The Problem Oriented
Approach to the Patient
Lafayette Medical Education Symposium
January 9, 2013
Stephen R Ash, MD, FACP
IU Health Arnett
HemoCleanse and Ash Access Technology.
Lafayette, IN
The essence of art is discipline and
form…Larry Weed
Why Do We Make Personal Chart Notes?
• To synthesize and prioritize clinical data
from various sources
• To indicate our assessment, diagnoses
and plans (rarely done on daily basis)
• To communicate our assessments and
recommendations to others (i.e., to show
off)
• To support charges to the patient (after the
dismissal)
• Most importantly, to help ourselves
understand our own rationales.
The Problem of Clinical Data
• Whether presented by paper chart or computer
system, clinical data is massive, disorganized and
overwhelming when evaluated by physicians.
• Organization of data is still by department of origin,
rather than by organ system or disease.
• Worse yet, clinical data may reside in several
separate databases and programs, each of which
require time for login, selection of patient, and
display of relevant information.
• The physician must select elements from many
different screens, and correlate it to the organ or
disease of interest, in writing the chart note or H&P
• Computers in medicine are effective in displaying
information from various sources, but without any
organization of the data, review is slower and less
effective than with paper charts
• No study of computers in medicine has proven either
a decrease in cost or improvement of quality of care
What’s new? What’s
important? Dig down
and find out….
“What’s wrong
with this patient?”
is the hardest
question to
answer. On the
same patient, two
clinical programs
have complicated
problem lists or
none at all..
Hierarchy of Clinical Data
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Organ (Organ associated with related data)
Disease Diagnosis related to organ or system
Gross Anatomy (X-Ray, physical finding)
Microscopic Anatomy (histology, cytopathology,
cell counts)
Physiology (pressure, flow, vital signs)
Chemistry (blood, urine, other)
Derived parameters (clearance, BMI, etc)
Symptoms
But Most
Clinical Notes
Meander from
Problem to
Problem,
Organ to
Organ, and
Lack Focus
Same Staff,
New
Attending
with
ProblemOrientation
Weed’s Commentary, with all the Tact of a
Sherman Tank
Approach to the
Patient is in the
H&P:
1) Problem List*
2) Listing of Each
Active Problem,
Defined as
Thoroughly as
Possible (becomes
the Assessment)
3) Textual
Paragraph on
Progress of Disease
(History, Subjective
and Objective
Data)*
*Problems may be a
diagnosis, physiological
finding, symptom, physical
finding, or abnormal test
result..
Weed Emphasized Importance of a Complete and Accurate
List of Patient Problems, as Determined by the Patient,
Family, Nurse, or Physician:
In the H&P,
ROS and
PE Sections
Can Remain
Unified
And in Clinical Use, Physicians Organized a
“Plans” Section by the Problem Being Treated
For daily notes, Weed’s Original Concept was to
Include “SOAP” under each problem title:
A note organized by “SOAP” but without all data listed
under problem titles is NOT the Weed system.
In daily notes, SOAP
entries also should be
made under each
problem title heading
(the headings can be
omitted if desired).
Having a separate
“Plans” section is also
OK.
Daily Notes with Problem Organization
*My comment: This omission would be even easier to
recognize if the problem title included the physician’s
assessment of the most likely cause, such as “anemia
most likely due to GI blood loss.”
Weed Predicted the Central Role of the Problem
List in a Computerized Medical Record
And this was in 1968….
So, What Happened to this Elegant Weed
System?
• Weed worked to implement a paper-based system to
organize notes by problem number, not title.
• Weed’s comments and approach were abrasive.
• VA adopted the system and found it very helpful in
eventually developing a computerized medical record.
• Weed moved on to focus on computerized diagnostic
programs.
• Electronic medical record systems mostly were
developed to replicate the patient chart and to capture
charges, not to organize it according to patient problems.
