I do agree pomr has an important role in primary care and I like the proposal of Thomas to manage it in openEHR. I am not sure why pomr never took on in hospitals. Larry Weeds idea was not restricted to primary care.
Gunnar Klein, GP an professor of health informatics Den tors 27 juni 2019 19:14Thomas Beale <[email protected]> skrev: > Just reflecting on what a SOAP note has traditionally been (in my non-MD > understanding), the original idea was to use the 4/5 headings to capture > things to do with a specific problem in a clean way during consultations > and further 'clinical thinking'. We don't need to discuss this now; SOAP is > a very good model, epistemologically speaking (the common 7+ headings used > in many hospitals has another explanation - let's avid for now), so let's > just assume that SOAP headings are a good idea. > > In early attempts at the EHR, my impression is that a new SOAP note was > created in each consultation, and that previous SOAP notes were treated > like any other forgettable item in the EHR, like a BP measurement from 3 > month ago. But is is pretty clear that SOAP notes (if they are to be used) > should really be considered as 'persistent' Compositions (in openEHR, a > 'persistent' Composition is one containing content that is at least > potentially valid for all/much of the patient's life, e.g. most managed > lists, family history, vacc history and so on). If we treated SOAP notes as > persistent things that were always retruned to with each new consultation, > lab result, and intervention on that problem, the POMR view of things would > be very clear. > > The potential problem, at a computing/data level, is to implement the idea > wrongly, and to actually *include inline *the data items being generated > by all these activities, inside the SOAP note. This won't really work for > at least 3 reasons: > > - many Obs (including VS & labs) relate to multiple problems, e.g. > most vital signs - do you record copies in all (say) 4 extant SOAP notes? > No - that kind of data cloning destroys querying. > - quite often, docs and nurses do Obs that don't relate to a specific > problem. In the ER, the problem might not be known for some time; a GP > health checkup is not a problem-specific consult... so in these cases, you > don't have any SOAP note to which you would attach the data. > - it is often only clear later on which problems any given Obs, Dx etc > relate to, so really, the freedom is needed to commit isolated info (e.g. > recorded by patient devices) to the EHR, and then (maybe) link it to SOAP > notes later on. > > In openEHR, most if not all implementations I know of already operate on a > 'commit-data-now' basis, without trying to be very POMR. To make an openEHR > EHR a POMR, I would say that any SOAP note has to be given a status of > 'persistent' (or maybe some new status, like 'ongoing', which could be > changed later), and then, as different treating docs work with patients, > they will *progressively compile the content of any SOAP note*, using > linking to committed EHR content. This means a) post-hoc SOAP note building > can occur; b) more than one SOAP note can refer to the same Obs, labs, Dx > etc; c) querying for clinical Obs, Dxs etc remains independent of SOAP > notes and d) SOAP notes don't get lost in the miasma of past event data, > they are instead headline parts of the EHR. > > In this way, SOAP notes, inasfar as they are used in any given EHR, become > a progressively built *view *of each problem, not just a way of > structuring an encounter note. > > What do the healthcare professionals here think about this view? > > - thomas > On 27/06/2019 13:36, Marcus Baw wrote: > > I'm not ready to give up on POMR just yet. It is a lot of work and > difficult to maintain, as Ian points out, but as a locum GP, when I work in > practices that use problem orientation it is MUCH easier and safer to treat > people you don't know. Practices that just dump everything into the record > without Problem Orientation are just asking for trouble medicolegally IMO. > > What worries me about this conversation is that, among UK GPs, I'm > probably in the upper 0.1th percentile of health technology understanding > among them. I've been learning about openEHR since 2012. And I *still* > don't fully understand this conversation. Is it me? Or are we going to have > a bit of a problem getting your average clinician to participate in the > design of future POMRs unless we make it much less technical? > > Marcus > > On Thu, 27 Jun 2019 at 07:40, GF <[email protected]> wrote: > >> A few of my thoughts abd advice: >> >> 1- have a look at the CEN/ISO standard defining the concepts related to >> Continuity of Care. >> 2- For may years Dutch GP’s use the SOEP method of documenting the >> provision of health and care. (SOEP=Subjective, Objective, Evaluation, Plan) >> 3- For many years we collected data items under the heading of Problem in >> a Problem List f(PrL) or use by one Healthcare Provider (HcP) >> 4- Then the Episode (Ep) was introduced because GP’s started to >> collaborate with other HcP’s. >> 5-The progression of the developments in the Patient System over time >> cause changes in the title of the PrL and Ep. >> E.g. PL title = Reason for Encounter (cough); then PL title=Pulmonary >> infection; then PL title=Tuberculosis; >> Ep titles probably will have the same titles. >> 6- The Continuity of Care standard provides a lot a fine detail. In order >> to make things simple I used my compatible version of the medical treatment >> model of that standard, >> >> 1. *Observation* in the Patient system (PS) that is documented >> 2. *Evaluation* of the Observations, PrL, EL, etc leading to >> differential diagnosis, working diagnosis or determined diagnosis >> 3. *Planning*. Differential Diagnosis will lead to plans with goals >> to prove or disprove diagnosis or start treatment >> 4. *Actions*. Plans a re broken down to actioned and documented >> procedures influencing the PS or other (non-PS) systems for administrative >> purposes such as data exchange, requests, scheduling, updating the PL >> and/or Ep >> 5. Followed by Observations that are documented. >> >> >> Steps i to 4 each have a fixed Pattern Archetype as ENTRY archetype >> All PS and Ep’s are collected in distinct FOLDERs the FOLDER shows the >> progress of the health and care process over time. >> >> >> Gerard Freriks >> +31 620 34 70 88 >> +31 182 22 59 46 >> [email protected] >> >> Kattensingel 20 >> 2801 CA Gouda >> the Netherlands >> >> On 26 Jun 2019, at 22:30, Thomas Beale <[email protected]> wrote: >> >> >> On 26/06/2019 11:07, Thomas Beale wrote: >> >> As yet, the machinery to do this mostly exists, but there is little in >> the way of standardised patterns or usage of it to achieve any kind of >> standardised 'problem' document (NB: not the same as 'problem list' - which >> is one level up, and is a managed list of issues considered to be problems, >> usually inclding current Dxs such as diabete >> >> other than the SOAP heading structure, of course, as described in another >> post on this thread. >> Thomas Beale >> Principal, Ars Semantica <http://www.arssemantica.com/> >> Consultant, ABD Project, Intermountain Healthcare >> <https://intermountainhealthcare.org/> >> Management Board, Specifications Program Lead, openEHR Foundation >> <http://www.openehr.org/> >> Health IT blog <http://wolandscat.net/> | Culture blog >> <http://wolandsothercat.net/> | The Objective Stance >> <https://theobjectivestance.net/> >> _______________________________________________ >> openEHR-clinical mailing list >> [email protected] >> >> http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org >> >> >> _______________________________________________ >> openEHR-clinical mailing list >> [email protected] >> >> http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org >> > > _______________________________________________ > openEHR-clinical mailing > [email protected]http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org > > -- > Thomas Beale > Principal, Ars Semantica <http://www.arssemantica.com> > Consultant, ABD Project, Intermountain Healthcare > <https://intermountainhealthcare.org/> > Management Board, Specifications Program Lead, openEHR Foundation > <http://www.openehr.org> > Health IT blog <http://wolandscat.net/> | Culture blog > <http://wolandsothercat.net/> | The Objective Stance > <https://theobjectivestance.net/> > _______________________________________________ > openEHR-clinical mailing list > [email protected] > > http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org >
_______________________________________________ openEHR-clinical mailing list [email protected] http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org
