The problem-oriented medical synopsis. Applications to patient care, education, and research

Electronic problem lists: a thematic analysis of a systematic literature review to identify aspects critical to success

Objective

Problem list data is a driving force for many beneficial clinical tools, yet these data remain underutilized. We performed a systematic literature review, pulling insights from previous research, aggregating insights into themes, and distilling themes into actionable advice. We sought to learn what changes we could make to existing applications, to the clinical workflow, and to clinicians' perceptions that would improve problem list utilization and increase the prevalence of problems data in the electronic medical record.

Materials and Methods

We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to systematically curate a corpus of pertinent articles. We performed a thematic analysis, looking for interesting excerpts and ideas. By aggregating excerpts from many authors, we gained broader, more inclusive insights into what makes a good problem list and what factors are conducive to its success.

Results

Analysis led to a list of 7 benefits of using the problem list, 15 aspects critical to problem list success, and knowledge to help inform policy development, such as consensus on what belongs on the problem list, who should maintain the problem list, and when.

Conclusions

A list of suggestions is made on ways in which the problem list can be improved to increase utilization by clinicians. There is also a need for standard measurements of the problem list, so that lists can be measured, compared, and discussed with rigor and a common vocabulary.

A Computer Based Medical Record System

This paper reports the design and implementation of a computer based medical record system. Clinical data from a 27-bed general medical ward are captured at the point of generation and entered into a computer through a remote terminal. The data stored at present for each patient-admission include the identification, diagnoses, clinical history, findings on physical examination and a problem oriented case synopsis. Commands are available to enter, validate, reformat, and finally store the data permanently on computer files. Other commands locate all or part of specified records, decode and reformat the data for output, and print the output at the remote terminal or on a high speed line printer. Commands are also available for data file maintenance and for statistical research on the stored records. The system has been in operation for two years and over 1,000 records are currently computer-stored.

Describing complex clinical scenarios at the bed-side: Is a systems science approach useful? Exploring a novel diagrammatic approach to facilitate clinical reasoning

Clinicians often encounter patients having complex clinical scenarios (CCS) where diverse and dynamic diagnostic and therapeutic issues interact. A limited range of bedside methods are available to describe such patients and most often it is a diagnostic summary, a problem list, or a list of differential diagnoses. These methods fail to portray the interconnected nature of CCCs. They prevent visualization of a system of networks or a web of causation operative in CCSs.A more holistic conceptualization is required and the author argues for an approach based on systems science. The latter views the human body to consist of several closely linked organ systems, constantly interacting with each other and embedded in, and 'open' to the external environment. In order to capture the systems nature at bedside, a tool based on network diagrams, termed a Clinical Reasoning Map (CRM) is proposed which depicts diseases or conditions as nodes linked to each other by lines or arrows. The latter linkages follow simple rules: possible causes or associations as mere lines; probable cause using a single dotted arrow with directionality (from 'cause' to 'effect'); definite causal pathways by directional arrows; and bi-directional arrows to indicate organs-systems influencing each other.CRM's utility was investigated in several groups of undergraduate medical students. The results varied: 289, 5th year and 4th year medical students showed that 245 (85.5 %) perceived CRM improve their understanding of the case. However, there was no clear advantage in the CRM over a list of diagnoses in recall of key information. A majority (83.9 %) were keen to learn the technique of drawing a CRM. Postgraduates too found the tool to be useful to understand the interconnected nature of real-life complex case scenarios and pathogenesis of their multifaceted condition to generate differential diagnosis and to select appropriate investigations. Effectiveness of CRM is supported by adult learning theories such as meaningful learning and experiential learning.The author proposes that systems science and tools based in this approach such as CRM has utility in understanding and managing complex case scenarios. They differ significantly from other diagrammatic methods available in the medical literature.

