Opinion Paper Outline
Joel Buchanan, MD
Madison, WI
July 11, 2015
Accelerating the Transition: COMR → POMR
A Proposal
In 1968, Larry Weed published the seminal article on the Problem Oriented Medical Record, Medical Records that Guide and Teach. The article introduces two major concepts:
(1) SOAP note structure
(2) Problem Oriented Medical Record (POMR) documentation structure
In the forty seven years since the article was published, the SOAP note structure has been widely embraced. However, true adoption of POMR documentation has been much more limited. It is relatively easy for an individual provider to create clinic or hospital documents that adhere to the SOAP format. However, creating a POMR based note is more challenging and the standards are not totally clear. Should the POMR structure be used for (a) the assessment only? (b) the assessment and plan? Or (c) the entire note? Must all components of a note conform to POMR structure?
The advent of the EHR seems to offer a path to implementing POMR. Even in 1968, one of the many striking aspects of Weed’s article is his vision for using the computer to leverage his concepts. However, the progress on this path has been laborious and slow. While EHR based documentation offers the tantalizing possibility of moving from the established chronologic oriented medical record (COMR) to a POMR, the realization of this new orientation has been quite challenging for vendors and users.
Vendors have invested considerable R&D in tool development for POMR documentation, yet uptake remains slow. Several factors underlie this slow adoption:
(1) |
Time and Effort to Generate POMR Documentation |
|
Even with the new EHR POMR tools, the individual provider has to exert some time and effort to create POMR documentation. POMR supporters envision a positive ROI for this effort. However, the documentor does not feel this ROI at the time of documentation. |
(2) |
Critical Mass of Users within a Practice or Enterprise |
|
Most providers are in a group or multi-specialty practice. The success of a POMR structure for an individual in a group practice or multi-specialty clinic depends on adoption by a critical mass of providers. The individual provider only gets good ROI when fellow providers document using the same model. |
(3) |
Strutured EHR Data is Usually in Chronologic Format |
|
In the EHR, the default storage and retrieval of lab, imaging and procedure reports is still chronologic. |
Proposal: Apply POMR Structure at Time of Display Using Problem Oriented View
The medical record consists of:
Category #1: |
Documentation (provider and non-provider) |
Category #2: |
Results (structured and non-structured) |
Category #3: |
Orders (structured and non-structured) |
Category #4: |
Information submitted by the patient |
Category #5: |
Misc. |
Previous efforts to insure that the EHR is a Problem Oriented Medical Record have focused on enticing or forcing the provider to create documentation (Category #1 above) that adheres to a problem oriented structure. If done correctly, then the reader can easily see multiple instances of documentation (notes) that relate to a particular problem, but were produced on many different dates.
However, this "product" that makes work easier for the reader usually requires much extra work on the part of the documenter. We suggest a different focus, which carries a much lower human cost: the EHR can automatically apply a problem based structure for display and view of structured results (e.g. labs, imaging and procedure results) and structured orders. This provides tremendous value to the user with essentially no human cost.
See Demonstration of Problem Oriented View and click on the blue disclosure triangle next to epilepsy.