[This post, which was first published on The Health Care Blog on 5/10/13, is Part 2 of a commentary on “Medicine in Denial,”(2011) by Dr. Lawrence Weed and Lincoln Weed. You can read Part 1 here.]
- Managing chronic illness often involves multiple interventions that require adjustment over time, rather than a single treatment that results in cure/resolution. This requires tracking of physiologic variables and medical interventions over time.
- Chronic care of medically complex patients, especially those with multimorbidity, requires coordination of care among multiple clinicians at multiple sites over time.
- For the many people suffering from multi-morbidity, chronic medical problems and their associated interventions often interact. This makes it particularly important that care be individualized, and carefully tracked over time.
- Enabling patient awareness, participation, and commitment is essential, with the Weeds noting that “unavoidable complexity must somehow be made manageable by patients who need to cope with what is happening to their own bodies and minds.”
- Patient care – and hence the charting of medical data — must be oriented towards a single purpose: individualized medical problem solving for unique patients.
“[Informed patient] involvement requires external standards and tools that patients themselves learn to use, both independently and jointly with their providers. Without that patient involvement, unnecessary complexity and fragmentation occur, as multiple providers intrude on inherently personal decisions that patients are better positioned to manage for themselves.”
A medical record designed for individualized comprehensive care over time
“The medical record is critical for complex cases involving chronic disease and multiple problems, which is where the largest amount of healthcare resources are consumed.”
- A defined database of information, to store the relevant information that has been gathered;
- A problem list, with problems defined in terms of the patient’s needs;
- Plans of action for each problem, developed in light of the other problems;
- Progress notes on each problem, which document the process of following up, including gathering of feedback and adjusting the plan over time.
“A problem-oriented structure requires that all practitioners record each plan and progress note by the specific patient problem to which it relates. The patient’s total medical situation is summarized by a complete problem list appearing at the first page or screen of record…Enforcing the POMR standard means that individually relevant information is collected, considered, and acted upon by all practitioners and the patient over time, with the patient’s total situation taken into account every step of the way.”
“Without well-structured progress notes, clinicians can easily fail to recognize trends and correlations in data, lose track of significant test results, fail to consider interactions among multiple problems, or fail to coordinate their activities with other practitioners. These failings occur particularly with chronic illness.
The organized clinician’s guide to making a plan, and engaging patients
- Basis: this refers to the abnormalities/complaints that are evidence for the problem
- Status: whether the problem is getting worse, better, or staying the same
- Disability: this requires understanding the problem’s significance from the patient’s perspective (!)
- Goal: this should be articulated after conversation with the patient and after considering all other problems affecting the patient
- Follow course
- Parameters to monitor course and status of problem
- Parameters to monitor response to therapy
- Investigate further
- Hypotheses to be investigated
- Measures to investigate each hypothesis
- Complications to watch for
Why aren’t we using the POMR?
- Insufficient time allotted to provide care to each patient. Even with a smart POMR-ready EHR system that properly organized information by problem, I’d expect each encounter would require at least 30 minutes of physician time, if not much more.
- Insufficient financial incentives to practice comprehensive, person-centered, individualized, collaborative care over time. Unless you focus on a population of high utilizers with “ambulatory sensitive conditions,” a POMR approach seems unlikely to reduce hospital and ED utilization enough to keep the ACOs happy.
howdy Dr Kernisian
Dr Rick Weinhaus, a regular contributor to HIStalk, has posted on the matter a number of times.
http://histalk2.com/2013/05/13/ehr-design-talk-with-dr-rick-51313/
That post references the 2 paradigm organizational structures to review EHR data. He prefers the "snapshot in time" design.
Meaningful use has mandated that doctors manage a problem list. 25 years ago, very few if any doctors managed a problem list. Today, they all do.
I've talked with a few doctors about tagging EHR data with a problem that data can be looked up per problem instead of per note. It's do able. Some aspects of EHRs already support it – CPOE generally asks for a problem/ICD, as do lab tests.
As a UI specialist, I've thought about how that might work from a UI perspective. I see a spectrum of solutions: 1 end of the spectrum is tagging every piece of data with a relevant problem. This is obviously cumbersome and unacceptable from an efficiency perspective. The other extreme is keeping a persistent tag open at all times. All data entered while that tag is active is tied to that problem.
I think the latter is a rather elegant solution. It's simple and out of the way. However, I think it creates a liability problem. I also think that because it's out of the way, it's easily prone to being forgotten by an audience that not's conditioned and trained to think in a problem oriented fashion. If clinicians leave the wrong tags turned and forget about them, if they try to come back and use it, they will see junk data and blame the system, not themselves.
I want the concept to work. I would need to brainstorm further how to do this at a UI level. The database side is pretty simple (at least in our EHR), but the UI side presents a fun challenge.
PS. can you make the comments box bigger on your blog? i hate writing in 3" box when i have a 15" monitor.
https://www.dropbox.com/s/u1cszx1rta7p60k/Screen%20Shot%202013-05-17%20at%2012.49.56%20AM.JPG
hi Kyle,
yes it's tricky to think of how to properly operationalize these ideas.
sorry but the comment box is the blogger default and i have no idea how to change it…
I am REALLY stoked at your analytical attention to the Weeds' book.