Acta Clinica Belgica International Journal of Clinical and Laboratory Medicine
ISSN: 1784-3286 (Print) 2295-3337 (Online) Journal homepage: http://www.tandfonline.com/loi/yacb20
A Clinical Experiment With The Problem Oriented Medical Record J. van Egmond To cite this article: J. van Egmond (1975) A Clinical Experiment With The Problem Oriented Medical Record, Acta Clinica Belgica, 30:5, 349-355, DOI: 10.1080/17843286.1975.11717021 To link to this article: https://doi.org/10.1080/17843286.1975.11717021
Published online: 21 May 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=yacb20
349
A CLINICAL EXPERIMENT WITH THE PROBLEM ORIENTED MEDICAL RECORD*
J. van EGMOND**
I. INTRODUCTION
The analysis of the value of the medical record, actually used in patient care, reveals many problems, e.g. : - the fact that many complaints of the patient and many abnormal findings are not clearly solved by well-stated decisions. This observation rises the question as to there is incompleteness in the decision making process during patient care; - the fact that the record is not a good means of communication with colleagues, since it does not provide a clear, well ordered survey of all the events in the patient's medical life. The Problem Oriented Medical Record (P.O.M.R. (4, 5)) could solve (l, 2, 3) these difficulties as it provides a list of all problems which need decisions, and also because its very structure-in fact a system of progress notes-facilitates the understanding of the patient's status. II. AIMS OF THE EXPERIMENT
In order to evaluate the practical feasibility and usefulness of the list. of problems-the comerstone of the P.O.M.R.-an experiment was organized in an ambulatory ward of the Depart• This study was performed with grant NR. ERT/20-21/19 of the lnterministery Committee of Scientific Policy of Bel· gium. •• Medische Informatica Gent (Dir. Prof. Dr. R.J. Wieme), De Pintelaan 135, 9000 Gent.
ment of Internal Medicine of the State University of Gent. Three main questions were studied: - is the elaboration of a list of problems practically possible? - does this elaboration of the list of problems stimulate the physician to state clearly the decisions for each problem? - is a list of problems of help in the communication between the different physicians involved · in patient care? Ill. METHODOLOGY
The basic concepts of the study have been summarized in figure I. A patient consults a physician because he has complaints or because he is sent as a result of an examination. The physician is faced with a list of diagnostic problems which each will be solved by a diagnostic decision (diagnosis). Then therapeutic problems arise, resulting in therapeutic decisions: the prescription of treatments. It was agreed that the list of problems should be restricted to the diagnostic problems. All subjective and objective signs and symptoms were to be registered on a special form (figure 2). This form should mention all anamnestic and all actual problems. The list of problems should already reflect a certain interpretation of the signs and symptoms. Therefore, although all problems had to be listed, the problems were brought together in numbered problem-groups according to their apparent relations. It was stressed that the numeration of ACia Clinica Belgica. 30, 5 (1975)
350
CLINICA L EXPERIENCE WITH P.O.M.R.
Diagnostic p r oblems
investiga t ions
/
B
Diagnos t tc decis ion
making
DIAGNOSIS
..-------"----/ ~ Therapeutic problems
l Therapeutic deciston making TR EATMENT
Fig. 1 - Basic concepts of the clinical experiment with the P.O.M.R . the problem-groups should start at birth and should continue sequentially during the whole life of the patient. For each problem a diagnostic decision was to be written next to the problem and, if relevant , the therapeutic prescriptions would also be addeq. As the forms were to be filled in during the first' contact of the patient with the physician , the following rule for selection of the patients of the ward was applied: the physician uses the forms only for new patients and only if the physician is not overloaded with incoming patients. This selection rule was maintained although it became quickly evident that the physicians completed the form at the end of the observation of the patient. Acta C/inica Belgica. 30, 5 (19 75)
Before the experiment the collaborators were motivated by arguments about the expected medical , educational and scientific value of the list of problems. Later on regular contacts were maintained with the organizers of the experiment. Two teams of 4 assistants in internal medicine worked each for two months with the forms , elaborating 400 lists of problems with corresponding decisions. IV. RESULTS OF THE EXPERIMENT
A. General results The trial of 4 months proved extremely interesting as several new aspects of the " list of problems, were revealed .
