GeriTech

In Search of Technology that Improves Geriatric Care

patient engagement

Medicine in Denial: The Problem-Oriented Medical Record

[This post, which was first published on The Health Care Blog on 5/10/13, is Part 2 of a commentary on “Medicine in Denial,”(2011) by Dr. Lawrence Weed and Lincoln Weed. You can read Part 1 here.]

An excellent chapter in “Medicine in Denial” discusses the problem-oriented medical record (POMR), a comprehensive charting approach that Dr. Larry Weed began developing in the late 1950s.
The Weeds begin by detailing what a good health care record should allow clinicians, and the healthcare system to do. In other words, they start by clearly defining the needs of patients, the purpose of the medical record, and the kind of health care it should support.
Specifically, the Weeds make the following points:
  • Managing chronic illness often involves multiple interventions that require adjustment over time, rather than a single treatment that results in cure/resolution. This requires tracking of physiologic variables and medical interventions over time.
  • Chronic care of medically complex patients, especially those with multimorbidity, requires coordination of care among multiple clinicians at multiple sites over time.
  • For the many people suffering from multi-morbidity, chronic medical problems and their associated interventions often interact. This makes it particularly important that care be individualized, and carefully tracked over time.
  • Enabling patient awareness, participation, and commitment is essential, with the Weeds noting that “unavoidable complexity must somehow be made manageable by patients who need to cope with what is happening to their own bodies and minds.”
  • Patient care – and hence the charting of medical data — must be oriented towards a single purpose: individualized medical problem solving for unique patients.
In other words, the Weeds consider the longitudinal, comprehensive, person-centered, individualized, collaborative care of the medically complex patient to be a fundamental base scenario around which we should design healthcare, and healthcare information systems.
This left me deeply impressed, since most of what I read about changing healthcare seems to treat the primary care of medically complex patients as an afterthought, or special use scenario, rather than as the starting point from which we redesign our healthcare tools.
Also impressive to me was the way the Weeds consistently put the involvement of the patient front and center in their thinking:

“[Informed patient] involvement requires external standards and tools that patients themselves learn to use, both independently and jointly with their providers. Without that patient involvement, unnecessary complexity and fragmentation occur, as multiple providers intrude on inherently personal decisions that patients are better positioned to manage for themselves.”

Wow. It’s one thing to breezily advocate for patient engagement, and another to work out a healthcare framework that is designed to maximize the patient’s ability to meaningfully engage in, and individualize, his or her own care.

A medical record designed for individualized comprehensive care over time

“The medical record is critical for complex cases involving chronic disease and multiple problems, which is where the largest amount of healthcare resources are consumed.”

Having laid out their priorities, the Weeds state that the key to managing medically complex patients over time is to “use the medical record to organize the myriad processes of care around defined patient needs.”
Organization and order in the medical record is key, of course. The Weeds outline the following core four components for the POMR:
  • A defined database of information, to store the relevant information that has been gathered;
  • A problem list, with problems defined in terms of the patient’s needs;
  • Plans of action for each problem, developed in light of the other problems;
  • Progress notes on each problem, which document the process of following up, including gathering of feedback and adjusting the plan over time.
Importantly, the Weeds consider psychosocial problems to be significant, and say they should be included in the problem list. They also describe the creation of a patient profile describing the patient’s family and living situation, noting that “these data are essential for the practitioner to understand the patient’s ability to cope with medical problems and to work realistically with the patient in setting goals and planning for diagnosis and management.”
Advocates for patient-centered care, take note!
How to actually use the POMR in practice? The Weeds write:

“A problem-oriented structure requires that all practitioners record each plan and progress note by the specific patient problem to which it relates. The patient’s total medical situation is summarized by a complete problem list appearing at the first page or screen of record…Enforcing the POMR standard means that individually relevant information is collected, considered, and acted upon by all practitioners and the patient over time, with the patient’s total situation taken into account every step of the way.”

Hm. Although I think we can and should do a much better job of following up on patients’ problems over time, I found myself wondering how exactly the POMR can ensure that all problems are considered when making a plan for a specific problem.
For instance, many elderly patients have 15-20 items on their problem list, and they would probably have more if providers were comprehensive and documented everything that is a problem for the patient (issues such as sleep, pain, and falls are often underrecognized).
Even if we work with a chart that makes it possible for us to view a comprehensive problem list, it’s still a significant cognitive challenge to hold all those factors in one’s mind as one considers options for moving forward on a particular problem. And what do people tend to do when faced with cognitive effort? They tend to avoid it, especially if they are rushed, tired, or stressed. (Read the work of Daniel Kahnemanand others if you are skeptical.)
Now, clinicians are of course capable of putting forth cognitive and emotional efforts, but realistically, it’s very difficult to sustain such focus during several back-to-back visits.
Hence, I found myself feeling a bit the same about the POMR as I did regarding the Weeds’ ideas on standardized inputs and knowledge coupling: sounds like an excellent idea in theory, but also sounds labor-intensive and more than a little challenging to implement under current practice conditions.
This isn’t to say we shouldn’t seriously consider using the POMR. The Weeds are entirely correct when they point out that the failure to follow-up on problems is a serious, endemic problem with grave repercussions for patients and society. Especially when it comes to older patients with multiple problems, it can be very easy for problems like depression, incontinence, falls, or memory complaints to fall through the cracks as clinicians gravitate in a rushed visit to tinkering with blood pressure or diabetes management.
And we would almost certainly be providing better care over time if our charting methods made it possible to easily see how a given problem had been managed over time. For instance, in many cases, it’s actually quite difficult to find out how a patient’s high blood pressure or other chronic condition has been managed over the past few years. What medications have been tried and why were they changed? What related tests were done? We often find ourselves asking the patient for this information, or worse yet, not even taking the time to ask these questions because time is so short.
As the Weeds note:

