An Alternative Paradigm for Evidence-Based Medicine: Revisiting Lawrence Weed, MD’s Systems Approach

Abstract

Lawrence Weed, MD, is renowned for being the father of the Problem-Oriented Medical Record (POMR), the medical care standard for collecting, managing, and contextualizing patient data in medical records. What have been consistently overlooked are his teachings on knowledge coupling, which refers to matching patient data with associated medical knowledge. Together, the POMR standard and knowledge coupling are meant to form the basis of a systems approach that enables individualized evidence-based decision making within the context of multimorbidity and patient complexity.The POMR and knowledge coupling tools operationalize a problem-oriented model that reflects a sophisticated general systems theoretical approach to knowledge. This paradigm transcends reductionist approaches to knowledge by depicting how the meaning of specific entities (eg, disease constructs) and their associated probabilities can only be understood within their respective spatiotemporal and biopsychosocial relational contexts. Rigorous POMRs therefore require knowledge inputs from a network of interconnections among specific entities, which Dr Weed enabled through development of the Knowledge Net standard. The Knowledge Net's relational structure determines the applicability of knowledge within specific patient contexts. To enable the linkage of unique combinations of data in individual patient POMRs with existing medical knowledge structured in Knowledge Nets, Dr Weed developed the Knowledge Coupling standard.Dr Weed's standards for record keeping and knowledge coupling form the basis of a combinatorial approach to evidence-based medicine that fulfills Stange's call for a science of connectedness. Ensuing individualized processes of care become the dynamo powering a learning health care system that enables a co-construction of health premised on empowerment and intelligent human decision making, rather than promoting the artificial intelligence of tools. If the value of Engel's biopsychosocial model indeed relates to "guiding the parsimonious application of medical knowledge to the needs of each patient," Dr Weed's approach warrants serious consideration.

A problem-oriented systems approach to primary care system development: development and initial testing of the problem-oriented primary care system development record

“…Systems-oriented evidence-based decision making is contingent on the application of scientific knowledge to problems and issues of concern within particular contexts [6]. For this to occur, knowledge must be systematically structured in a way that is rational, conceptually sound and valid [16,17,30]. The structuring, application and development of knowledge require robust data input and management systems [3].…”

“…A relational database enables data to be structured and stored in the form of a semantic network [ 27 ]. This approach to structuring knowledge operationalizes a systems paradigm, whereby knowledge is conceived as a complex network of relationships [ 16 , 17 ]. The relational database provides a framework that captures statements regarding the content and dynamics of relationships between the PCSDR’s fields.…”

“…Problem-orientation enables the PCSDR to structure and contextualize interactions in a way that renders performance states and commensurate development functions meaningful. Problem-orientation is premised on a pragmatist philosophical conception of knowledge as problem-solving, and is one of the principal attributes for the domain of systems-oriented policy science [ 16 – 19 ].…”

“…Operationalizing the electronic record using a relational database enables data to be structured as knowledge in the form of a semantic network. This approach operationalizes a systems paradigm, whereby knowledge is conceived as a network of interconnections of constituent entities [16,17]. Knowledge is represented by the network itself, which is quite literally more than the sum of its individual entities [17,21].…”