The effect of problem-oriented medical records on clinical management controlled for patient risks

Problem-oriented documentation: design and widespread adoption of a novel toolkit in a commercial electronic health record

Background

Problem-oriented documentation is an accepted method of note construction which facilitates clinical thought processes. However, problem-oriented documentation is challenging to put into practice using commercially available electronic health record (EHR) systems.

Objective

Our goal was to create, iterate, and distribute a problem-oriented documentation toolkit within a commercial EHR that maximally supported clinicians' thinking, was intuitive to use, and produced clear documentation.

Materials and Methods

We used an iterative design process that stressed visual simplicity, data integration, a predictable interface, data reuse, and clinician efficiency. Creation of the problem-oriented documentation toolkit required the use of EHR-provided tools and custom programming.

Results

We developed a problem-oriented documentation interface with a 3-column view showing (1) a list of visit diagnoses, (2) the current overview and assessment and plan for a selected diagnosis, and (3) a list of medications, labs, data, and orders relevant to that diagnosis. We also created a series of macros to bring information collected through the interface into clinicians' notes. This toolkit was put into a live environment in February 2019. Over the first 9 months, the custom problem-oriented documentation toolkit was used in a total of 8385 discrete visits by 28 clinicians in 13 ambulatory departments. After 9 months, the go-live education and EHR optimization teams in our health system began promoting the toolkit to new and existing users of our EHR resulting in a significantly increased uptake by outpatient clinicians. In April 2022 alone, the toolkit was used in more than 92 000 ambulatory visits by 894 users in 271 departments across our health system.

Conclusions

As a health-system client of a commercial EHR, we developed and deployed a revised problem-oriented documentation toolkit that is used by clinicians more than 92 000 times a month. Key success elements include an emphasis on usability and an effective training effort.

Problem-oriented charting: A review

Problem-oriented charting is form of medical documentation that organizes patient data by a diagnosis or problem. In this review, we discuss the history and current use of problem-oriented charting by critically evaluating the literature on the topic. We provide insights with regard to our own institutional use of problem-oriented charting and potential opportunities for research.

Bringing science to medicine: an interview with Larry Weed, inventor of the problem-oriented medical record

Larry Weed, MD is widely known as the father of the problem-oriented medical record and inventor of the now-ubiquitous SOAP (subjective/objective/assessment/plan) note, for developing an electronic health record system (Problem-Oriented Medical Information System, PROMIS), and for founding a company (since acquired), which developed problem-knowledge couplers. However, Dr Weed's vision for medicine goes far beyond software--over the course of his storied career, he has relentlessly sought to bring the scientific method to medical practice and, where necessary, to point out shortcomings in the system and advocate for change. In this oral history, Dr Weed describes, in his own words, the arcs of his long career and the work that remains to be done.

Creating a culture of thoughtful prescribing

BACKGROUND

In the Netherlands 170,000 patients yearly fall victim to poor communication between health care professionals,with 44% of patients receiving inappropriate therapy as a result. Evidence indicates that this problem may be due to physicians learning to communicate therapeutic content by unstructured means during training.

AIM

To introduce a structured format for creating and communicating therapeutic plans; to provide for students opportunities to practice and feedback on their abilities.

METHODS

We developed the Individualized Therapy Evaluation and Plan (ITEP) for therapeutic decision-making and communication based on the subjective objective assessment and plan note. The therapeutic plans from students of the 2003 cohort were assessed with one simple and one complex case using a 15-point criteria form. Over the next 3 years students were given more practice using the ITEP and the average score on the complex case was tracked and compared to the 2003 cohort.

RESULTS

In cohort 2003, 82% of the students satisfactorily completed the simple case, while only 32% did so with the complex case. In subsequent years, the average scores on the complex case significantly improved from 3.8 to 6.8 with increasing practice.

CONCLUSIONS

Students can select a simple drug regimen, but without practice using the ITEP will not help to deal with multiple disease states.

Design should help use of patients' data

Checklists and other tools help doctors to use published evidence in clinical practice. Two other important sources of evidence, however, are the patient and his or her medical record. This series aims to advance the practice of evidence-based medicine by helping in redesign of medical records, drawing on insights from psychology, information design, and medical informatics; and by promoting changes analogous to those occurring in the medical literature. The four papers look at: the uses of medical records and importance of organising them so doctors can use the data they contain; different methods doctors use to search for data and how design of records can help or hinder these approaches; how we interpret data once found, and how record formatting assists this process; and the issues raised by computerisation of records.

Clinical Audit: Measuring the Quality of Individual Clinical Performance

Measurement of quality of performance is increasingly seen as part of the provision of a service within the National Health Service. This article describes how a group of occupational therapists in Southampton and South West Hampshire looked at a process known as clinical audit that is practised within the medical profession to see if it would be a suitable method of evaluating performance within occupational therapy. The group viewed it as a most suitable method and this study will be followed by pilot studies of the practice of clinical audit.

Increase in relevant data after introduction of a problem-oriented record system in primary pediatric care

We determined the effect of the problem list and standard data base components of the problem-oriented record (POR) on kibbutz clinic care. We compared quantity and type of data collected and number of problems identified before and after POR implementation at an experimental clinic with the same variables measured at a similar clinic. Family history, prenatal, natal, nutritional, immunization, environment, review of systems, psychosocial and total data collected, as well as number of chronic problems identified, increased significantly after POR implementation.

Controversy: pomr-the case in favour

The subject of medical records is not popular with clinicians these days. Having to see patients in the clinic without their notes is too common an experience, and one which raises the blood pressure of both doctor and patient. Paradoxically though, it does force us reluctantly to concede that these maligned documents do have a purpose. It might even persuade us that it is illogical to attach so much importance to them when they are missing, and to treat them with such indifference when they are not.