“Without well-structured progress notes, clinicians can easily fail to recognize trends and correlations in data, lose track of significant test results, fail to consider interactions among multiple problems, or fail to coordinate their activities with other practitioners. These failings occur particularly with chronic illness.

So true.

The organized clinician’s guide to making a plan, and engaging patients

In line with their orderly bent, the Weeds’ POMR model includes detailed suggestions as to how to document the plan for each problem. They propose the following element set for initial management plans:
  • Basis: this refers to the abnormalities/complaints that are evidence for the problem
  • Status: whether the problem is getting worse, better, or staying the same
  • Disability: this requires understanding the problem’s significance from the patient’s perspective (!)
  • Goal: this should be articulated after conversation with the patient and after considering all other problems affecting the patient
  • Follow course
    • Parameters to monitor course and status of problem
    • Parameters to monitor response to therapy
  • Investigate further
    • Hypotheses to be investigated
    • Measures to investigate each hypothesis
  • Complications to watch for
I found myself yet again impressed. Does your doctor do this when they diagnose you with a medical problem? I wish I could be doing this for my patients, but the truth is I often just rely on my brain to try to cover all these angles. Which means I’m not as consistently thorough as I’d like to be.
The element set above also struck me as a genuinely useful framework to support today’s all-important theme of “patient engagement.” To begin with, consistently documenting disability and goals would go a long way towards getting clinicians to understand medical problems from the patient’s perspective.
Then there’s the explicit outlining of the plan to follow the problem, further evaluate it if needed, and the complications to watch for. Imagine what an impact OpenNotes could have, if the notes being opened contained information such as this.

Why aren’t we using the POMR?

The Weeds’ description of the benefits of POMR sound terrific, so how is it that this approach is not yet in widespread use? After all, Dr. Weed developed this framework decades ago, and although the SOAP note remains in wide use, the comprehensive POMR approach itself seems to never have taken off. (I’m a bit embarrassed to admit that despite my long-standing interest in comprehensive primary care, I’d never even heard of Dr. Weed and the POMR until I researched this post
In “Medicine in Denial,” the authors posit that the POMR was never fully embraced because “the disciplines that the POMR imposes are alien to the culture of medicine,” which prefers to allow provider judgements to reign and the personal habits of providers to dictate care.
This strikes me as true, but feels insufficient as an explanation. I found myself wishing that the Weeds would’ve more clearly outlined some additional current obstacles to implementing the POMR approach in the outpatient setting.
Aside from the cultural expectations that physicians have regarding their work, the main obstacles I see to using POMR in primary care for Medicare patients are:
  • Insufficient time allotted to provide care to each patient. Even with a smart POMR-ready EHR system that properly organized information by problem, I’d expect each encounter would require at least 30 minutes of physician time, if not much more.
  • Insufficient financial incentives to practice comprehensive, person-centered, individualized, collaborative care over time. Unless you focus on a population of high utilizers with “ambulatory sensitive conditions,” a POMR approach seems unlikely to reduce hospital and ED utilization enough to keep the ACOs happy.
In other words, even if physicians were to accept that there’s a need for order and structure, I expect it would still be very difficult for them to implement a POMR approach.
Unless, of course, patients were to demand it en masse. Who else has more to gain than the patients and families?
Advocates for patient-centered care, take note!
[Read Part Three of this commentary on “Medicine in Denial” .]

Medicine in Denial: A book on how to really leverage technology to improve healthcare

[This post was first published on The Health Care Blog on 5/4/13, titled “Medicine in Denial.”]

“Any system of care that depends on the personal knowledge and analytic capabilities of physicians cannot be trusted.”

Finally, I’ve come across a really spot-on analysis of what ails healthcare, and some proposals that have serious potential to improve healthcare for people like my patients. Come to think of it, implementing these proposals would surely improve care for all patients.
The analysis, and the proposed fixes, are detailed by Dr. Lawrence Weed and his son Lincoln Weed, in their book “Medicine in Denial.” (The quote above is from this book.)
The book is a little long, but for those who are interested in leveraging technology to make healthcare more consistent and more patient-centered, I’d say it’s a must-read and must-discuss. (I’m a bit surprised that this book doesn’t seem to have many reviews, and that Dr. Weed’s ideas are not more often cited by those advocating for digital health and patient empowerment.) In particular, the Weeds’ book provides:
    1. An excellent description and analysis of two huge fundamental problems in healthcare. One is the way we persist in relying on fallible physician minds to manage the process of evaluating, diagnosing, and managing medical problems. The other is our lack of standards for consistently documenting and organizing information related to our evaluation and management of patients. Both lead to idiosyncratic, disorganized healthcare that generally serves patients poorly, especially those who are medically complex or have multiple chronic conditions.
    2. A proposed method of using computers and technology to consistently connect patient data to medical knowledge, leading to better diagnosis and medical management.
    3. A proposed method of reorganizing of medical records and clinical data. This “problem-oriented medical record” would provide a fundamental level of organization and transparency to the practice of medicine, and would allow better management of multiple problems over time.
    4. A vision of healthcare focused on empowering patients, and on enabling healthcare to be tailored to each patient’s needs, rather than driven by provider idiosyncracy or the blunt tools of evidence-based (aka population-based) medicine.
The book also covers several other topics, such as related problems in medical education and credentialing, and redefining competence in medicine. But the points above are the ones that resonated most deeply with me and my frustrations with the healthcare system.