Others promoted problem lists based on entry of
“episodes” under titles, not from daily notes:
SmartChart™ Problem-Oriented Computerized
Notation System
• Developed for use in my own practice of primary care
nephrology, on personal computers in 1978
• Problem list central to the record
• Notes created by choosing a problem title and entering
textual notes under each title, as described by Weed
• Entering a note indicated the active problem titles
addressed during that visit
• Progress note and H&P were created by listing active
problem titles and current entry plus all prior entries
under that note (creating a readable, informative history
as Weed predicted).
• Entries in a unified Plans section became orders and
prescriptions.
SmartChart Screen and Printouts Circa 1986
What Happened to SmartChart?
• Marketed by Ash Medical Systems from 19852000 in DOS and Unix operating systems
• Used in primary care, internal medicine and
nephrology practices
• Used in our nephrology practice and local
diaysis units until 2000
• Abandoned due to costs of Y2K conversion
• Concept of problem-oriented charting was
adopted by a number of computer companies:
Velos, Epic, and now Cerner.
Examples of Charting by Problem Title in CernerNew Nephrology Consult
Plus, Orders Placed Through PowerOrders are
Listed at End of the Note
These orders aren’t organized according to
problem title. However it is very easy to see which
of the detailed problem titles in the HPI justify
each of these orders (one or more). One purpose
of any well-written note is to justify all orders and
actions taken clinically.
Followup Notes Are Created By Additions Under Each Problem Title
And so on, with daily notes added under each
problem title that remains active. At discharge, these
notes form the basis of a detailed and cogent
discharge summary.
However, computers are supposed to diminish need
for duplicate entry, not increase it, aren’t they?
• If hospital notes are created manually within Cerner or
another program, the admitting or primary physician can
see them only by retrieving the prior hospital discharge
summary or notes.
• They then have to re-iterate this information in their own
H&P or visit note, the physician being the only link
between older and newer data.
• A truly problem-oriented system would allow continued
refinement of the problem title and chronologically list all
comments under the most recently updated problem title.
• Epic has such a system, Cerner is soon to offer a similar
or better capability.
• The problem list created in Cerner does not transfer to
Epic or vice-versa.
How I Do It
• To create my initial hospital consult, I update the
problem list in Epic, make comments under relevant
problems, and create a progress note through this
program.
• I then copy the text of this progress note to Word as text
only, then this text into the HPI section of Cerner .
• Further daily notes are entered into Cerner.
• In this manner, at least the problem list of Epic is
updated at the time of admission of the patient.
• If I see the patient as an outpatient, it’s then easy to
update the problem list with what happened during the
hospitalization.
On creation of H&P, I create or update
detailed problem list (in Display As) and
make text entries under each currently
active problem:
Then use the “.probe” SmartPhrase to copy problem titles
and notes into the progress note text:
Then copy this section to Word as a text-only note and then copy this into the
HPI section of the Cerner note. This is a little tedious, but doesn’t take much
time, and at least the problem list in Epic is up-to-date at the time of
admission.
Note, the more detailed the
problem list, the better:
Other specialties recognize the value of a detailed
problem description, though they may use the
comment field for maintaining the information:
Problem titles are still simplistic, and these are what are seen on
the Problem page of Epic. The textual description is accurate but
lengthy. The prior comment can be wiped out by physicians
making a later entry. Using one “Display AS” line, the problem can
be defined much as you would describe it to a partner, and there’s
more visibility and permanence. .
Many Hospitalists are Edging Towards Problem
Orientation.
HPI on Same Patient with Acute Renal Failure:
Weed woulld say, “Very well written and
informative, but not well organized…”
Initial Assessment and Plans
Section is Problem Oriented:
But Subsequent Notes Keep None of this
Depth or Detail
Conclusions: Advantages of Problem-Orientation
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Problem-oriented charting gives a logical structure to patient information.
Helps the primary care physician the most, since they try to address all
problems important to the patient, but also helps specialist.
