Clinical Terminology : What is a History and Physical (H&P)?

Hi fellow CMIOs, CNIOs, Applied Clinical Informaticists, and other #HealthIT friends,

Today, I'm sharing more on the importance of terminology, in untangling and streamlining clinical workflows. 

In day-to-day healthcare, effective communication is the bedrock of success. Ensuring accurate and efficient communication in healthcare settings hinges on the use of standardized clinical terminology and documentation practices.

So to better understand the importance of standardized terminology in untangling and optimizing clinical workflows, we will look at one of the most common anchors of clinical workflow - the History and Physical (H&P). 

The History and Physical (H&P) is one of the first things medical students learn to perform in medical school. (Since around 1968, it's been generally written in the same structure as the SOAP note by Larry Weed, MD.) Asking ChatGPT40 for a summary on 11-10-2024, I got this :

A History and Physical (H&P) is a comprehensive document that records a patient's medical history and a detailed physical examination performed by a healthcare provider. This documentation is typically created at the time of a patient’s hospital admission, outpatient clinic visit, or before a surgical procedure. The purpose of the H&P is to provide a structured, thorough assessment of the patient’s health status, which helps guide diagnosis, treatment, and ongoing care.

The H&P typically includes the following elements:

1. Chief Complaint (CC): A brief statement summarizing why the patient is seeking care, often in the patient’s own words (e.g., “chest pain”).

2. History of Present Illness (HPI): A detailed description of the patient’s current symptoms or concerns, including onset, duration, characteristics, associated symptoms, and any factors that worsen or improve the condition.

3. Past Medical History (PMHx): Information about any prior illnesses, surgeries, hospitalizations, and chronic conditions, as well as any ongoing treatments or therapies.

4. Medication History: A list of current medications, including prescriptions, over-the-counter drugs, supplements, and dosages.

5. Allergies: Details of any known allergies to medications, foods, or other substances, along with reactions.

6. Family History: Information about the health of immediate family members to identify any genetic or hereditary conditions.

7. Social History: Insights into the patient’s lifestyle, including smoking, alcohol use, occupation, living situation, and exercise habits, which may impact their health.

8. Review of Systems (ROS): A systematic check of the patient’s body systems (e.g., cardiovascular, respiratory, gastrointestinal) to identify any other symptoms that may not have been initially reported.

9. Physical Examination: A head-to-toe assessment performed by the healthcare provider, covering major organ systems and noting findings like heart rate, lung sounds, and any abnormalities.

10. Assessment and Plan: Based on the gathered information, the provider lists diagnoses (or differential diagnoses) and outlines a plan for treatment or further evaluation.

The H&P is essential for creating a baseline of the patient’s health status, supporting diagnosis, guiding treatment, and facilitating communication among healthcare providers. In electronic medical records (EMRs), standardized templates often guide providers through completing these sections thoroughly and consistently.

While ChatGPT40 gives us a reasonable starting point that most medical professionals will quickly recognize, I'd like to add that it did not explicitly call out Surgical history (SurgHx), Psych history (PsychHx), or OBGYN History (OBGYNHx), which are often separately called out in certain H&Ps.

So in addition to the PMHx, PSurgHx, SocHx, PsychHx, and OBGYNHx, the foundations of Larry Weed's SOAP note can be found in most H&Ps : 

• SUBJECTIVE (S) = What is the patient telling you? (e.g. CC, HPI, ROS, etc.)
• OBJECTIVE (O) = What do you see? (e.g. Physical Exam, Vitals, Labs, Radiology, etc.)
• ASSESSMENT (A) = How do you interpret this, and what do you think the patient needs?
• PLAN (P) = What is your plan to address these issues?

