BackgroundA 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.MethodsOn 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.ResultsIn 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.ConclusionsTwo 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.Electronic supplementary materialThe online version of this article (doi:10.1186/s12911-016-0341-0) contains supplementary material, which is available to authorized users.

SUMMARYObjectives: To develop a model as a startingpoint for developing a problem-oriented clinical notes application as a generic component of an Electronic Health Record (EHR). Methods: We used the generic conceptualization of Weed's problem-oriented medical record (POMR) to link progress notes to problems, and the Subjective, Objective, Assessment, Plan (SOAP) headings to classify elements of these notes. Health Level 7 (HL7) Version 3 and Unified Modeling Language (UML) were used for modeling. We looked especially at the role of Conditions and Concerns, and how to model these to document clinical reasoning. Results: We developed a generic HL7-based model for progress notes. In this model the specific clinical note has a condition as its reaMethods Inf Med 2012; 51: 507-515

By two years after the start of the implementation, all medical specialties utilized the clinical notes application. User satisfaction was neutral (3.2 on a 1-5 scale). Authors believe that the significant factors facilitating this transition mirrored success factors reported by other groups: a generic, consistent, and transparent design of the application; intensive collaboration; continuous monitoring; and an incremental rollout.

Citizens of the Netherlands receive excellent care, when they need it, insurance based funded according to the solidarity principle. Maintaining this system is a huge challenge, as we live longer and the demand for care is growing. With an increasing percentage of multi-morbidity in all age groups the need for integrated network organized care is growing at equal pace. Gradually the need to shift focus to prevention is increasingly understood, but a challenging business model is still lacking. The involvement of citizens in maintaining their health requires a focus on managing the social determinants of health. The concept of the holistic problem list and the overarching care plan provides a unique way to combine both health and disease management. Our vision is to bring control to the patient and promote coordination of all active problems across the health and social care network.

The health system in the Netherlands is one of the best in the world and it is a challenge to keep this affordable and accessible for everyone. A shift from care to lifelong maintenance of health is highly needed, but the drivers of change are missing. Obviously, the involvement of citizens is essential, but to introduce the change the indispensable incentives must be identified. The believe in integrated network care is growing, but it requires a fresh view on the integration of prevention and care, the involvement of the “old players” to create a new governance model, the supporting IT and adequate funding arrangements. In the Tiel region the implementation of the INCA model for integrated care in the primary care setting might make the difference for this journey.