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Health informatics pioneer Larry Weed dies at 93

Lawrence L. Weed, M.D., a pioneer in the world of health informatics and organization of patient information, has died at the age of 93. Weed passed away in Burlington, Vermont, on June 3 after a fall two weeks earlier, his son Lincoln said.

Weed created the who created the problem-oriented medical record (POMR) and the subjective, objective, assessment, planning (SOAP) format of progress notes that became ubiquitous. He had advocated for what now is known as clinical decision support for at least 60 years, talking often about “coupling” patient problem lists with medical knowledge that changes often.

“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,” Weed said in a 2004 story I wrote for Health-IT World, a former spinoff of Bio-IT World. Thus, according to Weed, paper records were inferior to computerization — and they were half a century ago.

While at the University of Vermont in 1976, Weed co-developed an early electronic medical record called the Problem-Oriented Medical Information System, or PROMIS.

In 1991, the Institute of Medicine report, “The Computer-Based Patient Record:  An Essential Technology for Health Care,” (revised 1997) said that the problem-oriented medical record “reflects an orderly process of problem solving, a heuristic that aids in identifying, managing and resolving patients’ problems.”

In a seminal 1968 article in the New England Journal of Medicine, Weed wrote:

Since a complete and accurate list of problems should play a central part in the understanding of and management of individual patients and groups of patients, storage of this portion of the medical record in the computer should receive high priority to give immediate access to the list of problems for care of the individual patient and for statistical study on groups of patients.”

To this end, Weed developed a system of “problem-knowledge couplers,” and founded PKC Corp. in 1982 to market his idea. The company landed a series of government contracts, but struggled to catch on in the public sector. Weed was forced out by investors in 2006, and PKC was sold to consumer health company Sharecare — founded by WebMD founder Jeff Arnold and TV doctor Mehmet Oz, M.D. — in 2012.

Weed described the framework of problem-knowledge couplers in a 1994 article in the journal Medical Interface.

A true Renaissance man fond of quoting Francis Bacon, Tolstoy, Copernicus, Galileo and other celebrated philosophers, Weed was known as a brilliant educator, deep thinker and an engaging speaker. At the age of 89, he commanded the stage for a good 75 minutes at the HIMSS13 Physicians’ IT Symposium, and received two standing ovations.

“The worst, the most corrupting of all lies is to misstate the problem. Patients get run off into the most unbelievable, expensive procedures … and they’re not even on the right problem,” Weed said during that memorable presentation in New Orleans.

“We all live in our own little cave. We see the world out of our own little cave, and no two of us see it the same way,” he continued, explaining the wide deviation from standards of care. “What you see is a function of who you are.”

Lincoln Weed lamented that health IT companies have not always paid attention to these ideas. “The informatics community hasn’t really caught up to my father’s work,” the son said. “It’s not about technology. It’s about standards of care.”

The problem-oriented medical record is a standard for organizing information in a record. Couplers are standards for collecting data to generate recommendations based on the ever-changing body of medical knowledge, according to Lincoln Weed.

Some of Larry Weed’s ideas did catch on, notably, the SOAP note. However, some have recently rethought that format for the digital age, swapping the first two and last two element to create the APSO note. Weed defended his approach in 2014.

Weed stayed active up until his last day alive, according to Lincoln Weed. The day Larry Weed died, he discussed a poorly adopted National Library of Medicine personal health records project with sons Lincoln and Christopher. Lincoln recalled that his father said the NLM tool needs to let patients enter their own health data.

“I’m hopeful that the NLM is close to jumpstarting that process,” Lincoln Weed said. “Dad died with more optimism than he had had in a long time.”

Indeed, it could be argued that Weed was a founding father of patient empowerment. Back in 1969, Weed wrote a book called “Medical Records, Medical Education, and Patient Care.” In that, he said, “patients are the largest untapped resource in medical care today.”

Lincoln Weed said that the late Tom Ferguson, M.D., who founded the journal Patient Self-Care in 1976, “thought Dad was one of the originators” of the empowered patient movement.

