Table 2 Determinants with definition and extracted statements of importance

Clinical practice/reasoning

Clinical practice and or reasoning used we defined as the normal clinical routine of a clinician.

• The problem list can support the clinical practice

 ○ by giving up-to-date information about a patient enabling management of important health factors [7, 9]

 ○ by providing a guideline to secure all problems are discussed clinically and with the patient [12]

 ○ by sorting information, source oriented and in chronological order [8, 12]

 ○ by enabling clinical decision support [15, 16]

 ○ when notes are efficient and to the point [2, 16]

• It should be fully integrated in the workflow of a patient visit otherwise the use of the POMR will only increase work load rather than increasing efficiency and quality of care [11, 12]

• It should be possible to merge or link problems and their interventions, as problems are not always treated one at the time, to prevent fragmentation of patients data [8, 10, 12, 13]

• The mandatory items should be useful and applicable to the specific care situation, for diagnoses and interventions it makes sense to have mandatory items, but for routine interventions these should not be mandatory [8]

• When supporting clinical practice it is important to remember that attitude towards the problem list and its use can differ substantially between clinicians. Therefore different ways of working with the problem list should be supported [14, 17].

Complete and accurate problem list

How to deal with the wish of complete and accurate problem list.

• Participation of the patient in reviewing the problem list allows the clinician to update the problem list accordingly and can support a meaningful patient-clinician dialogue [6, 11]

• Problem list must be maintained and updated according to organization-wide guidelines, in order to be reliable and to give a relevant overview of available patient information [2, 7, 9, 12, 14, 15, 17–20, 23, 24, 27–30]

• All caregivers should be able to update the problem list, organizations should make, a choice if there should be separate lists for different caregivers [14, 18]

• System support can be used to complete the problem list [14, 15, 20, 21, 25, 26, 31]

• Clinical notes should be linked to problems [13, 15, 22, 29]

• Reviews of the problem list together with patients can improve the quality of the list [6, 11, 15]

Data structure/content

Data structure and content is about the structure of the data and the content of the record or problem list.

• There are a lot of different opinions about what, diagnosis, complaints, concerns, interventions, should be added to the problem list and who has to add this. Policy is needed so that users use the problem list in the same and proposed manner [9, 12–14, 19]

• It should be possible to link problems, so relationships between them can be made clear, and similarly it should be possible to link clinical notes to multiple problems [8, 10, 13].

• Problem list should have a dictionary/taxonomy behind them so codes from codesytems like ICD 9 ICD 10 and SNOMED, can be extracted. [6, 11, 18, 22]

• The required and mandatory information should make intuitive sense to the user. For example, enforcing information entry for routine interventions is not necessarily useful [8]

• It has to be possible to specify coded entries further by providing free text at entry [12]

• All clinicians should be able to register their problems with the appropriate coded problem list [12, 22]

Efficiency

Efficiency is gaining the most out of your time and resources.

• The POMR will only be adopted successfully if it is time efficient

 ○ The amount of work to fill in the format should be equivalent or reduced compared to currently employed use of POMR [2, 8, 32].

 ○ Clinical notes should be to the point and optimized [2, 8, 16]

 ○ The time gain should result from providing a quick overview of the patient [7, 14]

 ○ Electronic POMR should be fully integrated in the workflow of a patient visit otherwise it will increase work load [11, 12]

 ○ System support should help to improve efficiency (see below)

• The quick overview of the patient is important

 ○ to ensure increased efficiency (as outlined above).

 ○ to provide, efficient and therefore high quality care [7, 14]

• Using encoded problem list items

 ○ Makes sure all professionals using the list agree on the meaning of an element [22]

 ○ Makes clinical descision support possible [22], see also below.

Functionality

Functionality is used in this article for technical functions/features the system should have.

• It has to be possible to link problems and interventions. Moreover when updating the original input of the problem list it should be possible to change the hierarchy of the problem list when the diagnosis becomes more precise [8, 10, 12, 13, 27, 35, 36]

• A search function has to be implemented to prevent redundant entries [18, 35]

• The encoded list should be able to handle synonyms and free text entries or misspelled entries and should have an auto-suggestion feature [2, 6, 12, 31, 32]

• Filter and custom views should be possible [8, 12, 18, 24]

• Clinical decision support should check the problem list and assist the clinician in filling out the problem list [15, 21, 25, 26, 33–35, 37]

• It has to be possible to specify coded entries further by providing free text at entry [12]

• The problem list should work as a table of contents of the medical record [13, 18]

Interoperability

Interoperability is the possibility to transfer data between systems without losing its information and context.

• The problem list should be filled from all available clinical information systems to provide a complete view on the patient and not loose data entered in another system [2, 18, 28, 37]

• Problem list should have a dictionary/taxonomy behind them so codes from code systems, like ICD 9 ICD 10 and SNOMED, can be extracted, enlarging the interoperability [6, 11, 18, 22]

Multi-disciplinary

The definition used in this article for multi-disciplinary is the combination of different clinicians and health professionals.

