un analisis del uso del metodo orientado a problemas

8/13/2019 Un Analisis Del Uso Del Metodo Orientado a Problemas

1/6

Medical Education, 1977, 11, 341-346

An analysis of the use of problem oriented medical records(POMR) by medical and surgical house officers: factorsaffecting use of this format in a teaching hospital

L. CARO L FERNOW, I. M c CO L L, C H R I ST IN E M A C K I E A N D M. RENDALLKings Fund Record Pr oject , Department of Surgery, Guy s Hospital , London

Summary Guys by medical and surgical house officers and toOne set of case notes a week for 12 successive weekswas selected randomly for each of twenty-eighthouse officers and scored for use of the POMRformat in the data base, initial plans, and progressnotes. Analysis was based on 336 sets of records.The purpose of the study was to obtain informationwhich might improve the techniques of teachingPOMR to junior hospital staff.

The significant findings were: marked differencesin scores among house officers; those who performedwell or badly did so in all three components of thesystem; high scorers in the medical group identifiedmore problems with no evidence that their patientswere more ill; scores were better for house officerswith favourable attitudes toward POMR and scoreswere better in the innovative sections if senior staffused the system; house officers with BA or BScdegrees scored better with initial plans and progressnotes. No positive effect of feedback was demon-strated.

Key words: *POMR; *HOSPITALS, TEACHING;INTERNSHPND RESIDENCY; EDUCATION,EDICAL,GRADUATE; ATTITUDEF HEALTH PERSONNEL; EVALU-ATION STUDIES; LONDON

IntroductionThe objective of this study was to evaluate the use ofthe Problem Oriented Medical Records format at

Correspondence: Dr L. Carol Fernow, Kings FundRecord Project, Department of Surgery, Guys Hospital,St Thomas Street, London SEI 9RT.

examine the ways in which feedback and attitudesaffect this use. The specific questions we wished toanswer were the following: 1) how well do the houseofficers use the three major components of thePOMR format for which they are primarily re-sponsible, i.e. data base (basic admission infor-mation), initial plans, and progress notes? (2) Arethe performances in each of these three componentsuniform for a single house officer?(3) Does feedbackof scores affect performance? (4) Are scores affectedby the house officers attitude towards POMR?( 5 ) Are scores associated with the house officersperception of the attitudes of the firms consultantsand registrars towards POMR? (6) Do scores forthe house officers with BA or BSc degrees differfrom scores of house officers who have not had thisadditional academic experience?

BackgroundThe plan for this study originated in the need tostimulate better and wider use of the POMRrecording method at Guys after it became officialhospital policy in 1974. A booklet entitled Guide-lines for the Preparation of the Problem OrientatedMedical Record had been distributed to all staff.Although additional enquiries were welcomed bythe Steering Committee it was soon apparent thatthese measures were not enough to effect the desiredconversion to the new method of recording. Theexperience of the University of Connecticut Schoolof Medicine had been that a score of format re-turned to the intern or house officer could be animportant adjunct to improved performance in the

341


2/6

342 L . Carol Fernow et aluse of POMR (Roberts et al. 1973). With this inmind a method of scoring the notes for POMRformat was devised.

Studies involving review of patients records havecontributed to our hypotheses. Ciocco et al. (1950)corroborated the findings of Huntley that changein one port ion of the clinical record . would be areliable indicator of the effect of changes in the chartconference procedure on the overall quality of theclinical record. Huntley et al. (1961), Morehead(1970) and Peterson et al. (1965) also identified aconsistency in the different medical recording tasks.

We anticipated that the performance of housemenwould be influenced by the attitudes and behaviourof senior staff toward POMR, and we expected tofind that those who had used the system best weremore thorough and thus identified more problems.We also thought that house officers who obtainedBA or BSc degrees prior to graduation from medicalschool might use POMR better. An analogy madebetween a chess game and POMR (Tufo e t al.1973a), describes a conceptual structure that thetraditional record does not have.

Users of POMR describe two inter-related types offeedback which result from examination of (1)procedural performance, in the use of this system,i.e. review of format, and (2) clinical performance,i.e. review of the thoroughness and reliability of themedical logic. We began with the former becausecorrect use of the format must precede effectivereview of clinical performance. It has been shownthat case notes can be reviewed for procedure bynon-medical personnel (Tufo e t al., 1973 b).