With patient-generated data and now genomic information making its way into clinical practice, a system for organizing medical records is more necessary than ever, Lincoln Weed said. Equally important, he said, is a computerized system for matching the patient problem list with all known, relevant information to address specific problems — couplers.

“I’m glad Dad has left me with these things to work on,” said Lincoln Weed, a retired attorney who co-authored “Medicine In Denial” with his father in 2011.

Weed, who earned his medical degree from Columbia University in 1947, is survived by five children, a sister, two grandchildren and two step-grandchildren, according to the Burlington (Vermont) Free Press.  He was preceded in death by his wife, Laura, a physician herself who died in 1997.

Weed’s public memorial will focus on his lifelong love of classical music. His children are planning a memorial concert on Sept. 17 at 4 p.m. Eastern time at Charlotte Congregational Church, 403 Church Hill Rd, Charlotte, Vermont, according to the Burlington Free Press.

Here is a video of Weed from a well-known grand rounds he presented in 1971. It was unearthed by a Weed disciple, Art Papier, M.D., of clinical decision support vendor VisualDx.

June 18, 2017 I Written By

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APSO vs. SOAP, continued

A couple weeks ago, I had a story in Healthcare IT News about the growing use of the “APSO” notes for documenting patient encounters. APSO flips around the traditional SOAP format (subjective, objective, assessment, plan), ostensibly making it easier to view progress notes in electronic health records.

As I reported, APSO is in wide use at University of Colorado Health and at Lucile Packard Children’s Hospital in Palo Alto, Calif. Baystate Health in Springfield, Mass., found that hospitalists focused most of their attention on the “impression and plan” sections of patient records, essentially the AP part of APSO/SOAP. Physicians at Epic Systems, according to University of Colorado’s Dr. C.T. Lin, are recommending APSO as a best practice.

Yet, the inventor of the SOAP note, Dr. Larry Weed, still believes his format is superior. You saw his comments in the Healthcare IT News story. But every time I have the privilege of speaking to the nonogenarian Renaissance man, he always has more to say than I can fit into the average article. I often can’t keep up in my note taking, but, fortunately, in this case, Weed and his son/occasional co-author Lincoln, took the time to put their thoughts in writing for me.

I left most of their comments out of the story due to space limitations. I don’t have that problem here, so I present their entire statement to me:

The following represents our collective thoughts, including references to relevant portions of Medicine in Denial [their 2011 book].

The supposed advantage of the APSO alternative — that it begins with the physician’s assessment rather than data — is actually a failing. This sequence tends to make the note provider-centered rather than patient-centered, and judgment-based rather than evidence-based.  In contrast, beginning the progress note with data disciplines the provider’s assessment. The provider must think in terms of specific data, specific problems on the problem list to which the data relate, and the interrelationship of each problem to the other problems on the list. Moreover, it’s important to begin the progress note with subjective (symptomatic) data from the patient rather than so-called “objective” data,  As Medicine in Denial states (p. 168):
“… progress notes should begin with subjective data, because progress should be assessed from the patient’s point of view.  Practitioners should be alert to discrepancies between subjective and objective data (for example, where the patient does not feel better when lab results show improvement). These discrepancies may signal an error in data or misstatement of the patient’s problem.”
In short, provider thinking can be disciplined with problem-oriented SOAP notes as a standard of care. Yet, regulators and academics who are in a position to act on this issue have shied away from the whole notion of standards of care for organizing data in medical records. See our comments on ONC’s Stage 2 regs and our comments on the PCAST Report.
The need for standards of care in medical records goes far beyond the SOAP vs. APSO issue in progress notes. In fact, that issue is secondary. Two more fundamental issues for medical records are the following:
  1.  Determining initial inputs to the record. Initial inputs are determined by selection of data needed for the patient’s problem situation, and once the data are collected, analysis of the results.  Both selection and analysis are fatally compromised when determined by the physician’s clinical judgment. External standards and tools, based on a combinatorial standard of care, must govern the selection and analysis. Once that happens, then judgments of patient and practitioners (not just physicians) may supplement the combinatorial minimum standard.  See Medicine in Denial, pp. 53-61, 69-79, 136-37, 145-52.
  2.  Organizing the medical record around the problem list. Once initial data are collected and a complete problem list is defined, then care plans, orders, and progress notes should be problem-oriented, that is, labeled by the problem(s) to which they relate on the problem list. This disciplined practice is essential to justifying provider actions in terms of defined patient needs. Yet this practice is not followed or enforced with consistency. Indeed, some EHR systems do not even enable electronic links between the problem list and care plans, orders and progress notes. See Medicine in Denial, pp. 134-35, 144, 159-60, 166-67.
Like so much else in medicine, medical record practices are a Tower of Babel. Medicine need standards of care for managing clinical information (knowledge and data) no less than the domain of commerce needs accounting standards for managing financial information. This failing is a primary root cause of the health care system’s failures of quality and economy.