“The concept of a physician as we know it is not viable”

The Weeds point out the obvious: there exists far too much medical information for the human brain to keep it all in mind, and apply it in a consistent and thorough fashion during a medical encounter.
This creates serious problems when it comes to the core medical work of diagnosis and providing treatment recommendations. To being with, when a patient comes to a physician with a complaint, the physician invariably does not collect enough data. (Just take a look at any UpToDate topic – or JAMA clinical review article — on evaluating a common complaint, and ask yourself if clinicians usually inquire about everything they should. We don’t.) Instead, clinicians ask questions somewhat idiosyncratically, depending on factors such as their initial hunch, their specialty habits, etc.
Next, physicians do a highly imperfect job of matching the patient’s data – i.e. the positive and negative findings – with medical knowledge. This results in a diagnostic conclusion that is often wrong, or in a differential which is incomplete.
As the Weeds point out, a patient with a medical concern can go see three different doctors and emerge with three different diagnoses. And of course, just as clinicians are idiosyncratic in their diagnostic processes, they are also idiosyncratic in how they recommend further evaluation, or in prescribing a management plan.
Doctors will call this “clinical judgement,” but the Weeds consider this unacceptable human-generated variation in medical practice, and I have to say that I agree with them.
To make matters even worse, not only are clinicians applying idiosyncratic human processes to diagnosis and management, but they then go on to document their findings and thought-processes in spotty idiosyncratic ways. This leaves the patient without a good record of his or her medical findings, and makes it difficult for subsequent clinicians – or the patient, for that matter — to reliably build upon the efforts of the initial clinician.
In short, the Weeds argue that medicine is plagued by a culture of severe, pervasive disorder. We are not orderly in how we evaluate patients, we are not orderly in how we match their data to our existing knowledge base, and we are not orderly in how we document our clinical processes and data.
The Weeds attribute much of this to medicine’s habit of valorizing the individual physician’s intellect and autonomy. Because of this, we persist in organizing healthcare around the efforts of fallible physician minds. The authors declare that the profession of medicine is in terrible denial.
I found myself agreeing, yet again, with them.

The computer-assisted alternative

To counter the existing sorry state of affairs, the Weeds propose a “standardization of inputs,” and argue that clinical judgement should be applied after we use computers and technology to complete two key tasks. The first task is to reliably identify and collect the necessary information from patients, via standardized questionnaires that are tailored to the complaint in question. The second is to use a “knowledge coupler” to analyze the patient’s responses and propose a list of diagnostic possibilities.
Only then should clinical judgement really enter the picture, and according to the Weeds, this should be applied in order to tailor the next clinical steps to the patient’s preferences and individual circumstances. (Hear hear! I like it.)
Presumably the reflexive response of many physicians will be to decry this as cookbook medicine.
Is it? Having been dismayed by the spotty clinical work that many physicians produce under today’s usual rushed outpatient conditions, I’m not sure a little cookbook structure is such a bad thing. As the Weeds point out, the purpose is to start with a solid, consistent foundation, and *then* proceed to individualizing:
“Decision-making must begin with a simple, mechanical process of association between data and knowledge, conducted without reliance on the practitioner’s mind. Thereafter, the processes of care must remain highly organized and explicit. Care would become highly standardized at the front end, and medical decisions at the back end would become highly individualized – precisely the opposite of the status quo, where physicians have broad discretion during the intial patient encounter but are expected to conform to standardized, “evidence-based” guidelines in their ultimate decisions.”
Being a junkie for order and completeness, I found myself quite attracted to the concept of standardizing inputs and applying a knowledge coupler before bringing in a physician’s clinical judgement. (The Weeds call this the “combinatorial” approach, as compared to the now predominant “judgemental” approach, which relies almost entirely on clinical judgment.)
How fantastic would it be if my elderly patients complaining of falls could have worked through a nice thorough questionnaire and computer-assisted differential, all before I even sat down to hold their hand. And it would be even better if such digital assistance would enable the non-geriatricians to identify orthostasis and medication side-effects as source of falls in the elderly.
But is it actually feasible to apply questionnaires and knowledge coupling to most older patients? I couldn’t help thinking that it would take my patients a long time to go through the questionnaires, and that they would probably need someone’s assistance.
The Weeds do address likely objections to the combinatorial approach. They point out that “comprehensive does not mean exhaustive” (but actually it does, when it comes to geriatrics). They also note that even if a standardized initial data collection is time-consuming, this should be considered time well-spent if it leads to better quality diagnosis and management. (On this I agree.)
Still, I couldn’t help but wonder if detailed data collection might not be more overwhelming for patients and providers than they admit. It certainly would’ve helped if the Weeds had provided an actual example of a sample questionnaire for one or more common complaints in an older adult.
For example, for shortness of breath, I presume an older person with history of CHF, CAD and COPD will require a more detailed questionnaire than a young adult with no significant past medical history. What would such a questionnaire actually look like? And how long would it take to complete?
In short, I found myself easily persuaded by the theoretical case for a technology-assisted combinatorial approach, rather than today’s terribly error-prone judgmental approach. But I was left uncertain as to how feasible it actually would be to implement in the case of complex elderly patients.
[See Part Two and Part Three of this commentary, which address some of the other key concepts discussed in “Medicine in Denial.”]
See here for comments to this post at The Health Care Blog.

