by Lt. Col. Liam Toth, Deputy CMIO AFMS

2020 Graduate, DoD Clinical Informatics Fellowship

Dr. Lawrence Weed sees a problem with the current state of the medical record.  It is poorly organized.  It is minimally standardized.  There is too much information in too many places for any human to effectively manage patients.  In fact, he felt that “misdiagnoses are not failures of individual physicians.  Rather they are failures of a non-system that imposes burdens too great for the physician to bear.”  So, he took it as his personal mission to rectify what he recognized as the major problems in medical records - even going so far as design and implement his own electronic medical record.  That was all prior to 1971 and before his ridiculous “SOAP” note gained any traction…

But it was his other conviction (which inspired the SOAP format) that now has a bigger impact on the electronic medical records.  The Problem Oriented Medical Record (POMR).   Problem list requirements found their way into the meaningful use criteria – which meant that every EMR would include a functional problem list - including our very own MHS GENESIS.  (keep reading – our problem list example is at the end)

Why use POMR?

Dr. Weed probably put this best: “We aren’t taking care of records, we are taking care of people”

Using a problem-based orientation places our patients at the center of care and NOT our own needs for documenting things quickly.  The long game is that if we orient ourselves around problems, we will be able to longitudinally understand the care of the patient through the evolution of the problems themselves.  And although Cerner’s Millennium has not quite yet realized that vision, it is making strides towards making a longitudinal care record a reality. But this only works IF we use (and reconcile) the problems list.

Still on the fence?  Here is Dr. Weeds 1971 grand rounds.  He was right then. He is still right now. 

https://youtu.be/qMsPXSMTpFI

What is the reluctance?

I would say the biggest is the vocabulary.  How we arrive at the “problems” and define the “problems” within MHS GENESIS is still extraordinarily difficult because of SNOMED/ICD-10CM.  And if we keep asking why we probably arrive at the root problem of the record still being a better billing tool than it is a medical record.  Specifically, the coding requirements creating a problems-based system that is difficult to understand, impossible to navigate, and not standardized in a meaningful way.  On top of that the first time you get the problem list in GENESIS (primarily from AHLTA) you will see too much meaningless information to make it useful.  So it takes time to “fix” the problem list.

That’s not encouraging – anything we can do?

I’m glad you asked.  First, fix the problem list the first time you see the patient.  It takes time…once.  But once it is done it can be an incredible tool for optimizing both the care of the patient AND your own efficiency. Second, hold other people accountable for the problems list.  It should be a prominent area for Peer Review (which means eliminating some other more meaningless questions on peer review).  Third, if you ware an educator, educate.  Make students accountable for their documentation and problems.  Finally, use problem shortcuts (such as quick visits) to ease creating the problem list.

What about GENESIS?

The following is NOT exhaustive.  On purpose.  This is the problem list as part of the standard mpage workflow and should be the place you are most likely to interact with the problems. There’s A LOT going on here so its impossible to be exhaustive out of the gate…

1. Reconcile outside record – see last week for more details
2. Classification – the two major options are “Medical and Patient Stated” and “All”.  The major “All” classification is “Nursing”.  This allows nurses to make problems without them being a medical diagnosis.  And they can be changed (#11 Modify) later if desired.
3. Add as – choices include: This Visit, Chronic, This Visit and Chronic
4. Search area for problems. Uses the default vocabulary.  MHS default is SNOMED (which includes the ICD-10 CM).  The VA has purchased and is using Intelligent Medical Objects (IMO).
5. Unspecified problem – if a problem hasn’t been specified enough it will notify you here (you can see the explanation point as well) and take you to the specify problem screen…which is arguably one of the less fun parts of the problem list.
6. Priority – sets the problem priorities for the visit
7. Code & Classification – ICD-10 Code for any “This Visit” problems (Codes can also be seen in the additional information screen on the right).  The Classifications are the same as #2
8. Actions – Can easily change problems from This Visit to Chronic to Both or resolve problems
9. Resolve – Chronic problems can be “resolved”
10. Resolved Chronic Problems (and All Previous This Visit problems) – both are closed by default, but old problems can be seen when desired
11. Modify – Opens a new screen with additional details to further delineate problems
12. Show History – This is the beginnings of the longitudinal care record. Expanding this section will give you all of the dates when the same diagnosis has been used.  I fully anticipate this section to expand significantly in the coming years to include the ability to see A/P information and jump to specific notes. 
13. Comments – Comments can be added to each problem that are not part of the notes (but are part of the record).  Inconsistently utilized to add additional information about the problems.