For that matter, Lin had more to say than what you saw in the story. He discussed the supposed importance of the subjective and objective elements. “That’s true in cases where there is diagnostic uncertainty,” Lin said. But he added that those components are still there for reference, jut not up front.

Lin called SOAP “a phenomenal innovation,” but suggested that EHR complexity sometimes makes it difficult to find the assessment and plan. For example, he said that a non-Epic EHR in the emergency department at UC Health has as many as 17 different screens for progress notes. “At least with APSO, you would collect the assessment or plan in the first half,” Lin said.

Because SOAP is so entrenched, Lin ran into much resistance when he proposed switching to APSO at 40 affiliated practices. He, of course, heard the tired, “But we’ve always done it this way” defense.

“I learned myself about culture change very acutely,” Lin said. “I was literally shouted out of the room by our physician leadership.” He had neglected to prepare the heads of various departments and clinics for the change in advance of the meeting where he announced the plan.

He subsequently had to have individual conversations with all 40 practice directors. And then Lin dropped a great quote from none other than Niccolo Machiavelli (speaking of Renaissance men): “Those who benefited from the old order will resist change very fiercely.”

Yes, that’s absolutely perfect for an industry as resistant to change as healthcare. But is APSO superior to SOAP? I’d love to hear your thoughts.

May 20, 2014 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality fast $5000 loans-cash.net with bad credit, hospital/physician practice management and healthcare finance.

Patient safety update

I’m passionate about patient safety. I’m happy to report a couple of things that aren’t exactly breaking news, but still worth bringing to your attention.

First off, there is a fairly new peer-reviewed journal called Diagnosis, and it’s about exactly what the title suggests. The first, quarterly issue, from German academic publisher De Gruyter (North American headquarters are in Boston), came out in January, so the second issue should be published soon. The online version is open access. That means it’s free. (A print subscription is $645 a year.)

A highlight of the premiere issue is a submission from the legendary Dr. Larry Weed and his son, Lincoln Weed, discussing diagnostic failure and how to prevent it. “Diagnostic failure is not a mystery. Its root cause is misplaced dependence on the clinical judgments of expert physicians,” they begin. The answer? Clearly defined standards of care and wider use of clinical decision support tools. It’s not anything new. Larry Weed has been advocating this for a good 50 years and saying that the unaided human mind is fallible for probably 60 years. Yet, medicine still largely relies on physicians’ memory, experience and recall ability at the point of care.

This doesn’t mean evidence-based medicine ,which is based on probabilities. Probabilities are fine when the patient has a common condition. They’re useless for outliers. No, Weed has long said that IT systems should help with diagnosis by “coupling” knowledge to the patient’s particular problem, and this starts with taking a complete history.

Weed, of course, created the SOAP (subjective, objective, assessment, plan). I recently talked to a CMIO who is advocating flipping that around a bit  into an “APSO” (assessment, plan, subjective, objective), which he said works better with electronic records. I’ll have more on that in an upcoming article for a paying client, and I’ll probably want to dive into that again in the near future.

