COVID-19 related neuroimaging findings: A signal of thromboembolic complications and a strong prognostic marker of poor patient outcome.

Problem list completeness in electronic health records: A multi-site study and assessment of success factors

A method and knowledge base for automated inference of patient problems from structured data in an electronic medical record

A web-based, patient-centered toolkit to engage patients and caregivers in the acute care setting: a preliminary evaluation

https://dash.harvard.edu/bitstream/handle/1/10121116/3384110.pdf?sequence=1

Improving Completeness of Electronic Problem Lists through Clinical Decision Support: A Randomized, Controlled Trial

My hospital’s electronic medical record helpfully informs me after 1 week on service that there are 524 data available for my attention, a statistic that would be paralyzing without a cognitive framework for organizing and interpreting them in a manner that can be shared among my colleagues. Accurate information flow among clinicians was identified early on as an imperative of hospital medicine. Much attention has been focused on communication during transitions of care, such as that between inpatient and outpatient services and between inpatient teams, taking the form of the discharge summary and the sign-out, respectively. But communication among physicians, consultants, and allied therapists must and inevitably does occur continuously day by day during even the most uneventful hospital stay. On academic services the need to keep multiple and ever-rotating team members on the same page, so to speak, is particularly pressing. The succinct and accurate problem list, formulated at the end of the history and physical examination and propagated through daily progress notes, is a powerful tool for promoting clear diagnostic and therapeutic planning and is ideally suited to meeting the need for continuous information flow among clinicians. Sadly, this inexpensive and potentially elegant device has fallen into disuse and disrepair and is in need of restoration. In the 1960s, Dr. Lawrence Weed, the inventor of the “SOAP” note and a pioneer of medical informatics, wrote of the power of the problem list to impose order on the chaos of clinical information and to aid clear diagnostic thinking, in contrast with the simply chronological record popular in earlier years:

/pdf/clear-writing-clear-thinking-and-the-disappearing-art-of-the-20brymmxux.pdf

Clear writing, clear thinking and the disappearing art of the problem list.

The author argues that the well-formulated problem list is essential for both organizing and evaluating diagnostic thinking. He considers evidence of deficiencies in problem lists in the medical record. He observes a trend among medical trainees toward organizing notes in the medical record according to lists of organ systems or medical subspecialties and hypothesizes that system-based documentation may undermine the art of problem formulation and diagnostic synthesis. Citing research linking more sophisticated problem representation with diagnostic success, he suggests that documentation style and clinical reasoning are closely connected and that organ-based documentation may predispose trainees to several varieties of cognitive diagnostic error and deficient synthesis. These include framing error, premature or absent closure, failure to integrate related findings, and failure to recognize the level of diagnostic resolution attained for a given problem. He acknowledges the pitfalls of higher-order diagnostic resolution, including the application of labels unsupported by firm evidence, while maintaining that diagnostic resolution as far as evidence permits is essential to both rational care of patients and rigorous education of learners. He proposes further research, including comparison of diagnostic efficiency between organ- and problem-oriented thinkers. He hypothesizes that the subspecialty-based structure of academic medical services helps perpetuate organ-system-based thinking, and calls on clinical educators to renew their emphasis on the formulation and documentation of complete and precise problem lists and progressively refined diagnoses by trainees.

Perspective: Whither the problem list? Organ-based documentation and deficient synthesis by medical trainees.

Inspired by the ABIM Foundation’s Choosing Wisely® campaign, the “Things We Do for No Reason” (TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent “black and white” conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.

/pdf/things-we-do-for-no-reason-neuroimaging-for-hospitalized-txuupr16qr.pdf

Daniel M. Kaplan

Papers

Clear writing, clear thinking and the disappearing art of the problem list.

Perspective: Whither the problem list? Organ-based documentation and deficient synthesis by medical trainees.

Things We Do for No Reason: Neuroimaging for Hospitalized Patients with Delirium.