Determinants of a successful problem list to support the implementation of the problem-oriented medical record according to recent literature

Sereh M J Simons, Felix H J M Cillessen, Jan A Hazelzet, Sereh M J Simons, Felix H J M Cillessen, Jan A Hazelzet

Abstract

Background: A problem-oriented approach is one of the possibilities to organize a medical record. The problem-oriented medical record (POMR) - a structured organization of patient information per presented medical problem- was introduced at the end of the sixties by Dr. Lawrence Weed to aid dealing with the multiplicity of patient problems. The problem list as a precondition is the centerpiece of the problem-oriented medical record (POMR) also called problem-oriented record (POR). Prior to the digital era, paper records presented a flat list of medical problems to the healthcare professional without the features that are possible with current technology. In modern EHRs a POMR based on a structured problem list can be used for clinical decision support, registries, order management, population health, and potentially other innovative functionality in the future, thereby providing a new incentive to the implementation and use of the POMR.

Methods: On both 12 May 2014 and 1 June 2015 a systematic literature search was conducted. From the retrieved articles statements regarding the POMR and related to successful or non-successful implementation, were categorized. Generic determinants were extracted from these statements.

Results: In this research 38 articles were included. The literature analysis led to 12 generic determinants: clinical practice/reasoning, complete and accurate problem list, data structure/content, efficiency, functionality, interoperability, multi-disciplinary, overview of patient information, quality of care, system support, training of staff, and usability.

Conclusions: Two main subjects can be distinguished in the determinants: the system that the problem list and POMR is integrated in and the organization using that system. The combination of the two requires a sociotechnical approach and both are equally important for successful implementation of a POMR. All the determinants have to be taken into account, but the weight given to each of the determinants depends on the organizationusing the problem list or POMR.

Keywords: Electronic Health Record; Implementation; Problem-oriented medical record; Review.

