Improving Electronic Health Record (EHR) Functionality:

Toward the Solution-Oriented Medical Record

James J. Cimino

Chief, Laboratory for Informatics Development

NIH Clinical Center

US National Institutes of Health

Bethesda, Maryland, USA
Outline

• Motivation for better health records

• Creation – the Problem-Oriented Health Record

• Evolution – the Solution-Oriented Health Record

– How did we get here?

– Where we are going?

– Where we will be?
Florence Nightengale

Nightingale F. Notes on Hospitals. London: 

Longmans, Green and Company; 1863:176

In attempting to arrive at the truth, I have applied 

everywhere for information, but in scarcely an 

instance have I been able to obtain hospital 

records fit for any purposes of comparison. If 

they could be obtained they would show 

subscribers how their money was being spent, 

what amount of good was really being done with 

it, or whether the money was not doing mischief 

rather than good

Barnett GO, Jenders RA, Chueh HC. The computerbased clinical record--where do we stand? Ann Intern 

Med. 1993 Nov 15;119(10):1046-8
“A general purpose [health] record system would serve 

to improve the quality, planning and administration of 

health services, to help in the evaluation of 

comparative therapies, and to forward research on 

epidemiology and human genetics, and problems of 

diagnosis and especially on the natural history of 

disease.”

“We recommend the establishment of a special 

standing committee...to guide the development of a 

general purpose health record system...”

- President’s Science Advisory Committee

 Life Sciences Panel , 1963
Weed LL. Medical records that guide and teach. 

N Engl J Med. 1968 278(11):593-600 and 

278(12):652-657. 

www.youtube.com: Patient Care and the Medical Record

CVA: Cerebrovascular Accident 

(Stroke)

SSKI: Potassium Iodide Oral 

Solution

LE Prep: Test for Systemic Lupus 

Erythematosus

Blood Pressure 180/100 (high)

BBIs: ???

CBC: Complete Blood Count

What Did Weed Want?

• Each medical record should have a complete list of all 

the patient's problems, including both clearly 

established diagnoses and all other unexplained 

findings that are not yet clear manifestations of a 

specific diagnosis, such as abnormal physical findings 

or symptoms

• Careful analysis and follow-through on each problem 

as revealed in the titled progress notes, requiring that 

the proper data be collected and that the conclusions 

drawn from this data are logical and relevant
Plan

Assessment

The Problem-Oriented Medical Records:

(SOAP)

Objective

Subjective
In the beginning, there was....

Billing

Subjective

Objective

Assessment

Plan
Ancilliay Systems Make their Contribution

Billing

Results

Subjective

Objective

Assessment

Plan
The Beancounters Triumph!

Billing

Results

Subjective

Objective

Assessment

Plan
Can you say: Return on Investment?

Billing

Orders Results

Subjective

Objective

Assessment

Plan

Comments on EHRs Today

“We called it the Sunny von Bülow bill. These companies that 

should have been dead were being put on machines and kept 

alive for another few years,” said Jonathan Bush, co-founder of 

the cloud-based firm Athenahealth and a first cousin to former 

President George W. Bush

“On a really good day, you might be able to call the system 

mediocre, but most of the time, it’s lousy,” said Michael 

Callaham, the chairman of the department of emergency medicine 

at the University of California, San Francisco Medical Center

“Nothing that these companies did in my eyes was spectacular,”

said John Gomez, the former head of technology at Allscripts
Clinical Decision Support

Alert

Sometimes, the informaticians get to be in charge

Billing

Orders Results

Subjective

Objective

Assessment

Plan
We have been doing these for over 40 years
Automated Clinical Decision Support

Alerting and 

Reminder 

System
Infobuttons

Anticipate 

Need and 

Provide 

Queries

i


Alert

Clinical Decision Support

Dawn of Computer-Based Clinical Documentation

Billing

Orders Results

Subjective

Objective

Assessment

Plan


?

Alert

Clinical Decision Support

Better Data Capture

Billing

Orders Results

Subjective

Objective

Assessment

Plan
Better Data Capture

• Mobile and home devices

• Systematic, consistent discrete data capture for 

the purposes of “learning from every patient”

• Smart inclusion of relevant data into notes

Alert

Clinical Decision Support

Better Views of the Record

Billing

Orders Results

Objective

Assessment

Plan

Subjective
Better Views of the Record

• Disease-specific patient-oriented summaries

• Sign-out to support transitions

• Expert systems to render context-sensitive summaries

• Integration of personal genomes into EHRs

• Medication timeline

• Heads-up displays

• Automated communications: discharge summaries, 

patient letters, etc.

