Lots of interesting thoughts and perspectives here!
In the NHS there is the added complexity that primary care and secondary care
are different organisations, each maintaining their own patient records (with
responsibility for maintaining accuracy), and even if it were possible for them
to share the same problem list, it would be unclear who would be responsible
for curating it.
I have been working on a project to try to scope out this area and produce
guidance for improving problem and diagnosis recording. The project is led by
the Professional Record Standards Body and the Royal College of Physicians
Health Informatics Unit, and our report should be published in a couple of
months (I can send the draft to anyone who is interested).
Personally I think that terminology ('problem' or 'diagnosis') can be
confusing. In my understanding there is a concept of an evaluation which
represents the clinical understanding of a fact about a patient ('condition',
'diagnosis', 'sign', 'symptom', 'problem'). This is generally similar among all
clinicians (although some may be interested in more detail than others), but
can change over time either because the patient's condition changes or the
clinical understanding of the condition changes. This is distinct from the
'problem attribute' of an entry in a problem list, which is a statement of its
importance to healthcare task planning (e.g. whether the problem is active or
inactive, major or minor, high or low priority), and can legitimately vary
between clinical specialties according to their particular focus.
The task for the EHR is to present the list of patient's problems in a way that
facilitates clinical decision making. This may be through the coded problem
titles (e.g. diabetes is always important for every clinician to know about, a
common cold is unimportant after X months), concurrent prescriptions (e.g.
gastro-oesophageal reflux is considered active as long as the patient is
prescribed antacid medication), explicit manually created problem links (e.g.
shortness of breath is due to heart failure, amitryptiline was started because
of pain), and explicit manual problem attributes (e.g. the GP has marked
osteoarthritis as a major active problem).
Without any problem attributes the system should ideally be able to present a
useful list by using problem attributes inherited from the code. However,
creating the 'problem profiles' associated with diagnosis codes requires
thought and broad consensus among clinicians, and is a major piece of work. But
I think it is necessary in order to be able to reap the benefits of coding for
clinical usability of systems. In parallel a change is needed in the way
clinicians use problem lists, with a focus on trying to refine and improve the
problem list with each consultation so that it becomes more precise and
accurate over time.
Going forward we want to develop more thinking in this area through the Faculty
of Clinical Informatics in the UK, and it would be good to hear from anyone who
would like to get involved.
Thank you,
Anoop
---
Dr Anoop D. Shah
Clinical Lecturer, UCL Institute of Health Informatics
THIS Institute Postdoctoral Fellow
Honorary Consultant in Clinical Pharmacology and General Medicine,
University College London Hospitals NHS Trust
Room 403, Institute of Health Informatics, University College London, 222
Euston Road
London, NW1 2DA
Email: [email protected] / [email protected]
Mobile: +44 (0)78 7676 7478
Website: https://www.ucl.ac.uk/health-informatics
<https://www.hdruk.ac.uk/>
________________________________________
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To: [email protected]
Subject: openEHR-clinical Digest, Vol 81, Issue 19
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Today's Topics:
1. Re: Problem orientation in OpenEHR (Paul Miller)
2. Re: Problem orientation in OpenEHR (Ian McNicoll)
----------------------------------------------------------------------
Message: 1
Date: Fri, 28 Jun 2019 10:48:06 +0100
From: Paul Miller <[email protected]>
To: For openEHR clinical discussions
