Building a Reliable System of Medical Care (in Health Information Management: Reality, Visions and Future Roadmaps) It was 300 years ago that Battista Morgagni gave to the world a systematic treatise in two volumes containing the records of some 640 dissections along with the symptoms during the course of the illness with a precision of statement and exhaustiveness of detail. Morgagni was the first to understand and to demonstrate the absolute necessity of basing diagnosis, prognosis and treatment on an exact and comprehensive knowledge of anatomical conditions. His treatise was the commencement of the era of steady or cumulative progress in pathology and practical medicine (a statement in the 1911 Encyclopedia Britannica at the time of the 1910 Flexner report which produced the modern medical school). From Morgagni’s time on, disease began to be viewed as “the cry of the suffering organs”. Many of the false notions of the nature of disease, for example the humor theory of surpluses of fluids (e.g., blood and bile) that had held sway since the times of Hippocrates and Galen were discredited. The practical application by practicing physicians of Morgagni’s insights would require that each practicing physician could and would elicit and then recognize in each patient the combination of symptoms and physical findings, the cry of a specific suffering organ, the diagnosis. The public has been led to believe that a degree from a medical school and a license from a state to practice medicine enable the mind of a physician to do what Morgagni’s insights required. But the present reality is that the unaided mind of a licensed physician is not capable of remembering, keeping up-to-date and processing all the combinations of symptoms and physical findings of all the diseases described by Morgagni and his successors, but physicians are willing to act as if they are capable because they were given a license to practice medicine. That license was given because they sat through courses and passed exams in medical school. They were never given the right tools to recall and process the appropriate knowledge from the literature and from the patient at the time of actual practice, and mistakes in medicine are now the third most common cause of death.1 Francis Bacon told us 100 years before Morgagni that when we extol the powers of the human mind, we do not search for its real helps. And deaths—for example from an undiagnosed ruptured appendix or a fatal case of Addison’s disease—that could have been successfully treated if the diagnosis had been made will continue to occur if the practice of medicine is left to the unaided minds of autonomous physicians. As Bacon said: “Our only remaining hope and salvation is to begin the whole labor of the mind again; not leaving it to itself, but directing it perpetually from the very first, attaining our end as it were by mechanical aid.” The “real helps” for the mind that Bacon urged us to search for are not provided in the present system of medical care, but they are known, written about and ignored.2,3 The question we should explore here is how is it that the medical schools and a medical education system initiated by the Flexner report over a century ago produce so many physicians who are willing to make medical decisions that are in error so often. The answer is that the Flexner report led to medical schools that are based on the premise that if a medical school required the student to sit through courses in the basic sciences such as biochemistry, physiology, pharmacology etc., followed by two years of seeing patients on wards and in clinics, they would be able to do what Morgagni’s insights required. But the reality is that the [1]

student does not see connections between what he is learning in the basic science courses and the care of patients and would not remember them even if he did two or three years later when seeing a patient in a busy clinic . Nor would the PhD teaching him biochemistry be any help because he does not see the connections either and never has been required to operate under the time constraints of medical practice. What Flexner missed was that medical students need to learn a core of behavior, the intellectual behaviors essential to modern science. First identified by Francis bacon four centuries ago, these behaviors include the habitual use of external tools and techniques and standards to produce and manipulate complex information. Yet, in medical education, credentialing and practice these scientific behaviors are conspicuously absent. This gap between the behaviors of scientific and medical practitioners becomes all too obvious when one compares the training and examination of basic science PhD candidates with that of medical students.4 What we are witnessing now is a spectacle of “fragments of intention” that leads to passing exams, getting licenses to practice medicine and finally to the multiple deaths from errors. But the damage to the student and the patients he will see in the future is deeper and longer lasting than we realize because although the faulty system does not give the tools and the competence that good care requires, it does give authority to the physician so trained to go on making mistakes and eventually for some to acquire leadership positions that defend the system that produced them. A critical point in the journey of a medical student through medical school is the day he is asked to actually work-up a patient with a problem. For example if the problem is a complaint of abdominal pain, does the student know the 70 plus causes of abdominal pain and the combination of findings on history and physical examination for each cause as he starts to work up the patient. Since no one could know all that, does the student hesitate and say to the resident in charge, “I feel anxious and insecure because I do not know all I should know to serve this patient properly,” and then refuse to go on? Does the resident say “be a big boy and do the best you can. We all have to go through these clerkships to develop clinical judgment and become a physician.”? How many of us in our training have answered: “It is not a question of my being willing to keep going and becoming a physician that tried to learn clinical judgment from experience. It is a question of whether I want to stay in a faulty system that puts patients at risk while I advance my career and lose my scientific integrity.” How many colleges focus on MCAT scores and just on getting their pre-med students into medical school and ignore having them understand what is going on in medical schools before they ever get into the position that the student just described finds himself. Pre-med students should be reading Francis Bacon and preparing themselves to recognize phrases like “clinical judgment” as one of Bacon’s “Idols of the Mind” that lead us into fallacies. They should be reading the philosopher Whitehead who wrote in 1911: “It is a profoundly erroneous truism that we should cultivate the habit of thinking about what we are doing. The precise opposite is the case. Civilization advances by extending the number of important operations which we can perform without thinking about them.”5 They should be studying a recent article6 on diagnostic error that states: Diagnostic failure results from misplaced dependence on the clinical judgments of expert physicians. The remedy for diagnostic failure involves defining standards of care for managing clinical information (medical knowledge and patient data), and implementing those standards with information tools designed for that purpose. These standards and tools are external to the minds of physicians, thus bypassing two inherent constraints on human cognition: limited [2]

