Medicine is Still ‘In Denial’ Over Clinical Decision Support

Sometimes it’s better to be lucky than good.

Last month, in my very first post for EMR and HIPAA, I mentioned Dr. Larry Weed in my commentary about the general public’s perception of clinical decision support. I referred to a 2007 study in the journal Medical Decision Making, which said, “Patients may surmise that a physician who uses a [decision support system] is not as capable as a physician who makes the diagnosis with no assistance from a DSS.” I then noted that Weed has been saying for more than 50 years that physicians shouldn’t have to rely on their memory to make clinical decisions when computers can help them process an increasingly voluminous knowledge base.

As it turns out, Weed read my commentary. (I’m guessing that a computer, i.e., Google Alerts, led him to the post. See, computers really can help find the information we’re looking for. Who knew?) And, as it also turns out, Weed and his son, Lincoln, a Washington, D.C.-area attorney who now consults on health privacy issues, just had their latest book, “Medicine in Denial,” published. They both contacted me last week to share this news.

“A culture of denial subverts the health care system from its foundation. The foundation—the basis for deciding what care each patient individually needs—is connecting patient data to medical knowledge. That foundation, and the processes of care resting upon it, are built by the fallible minds of physicians. A new, secure foundation requires two elements external to the mind: electronic information tools and standards of care for managing clinical information,” reads the book’s opening paragraph.

Yep, that sounds like clinical decision support to me.

“Deep disorder pervades medical practice. Disguised in euphemisms like ‘clinical judgment’ and ‘evidence-based medicine,’ disorder exists because medical practice lacks a true system of care. The missing system has two core elements: standards of care for managing clinical information, and electronic information tools designed to implement those standards. Electronic information tools are now widely discussed, but the necessary standards of care are still widely ignored,” reads the book’s description.

The Weeds believe current EHR systems don’t measure up, and they said so in comments submitted in response to the December 2010 President’s Council of Advisors on Science and Technology (PCAST) report on health IT, which recommended against standardizing EHR formats. “Sound standards for the structure of medical records provide essential standards of care for managing clinical information.  Medical practice needs these standards no less than the domain of commerce needs accounting standards for managing financial information.  Failure of recognize this principle is a root cause of health care’s failures of quality and economy,”  the Weeds said in their comments.

It’s a principle that Larry Weed, 88, has been advocating since he developed the problem-oriented medical record in the 1950s. 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.”

And 20 years later, medicine hasn’t changed much. Perhaps, though, it takes longer than that. Lincoln Weed also referenced a story I wrote for InformationWeek on May 10. I noted that the Consumer Partnership for eHealth’s Consumer Platform for Health IT referred to consumers as “”the most significant untapped resource” in healthcare.

Well, wouldn’t you know, Larry Weed has written the following: “patients are the largest untapped resource in medical care today.” That was from his book, “Medical Records, Medical Education, and Patient Care”. That book was published in 1969.

Instead of ending this post on a down note, let me just add that I would have had an interview with Dr. Weed this week, but he just left the country for a speaking engagement. He’s 88 and still traversing the globe, fighting for what he believes in. Don’t we all wish we had that kind of passion?

About the author

Neil Versel

Neil Versel


  • ICD-9 Problem Lists are not helpful and can be harmful. They are duplicative and lack narrative detail. Dr. Weed’s intent is right but the execution (because billing has driven EMR development) has been poor. We took a wrong turn with the current crop of EMRs but hopefully the next generation of products will focus on actual patient problems and not billable diagnoses.

  • Brian is exactly correct … hijacking EMR pt problem/treatment plan outline in order to further disect each treatment “brush stroke” exists for the payers not patients.

    As for Neil Versel … I wonder if the Weeds sent him an autographed copy of their book in thanks for helping them market it. Given ONC’s dictatorial meaningful use definitions along with ICT-9 (and ICT-10) I wonder if it is medicine or the Weeds who are the ones in denial?

  • neil, congratulations for getting Dr Weed to comment on your blog, he is truly one of the legendary figures in healthcare. Demonstrates the high quality of your blog and your journalistic skills in not being superficial like many HIT pubs.
    Dr Weed’s work is pivotal to the development of CDS and he has always faced resistance. his initial work on medical records took decades to become the norm, but now every medical student is taught the Weed way of capturing data, unfortunately they probably are not told about Dr Weed.
    His sort of thinking is critical in getting adoption and widespread use.
    Dr George Margelis

  • Given the emphasis on technology in the book, it seems strange that “Medicine In Denial” is not available in epub or Kindle format. Does anyone know if that is in the works?

  • Dr. Weed is one of a kind (in a good way) – he is a physician who has argued that the physicians’ unlimited license is a barrier to quality in healthcare.

    The physician is licensed – but perhaps unqualified – to perform many of the routine tasks that come her way in any given day. The complexity of healthcare exceeds her skills and training.

    Medicine deals with this complexity, not with automated decision support but with specialization.

    Referrals to physiatrists, surgeons and physical therapists for many routine, “lifestyle” problems lead to unwarranted imaging, uneccesary surgery and more procedures without comensurate gains in “health”.

    I’ve been waiting for Dr. Weed’s new book for three years and I’m glad to hear that he has finished his work.

    Tim Richardson, PT

  • I read your article and I would like to get acquainted. I am very interested in helping medical groups use Problem Oriented Medical solutions starting with the front end like PKC or Prime Care. This would provide a good start by not having to replace their current system. My goal is to help in any way I can in extending Larry’s ideas. I am also looking into hospitals recruiting Doctors for new EMR systems.
    Let’s talk when you have a chance. My cell phone number is 951-545-4273

  • Weed has got a lot right. Like most others however I suspect he still believes that EHR & CDS etc are tools for physicians broadly similar to the current model. Deep in our soul we know that is not so and future physicians will be unrecognisable from where we stand. It is this realisation that puts us in denial. What we have been and what we are is soon to be largely obsolete. We need to screws how to select, educate and train this new breed (more correctly these new breeds). IT in healthcare is not to make things easier for us but better for patients

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