Problem List Management
A list of active health conditions (“Problem List”) appears in all charts in all contexts. Problem List entries can be signs, symptoms, presentations, disorders or diseases that have an impact on, or could be impacted by, a patient’s current care. This section focuses on problem management skills consistent with Connect Care Problem List Norms.
Definition - Health Problems
An health issue, condition or disease is an active health problem if:
it is the reason the patient sought help (principle problem)
it is a comorbidity that could affect or be affected by the reason a patient sought help
it is subject to active investigation or intervention (e.g., medication therapy)
The "principle" problem is the main reason for presentation ("chief complaint"). At admission, it is the "admitting diagnosis". It will likely become more specific by discharge and becomes the "discharge diagnosis". See Managing Problems below for more detail.
Problem vs. History
A patient's Problem List is not the only place where a health condition can be documented. The "Medical History", "Surgical History" and "Family History" chart sections also hold information about health conditions. Indeed, good problem list management is often about knowing when to move problems back and forth between the Problem List and Medical History.
When should conditions be moved or added to the Problem List and when they should be resolved or moved to the Medical History?
Problem: A condition belongs on the Problem List if it is current and active, as reflected by associated diagnostic, therapeutic, rehabilitative, palliative or other interventions.
History: A condition that no longer impacts, or is impacted by, a patient’s current care should be resolved (removing to the past list), or moved to the Medical or Surgical History.
Problem lists are managed with the Problem List activity (available to all contexts), Problem Oriented Charting activity (available to inpatient contexts) and problem list print groups found in various navigators (e.g., admission, discharge, outpatient, etc.). In all cases, new problems can be added by typing keyword(s) in a problem search box. A list of possible matching problems will appear and the best fit can be selected. The problem searching tool has features that make it easier for clinicians to find what they want when dealing with routine, common or unusual problems.
Routine and Common Problems
Some health issues are routinely managed by clinicians in particular specialties. These can be added to a personal preference list for quick browsing or searching. When performing a problem list search, select the commonly encountered health condition item, right-click, and use the popup menu to add it to a personalized list of common or routine issues.
Some health conditions will be new to prescribers, who may not be familiar with the best term or level of detail to use when adding the issue to a problem list. In such cases, an embedded diagnostic code explorer can be a big help. This is activated with the "DxReference" link just to the right of a problem search tool box. After entering a common synonym for the health condition of interest, an interactive terminology tree will facilitate selection of the best diagnostic concept at the most appropriate level of specificity.
When to Add a Problem
An affirmative answer to any of the following questions merits adding a health condition to the Problem List:
Is the issue/condition a reason for presentation?
The reason for admission is usually marked as the patient's principle or primary problem. A reason for consultation, or emergency visit, or outpatient follow-up also belongs on the active problem list.
Could the condition affect the reason for presentation?
Co-morbidities that contribute to admission belong on the Problem List. Heart failure, for example, could complicate the management of an exacerbation of chronic obstructive pulmonary disease.
Could the reason for presentation affect the condition?
Many chronic conditions can destabilize when a different problem presents or is managed. A common example is chronic kidney disease, which may slip into acute kidney injury in association with an acute infection.
Is the patient being treated for the condition?
If a patient receives medication or other ongoing treatment for a health condition, that condition should be considered active and be placed on the Problem List. Changes to medications mandated by other problems (e.g., kidney failure) could affect the condition.
If a medication is used solely to prevent a possible future problem, no Problem List entry is needed (e.g., statins as part of preventive care would not merit a Problem List entry but statins used to treat familial hypercholesterolemia would).
Prior problems recorded in the Medical History can be "promoted" (moved) to the active Problem List, as happens when recurrent (not ongoing) issues resurface. When the recurrence or exacerbation resolves, it can be moved back to the Medical History.
When to Resolve a Problem
An active Problem List entry should be "resolved" when it has been managed to a new baseline and will not be the subject of ongoing care. A treated infection, for example, can be resolved if no future action is anticipated. An acute exacerbation of a chronic condition (entered as an independent problem, e.g., acute kidney injury, in addition to the chronic problem, e.g., chronic kidney disease) can be resolved if a new baseline is attained.
Resolved problems do not go to the Medical History. They remain available in a list of "Past Problems", which can be exposed at any time.
When to Move a Problem
An active problem should be moved to the Medical History if it no longer meets conditions for being "active" but remains important to a patient's future risk or prognosis. That a patient had pulmonary embolus (PE), for example, should be moved to the Medical History when PE treatment is complete; a past PE has a significant impact on future PE and other risks. A resolved urinary tract infection (UTI), however, would not be moved to the Medical History unless recurrent UTIs emerge and the problem detail is revised to reflect this (some clinicians may keep recurrent UTIs as an active problem if, e.g., prophylactic antibiotics are in play).
