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.

23 replies »

  1. 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.

  2. 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 Alere, Inc.).

    The HIE is accessible to the physician and the patient, and has a dashboard to keep track of ALL medical problems and their status, per patient. The system also offers analytics and population health with the data, as well. It sounds like it is exactly what you are looking for.

    I hope you’ll be interested in a taking a couple minutes of your time to take a look as it is truly revolutionary, and the responses we get from physicians are outstanding – they can’t believe that someone finally created the system to bridge all of the gaps!

    If you’re interested, feel free to email me at:


  3. @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 offered this above services to individuals, the problem being individuals normally (unless they were already my client when I was providing care) do not clamor to request these services. Some FAMILY members have started to see the importance.

    I personally feel the coordination would best be done based through the PCP. Knowing this would help immeasurably, I have approached many PCPs — not receiving the interest that I had hoped.

    I have also NOT been impressed at ALL with the technical advances as far as really addressing the needs of either the patient or the providers. I was excited in the beginning because I THOUGHT finally there was going to be an easy place in which to put all this information providing a central access point — NOT

  4. hi Adam,
    Your story is fascinating. You’ve probably seen the recent reports that physician dissatisfaction with EMRs is on the rise; will be interesting to see if that creates an opportunity for a new generation of products that is a better fit for our needs.
    I should think that these companies will soon be dying to work with someone like you.

  5. 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 time on each shift trying to contact PCPs to figure this out, so as to not duplicate care/waste resources. (But these phonecalls take me away from my patients!) .

    And even if a patient has miraculously been seen within my own hospital in the recent past, I still have to do what Leslie mentions — sift through months & years of outpatient notes — and am therefore often in danger of missing the most details that are most relevant to this ED visit.

    If I could see on Leslie’s list that the patient’s depression hasn’t been addressed yet, or that their incontinence is a longstanding issue, it would help me to focus in on the mental health symptoms, or avoid the costly spine MRI.

    Of note, this is PARTICULARLY important for the geriatric population who (unless they’re particularly empowered and mentally sharp) may not have any recollection of their recent medical history.


  6. 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 import patient-provided information is a way that is usable by doctors, without polluting the clinical reliability and accuracy of the system.


  7. 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.

  8. @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?

  9. 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…

  10. 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) — unfortunately this results in non-payment to the provider, financial burden directly on the patient, and often resulting in patient not being able to continue to address their medical need. I have mentioned LABELS as a problem, but so too is the memory of the patient — never think of it either within the confines of the time in the office if they do remember. Continued PERSONAL follow-up, coordination and checks and balances is needed – but rarely paid for by the client nor the PCP. I want to applaud you because you brought problems, solutions, and the format for discussion! Thank you! — Deb

  11. 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 http://video.folup.com/ and let me know if we can hold a conversation offline

  12. 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” (http://www.physiciansweekly.com/diabetes-treatment-burden/) 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 of all involved in providing and receiving care.

    Greg Weidner

  13. 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: http://www.practicefusion.com/blog/allergies-overhaul/

  14. 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 the best HPI, PMH and other portions of the chart making it very easy for us to focus on the one or two problems closest to or farthest away from resolution.
    I wish there was some way for us to get our vendors to restructure the purchasing structure so that each patient would be a defined user. Could guarantee if that was the case the applications would be much easier for all of us to use.
    Carry on documenting these thoughts as they really help cristalize ours.

  15. 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, labor intensive, and promote errors.

    Don’t buy. Don’t be a guinea pig.

  16. This post strikes at a fundamental issue indeed, the problem list as the driver of primary care delivery, and the difficulties in managing it absent a standardized methodology. I would pose that each doctor needs her own version of a problem list for each patient in cases where the chart is shared – that is, unless it until a truly standardized nomenclature and methodology are extant in the new HIT-enabled delivery system. It cannot merely be the list of icd-9 or -10 codes: it must be able to incorporate free text issues and little reminder items. In my clinic, my problem list is a simple bullet list of free text problems cut and pasted in the pmhx section of the note and amended as needed each new note/ visit. Even if all an emr did was allow this kind of simple text editing, e-prescribing, and a typed version of the plan section for patients to take home after the visit, it would prove its value; that’s the importance if keeping the problem list organized, effecting better care. But agreeing with your post, an improved methodology would go even further.

