Zen and the Art of Charting

One of the many challenges I face in my clinical work is keeping track of a patient’s multiple health issues, and staying on top of the plan for each issue.

As you might imagine, if I’m having trouble with this, then the patients and families probably are as well.

After all, I don’t just mean keeping up with the multiple recommendations that we clinicians easily generate during an encounter with an older patient.

I mean ensuring that we all keep up with *everything* on the medical problem list, so that symptoms are adequately managed, chronic diseases get followed up on correctly, appropriate preventive care is provided, and we close the loop on previous concerns raised.

This, I have found, is not so easy to do. In fact, I would say that the current norm is for health issues to frequently fall between the cracks, with only a small minority of PCPs able to consistently keep up with all health issues affecting a medically complex adult.

What kinds of things fall through the cracks? Here’s a list off the top of my head (for the primary care of adults with multiple chronic conditions):

-Cognitive impairment
-Depression and/or anxiety
-Advance care planning
-Moderate anemia
-Chronic kidney disease
-COPD (esp Stage I and II)
-Difficulty managing medications

Why do these fall through the cracks? I suppose it’s a combination of lots of little things. To begin with, many of these are problems that don’t lead to easy concrete steps a PCP can quickly implement within a short follow-up visit. Within a busy clinic day, it’s almost impossible to not find oneself gravitating towards the path of least resistance and least cognitive effort.

Then there’s the too many people involved issue. Many patients, especially in Medicare, see several specialists. It becomes easy for clinicians to assume that another clinician will address an issue.

Then there’s the way most primary care visits are structured. The biggest problem is that they are short (10-15 min), which makes it hard to address more than 1-3 issues. Patients often have their own acute concerns, which can make it hard to follow up on chronic conditions. And many doctors spend only minimal time reviewing the chart before the visit, or even after the visit.

And finally, we have our clinical charting habits, and our charting systems.

Charting and comprehensive problem list management

Historically, most charting systems haven’t prioritized keeping excellent track of all problems affecting a patient. In the old paper chart system, many providers kept a problem list within the chart, but there was no mechanism for ensuring regular checks on every item there. Furthermore, a problem mentioned by a patient, even if documented in a progress note, might easily never make it onto the problem list.

In truth, the old system stunk from a lets-be-sure-to-not-lose-track-of-issues perspective. We essentially left it to individual clinicians to figure out what needed to be followed up on, and they cobbled together various error prone strategies, like leaving little to-do lists scribbled in the margins of their notes, briefly looking over the assessment & plan from the last 3 visits, or trying to skim the whole problem list at the annual physical.

Needless to say, patients and families were pretty uninvolved in this process, unless they were in the minority who take careful notes and try to keep their own problem list. This meant that not only were patients often poorly informed as to their health issues, but that we were missing an opportunity to let them help us make sure we didn’t forget about any important health issues.

And now we are all transitioning to EMRs. This makes things generally a little better, but not a lot, because again, the focus in designing EMRs has been to help doctors document for billing and for in-the-moment clinical care, rather than making it easy to keep up with a longer comprehensive list of ongoing problems.

For example, although I really like the EMR system I currently use (MD-HQ), when I start a clinical note, I’m faced with a blank text box. Sure, I can easily look at the list of past medical problems (and insert it into the note), or the recently used ICD-9 codes, but that’s not the same as seeing what problems I need to follow-up on, either because I addressed them recently, or because it’s been a while since they were addressed.

Meanwhile, the patients and caregivers are also lacking a way to keep up on the problem list, since this isn’t currently shared through the patient portal.

Can’t we do better? Really, I end up thinking that what I need is a health issue management system, accessible to me and the patient, that can help us keep track of all the medical problems and their status.

Primary care as ongoing problem list management

What would this look like? Well, I’ll start by describing what I do now, and then I’ll offer some thoughts on what I think would help me.

What I do now:

During a visit, I almost always organize my clinical thinking around “problems.” These end up listed in my assessment and plan at the bottom of the note, where I usually include a comment as to the status, the differential (if applicable), and my own plan for managing and following.

I provide written recommendations, listed by problem. However, as I pointed out in my blog post on multiple recommendations, the patient’s version doesn’t usually list every problem that I documented in my note. (I find that people get overwhelmed by a list that is too long, plus the more I write in layman’s terms, the more time it takes me.)

I review the past problem list in each visit. At a follow-up visit, I look at the last visit’s problem list, in order to follow-up. This means I often copy and paste the assessment and plan, and then edit the details.

But I’ve run into little operational problems with this. For example, now that I provide a fair amount of care by phone and email, many encounters generate a shorter less structured note, so I find myself scrolling back through my notes, looking for one that has a longer problem list.

I try to keep track of problems not recently addressed. It’s not always possible to address everything listed in the previous visit (people come in with new concerns, among other issues.) So sometimes I have a “Not addressed today,” section at the bottom of my list, but I’m not as diligent as I’d like to be, especially when things are busy.

