Remembering the Classics: Problem Oriented Medical Records: How best to Collect, Analyze, Synthesize and Clinically Apply Patient Information Imagining Computers Facilitating Clinical Care part 2
Alan Jay Schwartz, M.D., M.S.Ed. and Mark S. Schreiner, M.D.
Original article
Weed LL. Medical records that guide and teach. N Engl J Med. 1968 Mar 14;278(11):593-600. doi: 10.1056/NEJM196803142781105. PMID: 5637758.
Original article
Weed LL. Medical records that guide and teach. N Engl J Med. 1968 Mar 21;278(12):652-7 concl. doi: 10.1056/NEJM196803212781204. PMID: 5637250.
In 1973, shortly after Hurst’s positive commentary on Weed’s POR, Stephen E. Goldfinger offered an appraisal of the Weed system in “The Problem-Oriented Record: A Critique from A Believer”.(6) Highlights of Goldfinger’s 5 categories to consider and conclusion:
“1. The POR is…a system designed to organize and display data, thoughts, and actions pertaining to medical care. It does not pari passu impart any degree of quality to such care.
2. Too little emphasis is placed on accuracy of the…data.
3. Unless there is some mechanism such as…crossing-out to detract attention from inferior and misleading entries, record analysis is apt to be no easier than it ever was for the epidemiologist.
4. What are we to do with all the problems that have been advanced to diagnoses with varying admixtures of data and intuitive skill?
5. …no reviewer can be guaranteed that the record…no matter how well problem oriented, faithfully displays all the ambiguous clues from a patient interview, the puzzling physical findings one is tempted to forget, or the detailed patient education that was carefully transmitted but hurriedly transcribed…patient care cannot be audited with assurance if the record is incomplete, and one must always go beyond the record to determine its magnitude of incompleteness.
Conclusion: A most important modification of Weed's schema for relating the data base to the problem list, plans and progress notes would be the insertion of "C.J." alongside every arrow to emphasize the point that all decision making is catalyzed by clinical judgment.”(6)
Accompanying the critique, an Editorial by Hurst(7), joined by colleagues, Kenneth Walker, and W Dallas Hall reiterated support for Weed’s system and Goldfinger’s cautions.
“The…POR is like a car. One creates a POR for a purpose. He plans to use the record to assess the quality of patient care and medical logic (audit). He plans to correct the deficiencies found from audit. He does not create the record merely to look at or polish. He cannot modify the essential elements of the POR record and still expect it to perform the task for which it was created. Not everyone will use the POR in the same way. The record is the tool that allows one to accomplish something he could not otherwise do.
We must be able to determine if the formulation of a problem is imprecise because the data were unreliable or because the data were analyzed improperly.
Dr. Goldfinger is as concerned…that the POR…may be constructed in a superficial manner (constructing a faulty car). He is as concerned as we are that it may not be used at all (storing the car in the garage) or may be used poorly (driving recklessly) to assess the quality of medical logic and patient care. If the POR is not used properly, it will be impossible to correct deficiencies in medical logic and patient care.”(7)
The implications for current use of POR, big data, and AI to educate, conduct quality review and positively impact patient care requires training so that we won’t be at risk of “garbage in-garbage out”.
My own (MS) experience as a patient with Penn’s medical record has been mostly positive. However, I’ve had several experiences with inaccurate data seeping in. For years, #1 on my problem list was “history of thyroid cancer”. In fact, I had a benign thyroid nodule removed in 2003; on histology there were incidental thyroid microcarcinomas which never required treatment. Many subsequent physician visits have started with a request for update regarding my thyroid cancer. For the patient, it can be irritating and difficult to correct an inaccurate POR once someone has entered it into an electronic health record.
How has the electronic medical record affected your practice and personal medical experiences? Send your responses to Myron who will post in a Friday Reader response.
References
1. Weed LL. Medical Records That Guide and Teach. N Engl J Med 1968;278:593-600.
2. Weed LL. Medical records that guide and teach. N Engl J Med 1968;278:652-7 concl.
3. Hurst JW, Walker HK, Hall WD. More reasons why Weed is right. N Engl J Med 1973;288:629-30.
4. Johnstone RE, Fleisher LA. A 1966 Anesthetic Administered by Robert D. Dripps, M.D., Demonstrated His Experimental Style of Clinical Care. Anesthesiology 2016;124:1218-21.
5. Schwartz AJ. Anesthetic Records: Lessons about Ethics and Education. Anesthesiology 2016;124:1208-9.
6. Goldfinger SE. The problem-oriented record: a critique from a believer. N Engl J Med 1973;288:606-8.
7. Hurst JW. Ten reasons why Lawrence Weed is right. N Engl J Med 1971;284:51-2.