Problem lists – the forgotten tool

Pablo Millares Martin is a GP passionate about health informatics

GPs have been using electronic health records for decades. They are based on a model called “Problem Oriented Medical Record” (POMR), built on the term coined by Weed in 1968 before computers, where the “problem list” is not static in its composition, but is a dynamic “table of contents” of the patient’s chart, which can be updated at any time.¹ According to training provided to GPs by The Medical Protection Society, a clinician should look briefly at five items to prepare to see the patient: the problem list, the last consultation, the last hospital letter, the medication list and the last set of results.² Time is a commodity GPs lack. To be able to quickly review the patient, the problem list need to be be accurate, clear, concise, current, and precise.³

The reality is far from ideal. When records are accessed and problem lists read, they frequently fail to provide a picture of the patient. They are seldom used as a “table of contents”; more often they are not read, or they are used as organisers where the focus could be administrative (reflecting attendance, immunisations, allergies etc., issues that are better stored and checked elsewhere in the record) or clinical (based sometimes on generic codes to specify “infective disorder” or “respiratory disorder” so all diagnoses linked to that “department” are added to the respective folder). They could be a mixed bag, depending on who has been using them. But in most cases, they are incomplete and out-of-date, for example “Patient currently pregnant” lingering for several years or simultaneous active problems of “diabetes resolved”, “pre-diabetes” and “type 2 diabetes”, creating misinformation and confusion.

Problem lists are frequently of poor quality; training and guidelines are needed to remedy this.⁴ The objective of this article is to discuss the limited guidelines available for general practice³ and in general, from the Royal College of Physicians.⁵ The plan is to expand on them, to teach, and to serve as the basic training so desperately required if problem lists are going to be a useful tool to understand the patient and provide informational continuity.

Guidelines

The problem list’s content should be based on the following principles:

• The problem list should include only conditions which are relevant to a patient’s current care, such as those for which they are currently receiving treatment or follow-up, including issues that can affect current or future treatment.^3-5 Not every consultation needs to be included in a problem. An overpopulated list with inconsequential items makes it confusing and less likely to be used.^3,4
• Major past conditions that may have long-term consequences or complications, such as myocardial infarction or breast cancer, should be present.⁵ It is important to consider changing codes depending on the stage. After active treatment for the condition, codes in the active problem list should be amended to indicate this, for example ischaemic heart disease and history of breast cancer, leaving the other codes as inactive for future reference if required.³
• Chronic disease.⁵ Any disease that needs monitoring or recurrent medication. These may be separated into major/significant or minor depending on the severity and/or impact on the patient’s quality of life. For example, Barret’s oesophagus, which as precancerous should be considered significant, or mild asthma or hay fever which could be considered minor.
• Operations that may have long-term consequences or complications (unless these are recorded separately in a summary).⁵
• Issues that may impact care, (whether social, psychological or lifestyle) are immediately visible in other high-profile sections. For example, an abnormal test result which needs to be followed up.⁵

Electronic health records typically have other high-profile areas for recording contact details, allergies, medication, and family history.⁵ They need to be used instead of the problem list for their appropriate content.

Maintenance

Problem lists will not be useful if they do not keep their quality markers: being accurate, clear, concise, current, and precise.³ Maintenance is essential to fix current shortcomings, but also to ensure they remain relevant, up-to-date, and uncluttered in the future. Problem list maintenance requires clinicians to act on each consultation as follows:⁵

• Checking the relevance of the current entrances in the list.
• Adding missing problems (which can be noticed by linking the medication the patient is currently taking to the items in the Problem List).
• Deleting incorrect problems and those that no longer affect treatment decisions.³
• Converting problems to inactive if they are no longer relevant, and changing/updating codes if appropriate.

Tidying inactive problems includes:

• Combining or merging problems that are duplicates, keeping the oldest one.
• Evolving each problem into the most up-to-date diagnosis. For example, is diabetes resolved, considered to be in the pre-diabetes stage or just well-controlled?
• Grouping related problems together. There is no need to have simultaneously “hiatus hernia”, “oesophagitis”, “duodenitis”, “helicobacter infection” and “dyspepsia” as different problems. One is enough to understand there is some caution to take when prescribing medication that could cause gastrointestinal bleeding.

Summary

Problem lists, which should support the consultation and provide informational continuity, are a problem which needs addressing. For that to happen training and consensus are paramount. Some basic rules have been presented here. Clinicians should constructively review problem lists, otherwise they will continue festering to eventually be forgotten. It would be a pity to allow this useful tool to end in the shadows of the electronic health record.

References

1. Weed, LL (1968). Special article: Medical records that guide and teach. New England Journal of Medicine, 278(12), 593-600.
2. Medical Protection Society (2015). Education and Risk Management. Medical Records for GPs, UK. Workbook. London, Medical Protection.
3. Newman DM, & Dhanda S. Taming the Problem List. Family Practice Management. 2023;30(3):5-9.
4. Millares Martin P, Sbaffi L. Electronic Health Record and Problem Lists in Leeds, United Kingdom: Variability of general practitioners’ views. Health Informatics Journal, 2020; 26 (3), 1841–1865.
5. Shah A, Quinn N, Chaudhry A, et al. Guidance for recording problems and diagnoses in electronic health records. Professional Records Standards Body and Royal College of Physicians Health Informatics Unit; 2019. Accessed August 13th, 2023. https://theprsb.org/wp-content/uploads/2019/10/Final_Diagnosis_Recording_Guidance.pdf

Featured photo by Markus Winkler on Unsplash