• The problem list should support communication between disciplines and coordinate the care of the patients’ problem [7, 10, 18, 22, 36, 37]

• An agreed approach and management support is necessary to maintain a multi- disciplinary problem list [14, 17, 22]

• Keeping the problem list up to date and accurate is important when working across disciplines on the same patient [19, 21]

  ○ The more clinicians can and are allowed to add to the problem list, the more complex the list becomes to maintain [18]

   ▪ When disciplines are responsible for updating the problem list entries of their own expertise this could be solved [2, 22]

• Standardized terminology enlarges understanding between clinicians [18, 22]

• Clear guidelines and instructions on usage will help (paramedical) professionals to know what to include on the lists. Moreover the view of other clinicians of the patients’ problems can be of great importance in the care of patients [12, 14, 22, 23, 27]

Overview of patient information

In an electronic health record overview of the patient data is of vital importance.

• In an EHR, providing overview of the patient data is of vital importance [8, 27]

• It should be possible to link problems and interventions, as problems are not always treated one at the time, to prevent fragmentation of the patients data [8, 10, 12, 13]

• The problem list should represent the patient data in a coherent and logical order, so it provides a cornerstone of the EHR, preventing errors due to missing information [11, 15, 18, 21, 25, 36]

• If well maintained and structured, a problem list can assist a multi-disciplinary approach [10, 13, 16, 36]

• Policy should help with constructing the overview of patient data, providing guidelines for adding or leaving problems of the list reducing confusion and preventing missing information [14]

Quality of care

The definition of quality of care is used in the broadest sense of the term, all which can influence the care of the patient.

• If all patient information is related to problems and the problem list is often updated it allows for an evaluation of the efficacy of the treatment [7, 13, 15, 22, 33]

• Communication and coordination between health professionals is supported by the problem list [7, 10, 15, 18, 21, 22]

• Clear policy on what to put on the problem list and for the users clear structure is essential [9, 10, 14, 18, 19, 27, 29]

• The problem list is a valuable tool to get overview of the data of (unfamiliar) patients [7, 8, 11, 12, 14, 15, 18, 25, 27]

• The length of the problem list indicates the complexity of the patient [12]

• The problem list helps practitioners to identify the most important health factors for each patient, enabling personalized care [9, 11, 31]

• All clinicians should be able to update the problems on the problem list, collegues can review the problem list and improve patient care by keeping it updated [14, 22, 36, 37]

• When patients are able to review their own problem list, this allows them to direct improve their own care and health [6]

System support

Systems can support the user of the POMR in many ways; Clinical decision support, autosuggest etc.

• Prescribing medication, and ordering diagnostics or interventions can automatically populate the problem list. Important with such features is that the system checks if the problem is already on the list, to avoid redundancy of problems on the list. [15, 21, 25, 26, 33–35, 37].

• Systems can be configured in a way that they can detect omissions in the problem list to give clinicians the opportunity to correct it accordingly (also in clinical decision support). The user should always be the one to accept or authorize the problem to the list, automatic adding of problems is not desirable [16, 18, 20, 21, 25, 26]

• Clinicians are more likely to contribute to the problem list if the system supports them with meaningful triggers [12]

• With consistency across the problem list and encoded entries the system can support reusing the information for multiple purposes, for instance billing and quality assessments and also the other way around: from billing codes to problems, for example [11, 14, 16, 25, 26, 37].

• Natural language processing, from free text extracting codes, can help populate and complete the problem list. Language in which this feature is developed and the completeness of the processing has to be taken into account before using this feature [15, 29, 38]

• If diagnoses have to be registered in another module they should automatically be part of the problem list [2, 18, 28, 37]

• The system should be able to make comprehensive summaries of the record using the problem list [39]

• The system should present related terms to the user when entering problems [31]

Training of Staff

With training of staff the professional training is meant, how many years of experience and the training on using the system.

• Users should be trained in using the problem list, its features and policies on the problem list. This increases the correct use of the problem list [12, 14, 25, 40, 42]

• Experience in medicine and medical profession also influences the use of the problem list this should be taken into account in training of staff [17, 25, 41]

• Training can increase the correct use of the problem list [12, 14, 25, 40, 42]

Usability

The definition of usability in this article is user-friendliness and user interface.

• Custom views and filters should be possible [2, 8, 18, 39]

• The interface should be intuitive and efficient [8, 13, 39]

• The encoded dictionary should be able to identify synonyms, misspelled entries and handle free text [2, 6, 12, 31, 32]

• System support has to be integrated at logical moments in the notes registry (e.g. orders and medication) [17, 25] e.g. actionable items

• The clinical status of the problems should be easily identifiable [18]