Treating Patients Is Not Same As Tracking Them

One of the many challenges I face in my clinical work is keeping track of a patient’s multiple health issues. As you might imagine, if I’m having trouble with this, then the patients and families probably are as well.

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:

1. Pain

2. Incontinence

3. Cognitive impairment

4. Depression and/or anxiety

5. Falls

6. Advance care planning

7. Chronic kidney disease

8. Difficulty managing medications

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 toward the path of least resistance and least cognitive effort.

And 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.

Meanwhile, we are all transitioning to EMRs. Their focus 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.

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.
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.

What would this look like? My suggestions:

• 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.

I would love to see EMRs move toward really facilitating the organization of clinical data by problems, and then supporting patients and clinicians in properly following those problems.

Leslie Kernisan, M.D., has been practicing geriatrics in San Francisco since 2006, and is board-certified in internal medicine and in geriatric medicine. A version of this article originally appeared on the Health Care Blog.