From Two Weeds, EMR Ideas Flower

Finally, I’ve come across a really spot-on analysis of what ails healthcare, and some proposals that have serious potential to improve healthcare for people like my patients. 

The analysis and proposed fixes are detailed by Lawrence Weed, M.D. and his son Lincoln Weed, in their book “Medicine in Denial.” 

The book is a little long, but for those who are interested in leveraging technology to make healthcare more consistent and more patient-centered, I’d say it’s a must-read.

In particular, the Weeds’ book provides:

An excellent description and analysis of two huge fundamental problems in healthcare. One is the way we persist in relying on fallible physician minds to manage the process of evaluating, diagnosing, and managing medical problems. The other is our lack of standards for consistently documenting and organizing information related to our evaluation and management of patients. 

A proposed method of reorganizing electronic medical records and clinical data. This “problem-oriented medical record” would provide a fundamental level of organization and transparency to the practice of medicine, and would allow better management of multiple problems over time.

A vision of healthcare focused on empowering patients, and on enabling healthcare to be tailored to each patient’s needs, rather than driven by provider idiosyncracy or the blunt tools of evidence-based medicine.

The Weeds point out the obvious: there exists far too much medical information for the human brain to keep it all in mind, and apply it in a consistent and thorough fashion during a medical encounter.

This creates serious problems when it comes to the core medical work of diagnosis and providing treatment recommendations. When a patient comes to a physician with a complaint, the physician invariably does not collect enough data. Instead, clinicians ask questions somewhat idiosyncratically, depending on factors such as their initial hunch, their specialty habits, etc.

Next, physicians do a highly imperfect job of matching the patient’s data – i.e. the positive and negative findings – with medical knowledge. 

As the Weeds point out, a patient with a medical concern can go see three different doctors and emerge with three different diagnoses. And of course, just as clinicians are idiosyncratic in their diagnostic processes, they are also idiosyncratic in how they recommend further evaluation.

To make matters even worse, not only are clinicians applying idiosyncratic human processes to diagnosis and management, but they then go on to document their findings and thought-processes in spotty idiosyncratic ways. 

The Weeds propose a “standardization of inputs,” and argue that clinical judgement should be applied after we use computers and technology to complete two key tasks. The first task is to reliably identify and collect the necessary information from patients, via standardized questionnaires that are tailored to the complaint in question. The second is to use a “knowledge coupler” to analyze the patient’s responses and propose a list of diagnostic possibilities.

Presumably the reflexive response of many physicians will be to decry this as cookbook medicine.

Is it? Having been dismayed by the spotty clinical work that many physicians produce under today’s usual rushed outpatient conditions, I’m not sure a little cookbook structure is such a bad thing. As the Weeds point out, the purpose is to start with a solid, consistent foundation, and then proceed to individualizing.

Still, I couldn’t help but wonder if detailed data collection might not be more overwhelming for patients and providers than they admit. It certainly would’ve helped if the Weeds had provided an actual example of a sample questionnaire for one or more common complaints in an older adult.

In short, I found myself easily persuaded by the theoretical case for a technology-assisted combinatorial approach, rather than today’s terribly error-prone judgmental approach. But I was left uncertain as to how feasible it actually would be to implement in the case of complex elderly patients.

Leslie Kernisan, M.D., is a geritrician with the UCSF Health system.