Modeling Problem-oriented Clinical Notes

OBJECTIVES To develop a model as a starting-point for developing a problem-oriented clinical notes application as a generic component of an Electronic Health Record (EHR). METHODS We used the generic conceptualization of Weed's problem-oriented medical record (POMR) to link progress notes to problems, and the Subjective, Objective, Assessment, Plan (SOAP) headings to classify elements of these notes. Health Level 7 (HL7) Version 3 and Unified Modeling Language (UML) were used for modeling. We looked especially at the role of Conditions and Concerns, and how to model these to document clinical reasoning. RESULTS We developed a generic HL7-based model for progress notes. In this model the specific clinical note has a condition as its reason. An assertion can be made about a condition. Any condition, observation or procedure can be a concern that has to be tracked. Utmost important is the relationship between constituting parts of a progress note and specially between progress notes by linking a progress note to conditions that are part of an earlier progress note. From this model a comprehensive hierarchical condition tree can be built. Several views, such as chronological, SOAP and condition-oriented, are possible. The clinical notes application is used in daily clinical practice. The model meets explicit design criteria and clinical needs. CONCLUSIONS With the comprehensive HL7 standard it is possible to model and map progress notes using SOAP headings and POMR methodology. We have developed a generic, flexible and applicable paradigm by using acts for each assessment that refer to a condition (1), by separating conditions from concerns (2), and by an extensive use of the working list act (3).

[1]  D Kalra,et al.  Electronic Health Record Standards , 2006, Yearbook of Medical Informatics.

[2]  E. B. Steen,et al.  The Computer-Based Patient Record: An Essential Technology for Health Care , 1992, Annals of Internal Medicine.

[3]  A Rappaport,et al.  Taking the problem oriented medical record forward. , 1996, Proceedings : a conference of the American Medical Informatics Association. AMIA Fall Symposium.

[4]  A. Rector,et al.  Foundations for an Electronic Medical Record , 1991, Methods of Information in Medicine.

[5]  B G M E Blobel,et al.  Semantic Interoperability , 2006, Methods of Information in Medicine.

[6]  Samson W. Tu,et al.  The helpful patient record system: problem oriented and knowledge based , 2002, AMIA.

[7]  Bernd Blobel,et al.  Analysis and Evaluation of EHR Approaches , 2008, MIE.

[8]  Robin C. Meili,et al.  Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. , 2005, Health affairs.

[9]  A. L. Rector.  Clinical terminology : Why is it so hard? : Challenges to Progresses , 1999 .

[10]  L. Weed.  Medical records that guide and teach. , 1968, The New England journal of medicine.

[11]  Peter D. Stetson,et al.  Model Formulation: An Electronic Health Record Based on Structured Narrative , 2008, J. Am. Medical Informatics Assoc..

[12]  L. Weed.  Medical records, medical education, and patient care;: The problem-oriented record as a basic tool , 1970 .

[13]  S. Kay,et al.  Medical Records and Other Stories: a Narratological Framework , 1996, Methods of Information in Medicine.

[14]  Christian Lovis,et al.  Section 2: Patient Records: Electronic Patient Records: Moving from Islands and Bridges towards Electronic Health Records for Continuity of Care , 2007, Yearbook of Medical Informatics.

[15]  Arie Hasman,et al.  The granularity of medical narratives and its effect on the speed and completeness of information retrieval. , 1998, Journal of the American Medical Informatics Association : JAMIA.

[16]  W J Donnelly,et al.  Why SOAP is bad for the medical record. , 1992, Archives of internal medicine.

[17]  Claus Bossen,et al.  Evaluation of a computerized problem-oriented medical record in a hospital department: Does it support daily clinical practice? , 2007, Int. J. Medical Informatics.

[18]  Amnon Shabo,et al.  Model Formulation: HL7 Clinical Document Architecture, Release 2 , 2006, J. Am. Medical Informatics Assoc..

[19]  Kaija Saranto,et al.  Definition, structure, content, use and impacts of electronic health records: A review of the research literature , 2008, Int. J. Medical Informatics.

[20]  A. Rector.  Clinical Terminology: Why Is it so Hard? , 1999, Methods of Information in Medicine.

[21]  Soumya Simanta,et al.  Why Standards Are Not Enough to Guarantee End-to-End Interoperability , 2008, Seventh International Conference on Composition-Based Software Systems (ICCBSS 2008).

[22]  Bernd Blobel,et al.  Enhanced semantic interoperability by profiling health informatics standards. , 2009, Methods of information in medicine.

[23]  J. Sidorov.  It Ain't Necessarily So: The Electronic Health Record And The Unlikely Prospect Of Reducing Health Care Costs. , 2006, Health affairs.

[24]  P. V. Biron,et al.  The HL7 Clinical Document Architecture. , 2001, Journal of the American Medical Informatics Association : JAMIA.

[25]  E De Clercq.  The index as a new concept towards an integrated framework for the electronic patient record. , 2002, Methods of information in medicine.

[26]  P. Shekelle,et al.  Systematic Review: Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care , 2006, Annals of Internal Medicine.