Wednesday, January 6, 2016

Problem Lists - What exactly is the "Past Medical History"?

Hi readers,

Happy 2016! For today, I'm going to try to tackle an interesting conceptual and terminology issue around problem list management, and how it relates to the Past Medical History (PMHx) - 

Many people, working to optimize their EMRs, work hard to try to 'curate the problem list' - WIthout good curation, problem lists can become very lengthy, and include issues like "Cough" under Past Medical History
  1. Some people see this as a failure of HealthIT ("Why is cough under the Past Medical History, when it's not a diagnosis?") - 
  2. Other people see this as a failure of the doctors using the system ("Why didn't anyone remove cough from the Past Medical History?") - 
What I find particularly interesting about this discussion is the wide variation in practice, when I read admission history and physicals. I think most docs, billers, and coders believe that, on admission, the doctor should document whatever the 'acute medical issues' or 'active medical issues' are - But what do these terms mean, exactly?
  1. If a patient with stable diabetes is now admitted with cellulitis, and the doc continues the diabetic medication - Should diabetes be on the active medical issues list?
  2. Or should the doc only code for the cellulitis?
In discussing this many times over the years, I find that many docs use the terms 'active medical issues' and 'acute medical issues' almost interchangeably. Are they really interchangeable?

But how are acute and active medical issues different? While these are are all good treatises on medical issues, I was wondering if I could approach this from a design standpoint, as a physician informaticist, with good conceptual definitions for the terminology, to make sure there is real clarity around the discussion. 

So, in trying to tackle this informational design issue, I've hammered out the following DRAFTED definitions, depicted on the following two slides, for your examination and discussion (the same concepts are on both, but each is displayed slightly differently) :

Slide 1 - "Bucket" depiction

Slide 2 - Same concepts, different depiction

I created these slides to try to create conceptual 'buckets' that problems/issues could easily fall into, allowing physicians to move items from one bucket to another as the patient moves from one provider to another - And then labeled them with terminology (and synonyms) that I believe best fit the concepts. (Please use your own judgment before adopting any of this terminology.)

What these slides do, however, is shed some light on why maintaining the problem list is more challenging than you might expect. It requires enormous clarity just to discuss the issues, and then when you examine the concepts in detail, there seems to be some breakdown in the definition of "Past Medical History". 

For example, in the scenario where the patient with stable diabetes is admitted for cellulitis - On writing the admission H&P, a doctor might code for both the Unstable (Acute) issue ("Cellulitis"), and the Stable (Chronic) Issue ("Diabetes, Type 2, Controlled"), since he/she has made the active medical decision to continue the diabetic medication while treating the cellulitis. 

However, on discharge, what do you do with these two Current(Active) issues (Stable and Unstable) in the EMR? 
  • The cellulitis might be moved to the Prior(Inactive, Resolved) Issue list, but 
  • the diabetes is still a Stable (Chronic) issue - which falls under the category of Current(Active) issues
So the problem is that, I suspect, most doctors would conceptually define "Past Medical History" as the items found in these three buckets : 
  1. Prior Procedures
  2. Prior (Inactive, Resolved) Issues
  3. Stable (Chronic) Issues - which conceptually falls under the category of Current (Active) Issues
It's the incongruence between "Past Medical History" and "Current (Active) Issues" that I find most interesting - Past isn't really in the past, if it's still in the present

It's also interesting to note that the commonly-used term "Reason for Admission" typically only includes issues that would fall under the Unstable (Acute) issues bucket - But the Admission H&P typically includes more issues, especially if they involve active medical decision-making (E.g. both Unstable (Acute) issues + Stable (Chronic) Issues)

In practice, I find many docs will only include as many Stable (Chronic) issues as time (and patient census) allows - It's interesting to ponder how this impacts coding and billing on the national level.

Finally - I believe these slides support the argument that the terms "Active Medical Issues" and "Acute Medical Issues", although related, are in fact not interchangeable. (I suspect that Acute is really a sub-type of the concept of Active medical issues.)

While my post today doesn't have any great answers, I hope these slides, and this discussion, have at least shed some light on the concepts and terminology surrounding problem list management, and how they impact EMR usage, coding, and billing on the national level.

Have any thoughts about problem list management? Leave them in the comments section below!


Guillermo Diaz said...

I agree with your assessment. Patient's may take issue with the term issue. Possibly "Assessment" would be more acceptable. Active Medical Assessments and Acute Medical Assessments, which at the end of the day and at the point of care is what they are, our assessments. Past Medical History (PMH) is a muddled term of the past (pun intended) and given our change to digital medical records may begin to disappear from our medical lexicon altogether. In fact, when reviewing EHRs, PMH is really not much of a section any more or if it is it's buried somewhere in the chart. Problem Lists however are very prominent and they have the various statuses of Active, Resolved, etc.

matthew shafiroff said...

Thanks for the post. I also agree with Guillermo, the term "Past Medical History" should be retired. Medical problems can be active, acute, neither active or acute but relevant although not resolved (consider an individual in their Nth year of cancer remission, IBD or other autoimmune diseases (MS, Lupus, Psoriasis, Alopecia Arreata, etc.) requiring ongoing monitoring and maybe preventative treatment but not active or acute in the classic definitions of the term.
Our informatics approach must be nimble. We might be best suited with a greater focus on organ system approach with a temporal view.

Dirk Stanley, MD, MPH said...

Guillermo - Love your idea about renaming them "Assessments" - Being told "You've got issues" might just rub people the wrong way. :)
- Dirk :)