Introduction
Background
The inconsistencies
Why address the issue now?
Current policies lack direct guidance for practitioners
Methods
Study design
Survey instrument
Question | Category | Potential Controversy | Example |
---|---|---|---|
What problems should be included (Broad)?
| |||
1 Family History | Should family history only be listed in the family history section of the EHR or if important enough be included in the problem list. | Family history of breast cancer; Family history of diabetes | |
2 Social History | Should social history only be listed in the social history section of the EHR or if important enough be included in the problem list. | Construction worker; Non-smoker; Suspected alcohol abuse | |
3 Surgeries | Should surgeries only be listed in the past surgical history section of the EHR or if important enough be included in the problem list. | Appendectomy; Knee replacement surgery | |
4 Hospitalizations | Should hospitalizations only be listed in the prior hospitalization section of the EHR or if important enough be included in the problem list. | Hospitalized - May 2006 - MI | |
What problems should be included (Detailed)?
| |||
5 Latent chronic diseases | Should chronic diseases which are currently not receiving medical treatment be included in the problem list? | Asthma, no symptoms, no medications | |
6 Non-medical conditions | Should problems that are not a disease, family history, social history, surgery, or hospitalization be included in the problem list? | Medical anxiety; Medication non-compliance | |
7 Undiagnosed long term symptoms | Should symptoms that cannot be linked to a specific diagnosis of a disease be listed in the problem list? | Chest pain - work up completed, no diagnosable cause | |
8 Multiple occurrences of transitive illness | Should transitive illnesses that occur multiple times be listed in the problem list? | Multiple urinary tract infections | |
9 Sequelae problems | Should a disease caused by an original disease be listed in the problem list? | Coronary heart disease caused by diabetes | |
Terminology
| |||
10 Use of acronyms | Should practitioners use acronyms in the problem list or write out the full title of the disease? | DM or Diabetes Mellitus; CHD or Coronary Heart Disease | |
10 Level of detail of problems | What level of specificity should be used to describe a problem? | Diabetes; Diabetes Mellitus; Diabetes Mellitus Type II | |
11 Listing a sequelae | Should a problem caused by an original disease be listed with the original problem on the problem list? | Diabetes Mellitus Type II with renal manifestations | |
When to add or delete problems?
| |||
12 Timing (add) | On a problem where it is unclear if it is transitive or chronic, how much time or number of appointments should the practitioner wait until listing it on the problem list? | Back pain | |
13 Timing (delete) | When a chronic disease is cured or no longer receives medical treatment, should it be deleted from the active status problem list and if so, when? | Diabetes Mellitus Type II; Breast Cancer; Migraines | |
Sensitive Problems
| |||
14 Whether to include sensitive problems? | Should sensitive problems be included in the problem list? | Depression, HIV/AIDS | |
15 To include sensitive problems when other practitioners have access to the same record | Should all the patient’s practitioners know of all their diagnoses through the problem list in the EHR? | Anorexia Nervosa; HIV positive | |
16 To include sensitive problems when a patient disagrees with a diagnosis | Should a diagnosis that a patient does not believe they have be listed in the problem list? | Depression; Anxiety Disorder | |
17 To include sensitive problems when a patient has access to the problem list through an online patient portal | If a patient has access to their problem list through an online patient portal, should a diagnosis that could potentially hurt the patient’s feelings be listed on the problem list? | Obesity; Depression | |
Who can change the problem list across the following roles:
| |||
18 Specialist | Should specialists be responsible for adding or deleting problems that they diagnose or treat? | Asthma; Breast Cancer | |