What my home renovation taught me about practicing medicine

In
2006, as I was starting my geriatrics fellowship, we started renovating our
home.
This
took almost two years from start to finish. It was a long, arduous, expensive,
and often stressful process. And this experience ended up profoundly
influencing my philosophy as a primary care physician, and my approach to
practicing medicine.
To
this day, I’ve had minimal experiences as a primary care patient – I’m in my
mid-thirties, and am lucky to have always been pretty healthy.
But
I’ve been an inexperienced homeowner trying to muddle my way through a major home
renovation, and that, I will submit, has many interesting parallels with being
a primary care patient.
For
instance, although my life and overt health wasn’t at stake, we were investing
a lot of money – and time –  into a very
complicated undertaking in which we had no previous experience. (We ended up
entirely changing the layout of our flat, including moving the entire kitchen.)
We
had to identify professionals to work with, trust in their expertise and
ability to get the job done well, yet keep an eye on how things were going and
make sure to occasionally advocate for ourselves. And when the project would be
completed, we would be the ones living indefinitely with the consequences of
our choices and our experts’ choices.
So
when I think about physician-patient relationships, I end up thinking back to
my renovation experience, remembering our experience struggling through those
two long years. I think about how we negotiated trust and control with the
professionals involved. And I especially remember who felt helpful to us, who
didn’t, and why.
Here’s
what happened with two of the key professionals we encountered, and the lessons
I learned for practicing medicine.

Two professionals, two approaches

Now,
a renovation was a something neither my spouse nor I had experience with, and
we thought hard before deciding to go for it. But it seemed to be the best of
our options: we’d decided to renovate our flat because although it was
spacious, the layout was truly terrible and the kitchen finishings were
uninspiring to say the least. (We would’ve moved, but couldn’t find anything
else that we could afford. These were the boom years in SF real estate, so it
was cheaper to refinance our existing flat and remodel than to move and double
the mortgage.)
So
we told ourselves that our hard work and investment would result in a much
better space for living and would surely improve the overall value of our home.
We checked out some books on home renovation, and then we started looking for
help getting the project done.
The
first important decision we had to make was choosing an architect. We needed
someone to help us envision how we might change and improve our flat, and then
create the plans for a contractor to follow. In other words, the architect was
going to be the linchpin of our entire experience.
But
how to choose the right architect? None of our friends had worked with any
local architects. Somehow we found a few to interview, and ending up choosing
one who I’ll call Sam (not his real name), in part because he charged an hourly
rate rather than a percentage of the entire project.
Sam,
we realized over the next few months, was a big mistake. Although he was
capable and experienced as an architect, we repeatedly clashed over details of
the emerging design, and the experience of working with him was stressful. He
pooh-poohed our request for a pantry, since that interfered with the elegant
visual balance of his proposed kitchen design, and rolled his eyes when we
asked for a hallway door to separate the bedrooms in the back from the noisier
front part of the house.
Sam,
in other words, was more interested in realizing HIS vision for our home than
he was in helping us figure out how to create a comfortable space that met OUR
needs. He also didn’t have much patience for discussing little things, like our
making sure there were lots of electrical outlets conveniently placed.
Sound
like any professionals you know?
As
things got rockier with Sam, we started to consider the unthinkable: terminating
our relationship with him, and having someone else supervise the construction
based on Sam’s plans. This was a scary proposition to us: we didn’t like working
with Sam, but how to make sure we found someone better?
After
all, we needed SOMEONE to keep guiding us through the renovation. Despite my
doing constant research in online forums and through books, we were overwhelmed
by the complexity of the project, and I was terrified that we’d make more wrong
choices and end up with a mediocre outcome after investing so much in the
project.
Then
we took a look at our contract with Sam, and realized that although we had been
paying him for his time drawing the plans, the contract stipulated that plans
are “Instruments of Service” which remain property of the architect. In other
words, if we terminated the relationship, no plans to keep working with.
It
was, of course, a contract provided by the American Institute of Architects.
And as such, all the boilerplate heavily favored the interests of the
architect, not of the homeowner.
Luckily
for us, Sam himself proposed we terminate the relationship, and agreed to give
us the right to the plans, in exchange for our paying him for his time thus
far.
As
the strictly architectural work on the project had been completed, we opted to
replace Sam with a more affordable interior designer. This time, we were lucky
enough to find a very good person to guide us through the gazillion design
choices we still needed to make: Gale Melton.
Like
Sam, Gale charged an hourly rate, had years of experience, and had a good sense
of design.
But
unlike Sam, Gale made an effort to get to know our tastes and priorities, and
then applied her skills to help steer us towards designs that WE liked. Instead
of asking us “What do you want?” and looking impatient when we couldn’t
respond, she took time helping us discover and then articulate our preferences.
And throughout the following year, she helped us effectively process and
finalize a truly staggering number of design choices.
In
short, one expert professional performed a core part of his job but left us
stressed and frustrated. Whereas the other helped us navigate a dizzying array
of decisions and was instrumental in our creating a living space that is
comfortable, appealing, and a good fit for our needs.

