Leaving the Past Medical History actually to the past

In the original format of an Admission History and Physical, the “History of Present Illness” spoke to the single problem for which the patient needed to be hospitalized. The “Past Medical History” described problems the patient might have had in the past, but by definition, were behind them. In the days when patients were admitted for a single acute illness, the distinction was clean.

The 'Edwin Smith Papyrus', an ancient Egyptian text on the surgical management of trauma.

The Edwin Smith Papyrus, an ancient Egyptian text on the surgical management of trauma.

As medicine became progressively more successful turning once-fatal conditions in to manageable chronic diseases, the distinction between “Past Medical History” and the patient’s current problems became fuzzy. When a patient with type 2 diabetes mellitus is admitted to the hospital with urosepsis (excuse me, sepsis of urinary origin), is the diabetes part of the “history of present illness” or the “past medical history”?  The patient isn’t being admitted because of their diabetes, and yet, it’s wrong to say it’s part of their past medical history because its an ongoing, usually lifelong problem requiring active management. In practice chronic medical illnesses started to show up in both places – the HPI would begin “Ms X is a 75 year-old female with type 2 diabetes admitted for urosepsis”, but the diabetes would appear again in the PMHx. For patients with multiple chronic medical illnesses, the HPI one-liner got packed with a comma-separated list of ongoing conditions, which then line up duplicatively in the PMHx, there joined by medical problems truly in the past.

In an electronic health record this fuzziness becomes obvious because a problem-based EHR (Epic for example) forces the physician to put their nickel down. Is the Past Medical History really in the past? The actively managed Problem List is integrated in to documentation, order writing, signout, and many other clinical functions. The diabetes belongs on the “Problem List”, not the Past Medical History, because it is an ongoing, not past, condition.

I just finished discussing this at UCLA as the Medicine housestaff are building up their inpatients’ problem lists for the first time. At UCSF we’ve tried to move the culture towards using the Problem List for all the patient’s active medical issues, including chronic issues, and reserving the Past Medical History for items actually in past. I remember pitching this for the first time to our Medicine residency program leadership, who looked at me like I had two heads. (in the most friendly and collegial way) Today’s patient is likely to have more present problems than just one. It’s a culture change, but it’s more accurate, more concise, and consistent with the original distinction between the HPI problem(s) in the present and past medical problems in the actual past.

Charting on the Problem List

Still in its early stages at UCSF, one week old as of today, is inpatient documentation centered heavily around the Problem List.  This has been used by some providers in the ambulatory setting over the last year, but is now being used nearly universally on hospitalized patients.  Rather than writing an assessment and plan as free text at the bottom of an admission, progress, or consult note, each relevant item on the hospital Problem List will now have a unique assessment and plan note written specifically about that item.

This has several potential beneficial effects:

1) Sharpening a physician’s diagnostic thinking.

2) Improved continuity-of-care and ability to review a patient’s chart.  Currently, if a patient named Bob has COPD and you want to find out what has been done over the last ten years for his COPD, you have to sift back through every old note in the chart, looking for the ones where COPD was discussed.  Very time-consuming.  With the Problem List approach, Epic allows you to “View All Notes” for any given item on the Problem List.  This means that with a single click, you can conjure up every assessment and plan note written specifically about Bob’s COPD, whether from the ED, ambulatory clinic, or inpatient setting, going back through time.

We think this is a very powerful tool and are excited to see it begin to improve care.

You know you’re using an EHR when…

I just had my first “yup, we’re now using an EHR” moment.  I was working on populating Epic Problem Lists for the patients on the medical service I’m currently covering.  A not un-common “problem” we see here is the ever-familiar “waiting for placement.”  As we’ve all known for years, this is not considered a real diagnosis, and there is no ICD9 code.  We’ve always skirted the issue somewhat uncomfortably by continuing to write it into our text-based notes, knowing that it is “not real medicine” and yet at the same time knowing that it best reflects the reality of the situation.

And so, populating an Epic Problem List in the wee hours of the morning, I tried this:

There is no fooling a computerized database of ICD9 codes.  Welcome to the EHR.  I’m curious to see how we all work out a solution to “waiting for placement” that both reflects the clinical reality and the economic/billing realities.

(Side-note: I am Aaron Neinstein, a fellow at UCSF in Endocrinology, and a guest blogger invited by Dr Cucina to participate in his live-blog of Epic go-live.)