18 PCP | Should the PCP be solely responsible for adding and deleting all problems, regardless of who originally diagnosed the problem? | All potential problems | |
19 Nurse Practitioner | Should a nurse practitioner be allowed to add and/or delete problems when they care for a patient? | All potential problems | |
20 Other RN | Should an RN other than a nurse practitioner be allowed to add and/or delete problems when they care for a patient? | All potential problems |
Validation
Sample
Data analysis
Results
Response rate
n | Sample size | Response rate | |
---|---|---|---|
In-Person Interviews | 9* | 14 | 64.2% |
Online Questionnaire | 111 | 346 | 32.1% |
Online Questionnaire Respondents | Completeness Measure | Plurality Measure | ||||
---|---|---|---|---|---|---|
Assessment of 13 Yes/No vignettes for inclusion tolerance | Assessment of 20 vignettes for trends in choosing with the plurality | |||||
N | % Resp | Unadjusted Value | Adjusted P* | Unadjusted Value | Adjusted P* | |
Role
| ||||||
MD | 105 | 93.8 | 9.7 | ref | 15.1 | ref |
PA/NP | 6 | 5.4 | 10.8 | 0.5 | 14.6 | 0.3 |
Other | 1 | 0.9 | NA | NA | NA | NA |
Discipline
| ||||||
PCP | 85 | 76.6 | 9.7 | ref | 15.0 | ref |
Specialist | 9 | 8.1 | 9.9 | 0.9 | 15.3 | 0.7 |
Other | 17 | 15.3 | 10.2 | 0.2 | 15.0 | 0.6 |
Resident
| ||||||
No | 48 | 44.0 | 9.9 | ref | 15.0 | ref |
Yes | 61 | 56.0 |
9.4
|
0.0
| 15.0 | 0.7 |
Age
| ||||||
21-30 | 38 | 34.9 | 9.5 | ref | 15.1 | ref |
31-40 | 27 | 24.8 | 9.5 | 1.0 | 14.6 | 0.7 |
41-50 | 23 | 21.1 | 9.9 | 0.5 | 15.1 | 0.1 |
51-60 | 13 | 11.9 | 10.3 | 0.7 | 15.4 | 0.1 |
61-70 | 7 | 6.4 | 10.0 | 0.9 | 15.3 | 0.1 |
greater than 70 | 1 | 0.9 |
12.0
|
0.0
| 15.0 | 0.1 |
Experience
| ||||||
less than 1 year | 20 | 18.4 | 9.9 | ref | 15.6 | ref |
1-5 | 34 | 31.2 | 9.3 | 0.1 | 14.9 | 0.3 |
6-10 | 10 | 9.2 | 9.4 | 0.1 | 14.8 | 0.3 |
11-20 | 24 | 22.0 | 9.9 | 0.5 |
15.0
|
0.0
|
21-30 | 11 | 10.1 | 10.5 | 0.9 | 14.8 | 0.1 |
31-40 | 7 | 6.4 | 10.0 | 0.4 |
15.3
|
0.0
|
greater than 40 years | 3 | 2.8 | 11.0 | 0.6 | 15.7 | 0.3 |
Importance
| ||||||
1 - not important | 2 | 1.8 | 10.0 | ref | 14.5 | ref |
2 | 3 | 2.7 | 10.5 | 0.3 |
17.5
|
0.0
|
3 | 10 | 9.0 | 9.5 | 0.9 | 14.8 | 0.5 |
4 | 37 | 33.3 | 9.7 | 0.2 | 15.0 | 0.1 |
5 - very important | 59 | 53.2 | 9.8 | 0.4 | 15.0 | 0.2 |
% Resp | N | |
---|---|---|
Role
| ||
MD | 87.5% | 7 |
RN/NP | 12.5% | 1 |
Discipline
| ||
PCP | 25.0% | 2 |
Specialist | 75.0% | 6 |
Resident?
| ||
Yes | 12.5% | 1 |
No | 87.5% | 7 |
Experience
| ||
1-5 | 12.5% | 1 |
6-10 | 12.5% | 1 |
11-20 | 25.0% | 2 |
21-30 | 37.5% | 3 |
31-40 | 12.5% | 1 |
Characteristics of respondents
Character of responses
What problems should be included (broad)? | |||
---|---|---|---|
Question 1: Family History
|
Answers
|
% Res.
|
N
|
Donna goes to see her PCP and mentions that she is terrified of getting breast cancer because both her maternal grandmother and mother had breast cancer. Now her sister was recently diagnosed. Should Donna’s family history of breast cancer be mentioned on her problem list? | Yes | 76.2 | 77 |
No | 23.8 | 24 | |
Question 2: Social History
|
Answers
|
% Res.
|
N
|
John comes in to a medical center's urgent care ward with a small facial laceration from playing hockey. John mentions he's a male model to the physician and explains that he wants treatment that will minimize scarring. Should the doctor add John's occupation as a model to the problem list? | Yes | 7.9 | 8 |
No | 92.1 | 93 | |
Question 3: Surgeries
|
Answers
|
% Res.
|
N
|
Ritchie has an appendectomy performed at the local hospital. His PCP gets the medical record from the hospital. Should Ritchie's PCP add 'appendectomy' to Ritchie's problem list? | Yes | 73.5 | 72 |
No | 26.5 | 26 | |
Question 4: Hospitalizations
|
Answers
|
% Res.
|
N
|
Paul is hospitalized due to a heart attack caused by his coronary artery disease. At Paul's PCPs office 'coronary artery disease' is already listed on his problem list. Now Paul's PCP receives Paul's medical information from the hospital. Should Paul's PCP add another item specifically mentioning Paul's recent hospitalization to the problem list? | Yes | 50.0 | 49 |
No | 50.0 | 49 | |
What problems should be included (detailed)?
