Thursday, January 29, 2009

Of Progress Notes and Problem Lists

We need to squeeze the subjectivity out of healthcare and make it more measurable; more understandable from an algorithmic perspective. Data and math need to play a larger role in diagnosis and treatment. We're moving down this path, everywhere, so that's a good thing. A simple example is the widespread use of BMI (algorithm-based) as it relates to the diagnosis of "obesity." BMI is not perfect, but it's much better than the subjective definitions of proper body weight that my generation grew up with.

The current heartbeat of the EHR remains the subjective progress note-- and other text based reports. The progress note, though once helpful, is now the single biggest hindrance to physician efficiency in the use and adoption of the EHR. The progress note costs millions to workaround via transcription services. It's a bottleneck to closing the encounter and everything downstream that depends on that closing. It is an enormous anchor in our attempts to become more data and mathematically driven. I'd like to have a dime for every NLP project that has been funded in healthcare to overcome the subjective-objective barrier around progress notes and other text reports. Progress notes are too long to write and too long to read, and often times they are simply a summary of data from other measurable events like labs and medications. We need to change the cultural expectation in healthcare and the specific expectation of payers that the progress note is a necessary artifact of patient care-- it should become optional and applied only where history of present illness and/or diagnosis is particularly challenging, and discrete data cannot adequately tell the entire story to other members of the care team.

The problem list is simply another form of subjectivity, as currently utilized in healthcare. It's an abbreviated form of the progress note, with all the inherited variation and inability to reliably apply math or discrete analysis. In the past, I thought the problem list was going to become a breakthrough tool in healthcare, but I've seen it become yet another source of confusing information to the broader members of a care team, not a helpful tool. Problem lists have become personal versions of shorthand for the progress note-- and thus only reliably legible to the author.

If we could constrain the subjective contents of the problem list; use algorithms to populate the problem list where we can (e.g., infer diabetes from labs and meds); and apply industry-wide guidelines around its utilization, the problem list could become the most efficient way to "tell the story" of patient care, as well as become a more objective description of the clinical encounter and diagnosis, opening the door for discrete data analysis and the influence of math.

I offer these thoughts not as an IT guy trying to force a user interface on a physician, but rather as a lifelong "Information Utilization" guy who has had the benefit of exposure to many different information-intense environments.

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