capacities for information retrieval and processing, and innate heuristics and biases. Medical education and credentialing socialize physicians into misplaced acceptance of these constraints. Medical students acquire scientific knowledge, but not scientific behaviors. A scientific approach to diagnosis begins with using information tools to identify all diagnostic possibilities for the presenting problem and the initial findings needed to determine which possibilities are worth investigating in the patient. If the initial findings do not reveal a clear diagnostic solution, then information tools must be employed as part of a system of care to enforce highly organized follow-up processes, that is, careful problem definition, planning, execution, feedback, and corrective action over time, all documented under strict standards of care for managing the complexities involved. The thoughtful pre-medical student who reads the above may conclude that he does not want to be a traditional physician that goes through the present system of medical education and care but would rather seek to be part of a system of care that provides information tools adequate to meet the standard of care and training programs for individuals who want to become competent in the use of those tools in the part of the system they choose to function, much as a pilot learns to function safely as part of the transportation system. Before presenting a diagram of what a transformed system of medical education and care should look like, let us review the need for, and difficulties in achieving, such a transformation. Consider a distinction between two different types of health information: patient data and medical knowledge. Patient data resides in medical record repositories, while medical knowledge is transmitted from external text repositories (medical libraries and journals) to the minds of physicians. Their minds serve as intermediate knowledge repositories for use in patient care. Then, in patient care, physician minds perform an information processing function: matching knowledge with patient data. These repository and processing functions far exceed the capacities of the human mind. Moreover, even in situations where the mind’s information processing capacities are sufficient, reliance on the mind introduces disorder and undermines transparency, coordination, productivity, feedback, and improvement. The outcome is to cripple the entire health care system. Misguided reliance on the human mind causes a fatal voltage drop in transmission of medical knowledge from its original repositories in libraries and journals to its intended beneficiaries in patient care. The apparent solution to this voltage drop is information technology. Technology’s superior capacity to perform repository and processing functions has led everyone to hope that IT will somehow generate huge gains in quality and efficiency. All that is needed, on this view, is to define “meaningful use” of IT, as a condition for subsidizing its purchase. Yet, the current hopes for health IT are doomed to disappointment. Misguided reliance on the human mind is deeply embedded in the formative social institutions of medical practice—graduate medical education, credentialing systems, reimbursement, entitlements, the doctor-patient relationship. A wrenching transformation in those institutions would be the outcome of demanding truly “meaningful use” of health IT. That is far from happening. On the contrary, the culture of medicine is in a state of denial about the breadth and depth of the transformation that must come about—a transformation that ends the era of autonomous physicians and the medical schools that the Flexner report led to and begins the era of a system of medical care where knowledge is in tools and [3]

where people are trained to use those tools and trained to perform the actions in medicine that the tools recommend. Other fields of expertise have found that external tools do not destroy what is best in those fields. Beryl Markham discussed this phenomenon in her reminiscences about flying. On the attitude of an older pilot who resisted instrument-controlled flying, she wrote: After this era of great pilots has gone, as the era of great sea captains has gone—each nudged aside by the march of inventive genius, by steel cogs and copper discs and hand thin wires on white faces that are dumb, but speak—it will be found, I think, that all the science of flying has been captured on the breadth of an instrument board, but not the religion of it.7 The following diagram shows what the transformed system would look like. In understanding this diagram, one should keep in mind the following assertions: 1. The medical care system should be like the travel system, in which from childhood the traveler learns how to use the system to reach goals and destinations. Knowledge is built into the tools used to function within the system. It is not built into the traveler’s head or into the head of someone who is paid to guide the traveler through the system. 2. All users of the medical care system should read Appendix B of Medicine in Denial, entitled “Scientific principles that tell us why people must manage their own health care.” 3. People are trained to do for the patient those tasks and procedures that guidance within the system suggest but which the patient cannot do for himself. 4. Reading Chapter 13 by Kenneth Bartholomew in the book Knowledge Coupling and reading the book itself and the book Medicine in Denial equip the reader to better understand the need for, and practical application of, the system of care described in the diagram.

