Non-physician development of problem lists from office records

Area of Science:

• Health Informatics
• Medical Record Management
• Ambulatory Care

Background:

• The conversion of traditional office records to the problem-oriented medical record (POMR) has been perceived as costly.
• High expenses in terms of finances and physician time are often cited as barriers to POMR adoption.

Purpose of the Study:

• To evaluate the cost-effectiveness of preparing problem lists for POMR conversion.
• To assess the accuracy of problem lists generated by non-physician personnel from existing ambulatory patient records.

Main Methods:

• Non-physician personnel were tasked with creating problem lists from existing ambulatory patient records.
• Physicians subsequently reviewed and validated the accuracy of the generated problem lists.

Main Results:

• Problem lists prepared by non-physician personnel were deemed accurate by physicians.
• The cost associated with non-physician personnel preparing problem lists was substantially lower than when physicians performed the task.
• This method offers a significant cost reduction compared to physician-led chart review and problem list creation.

Conclusions:

• Utilizing non-physician personnel for problem list creation is an accurate and cost-effective strategy.
• This approach facilitates the conversion of outpatient records to the problem-oriented medical record (POMR).
• The findings suggest a practical solution to overcome financial and time-related barriers in POMR implementation.