Hi Paul, Indeed confusing but that just reflects real-world complexity.
It is important not to mix up SOAP and POMR Problem lists , though both were Larry Weed's invention. I used both in clinical practice. SOAP is a way of organising information during a single consultation Subjective, Objective, Assessment, Plan. POMR Problem Lists is a way of organising problems/diagnoses across multiple consultations or other patient contacts. As part of SOAP style data-entry the Assessment part might well contain a Diagnosis/Problem entry which may (but may not) appear on the POMR Problem list. Ideally linked back to the original consultation. Problem Lists may be flat and have simple attributes like inactive/active major/minor but may have much more complex nesting to reflect condition grouping, process groupings, temporal groupings. Some systems in the UK and Netherlands are entirely Problem driven i.e. for every new consultation the clinician must allocate it to an existing problem header or create a new one. And in non-primary care settings it is common to see Contextual Problem lists - Care plans, Outpatient consults, Speciality Problem lists e.g Renal medicine. https://www.archetextur.es/diagnosing-the-contextual-problem-list/?no-cache=1 Some stuff I wrote here https://openehr.atlassian.net/wiki/spaces/healthmod/pages/2949176/Problem+Issue+Diagnosis+and+Concern?focusedCommentId=2949237 and one of the best papers is http://www.differance-engine.net/chirad/healthrecords2007/The%20Problem%20Oriented%20Medical%20Record.doc Ian Dr Ian McNicoll mobile +44 (0)775 209 7859 office +44 (0)1536 414994 skype: ianmcnicoll email: [email protected] twitter: @ianmcnicoll Director, freshEHR Clinical Informatics Ltd. CCIO inidus Ltd. [email protected] Co-Chair, openEHR Foundation [email protected] Hon. Senior Research Associate, CHIME, UCL On Fri, 28 Jun 2019 at 10:48, Paul Miller <[email protected]> wrote: > Enjoying this thread but also finding it a challenge! > > In my experience the load required to maintain a POMR is significant, as > Heather points out, and thus it is often not done at all or done well and > maybe Marcus's suggestion of 'tagging' is simply a UI method for making it > easier to do, but it does not really solve much more. > > One of the problems here is that the medical profession has never agreed > what it means by POMR in respect of EHRs and implementations vary > significantly in different EHR systems, perhaps analogous the the diversity > of clinical information models in silo-ed systems than the openEHR approach > sorts. > > Tagging could be helpful metaphor but I think the magic would lie in > defining / agreeing what the LINK types were - 'caused by', 'to > investigate', 'prescribed for'??? Dunno - would need some work, but that > would then allow people to view the data in more logical and useful ways. > > Getting people to maintain all that is probably impossible, even with > super UI, so probably we would need to find clever ways to automate it - > but inevitably it will need some level of manual curation. > > I maybe don't quite understand yet the approach Thomas suggests for SOAP > persistence. In my head SOAP is a way of structuring an encounter (not > modelling a 'problem'), and various other such encounter headings are > present in other EHRs. Thus I think any encounter recorded in a SOAP > structure may relate to a 'problem', but not actually be the definition of > the problem itself. Although if an initial encounter record using SOAP or > whatever was persisted and curated I can see how that may build a > meaningful set of links, although still not sure we have the 'Problem' > defined there? > > Paul > > > -- > > Dr Paul Miller > > MBCHB MRCGP FFCI DRCOG DMI > Glenburn Medical Practice > Fairway Avenue > Paisley > PA2 8DX > Tel: 0141 884 7788 > > http://www.glenburnsurgery.scot.nhs.uk/ > > > > Clinical Lead > > NES Digital Service > > https://nds.nes.digital/ > > > > Mobile: +44 7711 346 928 > > Twitter: @docpaulmiller > > > On Fri, 28 Jun 2019 at 02:58, Heather Leslie < > [email protected]> wrote: > >> Great discussion. >> >> >> >> I think there are semantic issues at play here as well – the POMR use of >> ‘problem’ vs the ‘ProblemßàDiagnosis continuum’ that is used as part of >> the conclusion to a consult etc. Problems are problematic! Add in Contsys >> and then we start to get into tricky territory. >> >> >> >> In my discussions over the years, I think Ian’s view is closest to mine. >> And in a world where the reality of getting up-to-date Medication Lists or >> Problem lists of raw/real problems, diagnoses and procedures is not easy, >> the notion of the synthesised, coordinated, connected POMR Problems seems >> like a distant pipe dream. >> >> >> >> The openEHR LINKs nicely allow for Marcus’ and Richard’s dreams of >> connecting items in the health record. >> >> >> >> But imagine curating this for each of our patients with chronic disease – >> time and lack of funding will crush it in most clinical environments as >> they stand at the moment. >> >> >> >> But let’s keep dreaming and planning. If we can put the building blocks >> in place, and there are many that are ready to go within openEHR now, with >> CDS, smart UI, AI etc maybe much of this could be automated, or at least >> collated presented to a clinician for verification. >> >> >> >> Regards >> >> >> >> Heather >> >> >> >> *From:* openEHR-clinical <[email protected]> *On >> Behalf Of *[email protected] >> *Sent:* Friday, 28 June 2019 10:04 AM >> *To:* For openEHR clinical discussions < >> [email protected]> >> *Subject:* Re: Problem orientation in OpenEHR >> >> >> >> Thanks for all the responses >> >> I guess I see "problem" as a high level construct, decided by an expert >> clinician as a way of "coding" the client's various ongoing, significant >> issues in a way that is relevant to management. It could be a formal >> diagnosis like Diabetes or a less structured problem like "smoker". I am >> not sure how this could be coded in a consistent way - the definition of a >> problem can be quite subjective and in general it is the task of a >> sophisticated clinician. Short term issues like "Upper respiratory tract >> infection" or even "abscess" would not normally be defined as problems in >> my practice. >> >> I agree with Marcus on the understanding - I have struggled with the >> whole concept of OpenEHR for a long time as a sophisticated clinician and >> perhaps somewhat less sophisticated IT enthusiast. I see it as a data >> modelling system accessible to clinicians to allow computable models - >> which in turn will allow decision support. >> >> But I think the "problem" concept ids an important one >> >> Perhaps we should relax a bit - allow the clinician to create problems at >> their discretion which are not necessarily connected to other elements of >> the record. This is effectively how it works now. >> >> R >> >> >> ----- Original Message ----- >> >> *From:* >> >> "For openEHR clinical discussions" <[email protected]> >> >> >> >> *To:* >> >> <[email protected]> >> >> *Cc:* >> >> >> >> *Sent:* >> >> Thu, 27 Jun 2019 17:05:35 -0300 >> >> *Subject:* >> >> Re: Problem orientation in OpenEHR >> >> In a slightly roundabout way, Links from Problem-SOAP Compositiions to >> Entries committed at other times is essentially the equivalent of tagging, >> and indeed the UI could easily be built to make it look exactly like >> tagging, by presenting a list of existing SOAP note problem names, and the >> 'tag this under problem X' action would create the relevant Link. >> >> Literal tagging causes some issues in versioned, medico-legal EHRs, >> because you are updating the link target, not the logical link source, when >> there is nothing changing in the target. >> >> it seems to me we should think a bit more about (?semi-)persistent SOAP >> Compositions, and maybe a related micro-service to make it easy to do >> logical tagging that actually does the correct linking... >> >> - thomas >> >> On 27/06/2019 16:33, Marcus Baw wrote: >> >> If I wanted to solve POMR in a simple way without repetition, I'd use >> Tagging >> >> You'd tag anything relevant to the Problem with that problem's Tag, you >> index by Tags too, in a background job >> >> Then when searching by Problem you get all entries Tagged as relevant. >> >> M >> >> >> >> On Thu, 27 Jun 2019 at 19:32, Gunnar Klein <[email protected]> >> wrote: >> >> 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 >> >> >> >> _______________________________________________ >> 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 list [email protected] http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org
