Problem Oriented Health Record (POHR) (Jira PSS-2684)

2026 Updated Need:

Medicine has few generally accepted standards of care for organizing data entries in EHRs and determining the content of those entries. As a result, the design of EHRs depends heavily on idiosyncratic choices by EHR vendors and their customers, while the content entered in EHRs depends heavily on the idiosyncratic, on-the-fly judgments of clinician users during patient care. Yet those users are not equipped with problem-specific CDS tools designed to guide inputs to EHRs and lessen dependence on clinician knowledge and judgment. Moreover, the primary customers of EHR/CDS vendors are not clinicians but executives of provider organizations. The outcome is that many regard EHRs as clinically dysfunctional in their design and utility.

In particular, the National Academy of Medicine (NAM, formerly the Institute of Medicine) has found that EHRs are defective as records of clinical reasoning and information usage: "… much of the content of the record depends on what the clinician chooses to include, and thus there may be variations in the extent to which clinical reasoning is documented (e.g., what alternative diagnoses were considered, the rationale for ordering [or not ordering] certain tests, and the way in which the information was collected and integrated)." NAM, Improving Diagnosis in Health Care (National Academies Press, 2015), p. 102. The reference to “clinical reasoning” is significant, because the NAM report elsewhere observes that “proficiency in clinical reasoning” is “the clinician’s quintessential competency.” Yet, “clinical reasoning processes are difficult to assess because they occur in clinicians’ minds and are not typically documented in medical records.” Ibid., pp. 53, 94. These realities make EHRs defective as tools for guiding and documenting processes of care, scrutinizing care quality, supporting clinical research, and improving the economics of care.

Although record keeping standards are lacking, “there are some common conventions for structuring medical records (both in paper and electronic formats),” as the NAM report observes (p. 102). But those conventions are not treated as enforceable standards of care, nor are they optimized for clinical functionality. Moreover, variability results from “regulatory and local rules affect[ing] which members of the diagnostic team contribute to the documentation in a medical record and how they contribute,” ibid. Those rules vary by jurisdiction. Variability of that kind is clinically random.

To address these failings, the POHR (formerly referred to as the problem-oriented medical record (POMR)), was developed as a standard of care to govern organization, content and use of patient records. For example, the POHR defines detailed data categories (e.g. the various elements of a problem, of a care plan, of an encounter note) for data entries in the record. Users, by simply populating the categories, are automatically guided to assemble data and make decisions in a highly organized and clinically functional way.

In the 1990s, during the era of paper records, a committee of the NAM considered the POHR and wrote about it in favorable terms (under the heading “Guidance of Clinical Problem Solving”):

"The committee unanimously believes that patient records should guide and reflect clinical problem solving … "Although it did not specifically recommend use of the POMR, the committee did consider certain components of the POMR to be highly desirable in any computer-based record system. Those components include (1) a structured, systematically collected database; (2) an easily reviewed and updated problem list; and (3) routine recording of clinical formulations and plans for care and follow-up. … A minority of committee members maintained that one patient record format —the problem-oriented medical record first described by Weed—offers a superior alternative in guiding and supporting scientific reasoning and clear communication in medical practice. Those who favored the POMR format argued that it is a general model that rests on a firm theoretical foundation …" The Computer-Based Patient Record: An Essential Technology for Health Care (National Academy Press, 1991, rev. 1997), p. 91.

Subsequently, no clear alternative to the POHR has emerged (although some advocate "goal-oriented" records, which in fact are compatible with POHRs). Moreover, no institution has adopted and enforced truly problem-oriented records at scale. For example, problem lists are often incomplete and variable in how well they are used and maintained. Similarly, although EHRs usually include a core POHR capability — linking record entries (encounter notes, care plans, orders, results, etc.) to relevant problems on the problem list — clinicians do not consistently use this linkage capability. Automating such linkage has been the subject of research, but no automated approach has been generally accepted, and in any event fully automating such linkage may interfere with essential "human-in-the-loop" involvement. Most important, there is little understanding or use of a fundamental element of problem-oriented care: "knowledge coupling" CDS tools designed to identify needed patient data and couple the collected data with medical knowledge to reveal what the data mean. The output of these tools displays options for diagnostic and therapeutic decisions with the pros and cons of each option, all individualized to the patient. This knowledge coupling approach makes inputs to the record less dependent on human judgment and far more transparent than AI alternatives to human judgment. AT the same time, AI tools can be used to help build knowledge coupling tools in advance of their use and then to supplement those tools during or after their use in patient care.

In light of the above, there is a clear basis for HL7 to apply the POHR/knowledge coupling approach as as an organizing principle for standards to bring clinical functionality, consistency and clarity to EHR/