The excellent ICMCC daily newsletter just alerted me to this item from Permanente JournalInterview with Lawrence Weed, MD — The Father of the Problem-Oriented Medical Record Looks Ahead.

I hope to absorb it in the next day or two, and I invite people who know this history to do the same. It’s deep, and it’s connected to our roots here: when I went googling for the photo at left I discovered that our “Doc Tom”‘s Ferguson Report gave Weed an Outstanding Achievement Award.   In 1999.  To wit:

“Dr. Larry Weed is a pioneering visionary of Information Age health care. He deserves a Nobel Prize in Medicine–maybe two. After reinventing the patient medical record as the Problem-Oriented Medical Record and developing one of the first systems for computer-based patient records from 1956-1982, he set out to develop a computer-based tool, the problem-knowledge coupler, to provide just-in-time computer support to the provider and the patient as they work through the process of diagnosing and treating a n ew medical problem. His vision of a coherent health care system based on a new generation of computer tools points the way toward the next generation of medical thinking.”

In this new interview, 12 years farther down the road, computers are immensely more powerful than what he had then, and he has a decade more experience working with knowledge couplers. What has he seen, and what does he see looking forward? Wow.

(The other awardee in that Ferguson Report is none other than ACOR founder and SPM co-founder Gilles Frydman. Time capsule!)

A taste of the interview:

The true depth of the knowledge problem in medicine occurred to me when I found myself doing basic research in biochemistry at a university medical school.  As a scientist in the laboratory I was dealing with one problem at a time, making time and tasks the variable and achievement the constant. … I was asked to teach clinical medicine on the wards a couple months a year. It was at this point that the true nature of our predicament dawned on me. …

The multiplicity of problems the physician must deal with every day constitutes a principal distinguishing feature between a physician’s activities and those of many other scientists.

These realizations led me to develop the POMR [problem oriented medical record] so that medical students and practitioners could function in a structured, rigorous way more like that of workers in the scientific community. The POMR cannot change the multiplicity of problems that physicians face. But the POMR enables a highly organized approach to that complexity.

I cheated and skipped to the end of the piece, for his “look ahead,” and found these:

I have heard you eloquently make the case that the present practice of medicine is flawed in that it primarily depends on the physician’s limited memory and processing capacity when dealing with complex patient issues. What is your solution?

LW: I have spent more than 30 years developing and implementing what I have called “knowledge couplers.” Medical knowledge is used to select and analyze patient data, coupling the data in a matrix fashion with medical knowledge developed through research. The output of this coupling process is an organized display of options and evidence. …

… any automation that reliably couples patient data with the world’s medical research will be dramatically better than the unaided human mind.

The “knowledge couplers” are to be used, he says, in conjunction with the POMR and reform of medical education and credentialing. (I’d be laughed out of the discussion circuit if I proposed that – will Dr. Weed be marginalized for it?)

And this:

You have expressed concerns with both the type of individual accepted in medical school as well as how medical students are taught in their first two years. Could you tell our readers what you see as the issues and the implications to preparing these students to practice medicine?

LW: Today, students are recruited on the basis of how well they memorize and regurgitate facts. In the future because knowledge will be in information technology tools instead of in heads, students should be trained in the reliability of performance of given tasks that will be part of a complete medical care system. Students should be selected for their hands-on skills and interpersonal skills and not on the basis of their memory and regurgitation of facts.


Your writings make a very compelling argument for these changes in medical education. Yet, such changes are largely absent from health reform debates. Why do you think there has been such a complete lack of a dialogue on the subject? If educators disagree, why aren’t they saying so?

LW: The system that I just described is very threatening to many educators who are now in the business of moving knowledge through heads instead of using information technology such as knowledge coupling tools. They are judging students on how much they know instead of how well they perform in a well-defined and audited system of care. …

Enough – if you’re interested in this examination of the very nature of a doctor’s work, please read the whole article, and we’ll discuss.