Billing is automatically justified for the problem titles (and DRGs) charted
upon
The problem list, if sufficiently detailed, forms a cogent summary that allows
efficient care of the patient without need for review of old records.
Immense time is saved by avoiding need to review old charts.
The comments made relative to each problem title create a cogent history of
the progress and work-up of each problem, and can serve as a meaningful
H&P when up-dated with current status of the patient.
Duplication of entry of prior history is avoided, and actual daily entries are
fewer characters and faster.
Information entered and problem titles are reviewed daily for active
problems, making the data more detailed and accurate.
“Meaningful Use” of EMR’s will soon require an accurate problem list. If the
problem title sits right on top of each day’s note, the author is much more
likely to make it accurate.
Disadvantages of Problem Orientation
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Does take a litle more time with each note, mostly to organize and sort the
problem list by acuity. Progress note entries are actually shorter.
Requires a passion for defining each patient’s problem as thoroughly as
possible.
If the physician really isn’t interested in the history, etiology or severity of the
patient’s problems, the problem titles look rather vacuous, such as “ESRD”
or “ARF on CKD.”
Results in problem titles that are longer and a little harder to review in a list
with many others (always placing the common name of the problem as the
first word helps in this review).
Requires general consensus in use of the problem title, and agreement as
to which specialties should change which problem titles.
Ideally nurses and MDs would work from the same problem list but when
nurses tried problem-orientation 10 years ago, they wanted their own lists.
Loses benefit to all practitioners if the Problem List and comments do not
transfer between various computer systems, since maintaining two or more
lists is tedious and fosters inaccuracies, making the whole process more
trouble than it’s worth.
Really, the computer isn’t organizing any information, the problem list and
associated data is maintained by MDs and NPs.
Why Can’t Computer Systems Organize Clinical
Data by Organ System or Disease?
• Allow login and patient identification in parallel
programs/databases
• Display similar data from each database and
help to reconciliation of data
• Display and synthesize clinical data from all
available databases according to the organ or
patient problem.
• Encourages creation of new problem titles when
abnormalities are found that aren’t explained by
current problem titles.
• Creates problem-oriented notes and H&P from
physician daily entries. .
LLUMC Clinical Data
Repository
AAMC Group on Information Resources
May 2, 2008
Strategy
 Make reporting and analysis on clinical data
practical, simple, fast, and secure
 Support user needs with a single, general data
repository
 Create a patient-focused data warehouse that…
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Integrates clinical data from multiple sources
Transforms data to a common structure and format
Filters and cleanses data to assure accuracy
Organizes data for reporting and analysis
Enhances data to extend its value for reporting purposes
Supports unpredictable ad hoc queries and unknowable
future reporting requirements
Detailed Data Architecture
Knowledge Structures
ICD-9
SNOMED
Locations
Patient Event Data
Patient A
Encounter 1
Encounter 2
Visit 1
Event 1
Visit 1
Event 2
Event 1
Event 2
http://lomalindahealth.org/common/legacy/llumc/emergency
/patientcare/documents/patientcare-sepsis.pdf
A Really Helpful
Computer System
Depiction of patient
graphically, with icons
identifying organs
which have a defined
problem, and boxes
for clinical
abnormalities without
associated problem
titles.
Example: patient with
chronic kidney
disease, diabetes,
heart failure defined
but metabolic bone
disease that is not yet
defined in problem
list.
Problem titles
previously defined
by physician:
Congestive heart
failure, 25% ejection
fraction 2009
Diabetes Mellitus, on
pills in 2004, insulin in
2008
Renal Insufficiency due
to DM, creatinine 2 in
2010, proteinuria
Organ system
associated with an
abnormal result,
but no relevant
problem title:
Bone disease:
chemical
abnormality
Layers with data not
yet reviewed blink on
and off
With selection of an
area of body the
following layers of
information types
appear for each
problem title, from
various databases:
Pathology
Procedures
X-rays
Labs
Nursing Notes
Physician Notes
Problem Title
Congestive heart failure,
25% ejection fraction 2009
Diabetes Mellitus, on
pills in 2004, insulin in
2008
Renal
Insufficiency,
creatinine 2
in 2010,
proteinuria
Renal
Insufficien
cy due to
DM,
creatinine
2 in 2010,
proteinuria
Bone DiseaseNo Diagnosis Yet
Left click on the
heart icon and the
next layer of
information
appears
Congestive heart failure,
25% ejection fraction 2009
8/3/10; no rapid heartbeat. Playing golf regularly,
3/wk.