  17. Great post Leslie. The evolution of the EMR is continuing, but we need to ensure that clinicians stay involved in its development. Sure we are not there yet, but it is getting better.

  18. Doctor,
    I think you touch on some of the problem. As much as doctors complain that the EMR software doesn’t fit their needs, they aren’t truly in the market for one that does. (else I suspect your business would have prospered)

    What they want, even if they won’t admit it, is a product that will achieve ‘Meaningful Use’ and get them check from the .GOV. Can you imagine a software vendor showing you an EMR that did everything listed off in your ‘problem-oriented-medical-record but did not qualify for MU? (more often than not, they would be throw out of the office!!)

    As I think you discovered, software development is generally a much more difficult proposition than I think most would credit it. Time and resources are finite. These days, those finite development resources are given to MU and not much else. And really.. thats becasue that is what the demand is for. no MU = no sales.
    (lets not forget some other demands/regulations such as ICD-10 that are also taking development time/attention from some of these ‘physician frendly features)

    Once we find our way through the MU Stages/ICD-10 and things settle down, and all that code is in place and debugged, I see these voices (which are totally valid) gaining a great deal more traction. The potential for these feautres is certainly present, but making them a reality is not on the agenda at the moment. I believe that if building such a beast were a profitable proposition, it would be done.

  19. Great post Leslie, it’s great that the narrative about creating a problem-oriented EMR is on the rise.

    Like Adam’s comment, I’m also slowly giving up on EMR. It’s just sad that there can be so much discussion about EMR, and yet every company out there just copies what the other does and calls themselves tall. Seems like we need to reinvent the wheel here, but the paradox is that the technology is all right in front of us…We’ve just got to find a way to collaborate in the best interest of patient care rather than the business of health care.

  20. As a family physician, medical informatician, and hard-core devotee of the problem list, I thank you for this post. As a failed entrepreneur, I also thank you, albeit with a tinge of wistfulness. Making the problem list drive the clinical care process was the focus of my informatics research and passion. I even coined a few terms to express how this approach respected essential aspects of the traditional “problem-oriented medical record” but extended the concept to support how modern software could leverage the problem list to help doctors better help their patients: the “problem-driven paradigm” and the “problem-driven medical record”. I also agree that EMR systems today are documentation/billing focused and have previously suggested that the term “clinical command system” better reflects what we actually need. See here: http://blog.doctrelo.com/2010/12/the-electronic-medical-record-system-innovators-paradox/

    For the last 10 years, I dreamed of building an EMR for primary care with the problem list truly central to the experience. In 2006 I set out to do so. Eventually I started a company, engaged a partner and got so far as building a stand-alone e-prescribing system with the problem-driven paradigm at its core, albeit well short of what I ultimately hoped to achieve. Here’s an early demo: http://www.youtube.com/watch?v=IaTxPNY_0oY

    Unfortunately, development took much longer than planned, and in the interim, the health IT market dramatically changed with the passing of the HITECH Act as part of the ARRA. We had an almost-finished first product but with a market that had disappeared. Despite the fact that I badly wanted to develop that amazing problem-driven EMR system to help myself (and maybe you and others like us) practice better medicine, finances dictated that we had to abandon the dream.

    I strongly believe that EMRs which support the type of problem-oriented work that you discuss–and that I tried to build–would help us and our patients tremendously. Alas, I have sadly lost faith that the EMR vendors-left-standing are likely to move in this direction. They don’t share the vision… and the demands of meaningful use aren’t helping either. I yearn every day for the chance to build such a system because I know how much good it would provide. I struggle not just technically but also emotionally every time I use the kludge that is eClinicalWorks (or any other EMR) to try to provide quality chronic disease management for my patients that I know a problem-driven system like the one I wanted to build would enable. I hope that the EMR vendors pay heed and lead us out of the informatics dystopia that has emerged.

  21. The EMR iterations at present are impediments to the care you desire to provide. Paper records with color coded files are infinitely more efficient and safer than the jabberwock on the EHRs.

  22. This should be printed as a manifesto for every EMR developer from sea to shining sea. The Problem List is the core of healthcare, if that’s not the core of each and every interaction with the tech, what’s the bloody point of the tech? Oh, right, BILLING.