Determinants of a successful problem list to support the implementation of the problem-oriented medical record according to recent literature
Determinants of a successful problem list to support the implementation of the problem-oriented medical record according to recent literature
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DOI：
10.1186/s12911-016-0341-0
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发表时间：
2016-08-02
影响因子：
3.5
通讯作者：
Hazelzet, Jan A.
中科院分区：
文献类型：
--
作者：
Simons, Sereh M. J.;Cillessen, Felix H. J. M.;Hazelzet, Jan A.
背景：以问题为导向的方法是组织病历的可能性之一。以问题为导向的病历 (POMR)——根据所提出的医疗问题对患者信息进行结构化组织——由 Lawrence Weed 博士于六十年代末引入，以帮助处理患者问题的多样性。作为先决条件的问题列表是面向问题的医疗记录 (POMR) 的核心，也称为面向问题的记录 (POR)。在数字时代之前，纸质记录向医疗保健专业人员提供了简单的医疗问题列表，但不具备当前技术可能实现的功能。在现代 EHR 中，基于结构化问题列表的 POMR 可用于临床决策支持、登记、订单管理、人口健康以及未来潜在的其他创新功能，从而为 POMR 的实施和使用提供新的激励。方法：于 2014 年 5 月 12 日和 2015 年 6 月 1 日进行了系统文献检索。从检索到的文章中，对有关 POMR 以及与成功或不成功实施相关的陈述进行了分类。从这些陈述中提取了通用决定因素。结果：本研究纳入了 38 篇文章。文献分析得出 12 个通用决定因素：临床实践/推理、完整准确的问题列表、数据结构/内容、效率、功能、互操作性、多学科、患者信息概述、护理质量、系统支持、员工培训和可用性。结论：在决定因素中可以区分两个主要主题：问题列表和 POMR 集成的系统以及使用该系统的组织。两者的结合需要社会技术方法，并且两者对于成功实施 POMR 同等重要。所有决定因素都必须考虑在内，但每个决定因素的权重取决于使用问题列表或 POMR 的组织。
Background: A problem-oriented approach is one of the possibilities to organize a medical record. The problem-oriented medical record (POMR) - a structured organization of patient information per presented medical problem-was introduced at the end of the sixties by Dr. Lawrence Weed to aid dealing with the multiplicity of patient problems. The problem list as a precondition is the centerpiece of the problem-oriented medical record (POMR) also called problem-oriented record (POR).Prior to the digital era, paper records presented a flat list of medical problems to the healthcare professional without the features that are possible with current technology. In modern EHRs a POMR based on a structured problem list can be used for clinical decision support, registries, order management, population health, and potentially other innovative functionality in the future, thereby providing a new incentive to the implementation and use of the POMR.Methods: On both 12 May 2014 and 1 June 2015 a systematic literature search was conducted. From the retrieved articles statements regarding the POMR and related to successful or non-successful implementation, were categorized. Generic determinants were extracted from these statements.Results: In this research 38 articles were included. The literature analysis led to 12 generic determinants: clinical practice/reasoning, complete and accurate problem list, data structure/content, efficiency, functionality, interoperability, multi-disciplinary, overview of patient information, quality of care, system support, training of staff, and usability.Conclusions: Two main subjects can be distinguished in the determinants: the system that the problem list and POMR is integrated in and the organization using that system. The combination of the two requires a sociotechnical approach and both are equally important for successful implementation of a POMR. All the determinants have to be taken into account, but the weight given to each of the determinants depends on the organizationusing the problem list or POMR.