| |||
Question 5: Latent non-transitive diseases
|
Answers
|
% Res.
|
N
|
Tenesha recently moved to Boston and goes to see her new PCP for an annual physical. Tenesha says that she was diagnosed by a pulmonologist with exercise-induced asthma several years ago. Currently, she takes no medications to treat her asthma, is experiencing no symptoms, and the asthma does not affect her daily life. Should 'exercise-induced asthma' be added to her problem list? | Yes | 82.2 | 83 |
No | 17.8 | 18 | |
Question 6: Non-medical conditions
|
Answers
|
% Res.
|
N
|
Maria is a 52 year old woman and is afraid of doctors. She summons up the courage to go see a doctor for the first time in years because of a persistent cough. Should the doctor add a note about Maria's fear of doctors to her problem list? | Yes | 35.6 | 36 |
No | 64.4 | 65 | |
Question 7: Undiagnosed long term symptoms
|
Answers
|
% Res.
|
N
|
Jorge appears to have ongoing chest pain, but after a full work up the practitioner cannot diagnose the cause. Should the practitioner add an item about chest pain to the Jorge's problem list? | Yes | 96.0 | 97 |
No | 4.0 | 4 | |
Question 8: Multiple occurrences of transitive illness
|
Answers
|
% Res.
|
N
|
Helen is having her third urinary tract infection (UTI) within one year. Should the practitioner add a statement about the Helen's predisposition for urinary tract infections to her problem list? | Yes | 92.9 | 91 |
No | 7.1 | 7 | |
Question 9: Sequelae
|
Answers
|
% Res.
|
N
|
Sally develops coronary artery disease as a result of her Type II diabetes. Should the resultant coronary artery disease be listed on the problem list? | Yes | 100.0 | 97 |
No | 0.0 | 0 | |
Terminology
| |||
Question 10: Use of acronyms/Level of detail of problems
| |||
Sally is diagnosed with Type II diabetes. What term should the practitioner use on Sally’s problem list? | |||
Answers
|
% Res.
|
N
| |
DM | 1.0 | 1 | |
DM II | 16.5 | 16 | |
Diabetes Type II | 17.5 | 17 | |
Diabetes | 3.1 | 3 | |
Diabetes Mellitus | 1.0 | 1 | |
Diabetes Mellitus Type II | 58.8 | 57 | |
Other | 2.1 | 2 | |
Question 11: Listing of sequelae
| |||
If a practitioner wants to list Sally's coronary artery disease, how should coronary artery disease be listed on her problem list? | |||
Answers
|
% Res.
|
N
| |
Diabetes Type II with coronary artery disease | 0.0 | 0 | |
As a separate problem from Diabetes Type II | 100.0 | 97 | |
When to add or delete problems?
| |||
Question 12: Timing (add)
|
Answers
|
% Res.
|
N
|
Dr. Baker likes to include long term undiagnosed symptoms on his patients' problem lists. Catherine comes in for her first appointment with Dr. Baker complaining of lower back pain. If Catherine keeps coming to see Dr. Baker once a month complaining of lower back pain, at what appointment/month should Dr. Baker add an item about back pain to Catherine's problem list? | 1st appointment/month | 27.6 | 27 |
2nd | 12.2 | 12 | |
3rd | 25.5 | 25 | |
4th | 3.1 | 3 | |
5th | 0.0 | 0 | |
6th thru 11th | 4.1 | 4 | |
> 12th | 0.0 | 0 | |
It depends | 26.5 | 26 | |
Never | 1.0 | 1 | |
Question 13: Timing (delete)
|
Answers
|
% Res.
|
N
|
The practitioner does mention Helen's predisposition for UTI's on her problem list. Three months later, Helen is in for her annual physical and mentions that she has not had any UTIs for the past three months. Helen continues not to experience anymore UTIs. At what point should the item about Helen's predisposition for UTIs be removed from the problem list? | 1-3 months | 6.1 | 6 |
4-6 months | 4.1 | 4 | |
6-9 months | 5.1 | 5 | |
10-11 months | 4.1 | 4 | |
1-2 years | 38.8 | 38 | |
3-4 years | 6.1 | 6 | |
>5 years | 2.0 | 2 | |
Never | 8.2 | 8 | |
It Depends | 25.5 | 25 | |
Sensitive Problems
| |||
Question 14: Whether to include sensitive problems?
|
Answers
|
% Res.
|
N
|
Paul goes to see a psychiatrist and is diagnosed with depression. Should the psychiatrist add 'depression' to Paul's problem list? | Yes | 99.0 | 97 |
No | 1.0 | 1 | |
Question 15: To include sensitive problems when other practitioners have access to the same record
|
Answers
|
% Res.