Although it is possible for problems to appear in both Past Medical and Problem Lists, such overlap should be kept to a minimum. Medical Histories should be as concise as possible. They should not be cluttered with self-limited, temporary, inconsequential or remote issues lacking continued clinical importance. Appropriate Medical History entries might include resolved chronic conditions, like obesity, but not temporary problems like conjunctivitis, or intermittent symptoms like dry eyes.
When to Delete a Problem
Delete a problem if entered in error (patient never had the problem) or unequivocally duplicative. Resolve indicates that the patient is no longer experiencing the issue, whereas delete indicates that the patient never had the problem. When duplicates are detected, be careful to check whether the intended deletion has Overview information that should be copied to the problem that is retained.
Problems must map to codified terminology for medical conditions. Clinicians may encounter many options when picking a problem to add to the Problem List, with some options general (e.g., "heart failure") and others more specific (e.g., "heart failure with reduced ejection fraction").
Problem list management is not an exercise in perfection. There are many grey areas. In general, it is better to use less differentiated problems early in an encounter, and more precise ones once stability is established. The problem codification can be revised and refined many times.
Problem characterization should reflect clinical certainty. A symptom or presentation can be selected early (e.g., "lower abdominal pain") and revised when more information becomes available (e.g., "obstructive uropathy").
Given that the Connect Care Problem List is patient-centric, the tally of active problems for a patient can grow, especially if some clinicians break-out problems into a sub-issues (e.g., both "Chronic Obstructive Pulmonary Disease Exacerbation" and "Respiratory Failure"). Keeping lists lean is achieved through problem reconciliation, where inactive problems are resolved or moved periodically.
Finding focus within long lists is achieved through options for how lists are filtered, categorized and sorted (which can be saved as a personal preference). Problems can be grouped by:
By tagging problems as high, medium or low priority, individuals can bring the problems of greatest interest to the top of a list, with each user having the ability to manage priorities independently.
Problems can be filtered to display or hide past problems, multidisciplinary problems and/or hospital problems.
Lists can be grouped according to whether problems are chronic (long-term) or not.
Lists can be grouped by the body system (e.g., nervous) so that the problems relate to a particular specialty are easier to recognize.
A Problem List can grow to include many issues. By marking problems as high, medium or low priority, clinicians can ensure that derivative documentation (e.g., discharge summaries) reflects clinical priorities. Priorities reflect individual choices, and do not affect how other clinicians or specialties may organize the same Problem List.
A Problem List can be further managed by marking some problems as "chronic". Those that will be attended to during an admission can be marked as "hospital" problems. This speeds problem reconciliation at care transitions: the chronic problems automatically default to stay on the Problem List, whereas the hospital problems are flagged for possible resolution.
Problem overview notes provide a high-level summary of key attributes of health problems that any clinician might need to be aware of. They are stored at a patient level, and so are available in all care contexts (e.g., inpatient, emergency, outpatient, community, etc., care). Only one overview is associated with a health problem, and so overviews are jointly maintained by all prescribers.
While clinicians can populate overviews with whatever information serves their needs, standardized overviews work best for problems that persist over time... as happens with chronic illnesses. Accordingly, Connect Care offers a growing number of provincially curated overviews for problems associated with common chronic illnesses. Each is consistently formatted, presents as easy-to-read prose, and has interactive text for managing a minimum data-set relevant to chronic disease management.
As soon as a problem is added or activated in a patient's problem list, a link appears just below the overview edit box ("Problem Overview Data - ...") if a standardized overview is available. Easier is to add a SmartPhrase (use ".OVERVIEW...") to the problem overview. The resulting text is "interactive" in that anything in dark blue font can be selected in order to bring up the structured data editing form. A refresh of the overview text will update with the new information.
The same SmartPhrase can be used in any other documentation, such as a discharge summary. Or the patient problems can be brought into summative documentation such that the overview appears with the problem.
Problem List reconciliation involves periodic review and revision. It should occur, minimally, at transitions of care; including admission, discharge, first outpatient presentation and whenever there are significant changes in patient status. The clinician decides which problems remain active, which are primary, how problems are prioritized and which problems have become chronic.
Problem List "bloat" usually results from failure to reconcile. Some patients have complex health challenges and may legitimately have 10 or more diagnoses on their problem list. However, long lists often include problems that were not resolved or moved to the Medical History, as well as duplicates reflecting different specialty "takes" on the same problem.
Problem List Etiquette
Some clinicians may feel reluctant to revise (e.g., make more precise, add an overview, better characterize or categorize) a Problem because it is felt to be the responsibility (or "property") of another clinician. Connect Care is a shared health record, with collaboratively maintained problem, allergy, history, medication and other lists. All are entitled, indeed expected, to contribute to keeping lists relevant and succinct. All changes are recorded and there is always a way to backtrack from a change.