Interoperability and the EHR: The Problem Oriented Medical Record and the EHR

The Problem Oriented Medical Record covers the two basic divisions of patient information: the demographics (including social and medical history) and the actual progress note that tracks the visit activity.

The progress note itself is divided into four sections:  The Subjective, Objective, Assessment, and Plan (known by the acronym SOAP).  The Subjective section covers the history and depicts the symptoms as reported by the patient.  The Objective section includes the observations by the healthcare provider, along with specific investigative notes and test results. The Assessment section includes the assessment or physician’s prognosis. The Plan section includes actions performed, future treatments, and also any medications prescribed by the healthcare provider². 

The development of the Problem Oriented Medical Record forms the basis of the Electronic Health Record, or EHR. The Healthcare Information and Management Systems Society (HIMSS) defines The Electronic Health Record as an electronic record stemming from any health care encounter, with information including patient information, clinical notes, historical and current medical issues and medications, and visit specific metrics such as vital signs and lab data¹.The EHR is designed as a tool to automate clinical workflow, decision making, and record patient encounter information. The EHR will also support other clinical related activity, such as data transmission, ordering systems, data interfaces for labs, x-rays, etc…, and clinical decision support systems¹.

These developments of the EHR led to modular systems which could be used in different settings, with the value to improve patient safety being recognized. The American Recovery and Reinvestment Act of 2009 brought attention to the then current inefficiencies of medical records and increased focuse on the development, standardization, and use the EHR¹. The problem oriented format is a model that current EHR applications follow for patient encounter tracking. 

References:

1 Atherton, J (2011).  Development of the Electronic Health Record. American Medical Association Journal of Ethics. March 2011, Volume 13, Number 3: 186-189.  Retrieved from: http://journalofethics.ama-assn.org/2011/03/mhst1-1103.html or http://journalofethics.ama-assn.org/2011/03/pdf/mhst1-1103.pdf

2 Benson, T. (2012). Principles of Health Interoperability HL7 and SNOMED. Springer London. ISBN: 978-1-4471-2800-7 (Print) 978-1-4471-2801-4 (Online)