|
N
|
Janice goes to see a psychiatrist and is diagnosed with anorexia nervosa. She also goes to see a PCP, allergist, gynecologist, and neurologist at the same medical facility. While her psychiatrist's notes are restricted to the mental health department, all of Janice's other doctors are viewing a common problem list through an electronic health record (EHR) system. Under this scenario, should the psychiatrist add 'anorexia nervosa' to Janice's problem list? | Yes | 99.0 | 97 |
No | 1.0 | 1 | |
Question 16: To include sensitive problems when a patient disagrees with a diagnosis
|
Answers
|
% Res.
|
N
|
Dr. Thomas works at a mental health facility that encourages psychiatrists to add mental health problems to the patients' problem lists. During one of Dr. Thomas's patient visits, the patient strongly disagrees with the diagnosis of depression. Should Dr. Thomas still list 'depression' on the patient's problem list? | Yes | 75.5 | 74 |
No | 24.5 | 24 | |
Question 17: To include sensitive problems when a patient has access to the problem list through an online patient portal
|
Answers
|
% Res.
|
N
|
Dr. Brown works at a health center that offers their patients the ability to view their entire electronic health record online through a patient portal. Dr. Brown is with a patient whom he diagnoses with obesity. Dr. Brown knows this patient regularly checks the patient portal to review her medical record. Should Dr. Brown list 'obesity' on this patient's problem list? | Yes | 93.9 | 93 |
No | 6.1 | 6 | |
Who can change the problem list across the following roles:
| |||
Question 18: Specialist/PCP
| |||
Toby appears to have an asthma attack during a soccer game. His PCP refers him to a local pulmonologist. The pulmonologist diagnoses him with asthma and has access to the same electronic health record as the PCP. How should the pulmonologist address the problem list? | |||
Answers
|
% Res.
|
N
| |
The pulmonologist should add 'asthma' to Toby's problem list. | 77.8 | 77 | |
The pulmonologist should advise the PCP to add 'asthma' to the problem list in his follow up. | 9.1 | 9 | |
The pulmonologist should perform his regular feedback and assume the PCP will add 'asthma' to Toby's problem list if the PCP feels it is necessary. | 12.1 | 12 | |
Other | 1.0 | 1 | |
Question 19: Nurse practitioner
| |||
John recently moved to Boston and is going for his annual physical exam with a new health center. A nurse practitioner is giving John his physical exam and John tells the nurse practitioner that he was diagnosed with asthma by a pulmonologist. Should the nurse practitioner be able to add problems like John's asthma to the problem list or should only physicians be able to add problems? | |||
Answers
|
% Res.
|
N
| |
The nurse practitioner should be able to add problems to the problem list. | 93.8 | 91 | |
Only physicians should be able to add problems to the problem list. | 6.2 | 6 | |
Other | 0.0 | 0 | |
Question 20: Other RN
| |||
Carlos breaks his leg and goes to the hospital. The nurse is performing her medication rounds when Carlos mentions to her that he forgot to tell the triage nurse that he has hemophilia. What should the nurse do in regards to the problem list? | |||
Answers
|
% Res.
|
N
| |
The nurse should access Carlos's medical record and add 'hemophilia' to the problem list. | 22.7 | 22 | |
The nurse should tell the doctor that Carols has hemophilia and recommend that the doctor add 'hemophilia' to the problem list. | 60.8 | 59 | |
The nurse should tell the doctor that Carols has hemophilia and assume that Carlos's doctor will add 'hemophilia' to Carlos's problem list without specific recommendation. | 14.4 | 14 | |
Other | 2.1 | 2 |
General trends and findings
What to include in a problem list (broad categories): questions #1-4
What to include on a problem list (detailed inclusions): questions #5-9
Terminology: questions #10-11
When to add or delete problems: questions #12-13
Sensitive problems: questions #14-17
Who can change the problem list?: questions #18-20
Analysis of the completeness and plurality measures
% Resp | N | |
---|---|---|
Completeness Measure
| ||
6 | 1.1% | 1 |
7 | 2.1% | 2 |
8 | 18.1% | 17 |
9 | 23.4% | 22 |
10 | 23.4% | 22 |
11 | 19.2% | 18 |
12 | 12.8% | 12 |
Plurality Measure
| ||
11 | 1.1% | 1 |
12 | 4.3% | 4 |
13 | 16.0% | 15 |
14 | 17.0% | 16 |
15 | 19.2% | 18 |
16 | 22.3% | 21 |
17 | 13.8% | 13 |
18 | 6.4% | 6 |