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The Problem-Oriented Medical Record: Building a Pathway Back to the Joy of Practice
By John Goodson, MD

Let's take a big deep breath. The last five years have brought a veritable torrent of change for all of us involved in the day-to-day care of patients. We have lived in the fast-forward world of health care and now we need to take stock and strategize if we are to survive.

Information Overload
Perhaps the most significant change we've seen is the emergence of the cloud of Big Data. There was a time when information delivery was a steady and predictable breeze. Now it is a heavy wind that can become a hurricane. At other times, it envelops us like a thick fog, preventing us from seeing the data that truly impact patient outcomes.

Data come to us at all times from all sources, but the EHR is at the heart of the matter. It has become the central repository for all clinical data. We explore EHR databases that have endless pathways. This is exciting but also has a downside: namely cognitive overload and information chaos. Study after study in recent years has shown that clinicians are not satisfied with their EHR. Rather than helping productivity, EHR systems are hindering it.

We are an understandably frustrated lot. But we cannot back down; we have to step up. We need to build a better world for our work and for our patients. We were trained as physicians to practice the healing arts. We want to be good doctors for those under our care. This is our mission and this is the ultimate source of the endless joy that makes our work so extraordinary. The good news is that there is an answer.

Problem-Oriented Medical Records
Lawrence Weed, MD, anticipated the potential of information chaos in 1968 when he bemoaned the stream-of-consciousness narratives encountered in written medical records. The most important information, the thinking of physicians, could not be found. For Weed, information was to be used for the future care of the patient and therefore needed to be organized.

A few physicians executed Weed's vision by developing EHR systems with an intuitive problem-oriented workflow. Physicians at Massachusetts General Hospital, this author included, have worked to perfect a problem-oriented medical record (POMR) as a paradigm for the organization of data for use in clinical care.

Medical decision making is the epicenter of the evaluation and management of patients. Once we understand the issues ("problems"), we need to have the best tool for retaining our assessment and plan of care. With continuous care, a database can be built around each problem. Over time, problems range in levels of activity; new problems arise, old problems resolve or stabilize. Each problem has a lineage of information that can be accessed by looking backwards into the information retained with that problem.

Others have created problem lists in parallel with the narrative record but we decided that the problem list would become the organizing principle of our EHR.

Easing the Burden of Documentation
One of the immediate benefits of the POMR is the ability to manage the cognitive experience. Since doctors think in terms of "problems," this system is already more in line with the way we approach care delivery. Clinical practice improves with the systematic organization of information for medical decision making. In addition, care collaboration is facilitated since the work of the clinical team is documented according the same master list of problems.

Our system features a natural language vocabulary for labeling problems instead of having to use the cumbersome ICD vocabulary. Physicians can refer to problems the way they were taught in medical school. These are mapped to appropriate ICD codes.

With the POMR, the burden of documentation can be reduced during an encounter by automatically linking an action to a problem, simplifying postencounter documentation. This capability means caregivers need only make a few clicks to order tests, prescriptions, and refills; initiate phone calls; and send e-mails.

The system also provides problem-based decision support with the option to self-source. In other words, the POMR is able to look at a physician's previous behavior around a given problem and use that information to prepopulate some of the decision options at the encounter.

The 'Problem' Is the Solution
There are other long-term benefits to the POMR. Ultimately, this system improves our ability to measure quality and—through self-directed practice assessments and embedded education—the opportunity to select patients for special attention based on the directed clinical problems we identify for information organization.

Developers of this system believe that building an EHR based on the organizational power of the POMR is the change health care needs. Built by clinicians for clinicians, the POMR offers a tool for information collection, organization, and management that will improve patient care and professional satisfaction.

— John Goodson, MD, is a staff internist at Massachusetts General Hospital (MGH) and an associate professor of medicine at Harvard Medical School. He began working with the MGH Laboratory of Computer Science in 1983. Goodson is founder of the John D. Stoeckle Center for Primary Care Innovation, a primary care "think tank" within the MGH Division of General Internal Medicine. He is the senior consulting physician for Pri-Med/Amazing Charts, with whom he has developed the EHR InLight.