Empirical derivation of an electronic clinically useful problem statement system

Problem lists are tools to improve patient management. In the medical record, they connect diagnoses to therapy, prognosis, and psychosocial issues. Computer-based problem lists enhance paper-based approaches by enabling cost-containment and quality assurance applications, but they require clinically expressive controlled vocabularies. Because existing controlled vocabularies do not represent problem statements at a clinically useful level, we derived a new canonical problem statement vocabulary through semi-automated analysis and distillation of provider-entered problem lists collected over 6 years from 74,696 patients. We combined automated and manual methods to condense 891,770 problem statements entered by 1961 care providers at Grady Memorial Hospital in Atlanta, Georgia, to 15,534 Canonical Clinical Problem Statement System (CCPSS) terms. The nature and frequency of problem statements were characterized, interrelations among them were enumerated, and a database capturing the epidemiology of problems was created. The authors identified 23,503 problem relations (co-occurrences, sign-symptom complexes, and differential diagnoses) and 22,690 modifier words that further categorized "canonical" problems. To assess completeness, CCPSS content was compared with that of the 1997 Unified Medical Language System Metathesaurus (containing terms from 44 clinical vocabularies). Unified Medical Language System terms expressed 25% of individual CCPSS terms exactly (71% of problems by frequency), 27% partially, and 48% poorly or not at all. Clinicians judged that CCPSS terms completely captured their clinical intent for 84% of 686 randomly selected free-text problem statements. The CCPSS represents clinical concepts at a level exceeding that of previous approaches. A similar national approach could create a standardized, useful, shared resource for clinical practice.

Utility analysis of a computer stored diagnosis index and other medical record data

A computer-based system for storing items of medical record data including a complete coded list of diagnoses was established in 1971 for all patients admitted to a research-oriented medical ward. An analysis was made to assess the usefulness of such an electronically-stored data base from the stand-point of Unit activity, disease correlations, stability of diagnostic criteria, completeness of diagnosis lists and accuracy of coding. Over six years, 1972-77, there were 3569 admissions of which 1679 were first admissions. The most frequently made principal diagnoses were cerebrovascular accident (8%), myocardial infarction (5.4%), ischaemic heart disease (2.9%), rheumatoid arthritis (2%), duodenal ulcer (2%) and systemic lupus erythematosus (1.9%); the 33 most frequent principal diagnoses accounted for only 45% of all principal diagnoses made. The duration of stay (mean 16 days) was shown to depend on principal diagnosis but not significantly on age. Variability in annual incidence was significant for 24% of diagnoses; for some diagnoses this was readily explainable by extraneous causes, but for others it suggested an "instability" of criteria for that diagnosis. The probability of a minor diagnosis being "overlooked", using Dupuytren's contracture as an example, was shown to be high (50%). The rate of miscoding a diagnosis was 5%. This study, despite its illustration of the "softness' of diagnosis making in routine hospital ward practice, illustrates the potential or processing hospital diagnosis data by computer.

Social factors and clinical disease: a checklist data base for correlative analysis

The adequate care of a patient entails consideration of his social and psychological problems in addition to the relevant medical data. To facilitate this integrated approach, a Social Work Indices Checklist (SWIC) is described, and its use in practice is illustrated. A narrative report is generated from a possible 3095 items of information recorded in SWIC.

A problem-orientated outpatient record

A problem-orientated record for use in outpatient clinics has been in operation over a period of 2 1/2 years. Its special features include: (i) preprinted stationery bound in appropriate sequence in the conventional hospital record; (ii) clear presentation of an up-to-date list of each patient's past and present diagnoses; (iii) problem-orientated progress notes. This study considers the definition of an illness problem, recording of progress information, adjustments to a problem list in the outpatient setting and recording of minor "noise" problems. Experience with the system consisted of 5,000 patient attendances. A sampling of these indicated that there were 3-1 +/- SD 1-5 concurrently treated problems per patient, and there were 9-3 +/- SD 6-6 clinic visits per patient. The system was subjectively assessed by 18 doctors, using a semantic differential technique, with a high frequency of "yes" responses to "saves time", "benefits the patient" and "benefits the doctor". This and similar systems may help to resolve the present paradox of the clinical chart becoming decreasingly useful with increasing complexity of illness.