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December 19, 1977

Problem-Oriented Approach to Practice

JAMA. 1977;238(25):2697. doi:10.1001/jama.1977.03280260027007

To the Editor.—  The special communication, "Problem-Oriented Approach to Practice" (238:414, 1977), by Tufo et al demonstrates how problem-oriented medical records (POMRs) make analysis easier by recording visits in codable, retrievable formats.I disagree with the conclusions drawn by the authors. In all other phases of medical practice, to assess hypotheses controls are necessary to determine the difference between causation and association. The reported study has problems with both internal and external validity. The demographics and process of the practice were not held constant over the time of the assessment. Occurrences at the end of the investigation may be purely the result of changes associated with the passage of time, not with the use of the POMR format. The lack of controls reduces the ability to generalize to other situations, thus eliminating external validity.Determination of association with the record system is not appropriate, let alone causal conclusions.The economic