While this gives us a helpful framework to start from - it doesn't really clarify the eleven (11) different types of H&Ps that are commonly used in healthcare. Let's start off our journey by looking at the first four : 

I want to call out these first four (4) H&Ps because they are sometimes confused in elective pre-operative (and pre-procedural) workflow discussions : 

1. Primary (General) Pre-Operative (or pre-procedure) H&P and Risk Evaluation - That general pre-operative or pre-procedure H&P that is commonly done by a Surgeon, Proceduralist, or Primary Care Provider (e.g. Internal medicine, Family medicine, Geriatrics, Pediatrics, or OBGYN), which includes a pre-operative (or pre-procedure) risk evaluation and optimization plan.
2. Secondary (Focused) Specialist Pre-Operative (or pre-procedure) H&P and Risk Evaluation - That secondary, focused pre-op or pre-procedure risk evaluation that might be needed for patients with complex histories, typically done by one or more specialist(s) at the request of the Surgeon, Proceduralist, or Primary Care Provider doing the Primary (General) Pre-Operative (or pre-procedure) H&P and Risk Evaluation.
3. Interval H&P - That H&P where the Surgeon or Proceduralist briefly reviews, within 24h of surgery/procedure, the pre-operative H&P(s) - including the data elements PMHx, PSurgHx, FamHx, SocHx, Med List, Allergies, ROS, PE, and relevant labs and radiology -  and acknowledges that the information is all correct and accurate and that no changes or updates are needed prior to surgery/procedure, usually with a simple attestation : "I have read and reviewed the patient's pre-operative H&P and no changes or updates are required."  
4. Admission H&P - That H&P done by the Admitting Attending (or their clinical delegate) at the time of admission, usually to describe the patient's condition, reason(s) for admission, admission status, admitting team, admission active problem list and management plans, and contingency plans.  

While these contain many of the same data elements, they also contain different elements, and are authored by different provider(s) at different times. Mislabeling all of them as just "H&P" leaves potential room for confusion - For example, if post-operatively Inpatient Nurses seeking post-operative orders were to try to contact the PCP instead of the Surgeon, because the Pre-Op H&P and the Admission H&P are both labeled "H&P".

Similarly, distinguishing the Primary (General) Pre-Op H&P and Risk Evaluation from the Secondary (Specialist, focused) Pre-Operative H&P(s) is necessary to clarify who has the primary responsibility and what other specialist(s) might need to be involved in assessing a patient with a complex history (e.g. pulmonary, cardiac, renal, endocrine, or other complex medication, allergy, or anesthesia needs). Labeling both of these as an "H&P" just leaves room for confusing the two (e.g. a Surgeon sending the patient to a cardiac specialist for a primary risk evaluation.) 

If you have ever tried to create structured documentation, to encourage users to complete the data field(s) that are necessary and unique to each of these note types - You will quickly see why it's important to label each of these notes correctly. 

In short : Trying to 'keep it simple' by labeling them all as "H&P" only confuses users and makes it a challenge to structure your workflows. My advice : Call it what it is.

Just to be complete, I thought I'd share some of the other common types of H&Ps used across healthcare : 

These include : 

• 5. The Emergency Department (ED) H&P - That focused H&P that is commonly done by Emergency Medicine doctors, usually as part of their routine visits. (In some organizations, this is labeled an 'ED Progress Note.)
• 6. The Discharge Summary H&P - That H&P that is usually done by the Attending Provider (or their clinical delegate) at the time of discharge, to provide a synopsis of the patient’s hospital stay, covering the course of illness, treatments provided, and recommendations for follow-up. These also often include the admission reason, key findings, procedures done, discharge medications, patient's condition on discharge and instructions for aftercare, and they help enable a smooth handoff to outpatient providers to help ensure continuity of care and provide clear guidance for post-discharge recovery.
• 7. The Consultation H&P - That H&P that is often done by a specialist, either as part of an inpatient consult or an ambulatory referral, at the request of another provider seeking specialty evaluation.
• 8. The Annual Physical H&P - That H&P commonly done by a Primary Care Provider as part of an annual evaluation of a patient's overall health status and needs. These are often preventative in nature (rather than problem-focused) and usually cover the entire spectrum of a patient's health, including lifestyle factors, preventive screenings, immunizations, and a physical exam.
• 9. The Employee Physical H&P - That H&P commonly done by an Employee Health Provider as part of a pre-employment evaluation, fitness-for-duty evaluation, or workplace injury.
• 10. The Sports Physical H&P - That H&P commonly done by a Primary Care Provider, Cardiologist, or other Sports Medicine provider, to evaluate an athlete prior to playing competitive sports or engaging in other demanding physical exercise regimen.
• 11. The Insurance H&P - That H&P typically done by a Primary Care Provider or Insurance Provider to help evaluate a patient prior to completing agreements for an insurance policy.