MethodThis report is based o n the reviews of 336 case notesaf twenty-eight housemen*, fourteen with appoint-ments in general medicine and fourteen in generalsurgery. One set of case notes was selected at randomevery week for 12 weeks for each house officer. Thefirst eleven weeks of each house officers appoint-ment were not studied. During this time the in-troduction to POMR consisted of giving each houseofficer a copy of the Guidelines and a brief des-cription of the study during the house officersinduction course. One in-patient record of each

* House officers whose consultants actively discouragedthe use of PO M R were excluded from the analysis.

house officer was selected and reviewed during thesecond month by the project staff. They discussedthese results with the house officers, explained thestudy, and assured them that their identity wouldbe kept in confidence.

Beginning in the twelfth week of each six-monthhouse appointment, one case a week for each houseofficer was selected randomly for review. Notes werescored by a trained clerk using explicit writteninstructions and an objective evaluation question-naire that had been pre-tested on forty-eightnotes of six house officers. Partial or full credit wasawarded precisely, which accounts for scores toone decimal place. These scores were used both forfeedback and for this analysis. In addition to scoringthe POMR format, data were collected on thephysical, psychological, and social problems identi-fied by the house officer.The following information was returned throughthe hospital post to each house officer. 1) A photo-copy of the review with errors in format identifiedwas sent weekly. It was accompanied by appropriateexplanation and offers of assistance. (2) Everymonth for three months each general medical andgeneral surgical house officer received the statisticalresults of his monthly scores. In addition to the meanand median scores, the Kruskal-Wallis one wayanalysis of variance by ranks was performed to testwhether there was a statistically significant differenceamong the scores of the house officers.

The Kruskal-Wallis test seemed particularlysuitable because the display of the data on which thetest is based provided an intuitive estimate of eachhouse officers performance relative to his colleaguesand did not require a knowledge of statistics. Eachhouse officers scores were arranged in a columnwith the rank of each in the total array of scoresbelow it in brackets (1 = low). The houseman withthe highest sum of ranks was labelled A with theranks of B 7, nd D in descending order. Thecolumn of his scores was identified for each in-dividual house officer. The size of the statistic andthe interpretation of significance were also given.

In the final two weeks of the appointment, anattitudinal questionnaire was completed to deter-mine satisfactions and dissatisfactions with POMR,as well as perceptiom of the attitudes towardsPOMR of the consultants and registrars on the firm.Housemens responses were classified independentlyinto very enthusiastic, moderately enthusiastic,and not enthusiastic.


3/6

Use ofPOMR by house oficers 343

physicians0 0 0 0 0 0House

Analytical methoNon-parametric rank order sta istics were used tosummarize the data and to assist in the evaluation ofour hypotheses. We adopted the conventionalprobability level of P


4/6

344 L . Carol Fernow et althe three independent components of the score wereanalysed separately. These test statistics were allsignificant with a probability of less than 0 01 forthe data base scores of house surgeons. All otherprobabilities were less than 0.005, indicating thatthere were significant differences for both groups ofhouse officers in their grasp of different parts of thePOMR format. We observed furthermore thatindividuals who did well on one part of the formatgenerally did so on the others. While we had hopedto find that our feedback techniques improvedperformance in each successive month we wereunable to demonstrate this for the group as a whole.Relationship of scores on data base initial plans andprogress notes

We observed a correspondence in performance ineach segment of the format, particularly betweeninitial plans and progress notes, and this was borneout by tests on the medians of the twelve scores (seeTables 1 and 2).

The Kendall coefficient of concordance, W,measured the relationship of the ranks of the threesets of scores for data base, initial plans and pro-gress notes. The probability of a statistic as high orhigher than the W s found was P


5/6

Use o P O M R by house officers 345analysis was to attempt to identify factors whichmay have influenced these differences.

Dealing with them as separate samples it wasapparent that the scores and probabilities for medicaland surgical housemen did not differ* with theexception of the number of problems identified.Since we had no reason to think that one groupwould use the format better than the other, thesimilarity of the findings suggests that the method sat least reproducible in the setting of Guys Hospital.The two groups have been combined in the remaininganalysis in order to take advantage of the improve-ment in estimation which is afforded by a largersample.Relationship between scores and attitudes

Table 3 shows the median total scores on formatassigned according to attitude category. When theKruskal-Wallis one way analysis of variance byranks was performed, the results (Pt0.01)howeda significant difference n the scoreson format amongthe house officers with different attitudes. Theresults of the same test on data base, initial plansand progress notes P


6/6

346 L. Carol Fernow et a[.skill of recording using the POMR format, that wemust make the obvious statement that some used itwell, some moderately well, and others badly.Individuals tended to maintain the same standard ofrecording in each segment of the record.

