A thought-provoking video featuring Professor Lawrence Weed from 1971 recently resurfaced, reminding us of the revolutionary ideas behind problem-oriented medical records. Weed’s grand rounds at Emory University showcased his vision for a medical record structured around patient problems, a stark contrast to the then-prevalent “source-oriented” chaos. This problem-oriented approach, detailed in his 1964 and 1968 publications, gave birth to the SOAP note (Subjective, Objective, Assessment, and Plan), a framework designed to bring order and clarity to patient documentation. The aim was to create a Problem-Oriented Medical Record (POMR) that moved beyond mere data collection to become a tool for better patient care and clinical reasoning. This shift towards a more structured and thoughtful approach to medical notes was revolutionary for its time.
Weed’s problem-oriented format resonated deeply, even influencing how medical professionals present patient cases today. The transition from organ-system based presentations to problem-based discussions in settings like the ICU highlights the enduring value of his approach. Organ-based presentations, while systematic, often require mental translation into a problem-based framework to truly grasp the clinical picture. This translation effort underscores the inherent efficiency and clarity of problem-oriented thinking in medicine.
However, even as we embrace structured approaches like POMR, a tension persists between reductionist views of patient problems and the need for a holistic, “big-picture” understanding. Patients are more than just the sum of their medical issues. While systematic approaches are vital for effective medical practice, particularly in today’s fast-paced healthcare environment, they must be balanced with the critical ability to synthesize information and see the patient as a whole person. This synthesis, once naturally fostered by the act of writing paper notes, faces new challenges in the era of Electronic Medical Records (EMRs) like Epic.
The widespread adoption of Epic EMR systems has transformed healthcare documentation. While offering undeniable advantages over paper records and previous EMR systems, Epic’s problem-centric design takes Weed’s POMR concept to an extreme. In Epic, the problem list becomes the central organizing principle, fundamentally changing how notes are created. Instead of “writing a note,” clinicians now primarily “chart on problems,” addressing each issue individually. The system then aggregates these problem-specific entries into a progress note, creating a collection of fragmented assessments and plans electronically stitched together. This approach, while intended to enhance longitudinal tracking of individual problems like hypertension or chronic illnesses, can inadvertently lead to a loss of overall clinical coherence.
This hyper-focus on individual problems in Epic can hinder the crucial act of clinical synthesis. While charting by problem facilitates long-term tracking and data organization, it can also lead to notes that lack a cohesive narrative. Reading notes generated in this manner, one often struggles to discern the patient’s overall clinical trajectory – whether they are improving, deteriorating, or remaining stable. The crucial “story” of the patient’s illness can get lost in a sea of discrete problem-specific entries. The system, designed to streamline documentation, paradoxically can obscure the very information clinicians need most: a clear understanding of “what is going on with the patient.”
This issue is compounded by the time pressures and efficiency demands prevalent in modern medical training. Trainees, operating under duty-hour restrictions, are increasingly incentivized to adopt a “just the facts” approach, addressing patients as a series of isolated problems requiring algorithmic solutions. This “if X, then Y” mentality, while valuable in certain contexts, becomes problematic when it overshadows the need for a comprehensive clinical picture. Notes and presentations, in this environment, risk becoming mere data dumps, devoid of meaningful synthesis and clinical reasoning. This challenge extends beyond the well-documented issue of copy-and-paste, posing a more fundamental threat to clinical synthesis and diagnostic acumen.
Larry Weed himself anticipated the concern that a problem-oriented approach might lead to fragmented thinking. In his 1968 article, he argued that a complete analysis of each problem should, in fact, facilitate integration and synthesis. However, the current implementation within EMR systems like Epic, coupled with workflow pressures, can inadvertently hinder this integration. Connecting seemingly disparate problems – cough, sinus issues, and kidney failure – requires a deliberate effort to see the patient holistically, to identify unifying diagnoses that explain the constellation of findings. This crucial diagnostic synthesis becomes significantly more challenging when charting is primarily problem-by-problem, potentially leading to a collection of data points without a coherent clinical narrative.
Epic’s dominance in the EMR market underscores the urgency of addressing this challenge. While Epic is a robust and sophisticated system, steps are needed to safeguard and promote clinical synthesis within its framework. The key is to move beyond simply documenting problems to creating “diagnosis aware notes” – notes that actively engage with the diagnostic process and present a synthesized understanding of the patient’s condition.
To foster this shift towards diagnosis aware notes, a practical solution would be to incorporate a mandatory “Über Assessment” or “Big Picture” field within each Epic note. This dedicated space would prompt clinicians to explicitly synthesize the fragmented problem-specific data into a cohesive clinical narrative. Mousing over an information icon could reveal the field’s purpose: to communicate to the entire care team – nurses, consultants, social workers, and attending physicians – the overarching clinical picture. This section should articulate the major clinical questions, the patient’s trajectory (improving, worsening, stable), and the diagnostic and therapeutic reasoning guiding the care plan. Crucially, this space should not be used to reiterate the problem-by-problem details already documented elsewhere in the record. Instead, it should encourage a more synthetic, narrative, and insightful summary – a “story” of the patient’s illness.
By integrating such a feature, we can encourage clinicians to create notes that are not just records of individual problems, but rather Diagnosis Aware Notes Epic in their scope and utility. These notes would not only document care but also actively facilitate clinical reasoning, communication, and a more holistic understanding of the patient. This is not about rejecting the problem-oriented approach, which remains fundamentally sound, nor about abandoning EMRs, which are essential tools in modern healthcare. Instead, it’s about adapting and refining these systems to ensure they enhance, rather than hinder, the crucial art of clinical synthesis and diagnostic thinking. It’s time to proactively shape how these powerful tools influence our clinical practice and ensure that technology serves to elevate, rather than erode, the quality of patient care.
