How EHR came to be (or why doctors aren’t like airline pilots)

How EHR came to be (or why doctors aren’t like airline pilots)

April 25

After my recent posts about EHR (Electronic Health Records), my friends over at StorageCraft asked me if I knew any of the history behind them. So I did some web-based research and found out a few things:

The origin of the technical component of EHR is muddled. Several writers, including Houston Neal, said Lockheed developed and deployed the first “Clinical Data Management System” at El Camino Hospital in Mountain View, Calif. sometime in the mid-1960s. Others mentioned that Latter Day Saints Hospital in Salt Lake City, Utah implemented “Health Evaluation Through Logical Programming (HELP)” software in 1967. Meanwhile, Steve Lohr of The New York Times digs up information about a joint initiative between IBM and Akron Children’s Hospital back in 1962, although strangely no one currently working at the hospital knows how the program fared or when it was shelved.

However, the architect of the present-day EHR concept – where these records would provide a comprehensive patient history that other doctors, healthcare professionals, and even the patients themselves could follow – seems clear. Back in the 1960s, Lawrence L. Weed, MD, a Vermont-based doctor and researcher, found that the current state of “source-oriented” medical records contained lots of unrelated, uncorrelated, and incomplete information about a patient that was impossible to follow even if the doctor reviewing the records had superhuman memory skills.

Weed supplies examples of the problem with old-school source-oriented medical records in a 1971 video that I recommend watching if you have 53 minutes to spare (and don’t be scared off by either the length or quality of the video because Dr. Weed is a charismatic, captivating speaker – who’d a thought?). Holding a thick paper file, Dr. Weed describes the problems with source-oriented records, particularly when a patient has multiple conditions.

For example, he finds uncorrelated information about ear cultures and urine cultures, along with an order sheet for penicillin within this patient’s file and asks rhetorically.

Is she [the patient] urinating in her ear? And I don’t know if [the penicillin is] for her urinary tract infection, her pneumonia, or her inner ear because it doesn’t say!


After some laughter from the audience, Dr. Weed goes into the meat of the problem:

This is not an idle discussion of little technical bookkeeping details. The way you handle data determines how you think. Because of the multiple variables, the structure of the data determines the quality of output… A source-oriented record is essentially useless from the point of view of a rigorous audit. And if you can’t audit a thing, it means you do not have the means by which to produce quality. They’re inextricably intertwined.

In the late 1960s, Dr. Weed developed what he called the “Problem-Oriented Medical Record (POMR)” that has become a worldwide standard in the way EHRs are organized.

In a 2009 interview conducted by Lee Jacobs, MD, Dr. Weed discussed why he developed the POMR methodology.

The beginning clinical clerk, the new intern, and the practicing physician are confronted with an apparent contradiction. Each is asked, as a ‘whole’ physician, to accept the obligations of meeting many problems simultaneously and yet to give to each the single-minded attention that is fundamental to developing and mobilizing his or her enthusiasm and skill, for these two virtues do not arise except where an organized concentration upon a particular subject is possible.

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 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.

Dr. Weed, who turns 91 later this year, is still advocating the need for EHR, as well as his SOAP (Subjective, Objective, Assessment, Plan) format for documenting patient progress. At a recent conference, Dr. Weed discussed why medical education has been so resistant to the latter, after recalling a student asking him “why airplane pilots are so willing to undergo such rigorous training, testing and discipline, but medical students are not. I said, ‘Well, it’s because the pilot has to get in the plane. You don’t have to go up on the operating table.’”

Photo credit: Wikimedia commons