... each of which also has unique authors and unique data elements for unique purposes - So if you want to structure these notes, they will also require unique (descriptive) names. 

IN CONCLUSION : 

Terminology is important. The accurate capture of H&Ps relies heavily on standardized clinical terminology. From admission to discharge, the use of consistent terms and codes across each H&P type ensures that information is unambiguous and interoperable within the healthcare system. Applied Clinical Informatics professionals play a crucial role here, by:

1. Creating Templates and Standardized Workflows: Clinical informatics teams often design templates that incorporate standardized terminologies, improving the quality and consistency of documentation across providers and specialties.

2. Supporting Clinical Decision Support (CDS): By ensuring that H&P documentation aligns with clinical terminology standards, CDS tools can better identify risk factors, suggest interventions, and flag potential issues based on coded data from H&Ps.

3. Optimizing for Billing and Compliance: The use of terminologies like ICD-10 and CPT in H&P documentation is vital for billing accuracy. Standardized language not only supports coding but also ensures compliance with regulations.

So my four key take-home messages for this post include : 

• There are at least eleven (11) H&Ps commonly used in healthcare - If you are a clinical provider, a medical records professional, a billing/coding person, or a clinical informaticist, it is helpful to familiarize yourself with all of them.  
• Many federal and state regulations only refer to them as an "H&P" - This, and the common saying "An H&P is an H&P..." potentially only causes confusion and workflow challenges.
• The right naming conventions / labeling can help you structure your documentation, and clarify and optimize your clinical workflows. 
• Remembering the mantra, "Call it what it is" will help you reduce confusion and untangle even your most complicated workflows.

For Clinical Informatics professionals, understanding these elements is critical to optimizing workflows, enhancing patient care, and contributing to the data-driven future of healthcare. By promoting accurate and standardized documentation, we can facilitate the development of a healthcare system that is not only more efficient but also more responsive to the needs of patients and providers alike.

I hope this helps you plan your document index and naming conventions, to help streamline your clinical processes. If you have any feedback or other comments, please leave them in the comments section below!

Have any experience with naming conventions for your clinical documentation? Feel free to share and leave other feedback in the comments section below. 

Remember, this blog is [ DRAFT ] guidance for discussion and educational purposes only - Your mileage may vary. Always check with your Clinical Leadership and your own Legal, Compliance, Regulatory, and Informatics leaders before adopting any definitions or new clinical standards.

Why Terminology Matters

 Hi fellow Clinical Informaticists, CMIOs, CNIOs, and other HealthIT friends,

A short post this time - Just sharing how terminology management can impact EMR usability. 

Managing an enterprise EMR is a lot like owning a closet. Information is stored in certain virtual 'drawers', where people (users) get used to storing and finding the information they need to do their jobs.

The problem is, just like closets - Exactly where and how people like to store this information is an intensely personal, cognitively-driven process. If you have ever had to share a closet, you probably know how challenging it can be to share a closet with another person. 

Now, imagine having to share a closet with 500 people. The first step would be getting all 500 people together for a meeting, and discussing/reviewing : 

• Where should we keep the socks?
• Where should we keep the pants?
• Where should we keep the shirts?

Some people may have different opinions about where and how to keep things, but ultimately, you will need to make some final, group-based decisions. 

Still, some people may start working for your company after those group discussions/decisions are made, so it's helpful if you :

• ... have an easily-identifable pattern associated with your information storage and retrieval, and...
• ... if you label things correctly. 

Today's post is really about labeling things correctly. For teaching purposes, I sometimes simplify it as this : 

"Call it what it is."

It can sometimes be difficult to spot terminology issues, so I'll start with a simple hierarchy that helps explain the confusion that can create frustration for end-users :

Keep in mind that these are simple, real-world examples that we are using as proxies for more complicated, real-world clinical scenarios.

