Home Forums Discussions Feedback and Recommendations Diagnoses vs problems

I'm a new user of AC. I had previously developed my own "EMR" system, which consisted of a database (with demographics, problem list and rx list), together with the actual chart -- a large pdf file containing all scanned reports and visit notes. I was fairly happy with it, but obviously it was in no way CCHIT certifiable, and also didnt do eprescribing and rx interaction checking. I was resistant to most systems I saw because they didnt seem to suit my needs, but when I found AC it seemed to fit. I'm now in the process of transferring my records to AC, which is fairly straightforward and takes about 15 minutes per patient, since everything is already in pdf format and I just need to input the demographics, rx and problem list.

I have one issue I would like to bring up: the distinction between diagnosis lists and problem lists. A few examples:

Diagnosis: 414.00 CORONARY ATHEROSCLEROSIS OF UNSPECIFIED TYPE OF VESSEL
Problem: CAD - s/p cabg 2005, no angina, last ETT 2009 or
Problem: CAD - long history chronic stable angina

Diagnosis: 250.00 DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION
Problem: DM, longstanding, prone to hypoglycemia or
Problem: DM easily controlled with diet and weight loss


Diagnosis lists are vital for billing, for drug-dx interactions, for searching, for quality control etc. However, I find them not particularly helpful when trying to look at a concise description of a patient's problems. Problem lists are much better for this.

Most diagnoses correspond to a problem on the problem list, but not all. Some diagnoses may not have a corresponding problem (079.9, viral syndrome, doesn't necessarily need to be on the problem list), and some problems may not be pertinent to the diagnosis list (difficult family situation, problem paying for medication).

I have solved this issue for myself, at least for now, by including the problem list in the ROS field. This works ok, but it involves duplicate work, since anytime a new diagnosis/problem pops up, I have to add it to both places.

Suggestion: add a field to the diagnosis list which would contain free text, and would essentially be the problem description corresponding to the diagnosis. If a diagnosis has no corresponding problem list entry, leave the field blank. If the problem has no corresponding diagnosis, create a dummy ICD code for misc. problem.

Anyone else have thoughts about the diagnosis-problem dichotomy?

Michael Jacobson, MD
New York, NY

Michael,

Welcome to AC. I really appreciate your post. My work around has been to include this info in the PMH. It takes a little more time and space to list the info, and it must be updated periodically.

OHD-CAD, s/p failed PTCA, CABG 3-vessel, last angio/cath 10-2008.

I will also add a line or two in the diagnosis section following the ICD9 code/diagnosis.

I am not the AC guru on this forum. There are others in whose shadow I could only hope stand in! I'd like to see what the others do about this.

Tom

I am right with you on this one, and came to AC from exactly the same path that you did with a homebrew EHR. I find that AC was not all that compatible with my previous POMR approach to charting. Two members of our group do pretty much what you do, but I reserve the PMH block for things that are inactive and closed problems (like old surgeries). I changed my charting method so I just let the problem list populate with the diagnosis code for billing, then in the plan section do a rather extensive narrative summary of what I'm thinking and planning above the list of orders and prescription refills. This would never work if your hope is to have the chart note all done when you leave the exam room, but I don't try for that anyway. I need my chart note to remind me what I was thinking and planning when I saw the patient, and not just what I ordered or prescribed.

If you view AC a lot like your previous homebrew program, you can look at it as just a set of data fields, and put whatever you want in any field. We cannot change the names of the fields at this time, unfortunately, but that has been on the wish list as a reasonable priority. Remember, this is YOUR note and has to serve YOUR purposes.

I agree completely. Before I joined AC, I looked at many EMRs and they all had this limitation. I put my problem list in the PMH but then you can only update it when you have a note open. I, too, wish there was a field under the summary page where you could update the "problem List" without generating a note. That capability does not exist now and it is one of the great limitations of AC and nearly all EMRs. It is definitely a quality of care issue and should be addressed. Thanks for your post.

Thanks for comments so far! We all seem to be on the same page. I've actually been putting the active problems under ROS (under a heading: PROBLEM LIST), and the remote stuff like past surgeries under the PMH field.

I also considered putting the problem list in the assessment section but finally decided on the earlier sections.