5/10; no rapid heartbeat with less caffeine.
3/10; no chest pain. Doesn't see cardiologist
yearly. No murmur today. Does occasionally have
rapid heartbeat at night if drinks two cups of coffee,
lasts for a few seconds.
9/09; no chest pain lately. Went to cardiologist in
may '08, stress test was ok. Not short of breath.
Feels well in general. No murmur now. Has some
periods where heart goes fast, he feels it, usually in
bed, none lately.. Doesn't feel bad otherwise and
lasts only a few seconds. Drinks lots of mountain
dew, now less than 1 liter per day.
Diabetes Mellitus, on
pills in 2004, insulin in
2008
Pathology
Procedures
X-rays
Labs
Nursing Notes
Physician Notes
Problem Title b
Renal
Insufficien
cy due to
DM,
creatinine
2 in 2010,
proteinuria
Bone DiseaseNo Diagnosis Yet
Press Page Up and
each successive
layer of the most
recent information
appears.
Congestive heart failure,
25% ejection fraction 2009
Pathology
Procedures
X-rays
Labs
Renal
Nursing
Notes
Insufficiency
Renal
due
to DM,
Physician
Notes
Insufficiency,
creatinine
2 2Title
creatinine
Problem
in 2010,
2010,
in
proteinuria
proteinuria
Diabetes Mellitus, on
pills in 2004, insulin in
2008
Renal
Insufficien
cy due to
DM,
creatinine
2 in 2010,
proteinuria
Bone DiseaseNo Diagnosis Yet
Right click on the
data field to give
other views and
more data….
Add older data
Graph
Add item
Remove item
All new data
All new data (all
problem titles)
Data by table
Write today’s note
Congestive heart failure,
25% ejection fraction 2009
Pathology
Procedures
X-rays
Labs
Nursing Notes
Physician Notes
Problem Title
Diabetes Mellitus, on
pills in 2004, insulin in
2008
Renal
Insufficien
cy due to
DM,
creatinine
2 in 2010,
proteinuria
Bone DiseaseNo Diagnosis Yet
Graphs then
appear…
Congestive heart failure,
25% ejection fraction 2009
Pathology
Procedures
X-rays
Labs
Nursing Notes
Physician Notes
Problem Title
Diabetes Mellitus, on
pills in 2004, insulin in
2008
Renal
Insufficien
cy due to
DM,
creatinine
2 in 2010,
proteinuria
Bone DiseaseNo Diagnosis Yet
Continue pressing
Page Up and the
most recent data
will appear for each
data type.
Continuing Page
Up will display
layers of data for
other problems.
Congestive heart failure,
25% ejection fraction 2009
Pathology
Procedures
X-rays
Labs
Nursing
Notes
Renal
Physician Notes
Insufficiency,
creatinine
Problem 2Title
in 2010,
proteinuria
Exam: dipyridamole (Persantine) stress
test with Tc99m labeled sestamibi
(Cardiolite) SPECT imaging at rest and
at stress; left ventricular systolic
function and wall motion analysis with
gated images.
Indication: Pre-op evaluation, chronic
kidney disease
Procedure:
Rest 01/12/10: 10.3 millicuries of
Tc99m labeled sestamibi was injected
at rest and images were obtained 52
minutes later.
