Problem list problems with electronic medical records

In family medicine it has been common to keep a “Problem List” in patients’ paper charts. Usually placed on the left hand side, on top of the Medication List, it has given doctors like me an instant thumbnail sketch before considering the specifics of each patient’s visit for that day.

A typical Problem List would include diagnoses like diabetes, hypertension, high cholesterol or rheumatoid arthritis. It would list prior surgeries, like gallbladder surgery, hysterectomy and appendectomy, and medication allergies. Many of us also would list important tests done, such as a patient’s last colonoscopy or cardiac catheterization and make note of their family history.

Because Problem Lists are brief and the page usually has a fair amount of empty space, they can usually be digested in a quick glance, almost subconsciously and without effort.

In fifteen seconds or less I could prepare myself before seeing a colleague’s diabetic patient with abdominal pain, loss of appetite and loose bowels by checking that she had had her appendix out and a hysterectomy but never had agreed to a colonoscopy. I can also note that she is allergic to contrast dye and that her mother died from colon cancer at age 62.

The Problem List can usually be read as I walk down the hall to the exam room – that’s how quick it is to use. Because of its placement to the left in the chart, it can also be seen regardless of what page the chart is opened to on the right side.

My office notes tend to start with the presenting problem, and technically I don’t need to go into the items that are listed on the Problem List, as they are already so prominently displayed on the very first page of the patient’s chart. I may choose to do that anyway, after the presenting complaint. Incidentally, some insurance companies pay better if we spell out what we already registered semi-automatically by just glancing at the Problem List.

Occasionally I have worked with or taken over after internal medicine doctors. They do many things the way family practitioners do, but their use of Problem Lists is often different. Some of my internist colleagues leave the Problem List blank. Instead, they treat each patient visit as an independent event with no connection to the other pages in the medical record. They introduce the patient as if seen for the first time and begin every office note with an often lengthy summary, such as:

This 65-year old nonsmoking married white female with a past medical history of Type 2 Diabetes, contrast dye allergy, hysterectomy and appendectomy has a family history of colon cancer in her mother, who died at 62, yet the patient has previously declined screening. She presents today with…

As I look at Electronic Medical Records (EMR’s), which will be more or less required by law in this country in the next few years, I see a new type of Problem List, and it makes me sad. EMR’s tend to “populate” their Problem Lists automatically with every single diagnosis the physician makes. Important things like diabetes may drown among diagnoses of ordinary and self-limited things like influenza, colds, ankle sprains, ringworm and poison ivy – things that are unlikely to affect the future care of the patient. They would never be included in the original kind of Problem List unless a patient were to have those conditions often enough to be noteworthy.

One of the things I see happening in medicine today is that physicians are more and more documenting to serve the needs of others. Our own needs for speed and clinical efficiency are not driving the technology. Those who wish to count, evaluate and analyze what happens in the exam room seem to have more of their needs met by the technology we have available today.

Most electronic systems make it easy to document hoards of clinical data by just pointing and clicking, but they lack the ability to prioritize the data. Systems that don’t give clinicians the opportunity to distinguish between important and not-so-important data risk creating information overload and could cause the health care information system to clog up. Intelligent Problem Lists could help keep things in order.

A Country Doctor is a family physician who blogs at A Country Doctor Writes:.

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  • stargirl65

    I agree that problem lists can have a lot of irrelevant data if not well maintained. I have seen lists where diabetes is listed 5 times because the system kept loading it and no one ever looked at the list.

    My system allows chronic problems to stay on the list. It also allows acute problems to only stay on the list for a predetermined amount of time. I get to pick this time (one month I picked). So if she was in last month for acute sinusitis I can see this today. But next month it will disappear.

    I also find that things tend to stay on computer generated lists better. They are not “lost” in the chart or things left off when copied over

    The bottom line is that the list is only as good as the list maker. Computer charts or paper charts make no difference.

  • http://fastsurgeon.blogspot.com JF Sucher, MD FACS

    There’s a problem with “problem lists”. Doctors are confused over what is a problem. That is to say – Diagnoses (as you listed them) are not patient “problems”. Patient problems are, in fact, symptoms and complaints. Such as fever, cough, high blood sugar, abdominal pain, etc.. These problems can be chronic or change day to day. In other words, patients have problems, but physicians give them diagnoses.

    I submit that both EMR vendors have done an extraordinarily poor job in this arena because many healthcare providers also have not been taught these nuances. This does not change the fact that you still have a valid point about cluttered EMRs (there isn’t a single provider out there that isn’t keyed in on this issue). There are literally thousands of posts just like yours posted across the Internet over the past 15 years.

    The big problem is that this hasn’t changed because the industry is propped up by both major healthcare institutions and our federal government which have poured billions of dollars into terribly dysfunctional software and mandated its future use in perpetuity respectively.

    EMRs can be a very useful tool. But we are essentially eating these poorly designed, foul tasting products and smiling back at the chef asking for more gruel. Is there anyone out there that can stand up and tell the emperor he’s wearing no clothes, while at the same time able to show him a fine new robe?

  • jsmith

    “more and more documenting to serve the needs of others. ” Amen to that.

  • http://healbritannia.wordpress.com/ Bhetti

    Primary care in the UK uses computerised records heavily. There’s a PC in every general practitioner’s room. Needless to say, computers can slow things down.

    I’m not sure if it’s the same for you but don’t you have a list of ‘Active Problems’?

  • Jerry

    Our EMR has active problems and historical medical and historical surgical problems. We have a snapshot section that has both a general and subspecialty comment sections that only shows to others in that log-on speciality (eg dept ob/gyn) so what is important to our dept doesn’t pollute the other depts.

    Powerful EMR that has everything I desire, but still the rate limiting step is the 5000 providers sharing the chart must be willing to keep the various sections up to date. As I may see a patient nine times during a pregnancy, I have an incentive to make my other eight visits easier by cleaning up on the first visit. It would appear others do not have that incentive. I struggle with encouraging my colleagues and then listening to their persistent complaints that they don’t have time to clean up the EMR. It is always someone else’s job.

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