351
CLINICAL EXPERIENCE WITH P.O.M.R. M,l,G, LlJ ST
A..z.
PIJ.ATJJI
VA.N
PROBLlli!BI I.P.
IDENTIFICATIE
DAT.
Nr, SUBJ. CJBJ . SYMPTOM£N
DIAGNOS.Ii
BJlliANDJ:;LING
DAT.
Fig. 2- Lay-out of the form used for the registration of the anamnestic and actual problems. 1. The definition of a "diagnostic problem" as being congruent with all that the patient presents and that needs a diagnostic decision, is in actual practice a too general approach. The patient is often referred to a department of internal medicine with very specific questions, such as: - is the patient able to support surgery; - has the patient a specific illness; - screening examination. These problems, a result of the adaptation of medicine to the development of indepen-
dent medical subspecialities, form a not yet defined type of problems: the questions of one subspeciality to another concerning particular aspects of the patient. 2. It also became evident that our physicians are more used to think in terms of (differential) diagnosis than in terms of problems. 3. The clear formulation of the problems of a patient is difficult. It asks for a high degree of medical training and for a large amount of experience. Above all, it requires time necessary for an exact and objective evaluation Acta Clinica Belgica. 30, 5 (1975)
352
CLINICAL EXPERIENCE WITH P.O.M.R.
of the patient's situation and for the registration of the problems . This time aspect resulted in a complete change of the set-up of the project : instead of being used during the entire observation, the forms were completed at the end of the observations, just before or after the moment of writing the concluding letter to the family physician. At this moment a problem of duplications of effort arises and the list of problems is no more of great help to patient care. B. Detailed analysis of 400 forms In order of having more concrete ideas about the · practical value of the "list of problems" , 400 forms were analyzed in great detail. a) General Comments
cians became convinced of the usefulness of the "problem-oriented approach" and that they succeeded in the elaboration of very clear documents. 2. The decision making process - some new terms had to be introduced as preliminary diagnostic statements, e.g. "further investigation is necessary", .. . ; - sometimes a treatment was mentioned without a diagnosis; - for ± 10% of the records no diagnostic decision was registered for the listed problems. 3. Numeration of the problems - the collaborating physicians divided in almost all cases the life of a patient into two independent parts: the past history and the actual situation. This attitude was expressed by the fact that the numeration started almost always again at I for the actual problems in spite of already numbered anamnestic problems. In addition, in some forms the same problem received two different numbers, one in the past, another in the present history; - it was also easier to number the anamnestic problems (well defined situations) than the actual problems. Whereas about 60 % of the registered anamnestic problems were numbered, only about 40 % of the actual problems received a number.
In contrast to all expectations it appeared that the lists were not easy to interprete, a consequence of many factors, some of them being : - the lay-out of the forms; - the difficulties of formulation, recording and numeration of the problems and problemgroups. So one person , well-trained in the use of P.O.M.R., examined all forms and reordered them . No feed-back to the original responsible physician was possible as this physician was not asked to sign the forms and therefore could not be traced back. This analysis revealed several features concerning the practical implementation of the P.O.M.R. in the actual medical care of the patient:
4. The anticipated communicability of the list of problems was in most cases not achieved.
1. Formulation of the problem - m3;ny forms did not give a list of problems, but a list of possible diagnoses. This confirms the idea that the physician is more a diagnosis-solver than a patient's problemsolver; - it became also evident that the definition of a problem-group as a set of related problems is very difficult. Most often the signs and symptoms were listed without any attempt to bring them together; - a positive aspect is the fact that two physi-
b) Analysis of the Registered Problems 1. The distribution of the patients (table l) in the different age groups is similar for women and men and rather typical for the new-patient population of the ambulatory ward of the Department of Internal Medicine. 2. As the detailed analysis of the forms required an interpretation of the registered information, all following figures are the result of the approach of one person to all different forms . So the figures can only be considered to give pragmatic indications about the number of
Acta C/inica Belgica, 30, 5 (1 975)
CLINICAL EXPERIENCE WITH P.O.M.R.
