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

BMC Medical Informatics and Decision Making

Research Article

Felix H. J. M. Cillessen¹  Sereh M. J. Simons²  Jan A. Hazelzet² 

[1] Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands;Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands;

关键词: Problem-oriented medical record;    Electronic Health Record;    Review;    Implementation;   

DOI  :  10.1186/s12911-016-0341-0

 received in 2016-02-19, accepted in 2016-07-22,  发布年份 2016

来源: Springer

【 摘 要 】

BackgroundA 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.MethodsOn 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.ResultsIn 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.ConclusionsTwo 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.

【 授权许可】

CC BY   
© The Author(s). 2016