In any case - when labeling a button, folder, or other item in an EMR, it's important to have the appropriate level of granularity and accurate clinical terminology, or else you can lead to confusion for end-users : 

Suppose a user is looking for an apple. 

• In scenario #1 above, if we just refer to apples and oranges as "fruit" - users will need to spend time clicking through both boxes, looking for the apple. It might be in the left box, or the right box - They are both labeled "Box of Fruit", and fruit is not a granular enough term to identify the exact tool the user is looking for (an apple).

• In scenario #2 above, it's easy to find an apple. The first box is labeled, "Box of Apples".

So it's always very helpful to :

• understand and anticipate what the user will be looking for, and...
• understand the clinical terminology and associated hierarchies, and...
• call it what it is.

Some people might argue "Well, if both apples and oranges are fruit, why not keep them in the same 'fruit' folder?" For sure, there are some scenarios where this may make sense, especially if there are not many items to look for under a folder. 

However, keeping too many items in a folder can also lead to unnecessary time spent looking for things. 

So ideally, especially when storing a large number of items - It's helpful to understand the clinical role, the clinical context, the clinical terminology, and the higher/lower level concepts, to help identify the right term to label buttons in your EMR, for maximum efficiency and less clicks.

Hope this helps shed some light on common terminology issues that every organization has to manage as they configure their EMRs. If you're not sure about a term, reach out to your local Clinical Informaticist for guidance, tips on how to reduce clicks, and other common clinical workflow design issues.

Remember, this blog is for educational/discussion purposes only, and your mileage may vary. If you have any terminology tips or suggestions, please leave them in the comments box below!

Improving EMR Satisfaction by Better Anticipating Clinical Needs

Hi fellow CMIOs, CNIOs, Clinical #Informatics professionals, and other #Healthcare leaders,

I'm writing today to share my thoughts about how to improve EMR user satisfaction through a better understanding of the user's clinical roles and responsibilities, and how they impact EMR configuration and training. 

Allow me to explain. Imagine you see a group of people with white coats and stethoscopes, eating lunch together. What are their needs? Are they all one kind of provider, or different providers? How could you tell them apart? And even if you could somehow tell them apart, how would you know exactly what their EMR configuration and training needs are?

Most clinical people think of these as small details. To them, clinical roles seem fairly intuitive, and credentialing seems like little more than a time-intensive requirement to 'do paperwork' before you can begin working clinically. Both of these are common misunderstandings. 

The truth is that clinical roles in modern healthcare are very nuanced, each with their own clinical functions and supervisions needs, and so your exact clinical role and responsibilities have an enormous impact on your EMR configuration and training needs. Without a clear understanding of your clinical role and responsibilities, it's very  challenging to provide the right EMR configuration and training, which can lead to frustrated end users.

So to help improve EMR configuration, training, and user satisfaction - I thought I'd offer this little blog post to help you understand how clinical role terminology, supervision requirements, and onboarding/credentialing questions can help improve EMR configuration and training, as well as end-user satisfaction. 

So in short, we'll discuss some basics about four topics : 

• A - What is a Doctor (Physician)? What are the different types of Doctors (Physicians), and when/how are they supervised?
• B - What is an Advanced Practice Provider (APP)? What are the different types, and when/how are they supervised?
• C - What is a Provider (Prescriber)?
• D - What kind of questions can you ask during on-boarding/credentialing to help make sure you fully understand the provider's role and responsibilities, so you can better anticipate their needs and provide great configuration and EMR training?

Let's get started!

A. WHAT IS A DOCTOR (PHYSICIAN)?          
For those of us who have been through medical training, this all seems fairly intuitive. You finish medical school, get through internship, complete your residency, and many docs continue through a fellowship (subspecialty) training, before becoming an Attending Physician. And along the way, you will work with lots of great Advanced Practice Providers (APPs) including Advanced Practice Registered Nurses (APRNs), Physician Assistants (PAs), and others. 

But imagine if you weren't clinical. Looking at a group of people with white coats and stethoscopes, how could an administrative or IT person tell them apart? It helps to have some good definitions to work with!

Let's start by looking at what exactly is a "Doctor" (Physician).