Primary care physician as consultant


Would
I be the doctor I am today if I hadn’t gone through this renovation experience?
I’m not sure, especially since it took place during a formative time in my
clinical geriatrics training.
In
fact, as we were struggling with Sam in the fall of 2006, I completed two
months on the palliative care service. This was probably the most valuable and
concentrated clinical learning experience I had as a trainee, and included a
lot of teaching on communication skills. And of course, teaching on discussing
goals and adapting to people’s preferences.
These
two overlapping experiences prompted me to think long and hard about how physicians
help patients, especially in primary care.
My
conclusion was that how we practice as professionals isn’t just about having
sufficient depth of knowledge and the requisite technical skills.
It’s
also about our fundamental assumptions regarding how those skills should be
applied.
From
my renovation experience, we discovered that as homeowners we really wanted to
work with experts who:
·        
Made
an effort to understand our preferences, and helped us articulate them
·        
Educated
us so we could more effectively participate, and helped us understand likely
downstream consequences of certain choices
·        
Respected
it when we prioritized things differently from the expert
·        
Appreciated
that we had much more at stake in the project than the expert did
·        
Were
understanding when we occasionally sought an extra opinion from a third party,
or otherwise tried to double-check something
·        
Were
patient with multiple questions or attention to details
·        
Could
explain how recommendations were linked to a certain understanding of our
preferences or priorities
And
of course, we discovered that we *didn’t* want to work with experts who acted
as if they knew what was best and were annoyed when we didn’t agree.
We
also realized that we wanted to be able to switch experts, and if we ever have
to go through a renovation again, we’ll be sure to negotiate terms that allow
us to easily take our business elsewhere if we discover that an expert isn’t a
good fit for us.
So
in my own work as a primary care physician, I’ve tried to think of myself as a
consultant to the patient. My job is to serve the patient, usually by helping
him or her understand the medical situation and the options, and then working
out a feasible plan to move towards the person’s health goals.
Different
patients, of course, want different things. Some ask a lot of questions, others
don’t. Some are directive – in which case part of my job is to speak up if I
think the direction they’re taking is unlikely to lead them where they said
they wanted to go — whereas others really want direction (in which case the
clinician still needs to ask where they want to go).
Am
I as successful as I’d like to be in implementing this approach? I don’t really
know. I’ve gotten some nice feedback from patients and families over the past
several years, but ideally I’d have some more objective method of getting
feedback. (Or feedforward, as it were.)
Still,
I think this approach is overall sound, and is consistent with medicine’s
ongoing transition away from its historic paternalism, and towards approaches
that are more respectful, collaborative, engaging, empowering, and individually
tailored towards patients’ needs.
Now,
can anyone recommend a favorite tool or technology that allows providers to
quickly learn whether they are properly adapting to their patients’ needs or
not?
And
what metrics will ACOs use to encourage providers to act more like excellent
consultants? Or will ACOs even care, as long as utilization is controlled?
Fodder
for future blog posts.


Summing it up

My
approach to practicing primary care has been strongly influenced by my
experience slogging through an extensive home renovation, a process which
required my husband and I to depend on professionals for guidance and to
actually implement this major project.
We
discovered that some professionals were much more stressful to work with than
others, and found that we needed to work with those who were willing and able
to use their expertise to help us meet our goals. This meant we needed
professionals who were not only technically competent, but also had the skills
to solicit our goals and preferences, and then effectively collaborate with us.
Healthcare
is making a much-needed transition towards organizing around patients’ needs
and preferences. For me, it’s been helpful to think of my primary care role as
being a medical consultant there to help patients understand their medical
situations, and then assist them in reaching certain healthcare goals. However,
I haven’t yet identified a robust way of getting feedback on my performance.

Zen and the Art of Problem-Based EMR Design

[This post was first published on The Health Care Blog on 3/18/13]

How to effectively keep tabs on a patient’s multiple medical problems? And how to do so without losing sight of the whole person?

The first question is the one I wrote about in a recent blog post. The second was the theme of many of the responses posted on THCB and also LinkedIn.

I love this second question; it’s an issue that’s always been of interest to me. Plus it’s especially relevant in geriatrics, where we are constantly re-orienting our approach to problems based on what seems to be happening with the whole person. (Good PCPs do this too.)

