Preface by Michael Millenson: Lawrence L. Weed published a seminal article in the Archives of Internal Medicine on using the medical record to improve patient care back in January, 1971.
To give you an idea of how glacially the health care system changes, that same issue contained an article entitled, “Universal Health Insurance is the Wave of the Future,” by New York Gov. Nelson Rockefeller, and another, “What Possible Use Can Computers Be to Medicine?” by a Duke University physician that began this way: “The physician's attitude toward computing machinery has changed greatly in the last ten years. A bright future is predicted for its application within medicine.”
In an era when the autonomy of the individual physicians was nearly unchallenged, Weed boldly asserted that “modern data acquisition and retrieval systems” could help doctors make more accurate diagnoses and provide “proper care” more effectively. Weed has continued that same fight ever since, later joined by his son, attorney Lincoln Weed. In the process he has acquired neither fame, popularity or riches — merely become legendary to a small segment of us familiar with his work.
ABSTRACT: Medical practice lacks a foundation in scientific behavior corresponding to its foundation in scientific knowledge. The missing foundation involves standards of care to govern how practitioners manage clinical information. These standards of care, roughly analogous to accounting standards for managing financial information, are essential to exploit the enormous potential of health information technology. Moreover, without these standards and corresponding information tools, evidence-based medicine in its current form is unworkable. Medical practice has failed to adopt the necessary standards and tools, because its historical development has diverged from the paths taken in the domains of science and commerce. The culture of medicine tolerates unnecessary dependence on the personal intellects of practitioners. This dependence has blocked the use of potent information tools, and isolated medicine from forces of feedback and accountability, that operate in the domains of science and commerce. If the necessary standards and tools are adopted, health care cost and quality could become an arena of continuous improvement, rather than a quagmire of intractable dilemmas.
Medicine is built on a foundation laid by scientific knowledge. Medical practice, however, lacks a corresponding foundation in scientific behavior. This foundation cannot be found in "evidence-based medicine" and "health information technology." As currently conceived, those developments are crippled by practitioner behaviors that the domain of science rejected centuries ago. Medicine needs new standards of care to govern how practitioners behave in managing clinical information. These standards of care in turn must govern the design and use of information technology.
The necessary standards and tools have in large part already been developed, and have been used in patient care by some practitioners for many years.1 Yet, these standards and tools are largely absent from mainstream medical practice and medical education. Indeed, their absence is not even recognized, because they are incompatible with behaviors and beliefs instilled by medical education.
A simple example will illustrate the difference between mainstream practice and the rigorous scientific behaviors that medicine needs. Consider the ritual that occurs when a patient sees a physician about an unexplained symptom to diagnose—chest pain, for example. Physicians make educated guesses about the diagnostic possibilities that might account for the symptom. They proceed with a history, physical examination and laboratory tests, making more guesses about what initial data might be useful for investigating the diagnostic possibilities that come to mind. As they collect data, they make more guesses about what the data mean, and those guesses shape their judgments about what further data are needed. These highly educated guesses vary from one physician to another, and are not explicit—physicians do not carefully record their thinking or the information they take into account.
We use the term "guesses" because these initial judgments are made on the fly, during the patient encounter. The judgments are based on whatever enters the physician's mind when conducting the history and physical examination. What enters the physician's mind may be highly intelligent and sophisticated, but inevitably it reflects that physician's personal knowledge and experience. A more rigorous, truly scientific approach would not be so limited. Instead, diagnostic investigation should take into account everything that medical science has learned about what initial data are most productive for diagnosing the symptom in question. Once collected, the data should be matched objectively with corresponding medical science, not judged subjectively based on the physician's limited personal knowledge of medical science.
Take the chest pain example. Careful review of the literature shows that investigating this symptom needs to take into account approximately 100 diagnostic possibilities (involving most medical specialties). Each diagnostic possibility can be defined as a combination of simple, inexpensive findings from the history, physical and basic laboratory tests. Making all of these findings for all of the diagnostic possibilities results in approximately 440 findings on each patient. Each positive finding suggests one or more diagnostic possibilities. Each patient's particular combination of positive findings can be matched against all of the combinations of findings representing the diagnostic possibilities for chest pain. The output of this matching process is a set of diagnostic possibilities, plus the patient's positive and negative findings for each. These findings constitute initial evidence for and against each possibility, and the total set of possibilities represents the diagnoses worth considering for that patient. (Those possibilities for which no positive finding is made are not worth considering and can safely be ignored for that patient.)
This matching process is feasible only when software tools are used. Physicians do not have command of all the medical knowledge involved. Nor do physicians have the time to carry out the intricate matching of hundreds of findings on the patient with the medical knowledge relevant to interpreting those findings. Physicians thus resort to a shortcut process of educated guesswork. Euphemistically termed "clinical judgment," this behavior causes a fatal voltage drop in transmitting complex knowledge and applying it to patient data.
Digital information technology, because it makes possible an alternative to this behavior, represents a turning point in the history of medicine. The alternative has been available for half a century. Yet, medicine has failed to embrace it. In sharp contrast to other areas of science, medical practitioners are permitted to rely on personal intellect rather than tools external to the mind for basic information processing. Even now, after medical error is recognized as epidemic and "health information technology" is increasingly employed, no standards of behavior have been generally accepted, much less enforced, to require the use of external tools for applying medical knowledge to patient data.
The above discussion describes physician behavior at the outset of the diagnostic process. That is just one example of how scientific rigor is lacking throughout the complex processes of care, both diagnostic and therapeutic. Tolerating the variable judgments and habits and skills of autonomous physicians deprives the entire health care edifice of a secure foundation. The outcome is to block the forces of feedback, competition and accountability that would otherwise transform the status quo.
Other sources2 present in detail the standards of care and external tools essential to this transformation. What follows explores two questions. First, how did medical practice diverge from science in defining the behaviors expected of practitioners? Second, given that scientists are sheltered from the difficult conditions of patient care, is it feasible to bring the rigorous discipline of science to medical practice, where variables are uncontrolled and practitioners must cope with whatever problems patients present? The first question takes us back 400 years to Francis Bacon, the first thinker who systematically examined the intellectual behaviors on which modern science depends. The second question takes us from the domain of science to the domain of commerce, where scientific knowledge and technology are applied far more reliably and economically than has ever occurred in the domain of medical practice.