Besides, it’s hard to not notice that this isn’t exactly standard of care among other docs; the other day, I actually reviewed a PCP’s note that just said “Findings stable. No change in plan.” Sigh.

Some problems I list are actual ICD-9 diagnoses, but not all. For instance, in my multimorbid adult patient population, a problem like shortness of breath could be due to COPD, CHF, anemia, or all the above. I also deal with a lot of geriatric problems like falls, functional decline, cognitive impairment, etc, which are usually multi-factorial in nature.

Ideas for facilitating collaborative and comprehensive problem list management

Here’s what I think would be helpful to me:

If each patient’s chart included a list of problems. And this should always be viewable by the patient. Patients could be able to add problems from their end, but then we will also need a method to reconcile and periodically try to streamline the list, or we’d likely end up with some redundant problems.

If I could use the problems as tags for other data in EMR. When we get a diagnostic study back, we should be able to tag it with one or more relevant problems. We should also be able to easily tag medications and other aspects of the treatment plan with a given problem. Ideally the system would intelligently propose problem tags as you work (a brain MRI in a patient with a cognitive impairment problem should probably be tagged “cognitive impairment”; PFTs are likely COPD, etc)

The ability to link a follow-up activity to a problem. Let’s say we decide to follow-up on depression symptoms in 8 weeks. As I list the depression item in my assessment and plan, it would be nice to be able to tag it with some kind of prompt for future action. That way, if I start a SOAP note in 3 months, the overdue problem should pop up. Better yet, in seven weeks the system should remind me (and the patient!) that this problem is coming due, and encourage me to electronically send a symptom questionnaire to the patient, so that we can get the right data gathered prior to the visit.

If it were easy to view associated history, studies, and future events for a given problem. I often want to look back and see how an issue has evolved over time. It should be possible to see all the related SOAP notes, studies, hospitalizations, recommendations made to patient, pending follow-up actions, etc, when we look up a problem.

If SOAP notes prepopulated with recent problems, or overdue problems. In this computerized age, why do I have to scroll back through my notes to figure out what I was last working on when thinking about this patient? Would be nice if EMRs could help with this.

If the patient and I could negotiate which problems we’ll address prior to the visit. Rather than discuss this right during the visit, we should be able to set a little agenda before hand. This would allow us both to prepare a little better. We could also better anticipate how much time to allot for the visit.

If the system were smart enough to propose data relevant to a given problem. If it’s time to review anemia, show me the CBC trend and anemia-tagged meds. If the issue is CHF, show me the most recent echo summary. We clinicians should be able to tweak these to our preferences, but having to create each grouping of relevant data from scratch would be a little too bad.

Of course, since most of my patients also see other providers, I’d need a way to integrate what those docs do into the data for each problem, and this would be tough if they’d labeled problems differently. But that’s part of a PCP’s (or geriatrician consultant’s) job: to keep track of what the specialists said and did and integrate that into the comprehensive care of the patient. Even just being able to tag an incoming faxed consult report with a problem would help a little.

Summing it up

Keeping track of an older patient’s lengthy problem list is difficult, and it’s easy for issues to fall through the cracks and get forgotten.

We need EMRs to support clinicians in partnering with patients and families to keep better track of ongoing problems. I would love to see EMRs move towards really facilitating the organization of clinical data by problems, and then supporting patients and clinicians in properly following those problems.

Patients and families should be able to access their problem list and see the plan for each. This would help them understand their health (because just looking at today’s clinical notes probably won’t cut it), plan for visits, and ensure that all their health issues are followed up on (i.e. engagement!).

Leslie Kernisan, MD, MPH, has been practicing geriatrics since 2006, and is board-certified in Internal Medicine and in Geriatric Medicine. She blogs at GeriTech.

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Lisa DeLille Bolton FNPAmy CorradoMegan Ranney MD MPHPhac Le TuanLuis Saldana, MD Recent comment authors
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Lisa DeLille Bolton FNP
Lisa DeLille Bolton FNP

Yes: brilliant! I would add that the complexity of functional / behavioral / social factors as noted regarding geriatric patients also applies to patients of all ages with multiple chronic illness.