CAD/DM Smart Form: Graphs
Courtesy: Vanderbilt University


CAD/DM Smart Form: 

Patient View

Alert

Clinical Decision Support

Re-Using EHR Data for Better Evidence

Billing

Orders Results

Subjective

Objective

Assessment

Plan

Clinical Decision Support

Billing

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Clinical Decision Support

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Clinical Decision Support

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Analytics
Alert

Clinical Decision Support

Re-Using EHR Data for Better Decision Support

Billing

Orders Results

Subjective

Objective

Assessment

Plan

Clinical Decision Support

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Clinical Decision Support

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Clinical Decision Support

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Analytics
Re-Using EHR Data for Better Decision Support

• Using a clinical data warehouse to improve alerts

• Risk-stratification with risk-specific plans of care

• Raising clinical alerts based unusual patient care

• Personalized medicine supported by genomic data

• Context-driven dynamic alerts that learn

• NLP to analyze notes in real-time
Courtesy: Vanderbilt University
Alert

Clinical Decision Support

Better Reuse For Research (and Workflow)

Billing

Orders Results

Subjective

Objective

Assessment

Plan

Research
Better Reuse for Research (and Workflow)

• Data mining to detect adverse events

• Self-service hypothesis testing

• Alerts for subject recruitment

• Alerts for protocol violation

Courtesy: University of Cincinnati



Alert

Clinical Decision Support

There Are Still Pieces Missing

Billing

Orders Results

?

?

?

Subjective

Objective

Assessment

Plan

Research
Tactics versus Strategy
Medical Records the Guide and Teach

• Larry Weed mentions computers 24 times

“If we accept the limits of discipline and form as 

we keep data in the medical records the 

physician's task will be better defined, the role 

of paramedical personnel and the computer 

will be clarified, and the art of medicine will 

gain freedom at the level of interpretation and 

be released from the constraints that disorder 

and confusion always impose.”

Cook #1: a terrible cook

Cook #2: a vegan

Cook #3: an informatician
Alert

Clinical Decision Support

We Need to Make the Computer a Full Partner

Subjective

Objective

Assessment

Plan Billing

Orders Results

Research

What is the

Strategy?

Relate 

Findings to

Assessment

Coded

Signs

Coded

Symptoms
CAD/DM Smart Form

Smart View: 

Data Display

Smart 

Assessment, 

Orders, and Plan

Assessment and recommendations 

generated from rules engine

Smart 

Documentation

• Lipids

• Anti-platelet therapy

• Blood pressure

• Glucose control

• Microalbuminuria

• Immunizations

• Smoking 

• Weight

• Eye and foot examinations
CAD/DM Smart Form\

•Rules

•If patient has DM then 

goal BP < 130/80

•If the average of the blood 

pressure at the last 2 visits 

(in the last year) is above 

goal then return..
CAD/DM Smart Form

•Medication Orders

•Lab Orders

•Referrals

•Handouts/Education
CAD/DM Smart Form

Easy inclusion of assessment 

and orders into note
CAD/DM Smart Form: Workflow

Automatic inclusion of data 

(e.g., medications) 

Importation of 

data elements
Automated Inclusion of Data in Notes

• Adverse effects:

– Leads to note bloat

– Discrepancies in the record

• Alternative therapy:

– Annotate non-note data

– Create relevant views while composing notes

– Link observations to assessments - evidence

– Link observations to plan – monitoring strategy
Future Partnerships

• Evidence-based care

• Quality care

• Cost containment

• Genomics: diagnosis, treatment, prognosis

• Pharmacogenomics: patient, tumor, microorganism

• Meaningful use of electronic health records
Larry Weed, Again

It has been said that preoccupation with the 

medical record and the computer leads to 

neglect of the "humanitarian" side and the "art" 

of medical practice. 

The most humanitarian thing a physician can do 

is to precisely know what he is doing, and make 

the patient as comfortable as he can in the face 

of problems that he cannot yet solve.
Where Do We Go from Here?

• EHRs are less problem-oriented than paper ones

• Current EHRs are victims of their history

• Those who don’t study history are doomed to repeat it

• We need to stop thinking of the EHR as a diary

• We need to tell the EHR why we are doing things

Where Do We Go from Here?

• EHRs are less problem-oriented than paper ones

• Current EHRs are victims of their history

• Those who don’t study history are doomed to repeat it

• We need to stop thinking of the EHR as a diary

• We need to tell the EHR why we are doing things

• Then it can evolve to a solution-oriented health record

• Extinction is part of the evolutionary process

• IBM has tried to build EHRs before...

• Partners Healthcare purchased a commercial EHR
Acknowledgements

• Blackford Middleton: Partners Healthcare/Harvard

• Ken Mandl: Intelligent Health Lab (Harvard)

• Patti Dykes: Electronic Bedside Communication 

Center (eBCC; Harvard)

• David Vawdrey: SmartNotes (Columbia University)

• Dan Masys: Vanderbilt University

• Bill Tierney: Regenstrief Institute