How to effectively keep tabs on a patient’s multiple medical problems? And how to do so without losing sight of the whole person?

The first question is the one I wrote about in a recent blog post. The second was the theme of many of the responses and also LinkedIn.

I love this second question; it’s an issue that’s always been of interest to me. Plus it’s especially relevant in geriatrics, where we are constantly re-orienting our approach to problems based on what seems to be happening with the whole person. (Good PCPs do this too.)

And it’s an issue that good hospitalists think about too: several people brought up Bob Wachter’s post from last fall, in which he noted how using EPIC’s problem-based charting at UCSF’s hospital was having the unintended effect of making it harder for all clinicians to understand what the heck was going on overall with the patient.

Based on reading my post and Wachter’s post, an EMR designer asked me the following specific questions:

• Should the entire EHR be functionally and logically structured around problems, or would it be sufficient for a chart user interface to be presented in a problem oriented manner?
• What are your thoughts about the possibility of such a solution becoming overly reductionist, losing the patient between the problems?

Good questions!

Should an entire EHR be organized around problems?

Or would it be sufficient for a chart user interface to be presented in a problem oriented manner?

I myself like the idea of the problem-based interface being one of several options, as I can imagine myself wanting to toggle between a chronologic list of encounters (a comfortable and familiar view for many docs) and a list of problems.

Actually, a neat visualization of a problem list can be seen here (try clicking “show all health problems” in the matrix):

This was part of Graham Walker’s proposal for last fall’s Health Design challenge, and one of the things I really liked about it was how the size of the problem icon relates to “how important” the problem is. (We could quibble about how that gets decided, but it’s still a nifty idea!) As they say, a good graphic is worth a thousand words.

To return to EMRs and the problem list: I don’t know whether an entire EMR should be organized around the problem list; I’d have to see an example of this and probably try it before I could venture an opinion.

However, I certainly want to be able to view data in EHR via a problem-based interface, and in my previous post I described how this might be possible via using problems as tags. Between tags and a robust search function – think of Gmail, or Evernote – information in an EMR could become much more findable and organizable. Which would be great for clinicians!

How to keep a problem-based approach from losing sight of the person?

Easy in principle. The key is to make sure a clinician regularly considers the patient’s overall medical picture. To use the altitude analogies that are sometimes used in business, this corresponds to the 10,000-30,000 ft view. Another way to describe it would be to make sure to consider the forest, and not just a few trees (or a long list of individual trees).

In practice, this gets tricky for the following reasons:

• Many practicing doctors clearly are not routinely doing this.
• The ongoing shift – driven by technology, the need to collect metrics, and the worsening time-pressures under which doctors practice — in how doctors do their charting seems to be exacerbating this. Whereas doctors used to dictate whole paragraphs, or write out chart notes, now we have EMRs that provide templates or direct us to chart by problems. I agree with Bob Wachter and others who have pointed out that these technological shortcuts probably interfere with cognitive synthesis.
• We have no clear professional standards – that I’m aware of – that specify how and when doctors should perform this exercise in clinical big-picture thinking.
• Most EMRs seem to not be designed to encourage this kind of big-picture summary thinking.

This means that among physicians, when and how to consider the patient’s overall big picture medically remains a very individual and idiosyncratic practice.

(I myself like to start with a blank piece of paper and I jot down a 1-2 sentence summary of the patient’s medical situation, along with a few issues I want to address. Then I go look for the relevant supporting data within the EMR. And I do it right before I go in the patient’s room or house, because I can’t think as well once they start talking to me. Idiosyncratic!)

But to provide good care, physicians need to toggle between a zoomed-out, big-picture view of the patient, and also a zoomed-in, tackle-a-problem-in-depth view. This means that EMRs should assist physicians in either view, and ideally would remind physicians to address both.

How EMRs could help us keep track of a patient’s overall medical picture

In his post, Dr. Wachter ends up proposing that an “Uber Assessment” field be added to each EPIC note, and that clinicians be required to enter a free text narrative summary of what is going on with the patient. This, to me, sounds like the old written attending notes of yore, which usually consisted of one concise and high-yield paragraph. (I trained at UCSF in the days of paper hospital charts; Wachter was my attending for two weeks in 2004.)

But a commentator objects, and not just any commentator: it’s Dr. Lawrence Weed himself, creator of the “problem-oriented medical record”, in partnership with his son Lincoln Weed!

If you have read Dr. Wachter’s post, but not Dr. Weed’s riposte, I strongly urge you to return to the original post here, and read Weed’s comment in its entirety. (Be sure to use tech to your advantage: search the webpage for “Lincoln Weed” and you can find it right away.)