For those who still believe American healthcare is safe, effective and efficient, ProPublica worked with PBS Frontline and marketing firm Ocupop last year to produce a video “slideshow” called “Hazardous Hospitals.” It’s worth a view for healthcare industry insiders, and definitely merits sharing with laypeople. I recommend that you share it. Please. Do it. Now. I’m serious. Patient safety is a problem that doesn’t get enough attention. :)

 

March 25, 2014 I Written By

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When you talk health reform, don’t forget quality and IT, in that order

In my previous post, I was perhaps a bit too critical of Maggie Mahar in her hosting of last week’s Health Wonk Review. I noted that there was not a word about health IT in that rundown, but that’s not her fault. A host can only include what’s submitted, and apparently nobody, myself included, who contributed to HWR bothered to submit a blog post about health IT this time around.

But I continue to be troubled by this fixation so many journalists, pundits, commentators, politicians and average citizens have on health insurance coverage, not actual care. I blame most of the former for the confusion among the populace. People within healthcare know that you can’t talk about reform without including the serious problems of quality and patient safety, and people within reform know that IT must be part of the discussion even if they don’t always say so.

I would like to draw your attention to a story of mine that appeared on InformationWeek Healthcare this morning, about a report on care integration from the esteemed Lucian Leape Institute. The report itself did not say a lot about IT, but the luminaries on the committee that produced the paper are aware of the importance.

I was lucky enough to interview retired Kaiser Permanente CEO David M. Lawrence, M.D., who told me there has been “little attention” paid to the importance of a solid IT infrastructure in improving care coordination and integration. “What you now have is too much data for the typical doctor to sift through,” Lawrence told me.

That’s exactly the message Lawrence L. Weed, M.D., has been trying to spread for half a century, as I’ve mentioned before. And that’s pretty much how longtime patient safety advocate Donald M. Berwick, M.D. — also a member of the Lucian Leape Institute committee that wrote the report — feels. Berwick hasn’t always advocated in favor of health IT in his writings and speeches, but he has told me in interviews that the recommended interventions in his 100,000 Lives Campaign and 5 Million Lives Campaign are more or less unsustainable in a paper world.

Isn’t about time more people understand that widespread health reform is impossible without attention to quality and that widespread quality and process improvements are impossible without properly implemented IT?

 

 

October 29, 2012 I Written By

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Not so elementary, my dear Watson

In just the last few hours, I’ve seen a huge wave of pushback and doubt about Watson, the IBM supercomputer, being used for clinical decision support.

Yesterday, I covered a “healthcare leadership exchange” at IBM’s new Healthcare Innovation Lab in downtown Chicago. I posted some of my observations on the EMR and HIPAA blog, and made the case for diagnostic decision support.

I also wrote a story for InformationWeek, but that hasn’t run. Instead of posting my story, InformationWeek healthcare editor Paul Cerrato wrote a column about Watson already being “beaten in the medical diagnostics race” by Isabel Healthcare, a diagnostic decision support tool that’s been available for years. I have to admit, he’s right. I first interviewed Isabel founder Jason Maude probably in 2002 or so, and I first blogged about the company in 2005. I mentioned Isabel in a 2007 post that, interestingly, also alluded to the work of Don Berwick and Larry Weed.

Cerrato mentioned Jerome Groopman’s 2007 book, “How Doctors Think,” which discussed, in part, how IT could help doctors avoid many types of cognitive errors. “[D]octors tend to lean toward diagnoses that are most available to them in their day-to-day routine,” Cerrato wrote (emphasis in original). That’s exactly what Weed has said for decades, and exactly what Atul Gawande talked about in his groundbreaking book, “Complications.” Computers should not make decisions for physicians, but rather should help them reach the right conclusions, particularly when they see rare cases.