I'm gratified to hear that others have been struggling with this, and also that other EMR systems haven't done any better.

Michael J.

The problem is somewhat semantic in some sense.

You can create your own "problem" for the diagnosis field
Open the "search for dx" field and on the L side is add code.
You can then enter your problem and an artifical code (to recreate it) such as Problem: DM easily controlled with diet and weight loss = code M1. Then save. You can do 6 of them at a time with their own artificial "ICD" codes.

An issue with this would be that they are on the same "level" as a diagnosis and you would have to sift through the hash marks to separate them. Another issue is that it would move to the billing section and if you export your billing this would need to be ignored or the outside world would have issues (this is not a standard CPT code, DUH).)

Another way would be to create template for the top problems and simply drop a template into the problem section.

Issue with this is that they will not reoccur in the drop down box.

Another solution is to put them in the PMH (or ROS as you have chosen.) Yes, you can use the ROS but to my thinking PMH makes more sense. You can have templates that cross for both PMH and Dx list, so you can do both or either.

Ultimately everyone does it their own way.

One issue with all EMRs is that some things YOU adapt to and some things YOU modify to your tastes. AC is well poised to let you modify some things but some things you adapt.

Significant changes to the basic program would displease a segment of the AC the AC community no matter how small.

Look over some of the posts when versions 3,4,5 were introduced. Some new things are easy, just ignore them. I rarely use orders. They were made to codify in V4 or 5 and made them much more difficult to use, I use them occasionally but not much. I see why they were changed but the process is too cumbersome. Others adapted.

I strongly agree with Michael. In fact, this has been one of my largest complaints and suggestions over the past seven years. The way it is set up goes against the very nature of how medical notes and charts should be set up.

The issue, as I see it, is that AC does not seem to grasp the concept that PMH is different from Problem List is different from Past Diagnoses. I have always wanted the chart to open to a "face sheet page" (which could be optional) that basically contained the above along with the current med list and allergies. You could quickly glance through this before moving to the present encounter. It would be editable at any time.

The other issue is that chief complaints are NOT diagnoses. When viewing the Past Visits, one should see:

AOM
Sinusitis
Eczema
AOM
AOM
Bronchitis

not:

Hasn't felt well in two days
Fever and vomiting
Coughing all night

One should be able to glance at the Past Visit History and see that the patient has five ear infections in the past eight months. Sure, you can look at the dropdown list, but that is just not efficient. Plus, you can't quickly open the AOMs if you wish.

I know this sounds silly, but if you feel strongly about this, then vote Yes on #s 61 and 62 in the poll. It's a little frustrating. At this point, it looks like only 17 AC users (registered on the board) agree with this thread.

You just got my vote, Bert.

I've never been such a fan of the CC, with the notion that the patient's exact words are so important. In the CC I just put the main reason for the visit.

Quoting the patient verbatim reminds me of an exchange I had with an elderly Groucho-Marxy patient a while back:

"Did you see the urologist?"
"Yes"
"What did he say?"
"He said, hello..."

Michael J.

Hilarious. And I couldn't agree with you more on the chief complaint.

HAHAHA!! Too funny!. Hey, Bert, maybe you should add a forum topic called "Funny things Patients say/do". I have always threatened to keep track and have never gotten around to it. I also agree with you about the problem list and cc.

I'll make my pitch also for including an Active Problem list in an easily accessible place - for example the upper left side of the chart -

Indeed, I'd like to see the cumulative lists (problem list, allergies, current medication list, PMHx Interventions) and frequently referred to items on the chart's LEFT side, with the details of each new encounter on the chart's RIGHT side.


CHART LEFT SIDE . . .CHART RIGHT SIDE:

PROBLEM LIST.............Subjective
PMHx
ROS.........................Objective
Interventions
SHx.........................Diagnosis
FHx.........................Assessment
Allergies..................Plan
Current Meds list...... Prescribed Medications

Having the problem list contents appear as it does now, visible only when you click on it, is like having large opaque sign reading, "Windshield" plastered across your car's windshield, and allowing it become transparent to view the upcoming road, only when you click on it.


Bruce Morgenstern MD (Colorado)
Denver, CO