Problem List
The problem list needs to be far more flexible to be relevant to the logged in user. The user's problem list should be created by a combination of two types of actions: 1) explicit "promotion" of a clinical entity (preferably one that has standard coded terminology behind it) by the logged in user and 2) automatic promotion because of clinical rules that pertain to the logged in user's practice group.
The problem list always need to be "filterable" by attributes such as "active", "inactive", "resolved", etc.
The problem list should be composed of "actionable" entities, so that changes to the problem status are more easily rendered and so that an individual problem may be facilely linked to other activities such as ordered services. Another example of actions to be taken is creating the links between problems (see Dr Rose's discussion of "nesting" below); again, this should be specific to the logged in user since we all have varying ideas about how such nesting should be enacted - the important thing is to have the nesting tool within the user's grasp. Other actions can include attaching "comments" to the problem list entity (such as how could Dr Osler think that Mr Agony had "fibromyalgia", when it is clearly "somatization" disorder, signed Dr Jung (always electronically signed - no anonymous comments allowed!)
There should always be an opportunity to review a "composite" problem list for any patient within an enterprise (by the way, enterprise is very broadly defined; it could include a state-wide deployment). That composite list would be a listing of all problems that have been promoted to any authorized user's problem list. Display of that list should not be irritating; if 15 authorized users have "hypertension" on their problem lists, display "hypertension" once with a drill down for all of the instances of its instantiation. By the way, the display could/should also permit the logged in user to see any other clinician's problem list for the patient in focus.
If one adheres to these simple principles, the squabbling between users is both well documented but is non-intrusive. Dr Osler continues to have "fibromyalgia" on Mr Agony's problem list and user Dr Jung continues to have "somatization disorder" on Mr Agony's problem list. Neither has to see what the other has entered unless they choose to look at the composite list. Moreover, for Joint Commission reviews, there is a total problem list for any patient.
Moving on to discontinuing medications. In general, good housekeeping suggests that the following care team members receive notification of changes to prescribed medications (including dose changes as well as discontinuations): 1) prescribing clinician; PCP; listed supervisor of non MD clinician.