And it’s an issue that good hospitalists think about too: several people brought up Dr. Bob Wachter’s post from last fall, in which he noted how using EPIC’s problem-based charting at UCSF’s hospital was having the unintended effect of making it harder for all clinicians to understand what the heck was going on overall with the patient.

Based on reading my post and Wachter’s post, an EMR designer asked me the following specific questions:

  • Should the entire EHR should be functionally and logically structured around problems, or would it be sufficient for a chart user interface to be presented in a problem oriented manner?
  • What are your thoughts about the possibility of such a solution becoming overly reductionist, losing the patient between the problems?

Good questions!

Should an entire EHR be organized around problems?

Or would it be sufficient for a chart user interface to be presented in a problem oriented manner?

I myself like the idea of the problem-based interface being one of several options, as I can imagine myself wanting to toggle between a chronologic list of encounters (a comfortable and familiar view for many docs) and a list of problems.

Actually, a neat visualization of a problem list can be seen here (try clicking “show all health problems” in the matrix):

This was part of Dr. Graham Walker’s proposal for last fall’s Health Design challenge, and one of the things I really liked about it was how the size of the problem icon relates to “how important” the problem is. (We could quibble about how that gets decided, but it’s still a nifty idea!) As they say, a good graphic is worth a thousand words.

To return to EMRs and the problem list: I don’t know whether an entire EMR should be organized around the problem list; I’d have to see an example of this and probably try it before I could venture an opinion.

However, I certainly want to be able to view data in EHR via a problem-based interface, and in my previous post I described how this might be possible via using problems as tags. Between tags and a robust search function – think of Gmail, or Evernote – information in an EMR could become much more findable and organizable. Which would be great for clinicians!

How to keep a problem-based approach from losing sight of the person?

Easy in principle. The key is to make sure a clinician regularly considers the patient’s overall medical picture. To use the altitude analogies that are sometimes used in business, this corresponds to the 10,000-30,000 ft view. Another way to describe it would be to make sure to consider the forest, and not just a few trees (or a long list of individual trees).

In practice, this gets tricky for the following reasons:

  • Many practicing doctors clearly are not routinely doing this.
  • The ongoing shift – driven by technology, the need to collect metrics, and the worsening time-pressures under which doctors practice — in how doctors do their charting seems to be exacerbating this. Whereas doctors used to dictate whole paragraphs, or write out chart notes, now we have EMRs that provide templates or direct us to chart by problems. I agree with Bob Wachter and others who have pointed out that these technological shortcuts probably interfere with cognitive synthesis. 
  • We have no clear professional standards – that I’m aware of – that specify how and when doctors should perform this exercise in clinical big-picture thinking. 
  • Most EMRs seem to not be designed to encourage this kind of big-picture summary thinking.

This means that among physicians, when and how to consider the patient’s overall big picture medically remains a very individual and idiosyncratic practice.

(I myself like to start with a blank piece of paper and I jot down a 1-2 sentence summary of the patient’s medical situation, along with a few issues I want to address. Then I go look for the relevant supporting data within the EMR. And I do it right before I go in the patient’s room or house, because I can’t think as well once they start talking to me. Idiosyncratic!)

But to provide good care, physicians need to toggle between a zoomed-out, big-picture view of the patient, and also a zoomed-in, tackle-a-problem-in-depth view. This means that EMRs should assist physicians in either view, and ideally would remind physicians to address both.

How EMRs could help us keep track of a patient’s overall medical picture

In his post, Dr. Wachter ends up proposing that an “Uber Assessment” field be added to each EPIC note, and that clinicians be required to enter a free text narrative summary of what is going on with the patient. This, to me, sounds like the old written attending notes of yore, which usually consisted of one concise and high-yield paragraph. (I trained at UCSF in the days of paper hospital charts; Wachter was my attending for two weeks in 2004.)

But a commentator objects, and not just any commentator: it’s Dr. Lawrence Weed himself, creator of the “problem-oriented medical record”, in partnership with his son Lincoln Weed!

If you have read Dr. Wachter’s post, but not Dr. Weed’s riposte, I strongly urge you to return to the original post here, and read Weed’s comment in its entirety. (Be sure to use tech to your advantage: search the webpage for “Lincoln Weed” and you can find it right away.)

In his lengthy and detailed comment, Dr. Weed clarifies that SOAP notes should not be conflated with POMR:

“Like many others, Dr. Wachter equates SOAP notes with the “new model for patient care records,” known as the “problem-oriented medical record” (POMR). But SOAP notes are just one of four basic components of the POMR: (1) an initial database, including a “patient profile” of non-medical circumstances; (2) a complete problem list; (3) initial care plans for each problem, including goals determined with the patient, and (4) progress notes for each problem using the SOAP structure.”

He goes on to object to the idea of relying on clinical synthesis being done the old-fashioned way, which is to say, via physician judgment:

“Our difficulty with Dr. Wachter’s analysis is that he assumes the primary vehicle for clinical synthesis to be physician judgment. In reality, synthesis should begin before the exercise of judgment. That is, electronic tools should first be used to select patient-specific data points and then match those data with relevant medical knowledge. This initial information processing routinely yields clinical synthesis beyond what physician judgment achieves.”