353
2. it is not possible to draw any conclusion
Table 1 Frequency distribution of patients ~
d'
n
n
ISSN: 1784-3286 (Print) 2295-3337 (Online) Journal homepage: http://www.tandfonline.com/loi/yacb20
A Clinical Experiment With The Problem Oriented Medical Record J. van Egmond To cite this article: J. van Egmond (1975) A Clinical Experiment With The Problem Oriented Medical Record, Acta Clinica Belgica, 30:5, 349-355, DOI: 10.1080/17843286.1975.11717021 To link to this article: https://doi.org/10.1080/17843286.1975.11717021
Published online: 21 May 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=yacb20
349
A CLINICAL EXPERIMENT WITH THE PROBLEM ORIENTED MEDICAL RECORD*
J. van EGMOND**
I. INTRODUCTION
The analysis of the value of the medical record, actually used in patient care, reveals many problems, e.g. : - the fact that many complaints of the patient and many abnormal findings are not clearly solved by well-stated decisions. This observation rises the question as to there is incompleteness in the decision making process during patient care; - the fact that the record is not a good means of communication with colleagues, since it does not provide a clear, well ordered survey of all the events in the patient's medical life. The Problem Oriented Medical Record (P.O.M.R. (4, 5)) could solve (l, 2, 3) these difficulties as it provides a list of all problems which need decisions, and also because its very structure-in fact a system of progress notes-facilitates the understanding of the patient's status. II. AIMS OF THE EXPERIMENT
In order to evaluate the practical feasibility and usefulness of the list. of problems-the comerstone of the P.O.M.R.-an experiment was organized in an ambulatory ward of the Depart• This study was performed with grant NR. ERT/20-21/19 of the lnterministery Committee of Scientific Policy of Bel· gium. •• Medische Informatica Gent (Dir. Prof. Dr. R.J. Wieme), De Pintelaan 135, 9000 Gent.
ment of Internal Medicine of the State University of Gent. Three main questions were studied: - is the elaboration of a list of problems practically possible? - does this elaboration of the list of problems stimulate the physician to state clearly the decisions for each problem? - is a list of problems of help in the communication between the different physicians involved · in patient care? Ill. METHODOLOGY
The basic concepts of the study have been summarized in figure I. A patient consults a physician because he has complaints or because he is sent as a result of an examination. The physician is faced with a list of diagnostic problems which each will be solved by a diagnostic decision (diagnosis). Then therapeutic problems arise, resulting in therapeutic decisions: the prescription of treatments. It was agreed that the list of problems should be restricted to the diagnostic problems. All subjective and objective signs and symptoms were to be registered on a special form (figure 2). This form should mention all anamnestic and all actual problems. The list of problems should already reflect a certain interpretation of the signs and symptoms. Therefore, although all problems had to be listed, the problems were brought together in numbered problem-groups according to their apparent relations. It was stressed that the numeration of ACia Clinica Belgica. 30, 5 (1975)
350
CLINICA L EXPERIENCE WITH P.O.M.R.
Diagnostic p r oblems
investiga t ions
/
B
Diagnos t tc decis ion
making
DIAGNOSIS
..-------"----/ ~ Therapeutic problems
l Therapeutic deciston making TR EATMENT
Fig. 1 - Basic concepts of the clinical experiment with the P.O.M.R . the problem-groups should start at birth and should continue sequentially during the whole life of the patient. For each problem a diagnostic decision was to be written next to the problem and, if relevant , the therapeutic prescriptions would also be addeq. As the forms were to be filled in during the first' contact of the patient with the physician , the following rule for selection of the patients of the ward was applied: the physician uses the forms only for new patients and only if the physician is not overloaded with incoming patients. This selection rule was maintained although it became quickly evident that the physicians completed the form at the end of the observation of the patient. Acta C/inica Belgica. 30, 5 (19 75)
Before the experiment the collaborators were motivated by arguments about the expected medical , educational and scientific value of the list of problems. Later on regular contacts were maintained with the organizers of the experiment. Two teams of 4 assistants in internal medicine worked each for two months with the forms , elaborating 400 lists of problems with corresponding decisions. IV. RESULTS OF THE EXPERIMENT
A. General results The trial of 4 months proved extremely interesting as several new aspects of the " list of problems, were revealed .
