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Problem List
Until recently the "Problem List" was stated in terms of the "Diagnosis." The US Veteran Administration Healthcare services had their problem list that included additional data and Kaiser had theirs but few if any other healthcare organization had developed a non-diagnosis type of list. How what is wrong with this? The classification of diseases have been a complete failure in most cases. It has been estimated by one CEO of the largest healthcare organization in the US that over sixty percent of the diagnosis made by physicians are wrong. In one study in Hermosillo, Mexico only 27 percent of the death certification diagnosis were correct (and the cause of death should be the easiest type of diagnosis to evaluate). Given this data, we can safety conclude that very few of the statistics we get today are valid. By requiring the physician to make a diagnosis (ICD10) you are forcing him to put "something in the blank space" even if he is not sure (or does not have a clue!). Other than using a valid laboratory test or diagnosis imaging, it is extremely difficult to make a diagnosis. Even if the Diagnosis is not known (waiting results of surgery or labs) the care of the client must continue. Once the diagnosis is recorded all the "objective" data becomes lost in most today's systems. The problem with using Diagnoses is that the classifications for diagnosis are often changed...here today and gone tomorrow (or just outdated!) Lists of "Diagnosis" change as often as the weather. Once a diagnosis is recorded, it appears that all other information that has been collected is irrelevant. The data is never viewed again. Healthcare should have the ability to use new or different "Classifications" based on the particular requirement or new information. Classifications can be subdivided into smaller and smaller parts in order to be analyzed as new information is discovered. Problems developed from objective evaluations entities are/can always be analyzed. By analyzing the problems (symptoms, findings, and laboratory results) the most likely diagnosis can be determine. If abnormal symptoms/problems appear, then instead of the physician filling in the blank with "Diseases not classified elsewhere" or worse...guessing, new emerging diseases can be recognized sooner. As new information becomes available, if we have maintained all the "atomic" attibutes There is a move in the US away from listing diagnosis to the procedure of listing "Problems". Now these problems can be a diagnosis based on the ICD10 codes but only if the Problem is verified. This we believe is a step in the right direction to improve healthcare. What is really bad, is that many healthcare organizations uses "coders" in the back room to fill in the blank because the "the physician does not have the time to look up the data." The question is...how does the physician know what treatment to perform if he doesn't know what the diagnosis is? And then there is the great feat that the coders must do of reading the physicians notes! Let the healthcare professional list the problems of the patient...if the diagnosis can be made, then well and good...otherwise leave the field blank. The real problem with diagnoses is that, the diagnosis term, very often contains a concatenated of concepts and terms. Let us look at the "New" ICD10 codes (not the US version which is even worse!) and the example of Diabetics. (1) there are over 56 codes for Diabetics...oh sure! the HCP is going to go through all of these and pick the correct one... (2) Concatenate term ICD10 - E10.5 : "Malnutrition-related diabetes mellitus with peripheral circulatory complications" Or as Charles Harp wrong in his article: "404.00 - Hypertensive heart and Chronic kidney disease, malignant, without mention of heart failure and with chronic kidney disease stage I through stage IV, or unspecified..." This is a joke...Right! These codes where developed for paper based systems years ago. Not only are they not relevance today, but they are dangerous and poses a safety problem. If as was the 56 cases of coding for Diabetics, if the Healthcare Professional Coded the wrong diagnosis, the Client could be treated incorrectly. The coding also is difficult to read even if coded correctly. Now, I really do not care about the re-imbursement problem (the need for a specific diagnosis in order to justify a payment) but I am interested in Decision Support, and more importantly, ...
Charles Harp discusses the Decision Support argument and discusses the problem that each of these diagnosis to a computer system are Different (unless you go through and code sets that are either included or excluded from the Rule required to support Decisions ) Now while SNOMED, as Mr Harp discusses, has relationships to help the concatenated conditions, it does nothing for the ability to analysis data or to search for just the information required...i.e. (1) Disease: Diabetics (2) Type: Nutritional (3) Complications: Circulatory (5) Location: peripheral vascular As you can see, the one diagnosis actually contains several concepts that are "Attributes" or "Modifiers" of Disease. Data Analysis/Data Mining can now determine all relationships between the disease and attributes and do not have to rely on SNOMED telling us what they are...which is a little scary. The technique used by SNOMED can not be easily analyzed (almost impossible to Data Mine) and it is extremely time consuming/computer processing intensive to perform. Another example is the "Problem List." SNOMED lists Asthma, Diabetics Mellitus as Problem. The problem with this is that these Problems are "Diagnosis"...this assumes that the Problem has been positively identified. SNOMED mixes diagnosis, findings, and symptoms in their problem list. The solution, as Charles Harp suggests is to avoid using concatenated terms at all. The InHCc solution uses atomic entities (classes) and their attributes/Modifiers. The Domain (Data Sets) can be easily used to descript a Clients health status. It is more accurate, contains more information, and easier for the Healthcare professional to code. It is Best Practices and Evidence Based...and it can be Analyzed and Data Mined. It also creates "codes" that are more manageable. For example there is no need to create a data set that includes every permutation that is possible of a concept (such as disease) Asking the patient to state the problem in their own words Patients do not know enough about medical problems to be able to describe a “Problem.” They tend to leave out very valuable information, use local language terms (that could easily be misinterpreted if this information was communicated to others, and just not very safe. It is the healthcare professional job of enlisting the information from the patient in a decision tree structure format. A comment by a physician...."well, you should have told me that!" Diagnosis Examinations Many examinations that are given have no benefit to the patient. The question that a healthcare professional must ask himself is "by knowing this information, will it change my plan of care?" If the Diagnosis Examination would not change the plan of care...then why do it? Diagnosis If a diagnosis is recorded, it should have the Type/Classification (working, preliminary, post surgical, etc) and a best guess probability. The clinician should record ALL the reasons and Rational for this diagnosis. This is very important because the decision affects the plan for the management of the patient's care. Diagnosis "tests" may be valid to determine "what is the diagnosis" but A low probability or a "working" diagnosis hardly justifies expensive or "risky" procedures. Statistically Statistically, symptoms and findings occur with a predictable frequency with all "diseases/diagnosis." If the atomic values are recorded, and saved, diagnoses can be verified after the fact....even many years later. However, if only the "diagnosis is given, and retained in the medical records, there is no way that a diagnosis can be verified...unless it is through an autopsy! Atomic Values can also be used with "Expert Systems" to "predict" the diagnosis. Using a Decision Tree, a diagnosis can be made with a greater accuracy then can be made by a healthcare professional. Unknown Cause There are many new diseases occurring where there is no "diagnosis" or they are so rare, that a healthcare professional cannot possibility know the cause. Again, by accumulating the frequency of these atomic values (symptoms, findings, investigative results) in the population, new disease can be rapidly detected (a real surveillance system). Links
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