Problem-oriented documentation

The problem-oriented documentation (ProDok) is a project of a knowledge-oriented, coded basic standard for electronic medical records in Austria . This is about the concentration and alignment of the medical documentation on the problems of a patient . The term "problem-oriented documentation" (English: POMR problem oriented medical record) goes back to Lawrence L. Weed , doctor and medical IT specialist in Vermont . Weed also developed the SOAP documentation method: subjective (e.g. anamnesis with current complaints), objective (e.g. physical examination , laboratory ), assessment / analysis (e.g. previous history, diagnosis and differential diagnosis , summary assessment), plan (e.g. medication , further examinations, transfer, discharge).

The advantage of the project for problem-oriented documentation lies in the support of the process organization in the resident area.

User observations show that medical practice is strongly problem-oriented. The detailed and distant anamnesis is often only queried if the patient explicitly sees a subjective connection and therefore wants to provide the information. In the interest of efficiency, the doctor focuses more often on the current cause of the consultation and on health problems that are still open. In doing so, however, it would be particularly important to consider, recognize and treat the “averted danger” or the “scenes of danger” (according to Robert N. Braun , first Austrian professor of general medicine). Checklists can be very helpful here, as can reading specialist literature and questioning colleagues . Leaving it open is also an important therapeutic intervention, but it means limiting the waiting time, which requires efficient documentation. In the tight time frame of the medical practice with full waiting rooms, those strategies are most likely to be used that have provided quick and competent information in the past.

Project background

In Austria, the planning and financing of health care is an agreement according to Art. 15a B-VG (15a Agreement) between Federation and countries regulated the term of this Agreement is four years. This agreement originally only applied to the hospital sector. The currently valid agreement for the years 2005 to 2008 also regulates the agendas of the outpatient (resident) area; it only becomes legally binding in detail through accompanying laws for the relevant actors (e.g. doctors, hospital operators, etc.).

The current 15a agreement from 2005 contains principles, goals and implementation guidelines that address quality enhancement, interface improvement, medical documentation (e.g. ICD-10 coding by resident doctors), etc.

The Main Association of Austrian Social Insurance Institutions (HV) has statutory tasks that are regulated in the General Social Insurance Act (ASVG). These tasks include optimizing the relationship with the contractual partner, i.e. essentially with the doctors, but also with pharmacists, psychotherapists, etc.

In 2003, the AGM, headed by Heinrich Tinhofer , bought the RC code ( Result of Consultation Code ) from Wolfgang Edinger , a general practitioner and former managing director of a medical software company. The RC code contains most diagnosis terms like a thesaurus, but also most of the jargon terms currently used by Austrian doctors for consultation results . So-called speaker terms are condensed in a practice-relevant manner, and the terms are also used in the ICD-10 code of the BMGF and in the International Classification of Primary Care 2nd Edition ( ICPC-2 codes) of the World Organization of National Colleges, Academies and Academic Associations of General Practitioners / Family Physicians ( WONCA ). At the end of May 2006 the RC code contained around 85,000 terms and is constantly being developed.

In 2005 the HV bought the rules for problem-oriented documentation (ProDok) from Wolfgang Edinger. Previously, the exclusivity of the properties of ProDok in German-speaking countries was determined in a meta-analysis, while a survey of doctors among ProDok users confirmed its suitability for use in practice.

The further development and use of the ProDok for problem-oriented communication (ProKom) between service providers is carried out by the planning committees of the ProDok project in the Insurance Company for Railways and Mining , which was commissioned with the project management by the main association.

Properties and functions of the ProDok

The documentation of a problem follows the routine course of a patient consultation.

Step-by-step recording and documentation of a health disorder
Presentation of all entries (including years ago) on a health disorder in an overview
Standardized, unmistakable and permanent documentation through indirect coding (the text entered once is retained, even if the assignment of the text to ICD-10 codes should change later)
Assistance through corresponding medical catalogs (case graph, RC database)
Support through self-learning behavior
Decourse overview

Overview through problem list

In the list of problems, the current and ongoing health disorders are given in the card index. It usually shows at a glance the health problems of the patients with the level of diagnostic certainty and their duration.

Assignment of problem complexes

Secondary diseases can be assigned to a basic disease. Through this distinction and connection of main and secondary problems, basic and secondary illnesses can either be presented as a whole complex of problems or broken down into individual problems. Subsequent changes - decoupling of secondary branch and main problem or correction of the problem date - can be carried out. Completed problems are archived and can be reactivated if necessary.

Cataloging in systematic areas

All problems of a patient are automatically and subject-specifically assigned to twelve systematic areas. Through this cataloging, closed and thus archived health disorders can be quickly found. There are currently seven medical subjects ( general medicine , internal medicine , orthopedics , dermatology , gynecology , paediatrics , urology ) systematized in the database.