Note that the supervision model above requires a number of workflow configurations in an EMR - Most commonly, with orders and clinical documentation (notes) - 

• Which order(s) WILL require an attending countersignature?
• Which order(s) will NOT require an attending countersignature?
• Which note(s) WILL require an attending countersignature?
• Which note(s) will NOT require an attending countersignature?
• Knowing the EMR will function differently for Residents, Fellows, and Attendings - How will the EMR be configured for Fellows who sometimes moonlight as Attending providers?

In addition to a clear understanding of these roles, responsibilities, and configuration differences - It's also important that an organization have an easy way of knowing when doctors change their roles. (July 1st is not a guarantee that a doctor's clinical role will change!)

B. WHAT IS AN ADVANCED PRACTICE PROVIDER (APP)?       
With the expansion of medical technology and clinical specialties in the 1970s and 1980s, came a new set of providers who could help 'extend' the reach of the attending physician, including Advanced Practice Providers (APPs) such as : 

These roles also have unique EMR configuration and training needs, which are highly dependent on the supervision needs, which often depend on state regulations. Like Doctors/Physicians, having a clear understanding of these clinical roles and their supervision needs is key in providing the proper configuration, security, and training. 

C. SO WHAT EXACTLY IS A "PROVIDER" (PRESCRIBER)?      
So to put this all together, we can now represent the Doctors (Resident, Fellow, and Attending Physicians) and Advanced Practice Providers (APPs) as a common set of Providers (Prescribers), each with a DEA number and prescriptive authority, but with different supervision needs and expectations : 

Again, this catch-all term can be helpful, especially for pharmacies that want to provide services to all of these roles. It's not as helpful in legal/billing scenarios, where usually the Supervising Attending Provider (1c) (and sometimes the independent APRN!) are more commonly the focus of discussion.

D. CREDENTIALING AND EMR CONFIGURATION AND SUPPORT
So we've discussed how these clinical roles impact EMR security, configuration, and training. What other questions can you ask, to better anticipate a user's clinical needs, configuration needs, and training needs? While it may not be comprehensive, I recently drafted this list of questions you might ask a provider during on-boarding and credentialing, to better understand and anticipate their clinical, academic, research, and administrative needs:  

Again, this list of questions may not be comprehensive, but it helps show how good credentialing and provider on-boarding can help HealthIT people to better understand a user's clinical, administrative, research, and academic roles, and anticipate the specific needs for each role. 

I hope this was helpful in shedding some light on these important topics! Remember : It's the little details that matter. If you have any feedback or comments, please leave them in the comments section below.

Remember this blog post is for academic and educational discussion only - Your mileage may vary, and always check with your local Legal, Compliance, and Clinical Informatics experts for guidance in your own organization. Have any feedback or thoughts? Feel free to share below!

Culture, Terminology, and EMR Usability

Hi fellow Informatics friends and colleagues,

When sharing the secrets of electronic medical record (EMR) usability, some people are surprised at how much culture and terminology impacts user satisfaction. Allow me to explain.

EMRs are essentially tools used to store and retrieve patient care information. When configuring an EMR, the most common mistake is thinking it's 'like paper', simply a bunch of words, lines, and boxes on a page. EMRs are different - Buttons open menus that lead to other tools and actions, so it's more helpful to think of it more like you are organizing a closet: 

• Socks go in the sock drawer.
• T-shirts go in the t-shirt drawer.
• ... and so on.

Only an electronic patient record literally contains hundreds of drawers, each containing as few as a handful, or as many as hundreds of documents, images, vitals, or other data elements. E.g. : 

... and when you click on the button "RADIOLOGY ORDERS", one would expect to find the orders related to diagnostic and therapeutic/procedural radiology modalities.

So a key design element to consider : 

• How many items do you need to store in a chart, for patient care purposes?
• In which 'drawers' will you store them?

And so when organizing a closet at home, most people realize they don't have room for a separate drawer for every piece of clothing, so they will use some categorization scheme (that makes sense to them) to combine related items in the same drawer, E.g. : 

• Top Drawer = Undergarments (Socks, Underwear, and T-shirts)
• Bottom Drawer = Outer garments (Shirts / Pants)

We don't consciously think about categorization schemes very much, but our brains do this naturally, to try to make sense of the world, and establish a pattern that will ultimately help us get dressed in the morning. 

