Abstract
BackgroundThe clinical problem list is an important tool for clinical decision making, quality measurement and clinical decision support; however, problem lists are often incomplete and provider attitudes towards the problem list are poorly understood.MethodsAn ethnographic study of healthcare providers conducted from April 2009 to January 2010 was carried out among academic and community outpatient medical practices in the Greater Boston area across a wide range of medical and surgical specialties. Attitudes towards the problem list were then analyzed using grounded theory methods.ResultsAttitudes were variable, and dimensions of variations fit into nine themes: workflow, ownership and responsibility, relevance, uses, content, presentation, accuracy, alternatives, support/education and one cross-cutting theme of culture.ConclusionsSignificant variation was observed in clinician attitudes towards and use of the electronic patient problem list. Clearer guidance and best practices for problem list utilization are needed.
Highlights
The clinical problem list is an important tool for clinical decision making, quality measurement and clinical decision support; problem lists are often incomplete and provider attitudes towards the problem list are poorly understood
Medical records serve as an organizing structure for clinical decision making, a tool for communication to other providers, substantiation for billing, data for research and quality measurement and protection in the event of legal process
In 1968, Lawrence Weed, MD, published “Medical Records that Guide and Teach” which introduced the concept of the problem-oriented medical record (POMR) [1] and the ability to create and maintain a structured, coded problem list in a computer system
Summary
The clinical problem list is an important tool for clinical decision making, quality measurement and clinical decision support; problem lists are often incomplete and provider attitudes towards the problem list are poorly understood. Medical records serve as an organizing structure for clinical decision making, a tool for communication to other providers, substantiation for billing, data for research and quality measurement and protection in the event of legal process. In 1968, Lawrence Weed, MD, published “Medical Records that Guide and Teach” which introduced the concept of the problem-oriented medical record (POMR) [1] and the ability to create and maintain a structured, coded problem list in a computer system. This advance radically altered medical record keeping, and had important implications for how clinicians organized patient care and decision making processes. The problem list is critically useful when a clinician sees a new patient, giving him or her a “jumping off” point for the visit
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