Systematic areas using the example of a general practitioner:

Infectious diseases with general symptoms , febrile diseases, pyogenic infections
Diseases of the musculoskeletal system
Hormonal diseases, metabolic diseases , ...
Injuries
Diseases of the lungs , cardiovascular system , thorax
Diseases of the abdominal cavity
The diseases skin and appendages
Diseases of the eye and ENT area
Diseases of the urogenital area
Diseases of the blood and blood and lymph vessels
Diseases of the nerves and psyche
Other diseases

Support from the ProDok assistant

As a structured input aid, the ProDok assistant facilitates the systematic documentation of a health disorder. The subjective (anamnesis) and objective criteria (status) of an illness are recorded and documented step by step. Individual steps can be skipped and left out if necessary.

The individual areas of the ProDok assistant:

Cause of consultation
Collection area
Consultation result
rating
Therapeutic consequences
Decursion

Selection of the causes of advice

The causes of advice are systematized in eight areas and also assigned to a localization pictogram. With this combination of text and graphics, the reason for the advice can be selected quickly and easily. A stored database with all common causes of a health disorder provides assistance.

Conversion of the cause of the consultation into a consultation result

There are several options available for converting the cause of the consultation into a consultation result, depending on the case and needs:

The result of the consultation corresponds to the cause of the consultation
Selection of a certain suitable consultation result
Selection of a counseling result from the list of previous counseling results for a specific counseling cause
The result of the consultation is left open

Survey area - standardized entry of the essential survey criteria

The survey area enables the structured and clearly assigned input of anamnesis, status and specific findings.

A text entry of any length is possible per day and per area. The cause of the consultation can automatically be transferred to the anamnesis area and supplemented with additional texts. Input assistance in the form of text modules and self-created abbreviations enable quick and easy processing.

Consultation outcomes - selection and coding

The selection of the consultation result from a database with over 85,000 common consultation results by the user can be done in several ways:

The selection by text, self-created abbreviations or ICD-10 is controlled via an input field.
Using a systematic: restriction of the search results by subdividing them into subjects (general medicine, dermatology ...) and areas.
Filter option according to frequency in three levels (frequent or rare consultation results in your own subject, consultation results in all subjects)

Here, too, the focus is on user friendliness . The possibility of defining your own abbreviations and classifying the consulting results in your own frequency criteria ensures that the user can meet the individual requirements of the user. Alternative jargon terms to the main selection are also available via a secondary selection.

After the selection, the "indirect coding" is implemented automatically.

The RC code is a 6-digit alphanumeric primary code which encodes and permanently documents the doctors' consultation results 1: 1. The RC code can be converted into current national and international code systems (= indirect coding).

This is the core of standardized, distinctive and permanent documentation.

Consultation result details: Diagnostic security

This is where the details of the consultation result (classification of the degree of diagnosis and page number) and the therapeutic consequences are determined.

The Braun classification in combination with the RC code enables a clear statement to be made about how the doctor assesses the patient's health problem at the end of the consultation and thus enables ICD coding to be traced at any time.

The classification of the degree of diagnosis:

A - symptom ("fever")
B - symptom group ("flu-like infection")
C - picture of a disease without evidence of the same ("looks like ...")
D - diagnosis (proven)
E - state after
F - without disease significance ("health examination")

The consultation result can be differentiated or corrected via a breakdown according to therapeutic groups (all counseling results that belong to the same therapeutic group of the previously selected counseling result are listed).

In a therapeutic group, all disease terms that have the same therapeutic consequences and measures are combined. The database contains around 3000 such groups.

This is followed by the choice of the therapeutic consequences that will be taken for the patient.

For the normal case of variable therapy, a choice of therapy can be used to help determine which therapeutic consequences are usually intended to be implemented for the respective problem.
However, whole consequence complexes can also be saved and thus routine therapies can be created in addition to variable therapies.
Of course there is also the possibility of no therapy.

Self-learning behavior related to therapy and consequences

In addition to the documentation of the implemented consequences for the individual patient, further measures of a problem group (billing diagnoses, use of medication, forms ...) are learned and are immediately available for the next patient with the same problem.

Age group-specific learning of drug therapy

Medication suggestions are listed based on self-learning behavior. New variants in the prescription (differentiations in designation, number of operations or dosage) are automatically documented. All variants have a counter and are automatically sorted according to frequency. Medicines that are prescribed in the same work step are combined into a combination. The storage takes place in consideration of age groups.

The prescription plan offers a therapy overview through a decade of the previous drug therapy and shows not only the trade name, number and dosage of the drugs, but also the data of the first prescription, change in dosage, withdrawal date and costs.

Collective therapy behavior

In addition to the creation of individual therapies and therapy variants with comments and explanations, the collective therapy behavior can also be viewed on the basis of the ProDok users.

It would also be possible to display guidelines.

Decourse overview

The decurs overview contains a structured display of the course of the disease with a chronological representation of the problem "tree", the current therapy and the decurs text entries. The daily branches of the problem tree list the measures carried out, the current state of health and the daily consequences.