Anyone who's ever had to share a closet, however, knows there can be disagreements about categorization schemes, resulting in some interesting household debates. If you have children, you also know it's helpful to label drawers, or explain the categorization scheme, so your kids can find their clothes in the right drawers. Food pantries and refrigerators are common sources of domestic debates, because different family members might have different ideas about ideal organizational schemes.

So it's no surprise that people who are responsible for configuring and organizing an EMR often stumble upon the many cultural differences in thinking and terminology between "healthcare tribes" - E.g. between physicians, nurses, pharmacists, radiologists, laboratorians, ancillary services, medical records, finance, etc.

Here's a good teaching example to better understand what I'm talking about, and how these terminology issues have real-world impact in user EMR satisfaction : 

Imagine it's the year 2050. 

You run a hospital with an EMR. It is suddenly discovered that tomatoes save lives, so you prepare to have tomatoes in your hospital, keeping them in your Pyxis machine, and create tomato orders in your EMR, to order and release the tomatoes for patient care (when needed). 

After meeting with your available subject matter experts (SMEs), many of whom, for scheduling reasons, just happen to be from clinical Tribe A - your analysts build the "Tomato" order, and make it available under the "Vegetable" menu choice below :

Shortly after building this, you suddenly get complaints from Tribe B users, who couldn't show up to the earlier meeting but say, "Hey wait, tomatoes are technically berries, which are technically fruit - Here is the evidence : https://en.wikipedia.org/wiki/Tomato - So they should be listed under the "Fruit" menu choice instead! Those of us who know this can never find the Tomato order!"

You also get complaints from Tribe C users, who say, "What's a Tomato? We've never heard of that. Oh, wait, you mean that red thing we put in our salads/sauces/sandwiches? We've been doing this for 20 years, and in our experience, we've always called it a Golden Cherry."

Do you :

• OPTION 1. Listen to Tribe A, and file the tomato order under the "vegetable" menu, and educate Tribes B and C that tomatoes are red fruit that grow on a vine, are commonly used to make sauces/salads/sandwich toppings, and most commonly thought of as vegetables?

• OPTION 2. Listen to Tribe B, file the tomato order under the "fruit" menu, and educate Tribes A and C that tomatoes are red fruit that grow on a vine, are commonly used to make sauces/salads/sandwich toppings, and correctly categorized as fruit? 

• OPTION 3. Listen to Tribes A and C, rename the tomato order to a golden cherry order, file it under "vegetable", and educate Tribe A that tomatoes will now be referred to as a golden cherry and will be filed under the vegetable menu? 

• OPTION 4. Listen to Tribes B and C, rename the tomato order to a golden cherry order, file it under "fruit", and educate Tribe B that tomatoes will now be referred to as a golden cherry, and will be filed under the fruit menu? 

• OPTION 5. Bring Tribes A, B, and C together for a meeting, review the concepts, terminology, and taxonomy of tomatoes together, and agree to a functional definition (for your glossary!) that meets the needs of all three tribes : 

Tomato ('golden cherry') - A common red fruit/vegetable that grows on a vine in temperate climates, that is commonly used to make salads, sauces, and sandwich toppings. 

... and then build the tomato order, attach a synonym of 'golden cherry', and then file it under :

• the "vegetable" menu choice? 

• the "fruit" menu choice? 

• BOTH the "vegetable" and "fruit" menus? (making Tribe A complain that it shouldn't be making the fruit menu look messy, and Tribe B complain it shouldn't be making the vegetable menu look messy) 

• Or build a hybrid "vegetable/fruit" menu choice? 

... or more options we haven't considered yet?

How these terminology, taxonomy, and conceptual issue get managed will ultimately impact the satisfaction of users who are trying to find a tomato ('golden cherry') in the EMR for patient care.

Hope you enjoyed chewing on this interesting EMR terminology challenge! If you think terminology issues might be impacting your workflow, feel free to ask your local clinical informaticist for help! (#whyinformatics!)

