By Ragnhild Bassøe Gundersen
Chronological electronic patient records (EPR) are unclear and cumbersome. Other structures for EPR have been tried. Highly structured schema records require patients to fit into an adapted schema that is limited to part of the clinical reality, for example for leukemia or diabetes. Most patients fall outside such schedules. The core journal captures something further, but may lack important information relevant to many patients with unusual illnesses.
Lawrence Weed created a Problem-oriented medical record (POMR) named PROMIS. The structure of PROMIS lies in the SOAP (Subjective, Objective, Assessment, Plan) principle. But PROMIS lacked relationships between the diagnoses and the other journal information, including the journal notes. PROMIS did not live up to the health professionals needs and expectations. Thus problem oriented EPR got a somewhat negative focus among health professionals.
The chronological EPR as well as PROMIS assume that all patients can be adapted to a predetermined structure once and for all. EkviMed introduces a new type of Problem – oriented EPR, namely PEPR. PEPR lets the patient's problems determine the structure of the journal.
If the patient has no medications and no allergies, her PEPR needs no section on medications nor allergies. If, on the other hand, she has leukemia, a leukemia diagnosis is created and all information on leukemia (journal text on progress, treatment and prognosis) is linked to the leukemia diagnosis.
Should she also have an allergy, an allergy diagnosis will be created with associated journal text, investigation and treatment. We have 30 years of experience with such a journal structure. It is easy to use and provides a very good overview of all patient problems and eliminates irrelevant information.
PEPR takes the patients' perspective. Notes that deal with the same problem are kept in chronological order and separated from the notes concerning other problems. The chronology can be displayed in reverse order so that the most relevant is shown first.
You can quickly get an overview of each problem. Since all diagnoses are shown at the same time, the overview of all the patient's problems is excellent and each problem can be assessed against other problems. Thus PEPR provides a clear picture of the entire patient.
Related notes are quickly edited for referrals and epicrises. We illustrate this with an example. Many clinical problems develop over time, such as
The problem name is the last diagnosis in the problem chain, namely 'urosepsis'.
When clicking on the problem name the entire journal text for this serious problem is selected and the relevant journal note is used in the admission letter. The letters are tailor made for the recipient.
If the patient is hospitalized, information about each problem is collected. The journal text in the cystitis -> pyelonephritis -> urosepsis chain is quickly edited into a targeted epicrisis.
Of course, the epicrisis may contain notes on several issues, but these are edited separately. Thus the inpatient doctor and the GP receive a clear and easy-to-read epicrisis.
-> PEPR gives an industry leading overview over the patient’s medical history.
-> PEPR facilitates interdisciplinary cooperation.
-> Each health professional has a superior and immediate snapshot of the relevant medical history of his or her patient.
-> Information about the patient is written once only which in turn frees up time to the ever so important patient – health professional relationship.