The problem tree shows the previous day branches of a problem with arrows, date, text identifier and abbreviations for implemented consequences.

"*" Text entry available
D diagnosis
M drug
F form
L laboratory entry
B finding
V offsetting

Implementation of forms, reports, laboratory parameters

In individual functional areas, the problem is independently assigned to a large number of positions:

Forms and letters (sick leave, prescriptions ...)
billing
Laboratory parameters
Inability to work and sick leave
External findings
Self-reports

Subsequent assignment of card index entries

Any card entries (medication, text, forms, findings) can also be assigned to (several) problems at a later date.

Collective functions

Collective functions make it possible to access several problem or patient documentation at the same time.

Open problems can be closed collectively on the basis of predefined profiles, for example all flu-like infections still open from more than three weeks ago. This is particularly helpful for one-time consultations that were not completed because the patient did not make a follow-up visit.

Other collective functions include

Filter functions - the identification of problem cases according to certain criteria (certain diseases; all open / closed problems ...)
Output of data for statistical purposes

Focus on the patient

At the beginning of the ProDok project there was the vision: "In 2010 Austrian doctors will be the best in the EU ." With this guiding principle, the focus should be on the quality of care for patients. This can only be achieved through motivated, best possible service providers, for whom the best possible conditions must be given.

ProDok creates knowledge management for doctors for their patients in a core area of care, namely electronic medical history. The functionalities of the ProDok such as problem list, episodes (“case”) orientation, realistic classification, self-learning behavior during therapy and consequences, decurs, etc. result in a unique overview of the counseling and treatment progress of an individual problem with the respective complete review the problem-specific events. The structured surveyed doctors working with the ProDok confirm this.

Doctors can use the consultation time optimally for their patients. The coding obligation announced in Article 15a does not demand any additional time, because the indirect coding of the ProDok means that the doctors do not have to determine the code at all; instead, the EDP automatically takes over this process. The RC code inherent in ProDok maps the language of the doctors working in Austria 1: 1, resulting in an undistorted, original documentation image. The IT-based transformation of the RC codes into (aggregating) ICD-10 codes guarantees both their validity and the confidentiality of the original documentation. The completeness of the problem-oriented documentation not only ensures the quality of medical treatment, but also its proof - should this be needed.

Doctors who want to work with the ICPC-2 also receive an automatic transformation via the RC code thesaurus.

Using the generic standard of the ProDok project, all software companies are enabled to become "ProDok-compatible".

In the future, doctors will be able to find their way around the documentation they are used to when they are working as a substitute. And all the more benefits can be expected from problem-oriented communication between doctors in different branches. It can be developed from the ProDok process model. Through them, the messages between the doctors (in the EDP background) are encoded and can therefore be recorded in coded form in addition to the verbal representation of the addressed doctor's offices. This will result in a decisive advance in health telematics.

In the 15a agreement under the name ELGA , the federal and state governments in Austria agreed on the planning and establishment of an electronic health (health) file for patients. The necessary sociopolitical and, above all, data protection negotiation process is currently underway.

The enormous amounts of data in an ELGA are conceivable, but Austria has not yet had any experience with handling such amounts of data for the purposes of advice and treatment optimization. A large area of research for applied medicine is opened here.

With the large-scale use of ProDok in medical practices, the necessary basis and experience for a patient and doctor-oriented ELGA concept will be created.

privacy

Health data are particularly sensitive and sensitive data. Both the doctor's offices and the other health care facilities are subject to the strict rules of the Data Protection Act. Since the ProDok is a documentation in the respective doctor's office, the patient is automatically within this normative protective cover. New media, such as the e-card, and normative regulations, such as the new 15a agreement, are changing the way we communicate. In this regard, those responsible will have to assess the consequences of the technology and, if necessary, take measures to ensure optimal patient data protection.

partnership

Doctors have been working in (contract) partnership in the Austrian social security system for decades. The last basic contractual regulation regarding documentation dates back to 1971. In the meantime, EDP has found its way into the entire social context. In the health sector, the developments in health telematics and e-health initiatives as well as the relevant 15a agreement and its accompanying laws must be taken into account in an appropriate manner. This process is normatively designed by the contracting parties themselves in accordance with the framework conditions. With the Peering Point , the secure data transmission solution, the medical interest group and the social security system showed that large and trend-setting joint projects are also possible.

The ProDok was developed by doctors and will be further developed based on feedback from doctors' practices. The main association with its health insurance carriers supports and promotes this process with the ProDok project described here.

literature

Frank Warda: Electronic Health Records - Possibilities for Patients, Doctors and Industry. Current state of development in Germany. 2005, 300 pages, ISBN 3-938975-00-8

Web links

Problem-oriented documentation - Dr. Wolfgang Edinger (PDF; 196 kB)