Wouldn’t you know, “e-Patient” Dave deBronkart commented on my EMR and HIPAA post to say he just finished reading Groopman’s book. He tweeted a link to my post, which a few of his 6,500 other Twitter followers noticed. They also noticed EMR and HIPAA grand poobah John Lynn’s comment that the example in yesterday’s Watson demo, a 29-year-old pregnant woman being prescribed doxycyline was “pretty weak.” (He’s right, by the way.) Aurelia Cotta, who blogs about issues such as infertility and adoption, started this thread that also got South Carolina nurse Sunny Perkins Stokes interested:

[blackbirdpie url=”http://twitter.com/#!/AureliaCotta/status/76775042503028737″]

[blackbirdpie url=”http://twitter.com/#!/AureliaCotta/status/76775279565090816″]

[blackbirdpie url=”http://twitter.com/#!/sunnystill/status/76776486119555072″]

[blackbirdpie url=”http://twitter.com/#!/AureliaCotta/status/76782462893699072″]

[blackbirdpie url=”http://twitter.com/#!/AureliaCotta/status/76782822198743040″]

[blackbirdpie url=”http://twitter.com/#!/AureliaCotta/status/76783250663682048″]

[blackbirdpie url=”http://twitter.com/#!/sunnystill/status/76783933106307072″]

[blackbirdpie url=”http://twitter.com/#!/AureliaCotta/status/76784835267534848″]

[blackbirdpie url=”http://twitter.com/#!/AureliaCotta/status/76785122996789248″]

 

Well, there’s a reason why I call myself a “healthcare” reporter and not a “medical” reporter. I don’t know the science, and I do occasionally get myself in trouble when I start talking about things like whether doxycycline is contraindicated during pregnancy. (To my credit, I did attribute the statement to IBM’s chief medical scientist, Dr. Marty Kohn.)

As I was reading the above tweets and contemplating this blog post, I came across a link to some tongue-in-cheek pushback against Watson in healthcare. An anonymous radiologist who blogs about PACS as “Dr. Dalai” compared Watson to HAL, the diabolical mainframe in “2001: A Space Odyssey.” Dr. Dalai wrote: “Watch out, boys and girls, Watson is headed to a hospital near you, and he (it?) may challenge you as much as he did Ken Jennings.” Jennings, of course, is the Jeopardy! champion whom Watson beat earlier this year.

At first glance, I thought Dr. Dalai was yet another whiny physician clinging to the status quo. But he hit on the real issue: application of knowledge. Quoting from an interview with one of Watson’s programmers, Dr. Dalai noted that the supercomputer is being loaded with all kinds of medical reference material in preparation for “learning” human physiology and ultimately gathering experience in medicine. “This isn’t fair!  If I could just take a text book, stick it up my, ummmm, brain, and have it instantly memorized, I would be whiz, too!” he wrote.

Yeah, isn’t that the whole point of clinical decision support?

June 3, 2011 I Written By

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News and notes: Cool healthcare tech, telemed pushback and more

It’s Friday afternoon, and I realize it’s been days since I’ve posted here. (Make sure you catch my posts on EMR and HIPAA every Thursday, including my latest on Dr. Larry Weed and his critiques of current health IT systems.) I think it’s time for a rundown of some interesting developments this week.

Weed apparently is not the only one who’s disappointed in the pace of change in healthcare. Dr. Bill Crounse, senior director of worldwide health for Microsoft, was at the World of Health IT conference in Budapest, Hungary, to deliver some scathing remarks at about North American health IT. According to Canadian Healthcare Technology, Crounse called the U.S. and Canada the “worst of the worst in the industrialized world in the use of IT in healthcare.”

He explained: “I see physicians in perhaps less developed countries bypassing all that legacy technology and using commodity off-the-shelf contemporary solutions, using tablets and speech recognition and doing their discharges, all with technology that costs pennies on the dollar, and then I come home to America and look at these $150 million systems and say, ‘wouldn’t we be better spending that on patient care instead of IT?'”

EMRs just store health information, Crounse said. “It’s really what you do next that counts. Once we have information digitized, that doesn’t buy you value. It’s what you do with the information, how you use it to manage care, and to collaborate.”

While we’re talking about overseas events, Hello Doctor, a telemedicine service in South Africa, apparently is on hold less than a month after its April 17 launch. In an e-mail newsletter (not available on the Web, as far as I can tell), Telemedicine & E-Health reported:

Under fire from South Africa’s healthcare bureaucracy, Hello Doctor has suspended its telemedicine services, pending a meeting between representatives of the company and the Health Professions Council of South Africa (HPCSA). The council referred to its undesirable business practice committee Hello Doctor and two companies that have announced plans to offer a joint telemedicine service later this year, MTN Group and Sanlam. HPCSA has alleged that the companies violated rules that require a healthcare practitioner to do a physical examination and assess a patient before a diagnosis can be made. [News Alert, May 6 ]. HPCSA is drafting its own guidelines for telemedicine, an emerging competitor to nationally-licensed doctors.