And then, Weed completely wins me over with this paragraph:

“But this initial, tool-driven synthesis is not enough in complex cases. There what patients need is a highly organized process: careful problem definition, planning, execution, feedback, and corrective action over time, with patient involvement every step of the way. [Emphasis mine.] When applied to all problems on the problem list, this process enables clinical synthesis to emerge in a systematic, organized and reproducible fashion. Effective synthesis is tool-driven and process-driven. The tools and the process minimize reliance on unstructured clinical judgment, with all of its cognitive vulnerabilities.”

And also this one:

“Our concern with patient involvement suggests that a separate, aggregate assessment should be a vehicle for synthesizing patient and practitioner perspectives. This can be accomplished most effectively if the assessment is focused on setting priorities. [Emphasis mine.] Thinking about priorities naturally requires the practitioner and patient to consult each other, naturally requires them to consider the patient’s total situation (the initial patient profile and the current problem list), naturally focuses them on options for action, and naturally avoids diffuse narrative discussion. EHR fields for a “big picture” assessment should be structured accordingly. Implemented in this way, Dr. Wachter’s concept could be a valuable component in any medical record.”

Crucial points Weed makes that I love:

  • Electronic tools should help us quickly gather the relevant data points, and should provide much initial information processing.
    • Yes! We clinicians should not have to root around in an electronic chart, expending energy trying to find the information we need.
  • We need a good processes and tools to support clinical synthesis.
    • Given what we know about human fallibility in cognitive processing, this sounds like a terrific idea.
  • Cognitive effort should be in reviewing the output of the electronic processing, and in discussing with the patient. 
    • Being able to explain something to a patient in plain English is a great test of how well one understands things overall, and offers patients the opportunity to ask questions and participate in making a plan. Love it.
  • Assessment should be about setting priorities.
    • Yes yes yes! Especially in complex older adults, it’s easy for both clinician and patient to become overwhelmed by the sheer number of problems on the list. A joint effort identifying the top priorities serves all parties well.
  • Planning, execution, and feedback are important. 
    • This speaks to my concerns about letting things fall through the cracks. We need support in fully fleshing out how we will address a certain problem, in executing the plan, and in following up on how it’s going. Task/project management software could be adapted and used within a collaborative EMR to help with this.
  • Patient involvement is essential. 
    • Weed’s approach advocates for communication and collaboration with patients, both to set goals regarding plans for each problem, and to set priorities and work out an overall plan. Hear hear!

Discovering Weed’s historical contributions and recent views on medical charting was a very welcome perk of following up on my problem list post. He published a book in 2011, titled “Medicine in Denial.”

Has anyone read it? I’m wondering if Dr. Weed is involved in any ongoing EMR development efforts.

Summing it up

To do their work, clinicians need to address medical problems in depth and keep track of a potentially long list of problems, all while not losing sight of the patient as a person. This has always been challenging in medicine and is becoming more difficult due to information-overload and current trends in EMR charting. (Dr. Bob Wachter’s 2012 post on using EPIC to chart at UCSF hospital highlights some of these issues.)

A robust problem-oriented view within EMRs would be very helpful to primary care clinicians, and I would love to see problems used as tags within other aspects of the EMR. However, this problem-view would have to be implemented thoughtfully, in order to not hamper the clinician’s process for considering the patient’s overall medical picture.

Currently, when and how to consider the patient’s overall big picture medically remains a very individual and idiosyncratic practice, both in the hospital and in the outpatient setting. In the comments to Dr. Wachter’s post, the legendary Dr. Lawrence Weed details a number of ways in which technology could make this synthesis process more manageable (by helping to collect relevant data) and more structured for clinicians.

Dr. Weed also earns my undying admiration as he calls for clinicians to collaborate with patients in setting goals for problems, and in setting priorities, and in implementing a plan. It would certainly be interesting to try to implement some of Dr. Weed’s recommendations via EMR.

In search of a good caregiver support app

A friend invited me to his Carezone account recently, and I have a few thoughts to share.

For those not familiar with this product: it’s a web and app-based platform meant to help family caregivers stay “organized and effective.” It does offer encryption and privacy features, as it’s intended for a person’s care circle to be able to share potentially sensitive information such as medication lists, journal entries, and caregiving to-dos. (See some NYT coverage here; not clear that the reporter spoke to any caregivers or clincians but maybe that’s because it’s in the digital business section.)

Is it meant to share information with clinicians? As far as I can tell, no. There is nothing about sharing with a doctor on the website, and within Carezone, it seems you can only invite people as “helpers.”

So how did I end up in Carezone? Well, in general I often try things out pretending I’m a family caregiver, because I like to see what families might be experiencing in terms of user interface and options. So I’d signed in to Carezone several weeks ago, when a colleague mentioned recommending it to clients.

But in this case, I was invited to another person’s Carezone account because my friend wanted a few suggestions regarding the care of his elderly mother. To view the Carezone information, I had to create a login (my email) and password.

Hence I entered Carezone as a friend — or “helper,” per Carezone — but it’s not hard to imagine patients and families inviting their actual doctors to something like Carezone. After all, some patients currently come to the doctor with notebooks and file folders, so if they are now going to use an app to keep track of things, they will surely try to share this with doctors.