References

    1. [cited 2016 04–05]; Available from: .
    1. Shea CM, et al. Assessing organizational capacity for achieving meaningful use of electronic health records. Health Care Manage Rev. 2014;39(2):124–133. doi: 10.1097/HMR.0b013e3182860937.
    1. [27-11-2015]; Available from: .
    1. Weed, L.L., Special article: Medical records that guide and teach. New England Journal of Medicine. 1968: .
    1. Salmon, P., et al., Taking the problem oriented medical record forward. Proc AMIA Annu Fall Symp, 1996: p. 463–7.
    1. Wright A, et al. Increasing patient engagement: patients’ responses to viewing problem lists online. Appl Clin Inform. 2014;5(4):930–942. doi: 10.4338/ACI-2014-07-RA-0057.
    1. Bormel J. Problem lists are the keys to meaningful use. Put the big picture on your problem list. Health Manag Technol. 2011;32(2):40–41.
    1. Bossen C. Accounting and co-constructing: the development of a standard for electronic health records. 2011.
    1. Holmes C. The problem list beyond meaningful use. Part I: The problems with problem lists. J AHIMA. 2011;82(2):30–33.
    1. Kouematchoua Tchuitcheu G, Rienhoff O. Options for diabetes management in sub-Saharan Africa with an electronic medical record system. Methods Inf Med. 2011;50(1):11–22. doi: 10.3414/ME09-01-0021.
    1. Scichilone RA. Standardizing problem lists in physician practices. J AHIMA. 2011;82(11):50–51.
    1. Wright, A., F.L. Maloney, and J.C. Feblowitz, Clinician attitudes toward and use of electronic problem lists: a thematic analysis. BMC Med Inform Decis Mak, 2011. 11((Wright A.) Brigham and Women’s Hospital, Boston, MA, USA.): p. 36.
    1. Cillessen FH, de Vries Robbe PF. Modeling problem-oriented clinical notes. Methods Inf Med. 2012;51(6):507–515. doi: 10.3414/ME11-01-0064.
    1. Holmes, C., et al., Healthcare provider attitudes towards the problem list in an electronic health record: a mixed-methods qualitative study. BMC Med Inform Decis Mak, 2012. 12((Holmes C.) Brigham and Women’s Hospital, 1 Brigham Circle, Boston, MA 02120, USA.): p. 127.
    1. Wright A, et al. Improving completeness of electronic problem lists through clinical decision support: A randomized, controlled trial. J Am Med Inform Assoc. 2012;19(4):555–561. doi: 10.1136/amiajnl-2011-000521.
    1. Cimino JJ. Improving the electronic health record—are clinicians getting what they wished for? JAMA. 2013;309(10):991–92. doi: 10.1001/jama.2013.890.
    1. Luna D, et al. Accuracy of an electronic problem list from primary care providers and specialists. Stud Health Technol Inform. 2013;192:417–421.
    1. Acker B, et al. Problem list guidance in the EHR. J AHIMA. 2011;82(9):52–58.
    1. Campion FX, Richter JM. High-level adoption of electronic health records. J Med Pract Manage. 2011;27(1):50–56.
    1. Pacheco, J.A., W. Thompson, and A. Kho, Automatically detecting problem list omissions of type 2 diabetes cases using electronic medical records. AMIA Annu Symp Proc, 2011. 2011((Pacheco J.A.) Northwestern University Feinberg School of Medicine, Chicago, IL, USA.): p. 1062–1069.
    1. Wright A, et al. A method and knowledge base for automated inference of patient problems from structured data in an electronic medical record. J Am Med Inform Assoc. 2011;18(6):859–867. doi: 10.1136/amiajnl-2011-000121.
    1. Matney SA, et al. Development of the nursing problem list subset of SNOMED CT (registered trademark) J Biomed Inform. 2012;45(4):683–688. doi: 10.1016/j.jbi.2011.12.003.
    1. Wright A, et al. Use of an electronic problem list by primary care providers and specialists. J Gen Intern Med. 2012;27(8):968–973. doi: 10.1007/s11606-012-2033-5.
    1. Collins S, et al. A continuum of sociotechnical requirements for patient-centered problem lists. Stud Health Technol Inform. 2013;192:889–893.
    1. Falck S, et al. A trial of indication based prescribing of antihypertensive medications during computerized order entry to improve problem list documentation. Int J Med Inform. 2013;82(10):996–1003. doi: 10.1016/j.ijmedinf.2013.07.003.
    1. Galanter W, et al. Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE) J Am Med Inform Assoc. 2013;20(3):477–481. doi: 10.1136/amiajnl-2012-001555.
    1. Kadlec L. Resolving problem list problems. HIM’s role in maintaining an effective EHR problem list. J AHIMA. 2013;84(11):58–59.
    1. Makam AN, et al. Use and satisfaction with key functions of a common commercial electronic health record: a survey of primary care providers. BMC Med Inf Decis Mak. 2013;13:86. doi: 10.1186/1472-6947-13-86.
    1. Plazzotta F, et al. Natural language processing and inference rules as strategies for updating problem list in an electronic health record. Stud Health Technol Inform. 2013;192:1163.
    1. Ancker JS, et al. How is the electronic health record being used? Use of EHR data to assess physician-level variability in technology use. J Am Med Inform Assoc. 2014;21(6):1001–1008. doi: 10.1136/amiajnl-2013-002627.
    1. Samal L, et al. Electronic problem list documentation of chronic kidney disease and quality of care. BMC Nephrol. 2014;15(1):1–6. doi: 10.1186/1471-2369-15-70.
    1. Kumarapeli P, De Lusignan S. Using the computer in the clinical consultation; setting the stage, reviewing, recording, and taking actions: Multi-channel video study. J Am Med Inform Assoc. 2013;20(E1):e67–e75. doi: 10.1136/amiajnl-2012-001081.
    1. Walton SM, et al. A trial of inpatient indication based prescribing during computerized order entry with medications commonly used off-label. Appl Clin Inform. 2011;2(1):94–103. doi: 10.4338/ACI-2010-11-RA-0072.
    1. McCoy AB, et al. Development and evaluation of a crowdsourcing methodology for knowledge base construction: identifying relationships between clinical problems and medications. J Am Med Inform Assoc. 2012;19(5):713–718. doi: 10.1136/amiajnl-2012-000852.
    1. Hodge CM, et al. Problem management module: an innovative system to improve problem list workflow. AMIA Annu Symp Proc. 2014;2014:661–670.
    1. Mehta N, Vakharia N, Wright A. EHRs in a web 2.0 world: time to embrace a problem-list wiki. J Gen Intern Med. 2014;29(3):434–436. doi: 10.1007/s11606-013-2652-5.
    1. Walsh CG, et al. Enabling claims-based decision support through non-interruptive capture of admission diagnoses and provider billing codes. AMIA Annu Symp Proc. 2014;2014:1950–1959.
    1. Mowery D, et al. Building an automated SOAP classifier for emergency department reports. J Biomed Inform. 2012;45(1):71–81. doi: 10.1016/j.jbi.2011.08.020.
    1. Klann JG, et al. Health care transformation through collaboration on open-source informatics projects: integrating a medical applications platform, research data repository, and patient summarization. Interact J Med Res. 2013;2(1):e11. doi: 10.2196/ijmr.2454.
    1. Bredfeldt CE, et al. Training providers: beyond the basics of electronic health records. BMC Health Serv Res. 2013;13:503. doi: 10.1186/1472-6963-13-503.
    1. Feblowitz J, et al. Provider use of and attitudes towards an active clinical alert: a case study in decision support. Appl Clin Inform. 2013;4(1):144–152. doi: 10.4338/ACI-2012-12-RA-0055.
    1. Bakel LA, et al. A quality improvement study to improve inpatient problem list use. Hosp Pediatr. 2014;4(4):205–210. doi: 10.1542/hpeds.2013-0060.

Source: PubMed

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