Hi everyone,

I feel this will be my most important post ever. There are two issues to address here.

1. How everyone looks at the three basic tenants of information in a chart note. Debatable.

2. How it is presented in AC and how it can be used.

This will be long. I am sorry. I think it needs to be addressed mainly because AC (to their credit) will be making changes to how this is presented. First, let's start with what I/We think about the categories in the above subject. A lot of this is much more important to FP and Internal Medicine and Consultants, but it affects the pediatrician as well.

1. First, let us look at Problems. I think we will all agree that a Problem List is made up of problems that a patient has which may or may not need to be addressed at each visit. Problems may consist of hypercholesterolemia, hypertension, ADHD, Generalized Anxiety Disorder, Crohns. These are active problems. When a patient comes in for eczema, you may not talk about them, but the patient has those problems. At any visit, especially a physicial, you would likely address them. I would hope that FP (please just lump IM with FP -- sorry if I offend) would talk about these problems at a physical. Or maybe hypertension is so important, it is talked about even at a URI problem. The problem is the Summary sheet (the most poorly designed page or tab of AC is the only place to find these problems. And, unless you type them in, they are populated by Diagnoses. I always have to try it again, because it amazes me. I just gave George Washington an arm fracture diagnosis, and it is now an active problem. But, in six weeks, it will not longer be an active problem, it will be (according to AC if you change it), an inactive problem. I wouldn't even refer to it as that. I would now move it to PMH. I feel as though an inactive problem would be an active problem which has been treated and is now under control (hypertension now better with diet and exercise and medication) and would not be considered PMH (although one could argue this). Why? Because it has the potential to become active again. Take the arm fracture. Once fixed, it becomes PMH. It is important to note it, because it may one day impact your thinking (patient presents five years from now with left arm pain), but it is something you don't think about anymore.

Diagnoses are just that. To name some pediatric ones: chickenpox, eczema, otitis media, Hand/Foot/Mouth, Roseola. These are diagnosed, present, get better and are done. Some, like Chickenpox should definitely move to PMH. Very important when this patient is exposed to someone to know that. But, to put otitis media as a problem is not correct. Otitis media is not PMH. Chronic otitis is. Now, you can decide if chronic otitis media is an active problem. In pediatrics, it is. Every time I see a patient for otitis media, I have to decide do they need a consult or not. Strep throat is the perfect example. In the encounter list, it will either show up as pharyngitis or strep throat. Strep throat is diagnosed, treated with Pen-VK, and is gone. It is now automatically an ICD-10 code (with the descriptor) in encounters. It is not a problem. Again, chronic strep is. Maybe you need to be aware of the problem to rule out carrier or because he/she misses so much school with severe tonsillitis, that you need, again, to refer to ENT. The only argument would be if the patient developed Post-strep glomerulonephritis or Rheumtaic fever but, even then, it is listed in your encounters.

Past encounters: This has been my pet peeve since v1. The past encounters, arguably one of the most important section of the chart is populated AUTOMATICALLY by chief complaints. So a patient gives the chief complaint of "My legs have been hurting for the past four months," that is what shows up in past encounters. That is crazy. We have been taught since medical school that the chief complaint should be what the patient says in his or her own words. Where does that belong? In the chief complaint. Not in past encounters. You now diagnose this patient with RLS or Growing pains or even Leg pain. Maybe it is one leg, and you need to work them up for a malignancy. But, the encounter should show the diagnosis. In fact it should say diagnoses and not encounters. If you always use acute left otitis media as your ICD-10 code, you want that to show up there so you can see them at a glance and count them.

At the diagnosis field. That is where the diagnoses are put. The dropdown list is NOT problems. Again, Fifth's disease will now autopopulate the summary sheet as a problem and it is not a problem. I don't think we need to see the window which says, "The patient already has 'Fever' in their Problem List. Do you want to add it again?" It is NOT a problem. But, if you diagnose a patient with a URI or Fever, it will now populate your problem list in the summary sheet two, three, four times. I can see some advantage to adding it to your dropdown diagnoses as long as it can be removed especially if it adds a date. It would be cool to quickly see there are five ear infections. But, in general, I have kids with ADHD listed ten times. It's also nice to just grab the diagnosis, but it doesn't need to be duplicated.

Now, here is where workflow comes in. Because a list of diagnoses in the Problem List is not helpful to me, I have NEVER, EVER, EVER looked at that field. In fact, it just makes the summary for patient look bad. PMH and Problems should be entered manually by the physician. Problems don't crop up constantly even for the sickest patient, so it doesn't take much to add Crohns or HTN.

So, in summary, here are where these things are and what they mean and an added idea. PMH should be put in by the PCP and is something that usually has come and gone and means little to that patient's subsequent visits. We put 32 weeker as a PMH and a Problem, but the problem becomes inactive at a 18 months, the fact that they were a preemie means nothing. I would keep the fact that the baby was a preemie in PMH forever. The fact that they cannot turn over at four months is affected by the PMH or Problem List. The past encounters should be populated by your ICD-10 diagnosis not your chief complaint. Here is the key. Since for FP, especially, problems such as HTN, IDDM, Hypercholesterolemia, Parkinson's needs to be addressed frequently, it should be easy to see and easy to click on so that it moves to the assessment section easily. (maybe even everything you are doing for it moves over also -- propranolol, exercise). One shouldn't have to go to the Summary Sheet to see the problem list. Why not have problems located in the actual dropdown that says Problem List. You could select the ones you want. Or get rid of the Smoking Window and put problems there. The Smoking Window could even go in the Summary Sheet. The Summary Sheet needs a major overhaul. How many times have we recommended moving the Complete to default instead of the Due in the vaccine section at the bottom left? 30? 50? One less click. In fact, having that area be completely separate from where you enter vaccines is problematic.

The Problem List in Summary is so complicated these are the choices it gives:

Add
Resolve
Inactivate
Remove

And the dropdown list somehow has five options:

Show active problems only
Show resolved problems only
Show inactive problems only
Show resolved and inctive problems
Show all problems

Has anyone ever gone to summary sheet and selected Show resolved problems only? How is that helpful? The only way I would find it helpful would be to congratulate the patient. It is now inactive or PMH. To me, the only two things you would need are Active and Inactive, and they need to both show.

Again, there are two issues here. Which constitutes which especially an Inactive Problem vs PMH. But, a diagnosis is a diagnosis, and should always be in the encounter/diagnosis section (nowhere else). The other issue is where do you put them. I like to look at things as if it were a paper chart. It always mirrors how the electronic record should work. The first page you look at in a paper chart is the Face Page. It has the problems, the diagnoses, the allergies, etc. And, all three of these should be seen in AC on the first page. And, all three, (like Allergies), should be able to be edited without saving the chart.

I think the reason this occurs is AC doesn't have any physicians who work there who use the chart regularly. Jon Bertman was the last one, and I think he moved away from the day to day soon. And, beta testing isn't going to shed light on this. I have emailed Amazing Charts at least ten times in the past and gotten nowhere. Do AC programmers know what a "twip" is and how to fix it in ePrescribe admin section? Yes. Do, they have any idea the difference between PMH, Problems, Encounters, etc.? No. Should they? Maybe.

I would love to hear your comments. I think there will be many. This topic has NEVER been addressed on the board since I have been here.

Bert
Pediatrics
Brewer, Maine