Stress study on 01/12/10
(dipyridamole, Persantine): Rest BP
122/78, HR 76. ECG at rest: sinus
rhythm, incomplete RBBB. Patient was
given 48 mg dipyridamole (Persantine)
iv over 4 minutes. At peak stress BP
117/70, HR 97. ECG showed no
significant ST changes. No significant
symptoms.
Diabetes Mellitus, on
pills in 2004, insulin in
2008
Renal
Insufficien
cy due to
DM,
creatinine
2 in 2010,
proteinuria
Bone DiseaseNo Diagnosis Yet
Click on the box
without diagnosis
and the abnormal
data displays. MD
is prompted to
apply a diagnosis.
Congestive heart failure,
25% ejection fraction 2009
Pathology
Procedures
X-rays
Labs
Nursing Notes
Physician Notes
Problem Title
Diabetes Mellitus, on
pills in 2004, insulin in
2008
Renal
Insufficien
cy due to
DM,
creatinine
2 in 2010,
proteinuria
Bone DiseaseDiagnosis:__________
When a diagnosis
is applied, the icon
changes to a more
natural shape.
Congestive heart failure,
25% ejection fraction 2009
Pathology
Procedures
X-rays
Labs
Nursing Notes
Physician Notes
Problem Title
Diabetes Mellitus, on
pills in 2004, insulin in
2008
Renal
Insufficien
cy due to
DM,
creatinine
2 in 2010,
proteinuria
Metabolic Bone
Disease
The Problem-Oriented Physician Note Can Be Created Automatically
From Physician Textual Entries
Add older data
Graph
Add item
Remove item
All new data
All new data (all
problem titles)
Data by table
Write today’s note
Include:
All Reviewed Data
Selected Data
Nursing Notes
Other Physician Note Summarybb
Renal Insufficiency creat 1.5-3 in 10/08, creat 1.4 and 150 mg% protein in 2/10; creat 1.4-1.8 in 1/09 with pneumonia (prob dm); us 1/09=small
kidneys, thin cortices
10/28/10; creat slt up at 1.55, gfr 45, prot 5.8. Bs at home high just after meals. P/cr is 3.15, vd is 21, pth 65, phos 3.4, ldl good at 66. Urine eos neg.
Spep and ife are neg. No diff urinating.
3/10; creat stable to better at 1.36, gfr 52, ua shows 150 mg% protein. Phos 3.1, vd 25, pth 67, on one vitamin d daily. Iron sat better at 13% on one iron
daily. No diff urinating.
12/09; Creat slt better at 1.7, gfr stable at 40. Iron sat is low at 8%. Albumin 3..1. No diff urinating.
Congestive Heart Failure with 20% ejection fraction 2008
10/28/10; ck is 202, troponin 1.5. No chest pain.
3/10; bp runs now about 140/79 at home.
12/09; Bp now 140/60, 145/80 at home. On less enalapril, 2.5 daily.
DIABETES MELLITUS TYPE II on pills '04
6/10; last fbs 81.
3/10; glucose 75 on cmp but a1c is 10.6. Doesn't take actos daily, about 1 per 3 days.
12?09; Glucose at home runs 190-200 at night. last a1c was 8.9. Off actos lately and on prednisone.
In a more perfect world…
• Clinical data will be organized by organ system,
automatically establishing the correlations
• Graphic display will prevent the visual overload
of the physician, nurse or patient
• Specialists will review data already selected as
relevant to disease or organ of their focus
• System will prompt physicians to focus on and
assign a problem title to abnormal clinical status
or test results that has no apparent explanation.
Why can’t we have computer
systems like this?
• Physicians are not very good at defining what
we need, we ask companies to deliver what we
think they can give us.
• Software products are still essentially focused on
charge capture and reporting needs of
departments.
• Companies have “user groups” but shun really
new ideas.
• In the clinical arena, software companies fear
liability of creating systems that actually help the
physician prioritize data. and create diagnoses.
However, we can improve
EMRs by demanding problemorientation, lack of duplication of
entry, and ease of transfer of
data between systems.
Thanks for your attention….