351
CLINICAL EXPERIENCE WITH P.O.M.R. M,l,G, LlJ ST
A..z.
PIJ.ATJJI
VA.N
PROBLlli!BI I.P.
IDENTIFICATIE
DAT.
Nr, SUBJ. CJBJ . SYMPTOM£N
DIAGNOS.Ii
BJlliANDJ:;LING
DAT.
Fig. 2- Lay-out of the form used for the registration of the anamnestic and actual problems. 1. The definition of a "diagnostic problem" as being congruent with all that the patient presents and that needs a diagnostic decision, is in actual practice a too general approach. The patient is often referred to a department of internal medicine with very specific questions, such as: - is the patient able to support surgery; - has the patient a specific illness; - screening examination. These problems, a result of the adaptation of medicine to the development of indepen-
dent medical subspecialities, form a not yet defined type of problems: the questions of one subspeciality to another concerning particular aspects of the patient. 2. It also became evident that our physicians are more used to think in terms of (differential) diagnosis than in terms of problems. 3. The clear formulation of the problems of a patient is difficult. It asks for a high degree of medical training and for a large amount of experience. Above all, it requires time necessary for an exact and objective evaluation Acta Clinica Belgica. 30, 5 (1975)
352
CLINICAL EXPERIENCE WITH P.O.M.R.
of the patient's situation and for the registration of the problems . This time aspect resulted in a complete change of the set-up of the project : instead of being used during the entire observation, the forms were completed at the end of the observations, just before or after the moment of writing the concluding letter to the family physician. At this moment a problem of duplications of effort arises and the list of problems is no more of great help to patient care. B. Detailed analysis of 400 forms In order of having more concrete ideas about the · practical value of the "list of problems" , 400 forms were analyzed in great detail. a) General Comments
cians became convinced of the usefulness of the "problem-oriented approach" and that they succeeded in the elaboration of very clear documents. 2. The decision making process - some new terms had to be introduced as preliminary diagnostic statements, e.g. "further investigation is necessary", .. . ; - sometimes a treatment was mentioned without a diagnosis; - for ± 10% of the records no diagnostic decision was registered for the listed problems. 3. Numeration of the problems - the collaborating physicians divided in almost all cases the life of a patient into two independent parts: the past history and the actual situation. This attitude was expressed by the fact that the numeration started almost always again at I for the actual problems in spite of already numbered anamnestic problems. In addition, in some forms the same problem received two different numbers, one in the past, another in the present history; - it was also easier to number the anamnestic problems (well defined situations) than the actual problems. Whereas about 60 % of the registered anamnestic problems were numbered, only about 40 % of the actual problems received a number.
In contrast to all expectations it appeared that the lists were not easy to interprete, a consequence of many factors, some of them being : - the lay-out of the forms; - the difficulties of formulation, recording and numeration of the problems and problemgroups. So one person , well-trained in the use of P.O.M.R., examined all forms and reordered them . No feed-back to the original responsible physician was possible as this physician was not asked to sign the forms and therefore could not be traced back. This analysis revealed several features concerning the practical implementation of the P.O.M.R. in the actual medical care of the patient:
4. The anticipated communicability of the list of problems was in most cases not achieved.
1. Formulation of the problem - m3;ny forms did not give a list of problems, but a list of possible diagnoses. This confirms the idea that the physician is more a diagnosis-solver than a patient's problemsolver; - it became also evident that the definition of a problem-group as a set of related problems is very difficult. Most often the signs and symptoms were listed without any attempt to bring them together; - a positive aspect is the fact that two physi-
b) Analysis of the Registered Problems 1. The distribution of the patients (table l) in the different age groups is similar for women and men and rather typical for the new-patient population of the ambulatory ward of the Department of Internal Medicine. 2. As the detailed analysis of the forms required an interpretation of the registered information, all following figures are the result of the approach of one person to all different forms . So the figures can only be considered to give pragmatic indications about the number of
Acta C/inica Belgica, 30, 5 (1 975)
CLINICAL EXPERIENCE WITH P.O.M.R.
353
2. it is not possible to draw any conclusion
Table 1 Frequency distribution of patients ~
d'
n
n