<[email protected]>
Subject: Re: Problem orientation in OpenEHR
Message-ID:
<ca+owoyqjmh_d72et3bhs6p53tkyo6_rzwhzxz-qnrtqry-c...@mail.gmail.com>
Content-Type: text/plain; charset="utf-8"
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
https://eur01.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.glenburnsurgery.scot.nhs.uk%2F&data=02%7C01%7C%7Cd74c790266144f0784d708d6fbb90c4b%7C1faf88fea9984c5b93c9210a11d9a5c2%7C0%7C1%7C636973169532391300&sdata=umFiKWXdKedVekiaLYDUTzujOayBSvD1H0nj5AfVWwE%3D&reserved=0
Clinical Lead
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Mobile: +44 7711 346 928
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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 ?Problem??Diagnosis 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]
>
> https://eur01.safelinks.protection.outlook.com/?url=http%3A%2F%2Flists.openehr.org%2Fmailman%2Flistinfo%2Fopenehr-clinical_lists.openehr.org&data=02%7C01%7C%7Cd74c790266144f0784d708d6fbb90c4b%7C1faf88fea9984c5b93c9210a11d9a5c2%7C0%7C1%7C636973169532401308&sdata=mSG5dCHbdDAKk5tMBCyt7lmLHMJqe4bCF8jam78vAJw%3D&reserved=0
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------------------------------
Message: 2
Date: Fri, 28 Jun 2019 12:07:48 +0100
From: Ian McNicoll <[email protected]>
To: For openEHR clinical discussions
<[email protected]>
Subject: Re: Problem orientation in OpenEHR
Message-ID:
<cag-n1kwpzsmik83p9aaec8ykcrw8rgblbtsgqugcxoyntzh...@mail.gmail.com>
Content-Type: text/plain; charset="utf-8"
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://eur01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.archetextur.es%2Fdiagnosing-the-contextual-problem-list%2F%3Fno-cache%3D1&data=02%7C01%7C%7Cd74c790266144f0784d708d6fbb90c4b%7C1faf88fea9984c5b93c9210a11d9a5c2%7C0%7C1%7C636973169532401308&sdata=iaPu73tW8ahakeErhvFgx0Gu8dz8WF5KkXR3fYFy6nY%3D&reserved=0
Some stuff I wrote here
https://eur01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fopenehr.atlassian.net%2Fwiki%2Fspaces%2Fhealthmod%2Fpages%2F2949176%2FProblem%2BIssue%2BDiagnosis%2Band%2BConcern%3FfocusedCommentId%3D2949237&data=02%7C01%7C%7Cd74c790266144f0784d708d6fbb90c4b%7C1faf88fea9984c5b93c9210a11d9a5c2%7C0%7C1%7C636973169532401308&sdata=i%2FPt8blPd4OZyW%2FMBMZIf1PsZ11B8%2BfXFFfoHiRycWk%3D&reserved=0
and one of the best papers is
https://eur01.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.differance-engine.net%2Fchirad%2Fhealthrecords2007%2FThe%2520Problem%2520Oriented%2520Medical%2520Record.doc&data=02%7C01%7C%7Cd74c790266144f0784d708d6fbb90c4b%7C1faf88fea9984c5b93c9210a11d9a5c2%7C0%7C1%7C636973169532401308&sdata=z6IHn8fw6%2BxcTho%2Fh9EQddMKEocJZ9HiZ5cZepa3kwc%3D&reserved=0
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
>
> https://eur01.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.glenburnsurgery.scot.nhs.uk%2F&data=02%7C01%7C%7Cd74c790266144f0784d708d6fbb90c4b%7C1faf88fea9984c5b93c9210a11d9a5c2%7C0%7C1%7C636973169532401308&sdata=TrNGtlCs3FpjLf4pL3H1xVHJzx3dg22%2FtqC2FX6Emys%3D&reserved=0
>
>
>
> Clinical Lead
>
> NES Digital Service
>
> https://eur01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fnds.nes.digital%2F&data=02%7C01%7C%7Cd74c790266144f0784d708d6fbb90c4b%7C1faf88fea9984c5b93c9210a11d9a5c2%7C0%7C1%7C636973169532401308&sdata=qUBOY%2FrnhqLXWw4K28Qr0H2SZHOx02tVI%2BQFjsCdppI%3D&reserved=0
>
>
>
> 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 ?Problem??Diagnosis 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]
>>
>> https://eur01.safelinks.protection.outlook.com/?url=http%3A%2F%2Flists.openehr.org%2Fmailman%2Flistinfo%2Fopenehr-clinical_lists.openehr.org&data=02%7C01%7C%7Cd74c790266144f0784d708d6fbb90c4b%7C1faf88fea9984c5b93c9210a11d9a5c2%7C0%7C1%7C636973169532401308&sdata=mSG5dCHbdDAKk5tMBCyt7lmLHMJqe4bCF8jam78vAJw%3D&reserved=0
>>
> _______________________________________________
> openEHR-clinical mailing list
> [email protected]
>
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End of openEHR-clinical Digest, Vol 81, Issue 19
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