Amy Corrado

It was great to read your post, Leslie – Sound statements that, I have found, are reiterated through many healthcare providers today. If you are interested in seeing a Health Information Exchange system that uses all of a hospital’s (or healthcare system’s, or provider’s) disparate system’s information on each patient and gathers it in one place, creating the ‘health issue management system’ that you mentioned you are looking for, please let me know – I would be happy to set up a demonstration through webex, as that is exactly what we offer at Alere Accountable Care Solutions (a subsidiary of… Read more »

Deb Williams

@meganranney — That was the point was was TRYING to articulate. Coordination of ALL the healthcare information and providers. This is what I have focused on for years. It is important that information gleaned from each avenue the patient goes down (various providers, healthcare practices, etc.) is in one place, coordinated, checks and balances maintained. My focus has been on the disabled and the older population. Many of which do not have the ability to actively participate (as I noted above). Insurance does not pay for this and therefore it is not accessible to all. For many years I have… Read more »

Megan Ranney MD MPH
Megan Ranney MD MPH

Leslie, this is brilliant. Thanks for sharing your thoughts. One additional thought for all those developers reading: It’s also essential that this simple, prioritized problem list get communicated to “acute care providers” — whether they be within the same practice (e.g. a “sick visit” to one of Leslie’s partners), a pre-chosen consultant (e.g. an endocrinologist for unmanageable diabetes), or an unplanned visit to the emergency department (e.g., me!). One of my biggest frustrations is that I have *no idea* what patients’ PCPs are working them up for, or what their concerns are about a patient. I spend a ton of… Read more »

Phac Le Tuan

Thank you for a very clairvoyant post, identifying a really critical key need as perceived by a provider who is truly focused on improving health care. I believe the answer to this EMR issue also lies in providing tools for the patient to become a partner with their doctor in managing their own health care. Patients need to be empowered to help doctors help them, and patient-centered mobile apps must be able to interact with the EMR bidirectionally. It is not just about patients accessing their data stored in the EMR, it is also about EMR systems being able to… Read more »

Luis Saldana, MD
Luis Saldana, MD

Excellent post. Thanks for sharing this. The Problem List can be the platform for the care team to include patients. As we see new tools develop, we can use the problem list to generate ‘tasks” via clinical decision support. That said, I see more wrestling matches, struggles and indifference around this activity. I think your post is a call to focus our energies and efforts and getting this right. Thanks.

john trenouth

@leslie, Do you think 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?

How deep should the problem orientation be?

And what are your thoughts about the possibility of such a solution becoming overly reductionist, loosing the patient between the problems?

Leslie Kernisan, MD MPH

Thanks all for these comments!

Am particularly intrigued by David Voran’s idea of having medically savvy patients start their own note…an interesting twist on setting an agenda ahead of time.

Yes, lots of obstacles to developing a problem oriented EMR, but if patients and clinicians continue to ask for it, hopefully we’ll eventually get it…

Deb Williams

Fantastic and well-thought-out post! I have provided personal healthcare coordination for a number of years and this has always been a problem. Focus on new technologies is NOT going to take the importance of personal attention to these matters by the person(s) who are delivering the information to the record/practitioner. I see the necessity of the “labels” but it does not make me like them any more. Pigeon-holing continues to provide the cracks for people to fall through. Many doctors have stopped emphasizing the billing focus (as I think their talents should be directed to their specialty and the patient)… Read more »

Simon Spurr

Great post Leslie. There are numerous challenges that clinicians face when trying to track patients’ multiple health issues. Sophisticated EMR’s are playing a role however patient interaction is crucial, especially between consults. We developed FolUp for precisely these challenges. Have a look at and let me know if we can hold a conversation offline

Greg Weidner, MD
Greg Weidner, MD

Thanks for the thoughtful post, Leslie. An important element of your ideal state is the concept of treatment plans and goals for each problem, developed collaboratively with the patient and shared openly among all participants in their care (PCP, specialists, family/caregivers, ED, Hospitalists, etc.). This approach drives shared decision making and allows for thoughtful consideration of the “burden of treatment” ( for each individual. It would also truly leverage the power of HIT in managing and monitoring patient care across care settings, with the patient squarely at the center. We have to keep pushing toward that vision, for the sake… Read more »

Nrip Nihalani

Wonderful post Leslie.

Matthew Douglass

This exact problem is why we’ve kept billing *COMPLETELY* outside of the clinical documentation workflow in the Practice Fusion EMR. Billing should be secondary (if not tertiary) in all clinical encounter conversations.

We’ve also crowdsourced many of our core clinical features with our medical provider community. The latest one is centered around restructuring our allergy management screens:

Dr. David Voran

Great post Leslie. You know if the patient were to be one of the primary users of the EMR then they could help manage the problem list. I know many of us who are also patients in our system and are seen by other physicians manage our own charts and the problem lists are always accurate, up-to-date and managed. Lately I’ve been mandating that all of my internal patients (nurses, doctors, therapists, anybody who has access to the record) not only manage their own chart but when they do need to make an appointment start the note. These patients have… Read more »

Problem Child
Problem Child

The experiment continues, using the patients, doctors, and the masses of helth care professionals as guinea pigs, to benefit the cash registers of the vendors. Problem lists and medication lists are the infrastructure of creative, thoughtful, and timely medical care, and after 25 years of zero accountability, the vendors have shown zero innovation. The only way that they can get doctors to buy these flawed devices is by federal law, enticing them by promising increased income by capturing more charges, and federal medicare penalties. These systems fail to improve outcomes and fail to reduce costs, and they are exceedingly expensive,… Read more »