In his lengthy and detailed comment, Dr. Weed clarifies that SOAP notes should not be conflated with POMR:

Like many others, Dr. Wachter equates SOAP notes with the “new model for patient care records,” known as the “problem-oriented medical record” (POMR). But SOAP notes are just one of four basic components of the POMR: (1) an initial database, including a “patient profile” of non-medical circumstances; (2) a complete problem list; (3) initial care plans for each problem, including goals determined with the patient, and (4) progress notes for each problem using the SOAP structure.

He goes on to object to the idea of relying on clinical synthesis being done the old-fashioned way, which is to say, via physician judgement:

Our difficulty with Dr. Wachter’s analysis is that he assumes the primary vehicle for clinical synthesis to be physician judgment. In reality, synthesis should begin before the exercise of judgment. That is, electronic tools should first be used to select patient-specific data points and then match those data with relevant medical knowledge. This initial information processing routinely yields clinical synthesis beyond what physician judgment achieves.

And then, Weed completely wins me over with this paragraph:

But this initial, tool-driven synthesis is not enough in complex cases. There what patients need is a highly organized process: careful problem definition, planning, execution, feedback, and corrective action over time, with patient involvement every step of the way. [Emphasis mine.] When applied to all problems on the problem list, this process enables clinical synthesis to emerge in a systematic, organized and reproducible fashion. Effective synthesis is tool-driven and process-driven. The tools and the process minimize reliance on unstructured clinical judgment, with all of its cognitive vulnerabilities.

And also this one:

Our concern with patient involvement suggests that a separate, aggregate assessment should be a vehicle for synthesizing patient and practitioner perspectives. This can be accomplished most effectively if the assessment is focused on setting priorities. [Emphasis mine.] Thinking about priorities naturally requires the practitioner and patient to consult each other, naturally requires them to consider the patient’s total situation (the initial patient profile and the current problem list), naturally focuses them on options for action, and naturally avoids diffuse narrative discussion. EHR fields for a “big picture” assessment should be structured accordingly. Implemented in this way, Dr. Wachter’s concept could be a valuable component in any medical record.

Crucial points Weed makes that I love

Electronic tools should help us quickly gather the relevant data points, and should provide much initial information processing.

• Yes! We clinicians should not have to root around in an electronic chart, expending energy trying to find the information we need.

We need a good processes and tools to support clinical synthesis.

• Given what we know about human falliability in cognitive processing, this sounds like a terrific idea.

Cognitive effort should be in reviewing the output of the electronic processing, and in discussing with the patient.

• Being able to explain something to a patient in plain English is a great test of how well one understands things overall, and offers patients the opportunity to ask questions and participate in making a plan. Love it.

Assessment should be about setting priorities.

• Yes! Especially in complex older adults, it’s easy for both clinician and patient to become overwhelmed by the sheer number of problems on the list. A joint effort identifying the top priorities serves all parties well.

Planning, execution, and feedback are important.

• This speaks to my concerns about letting things fall through the cracks. We need support in fully fleshing out how we will address a certain problem, in executing the plan, and in following up on how its going. Task/project management software could be adapted and used within a collaborative EMR to help with this.

Patient involvement is essential.

• Weed’s approach advocates for communication and collaboration with patients, both to set goals regarding plans for each problem, and to set priorities and work out an overall plan.

Discovering Weed’s historical contributions and recent views on medical charting was a very welcome perk of following up on my problem list post. He published a book in 2011, titled “Medicine in Denial.”

Has anyone read it? I’m wondering if Dr. Weed is involved in any ongoing EMR development efforts.

Summing it up

To do their work, clinicians need to address medical problems in depth and keep track of a potentially long list of problems, all while not losing sight of the patient as a person. This has always been challenging in medicine and is becoming more difficult due to information-overload and current trends in EMR charting. (Dr. Bob Wachter’s 2012 post on using EPIC to chart UCSF hospital notes highlights some of these issues.)

A robust problem-oriented view within EMRs would be very helpful to primary care clinicians, and I would love to see problems used as tags within other aspects of the EMR. However, this problem-view would have to be implemented thoughtfully, in order to not hamper the clinician’s process for considering the patient’s overall medical picture.

Currently, when and how to consider the patient’s overall big picture medically remains a very individual and idiosyncratic practice, both in the hospital and in the outpatient setting. In the comments to Dr. Wachter’s post, the legendary Dr. Lawrence Weed details a number of ways in which technology could make this synthesis process more manageable (by helping to collect relevant data) and more structured for clinicians.

Dr. Weed also earns my undying admiration as he calls for clinicians to collaborate with patients in setting goals for problems, and in setting priorities, and in implementing a plan. It would certainly be interesting to try to implement some of Dr. Weed’s recommendations via EMR.

Leslie Kernisan is an internal medicine physician and geriatrician who blogs at GeriTech.