The data discussed here have suggested to us thatonce the logical principles which underlie the systemare understood, performance in all areas of use isgenerally high. Arriving at that level of understandingwould seem to require more frequent and formaltuition than potential users of POMR might anti-cipate. Recording in this format is not so simplethat it can be mastered in an evenings reading of awell prepared booklet, in an occasional meeting witha clinician skilled in its use, or solely by the feedbacktechniques that we have used.

The most obvious place to teach POMR is in themedical school, not only to avoid the difficulties andantagonisms of unlearning one way of recordingand learning another, but to take advantage of theconceptual emphasis in this environment. The betterscores in initial plans and progress notes of house-men holding BA or BSc degrees lends support to thebelief that POMR has a satisfying logic that tradi-tional recording does not. We think that, once havinglearned POMR, most clinicians would agree with thethree house officers who volunteered the commentin the attitudinal questionnaire: Now that I havelearned to use it I would never go back to the oldmethod of recording.

The association between the attitudes of the house-men and their use of POMR was not fully explained.Only two house officers claimed to have learned it inmedical school, and all said they had read theGuidelines before the review period began. Thedifferences in scores for initial plans according towhether consultants and registrars use the systemsuggest to us that performance in this difficult area sundoubtedly influenced by the example and interestof the senior staff. We have reached the conclusion,therefore, that a formal effort should be made toadvise senior staff in the use of the system. While werealize that the problem of converting to POMR ismagnified by years of experience with the traditionalmethod, we would hope to promote sufficientunderstanding among clinicians in senior positions,even those who were reluctant to change themselves,to encourage juniors to use the system well.

Although we could not demonstrate that ourmethod of feedback improved performance amongthe housemen as a whole, we had ample anecdotal

evidence of the determination of house officer Ato retain his position and of house officer B tosurpass him on the next months statistics. Thisproject promoted awareness of POMR at all levelsof staff throughout the different departments of thehospital. We believe that continual evaluation ofthe use of POMR procedure is essential, certainlyin the transitional stage between adopting POMRas hospital policy and full conversion to the system.The main value of the POMR system to cliniciansis that it allows the reconstruction and review ofmedical logic for educational purposes. Until suchtime as the format is generally used correctly thefull advantages of the system will not be realized.

AcknowledgmentsThis research was supported by a grant from theKing Edwards Hospital Fund for London. Theauthors wish to thank Rosemary Dalton of theDepartment of Community Medicine at GuysHospital for her careful and constructive reading ofthis manuscript.

Readers who would like more details of the study shouldwrite t o the Department of Surgery, Guys Hospital.

ReferencesROBERTS, .P., VILINSKAS,. DAVIDS, .S. (1973) Report-ing medical record quality. Hospital Progress 54, 36.CIOCCO,A., HUNT, H. ALTMAN,. (1950) Statistics onclinical services to new patients in medical groups. PublicHealth Reports 65 99.HUNTLEY, .R., STEINHAUSER,., WHITE,K.L., WILLIAMST.F., MARTIN,D.A. PASTERNAK,.S. (1961) Thequality of medical care: techniques and investigation inthe out patient clinic. Journal of Chronic Diseases 14, 630.MOREHEAD,. (1970) Evaluating quality of medical care inthe neighbourhood health centre. Programme of the Office

of Economic Opportunity. Medical Care 8, 118PETERSON,.L., ANDREWS, .P., SPAIN,R.S. GREENBERG,B.G. (1965) An analytical study of North Carolinageneral practice, 1953-1954. Journal of Medical Education31, 1TUFO,H.M., EDDY,W.M., VAN BUREN,H.C. , BOUCHARD,R.E., TWITCHELL,.C. BEDARD, OUISE1973a) ZmpIe-menting a Problem Oriented Practice (Ed. by K . Walker,J. Willis Hurst and Mary F. Woody), p. 27. MedcomPress, New York.TUFO, HENRY M., EDDY, W.M., VAN BUREN,H.C.,BOUCHARD,.E., TWITCHELL,.C. BEDARD, OUISE(1973b) Audit in a practice group. Applying the ProblemOriented System (Ed. by K . Walker, J. Willis Hurst andMary F. Woody), p. 32. Medcom Press, New York.

un analisis del uso del metodo orientado a problemas

Documents