The South African Medical Association also is fighting the service. “”It is no different from blind-dating. How sure are you whether you are getting the real doctor or not?” SAMA Chairman Dr. Norman Mabasa told Independent Online. Hmm, aren’t these the same kinds of objections we see in America? When will the medical establishment wake up and see that telemedicine is not a threat to their authority?

Well, at least some physicians are embracing new technologies. That’s the subject of a feature I just had published on Medscape,  “10 Totally Cool and Incredibly Useful Medical Gadgets: Technology That’s Changing Medical Care.” Feel free to argue with me and add your own.

And speaking about telehealth and arguing with me, I was the victim of intimidation of the media this week. A certain story I wrote about a telemedicine technology vendor was pulled from the Web yesterday after the company threatened to sue the small company that published it. The company accused me of writing a “defamatory” story and wondered if a competitor didn’t actually help me write the piece. Sorry, but I have a lot more integrity than that. I also was accused of mischaracterizing the state of the deactivated ambulance telemedicine service in Tucson, Ariz., which I said was “failed.”

The accuser referred to an April article in Telemedicine & E-Health written by Dr. Rifat Latifi, one of the driving forces behind Tucson ER-Link, and several colleagues that showed the efficacy of ER-Link in performing remote intubation. That’s great, but there needs to be a working network to support the “videolaryngoscope.” Tucson, unfortunately, no longer has one.

 

May 20, 2011 I Written By

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CDS commentary on EMR and HIPAA blog

I’ve just written my first post for the well-established EMR and HIPAA blog, one of the flagship sites for the Healthcare Scene network. (This site belongs to Healthcare Scene as well.) My post is a commentary about public perceptions of clinical decision support and a critique of failures by health IT developers, the healthcare industry and the media to design easy-to-use technology and communicate the purpose of CDS to the public. I’ll be writing weekly for that site, usually on Thursdays.

I quote Dr. Larry Weed in that post. If you want more on this pioneer in health informatics and healthcare quality, check out some of my previous posts and stories about him:

April 21, 2011 I Written By

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A must-read from Dr. Weed

Kudos to The Health Care Blog for publishing a long, two-part treatise this week from the legendary Dr. Larry Weed and his attorney son, Lincoln Weed, who talk about how “evidence-based medicine” really just represents educated guessing.

Dr. Weed has been arguing for close to half a century in favor of computers in medicine to aid in decision-making because the unaided human mind simply cannot recall all possible permutations of symptoms at the point and time of care. It’s been an uphill battle his whole career because he directly challenges so many elements of the medical establishment, but this is someone whom Don Berwick considers a hero.

It’s a long piece, broken into five installments, and it’s highly academic, even including endnotes, but worth your while.

Part 1: Medicine’s Missing Foundation for Health Care Reform

Part 2: Medicine and the Development of Science.

Part 3: Economy of Knowledge in Decision Making

Part 4: Harvesting Medical Knowledge from Patient Care

Part 5: Patient Autonomy

April 29, 2009 I Written By

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Mystery solved

A couple of weeks ago, I e-mailed some friends and colleagues in the biz wondering who originally said that installing an EMR without considering workflow redesign was just automating chaos. I surmised it was likely Don Berwick, David Brailer or Bill Stead.

One response said that, just like with Yogi Berra or Winston Churchill, I could always attribute it to Berwick and people would believe me. As it turned out, it was none of the above—not even Churchill.

In fact, the originator of the quote was Larry Weed. Weed even used the “automating chaos” line in an interview he did with me in 2004. In fact, he’s one of the most quotable people I’ve ever had the privilege of interviewing, which I also did in 2006.

June 17, 2008 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality fast $5000 loans-cash.net with bad credit, hospital/physician practice management and healthcare finance.