Here’s what I found: sections titled Journal, Calendar, Medications, To-Dos, Contacts, Notes, Uploaded Files, and Profile.

Looking for medical information, I started with the medications, which I find is usually the best-available proxy for a medical problem list when looking at a caregiver’s notes. Medications are presented in a list, with columns for “What it’s for” (which I like) and “Rx number” (really?) and “Where you get it.”

Next I skimmed the journal entries, which is where my friend has been keeping notes on what the doctors tell him; they are blog-like, in that they are time-stamped and go backwards in time.

And that was pretty much all there was to see. Was it helpful to me? So-so. We had a phone call and discovered that one of his mother’s key medications was not on the list. Oops, someone in the family had forgotten to enter it.

A few days later, I get an email from Carezone, with an updated journal entry. It occurs to me that PCPs are certainly going to think twice about these products if they end up getting cc’ed on everything that a family says to each other. I sign back into the service, and find some options in the settings to *not* get emailed every time there is an update.

What I think of Carezone so far

Many caregivers need help keeping track of their caregiving responsibilities, and need help coordinating with a circle of concerned families and friends. So there is definitely a need for this kind of app.

What I liked:

  • User interface seems pleasant enough
  • Medication list includes a column for “What it’s for” 
  • System suggests full medication names as one starts to type them in
  • Browser interface, which makes easier to enter information compared to smartphone

What needs improvement:

  • Entering medications seems onerous: multiple fields to type into (name, dose, how many times a day, who prescribed it, where did you get it, etc.). 
  • Features seem very basic:
    • Task list: you can assign a task to another helper on the case, but otherwise no
      due dates, no categories, just whatever you’ve put in the text box. If you’ve used anything more robust in the past, this feels a little anemic.
    • Calendar: doesn’t automatically understand the time something starts based on the text entry (if you’re a Google calendar user, this is annoying). Also doesn’t offer option to send calendar item to an outside Calendar like iCal or Google.
  • Doesn’t pull in info from other systems, such as pharmacy systems.
  • Doesn’t seem to offer any option to print things out, or export. For instance, no way to print medication list, other than to print from the browser.

Bottom line: Requires labor to enter data, features pretty basic, doesn’t seem designed to interface with clinicians (nevermind two-way communication; this doesn’t emphasize printing things to show the doctor), doesn’t seem designed to support medical management. Seems ok if a family wants to collectively blog about how an elderly relative is doing.

Can caregiving apps work without being designed for medical management?

This is perhaps my bias because I’m a physician, but I can’t help but think that these caregiver organization apps will be doomed to fail unless they can more robustly incorporate medical information and the medical care plan.

I say this because a very substantial part of what caregivers of older adults must do is manage medical issues. This includes things like:

  • Help an older person take scheduled medications. Big bonus if caregiver can snap a picture of the med and record it as taken.
  • Monitor symptoms and events, such as pain, falls, incontinence, confusion, shortness of breath, etc
  • Offer and track as needed medications, such as short-acting inhalers for COPD, pain medication for arthritis, heartburn medication, etc. 
    • This is really important to me. I usually have a lot of difficulty figuring out how much of an as-needed medication has been taken.
  • Implement non-pharmacological aspects of a medical care plan, such as timed toileting for incontinence, or a home exercise plan
  • Keep track of appointments and all the involved providers
  • Be prepared to provide an accurate medication list and health summary to medical providers. These providers might be entirely new, such as in urgent care or the ED, or might be regular providers, such as one of many specialists. (It’s not fair and right that patients need to handle this information exchange, but families need to be ready to do it, until we develop our perfect system of health information exchange.)
  • Take notes during a medical visit, to help an older person keep track of what the clinicians said, did, and recommended. (Again, not fair that this falls on patients, but currently important.)

In the end, I would think that caregivers might be better served by organizational apps which are extensions of personal health records, rather than free-standing apps stemming from a private social networking model.

Of course for this to work, the personal health record itself has to be properly designed to support the care of medically complex older adults — you’d think the entrepreneurs are planning for healthcare’s power users (aka Medicare beneficiaries) but as far as I can tell they often don’t.

This means a personal health record supports medical complexity, care coordination among multiple providers at different sites, and supports the involvement of family caregivers and paid caregivers. Such a record should also be able to inhale information electronically from various sources, rather than expect families to diligently type everything in themselves.

Can anyone recommend such a personal health record to me? Or a caregiver support app that helps with any of the above?

Summing it up

Caregivers sorely need tech tools to help them keep track of caregiving tasks, and help share this work with a person’s care circle.

I personally feel that caregiving apps need to be better designed to help caregivers manage the medical issues. Most older adults who need help from family and friends have multiple chronic conditions, and can have a fair amount of home medical management to address.

To date, the caregiver support apps that I’ve come across require labor-intensive data entry on the part of caregivers, and don’t seem designed to support the many medical tasks that caregivers often find themselves responsible for.

It’s possible that in the end, the better caregiver apps will develop as extensions of good personal health records, rather than as private micro social networking apps.

Addendum 2/27/13: I’ve received a tweet from Carezone and they DO support printing, however has to be done by using the browser’s print. See here for more info. I tried it out for a med list and it did look pretty good; I do think they should add a print icon to the interface though.]