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Explanation of terms in the diagram Knowledge Net: An organized collection of the entities (objects) of medical knowledge and the relationships among them, with commentary on the relationships. Couplers: A specific implementation of a generic concept, referred to as knowledge coupling tools. A Coupler is oriented around a problem, and is concerned with the diagnosis or the management of that problem. It is built from knowledge components drawn from the Knowledge Net. Most importantly, the relationships captured there become “voting” relationships in a Coupler, between possible findings, and possible diagnoses (as evidence or risk factors) or options for management (as “pros” or cautions). To be safe and effective and productive, software and knowledge bases of this kind must be designed to implement rigorous standards of care for selection and analysis of patient data in light of medical knowledge. These standards are based on a combinatorial approach (as distinguished from judgmental, algorithmic, and probabilistic approaches) to generating hypotheses and evidence.

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Together, the combinatorial standard for knowledge coupling and the POMR standard for medical records constitute generic standards of care for managing clinical information. These are standards that apply universally to medical problems and practice settings of all kinds. The notion of such universality may seem simplistic and naïve in the context of health care, with its extraordinary diversity and complexity. But the science of complex adaptive systems shows that simplicity and universality are essential goals for a complex activity such as health care. And part V of Medicine in Denial shows how these goals have been attained in two complex domains where health care operates—science and commerce. Health care lags centuries behind those domains in its lack of simple, universal standards of care for managing information. Those standards must be specific, operational and yet generic. And corresponding information tools must be usable jointly by all caregivers, by patients/consumers and by third parties (clinical researchers, regulators, payers). Standards and tools of that kind provide a necessary foundation for health care reform in general and, in particular, a foundation for reform concepts such as “patientcentered” and “consumer-driven” care, “medical home,” “pay-for-performance," “comparative effectiveness research,” and “meaningful use” of health IT. What needs to be built on that foundation is a unified system of patient-driven care, medical education, and clinical research, a system that harvests continuous feedback on provider performance, patient behaviors and medical knowledge. Medical education would mean instilling a core of behavior, not transmitting a core of knowledge, producing trustworthy practitioners, not fallible repositories of knowledge. Feedback for practitioners would be based on defined inputs and audit of performance under defined rules. Feedback for patients would be based on intelligible medical records revealing the exact connections between their own behaviors, their social environments and their medical problems. Feedback on medical knowledge would be continually harvested from medical records, coupled with scientific research and translated into precisely relevant, usable, new knowledge, accessed instantly through continually updated knowledge coupling tools. “Evidence-based medicine” would be transformed from standardized into highly individualized guidance for decisions. The surrounding support systems for patient care—regulators such as the FDA, public health agencies such as the CDC, drug and device vendors, educational and credentialing institutions, third party payers—all could function in a coordinated way, with better information than ever before. A patient-driven marketplace could evolve where advanced medical technologies would be selected not for raising provider incomes bur rather for their power to improve patient outcomes and lower everyone’s costs. Above all, patients could navigate a transparent and trustworthy system of care, empowered to manage their own health and their own care. ▪

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Marshall Allen, "How Many Die From Medical Mistakes in U.S. Hospitals?" ProPublica, 19 Sep 2013.

Accessed at: http://www.propublica.org/article/how-many-die-from-medical-mistakes-in-us-hospitals 2

Weed, LL., et al., Knowledge Coupling: New Premises and New Tools for Medical Care and Education, New York: Springer-Verlag, 1991. (See Chapter 13.) 3 Weed, LL., Weed, LD., Medicine in Denial, [Createspace], 2011. 4 Weed, LL., et al., Medical Records, Medical Education, and Patient Care, Cleveland: Case Western Reserve University Press (1969). (See the Introduction.) 5 Alfred North Whitehead, An Introduction to Mathematics, 1911.

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Weed, L. L. & Weed, L. (2014). Diagnosing diagnostic failure. Diagnosis, 1(1), 13–17. doi:10.1515/dx-2013-0020 Beryl Markham, West with the Night, 1942.

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