Otolaryngology: A SymptomOriented Text

The problem-oriented record that was originally introduced by Lawrence Weed in 1968 was designed to systematically organize data, thoughts, and actions of medical care. As a disciplined approach to formulating clinical impressions and plans, it was codified by its author and his disciples into the acronym, SOAP (Subjective, Objective, Assessment, and Plan). This cleansing of the traditional organ approach to disease has ultimately reached the last outpost of medical specialties, otolaryngology and head and neck surgery. Its newest disciples have organized the cardinal manifestations of otorhinolaryngologic disease into the SOAP methodology. The result is a symptom-oriented textbook that is designed to serve as an adjunct to standard reference books. The chapters are broadly arranged by symptom complexes, developing specific disease patterns and their management. Neurotology, sensory, and motor disturbances are included along with rhinology, facial trauma, neck masses, and disorders of speech. Apparently it is impossible, however, to escape

Confusion orientated medical records

In the 15 years since Dr William Bean wrote his Tower of Babel, 1963,1 hospital medical records have become increasingly bulky and incomprehensible. The caligraphic efforts of the few have given way to the team approach of the multitude, and to the cryptic cuneiforms of the harassed houseman have been added the voluminous written opinions of an army of specialised nurses, dietitians, social workers, psychologists, physiotherapists, consultants, and consultoids in training. To which must be added a modern passion for documentation based on the needs of government, malpractice lawyers, accrediting bodies, educa tors, administrators, auditors, and medical record librarians. So that if you visit a hospital ward you find that everybody is poring over paper and furiously scribbling away?and if you should ever manage to detach a nurse from her desk she is likely to hand you a patient's chart the size of a telephone book, or perhaps even a whole stack of volumes?the Greater Babylon Area Directory, detailed and complete, with all the suburbs and townships that once graced the fertile plain between the Tigris and the Euphrates. You feel faint at this stage and must sit down. You desperately turn over pages of forms and reports and nurses' notes, clothes lists and itemised accounts of services rendered, insurance forms and graphic charts, computerised laboratory data, and an informed consent form detailing the hazards of having a television set installed in the sickroom. It takes five minutes to find yesterday's temperature, twenty to understand the history, and an eternity to determine on which day the penicillin was begun. Suddenly the folder springs open, the papers fly all over the room, and the nurse and you are crawling all over the floor to pick them up; it takes another five minutes to reassemble the record in some sort of order, and then you may start your research all over again. Or you may continue your studies at the outpatient clinic, where the patients are already waiting, each with his own personal telephone directory?some dating back to the second world war. The pages are yellow and stiff and crumbling, the writing has begun to fade, the story makes no sense because the inpatient records are stored separately on microfilm in a warehouse out of the State?so you give up and just renew the digoxin for the eleventh year. It was to correct this that Dr Lawrence Weed first introduced his famous problem orientated records system.2 Convinced that the traditional source orientated record had become unmanage able and that radical changes were necessary, he developed a new system based on a longitudinal recording of the patients' problems rather than diagnoses, a problem being defined as anything that worried the patient or the doctor or anybody else.