Remember this blog is for education and sharing purposes only. Have other examples of terminology and classification systems impacting EMR usability and satisfaction? Or have you struggled with this yourself? Feel free to share in the comments section below!

Building your #Workflow Glossary

Hi fellow Clinical #Informatics and other #workflow enthusiasts, 

Happy 2019! While I continue to work on compiling the business case for Clinical Informatics, I thought I'd take a minute to talk about #workflow terminology. 

A. THE BACKGROUND :
Simply put - words matter. Any bilingual person who has ever tried to translate the phrase 'scram' or 'hit the road' into another language knows that a word-for-word translation does not always work. (Really? Hit the road..?) One might try to translate it as 'it's time to leave', but even that fails to convey the certain informal, vernacular quality that the phrase 'hit the road' conveys so well. So my advice to anyone working in a translational role - Do your best, but always translate at your own risk. 

In healthcare, we have a number of terms that people generally understand, but their exact definitions may vary from organization to organization. They include such common terms as : 

• Order
• Order Set
• Protocol
• Policy
• Procedure
• Guideline
• Standing Order
• Clinical Pathway
• Documentation
• Templates
• ... and more!

While almost all clinical staff have a general sense of these terms, their true understanding may not be exactly the same - And so, with regard to the term ‘protocol’, for instance, they may quietly have overlapping circles of a common understanding :

The problem is that these differences in understanding may result in dramatically different expectations about how exactly a 'protocol' works, and what it can do to help their workflow : 

• Can a protocol be used to allow a Registered Nurse to titrate an IV heparin drip?
• Can a protocol be used to allow a Registered Nurse to give a pneumonia vaccination?
• Can a protocol be used to allow a Respiratory Therapist to titrate the settings on a ventilator in the ICU?
• Can a protocol be used to allow a Registered Dietitian to modify a diet for an inpatient?
• What is the difference between a protocol and a standing order?

To increase the amount of common understanding, it's helpful to look at your federal and state regulations, along with your own safety and operational needs, to see if they offer any definitions that help clarify the answers to these questions :

After all, once there is a clear definition - then you can create a standardized template, development procedure, and staff education to give everyone on your team a greater, more standardized understanding of the tool and what it can do. Remember - It all starts with the definition.

B. THE PROBLEM :
Healthcare faces some challenges in harmonizing this terminology - What a protocol can do in some organizations is different than what a protocol can do in others. And despite CMS regulations which refer to the use of protocols, many federal and state regulations use these terms interchangeably - See this 2013 letter from the Centers for Medicaid Services (www.cms.gov), page 4 : 

Standing orders: Drugs and biologicals may be prepared and administered on the orders contained in pre-printed and electronic standing orders, order sets and protocols (collectively referred to as “standing orders” in our guidance) only if the standing orders meet the requirements of the medical records CoP.

And this, from the Interpretive Guidelines §482.24(c)(3) on page 78 : 

There is no standard definition of a “standing order” in the hospital community at large (77 FR 29055, May 16, 2012), but the terms “pre-printed standing orders,” “electronic standing orders,” “order sets,” and “protocols for patient orders” are various ways in which the term “standing orders” has been applied. For purposes of brevity, in our guidance we generally use the term “standing order(s)” to refer interchangeably to pre-printed and electronic standing orders, order sets, and protocols. However, we note that the lack of a standard definition for these terms and their interchangeable and indistinct use by hospitals and health care professionals may result in confusion regarding what is or is not subject to the requirements of §482.24(c)(3), particularly with respect to “order sets.” 

Making it even worse is when Informatics professionals then have to compare this with their state regulations :

... which may have slightly different understandings and definitions of these terms.

Fortunately, there are some very talented medicolegal and compliance experts out there, who can help an organization to develop a strategy for navigating these regulations, while planning their workflows, both before and after an EMR implementation. One of the best I've seen is Sue Dill Calloway, BSN MSN JD, who has a fantastic series of lectures on the importance of this terminology, for regulatory, financial, and patient safety reasons.

But in the absence of a simple, standardized national glossary, with good functional definitions of these tools - It can be very hard to develop the templates, development procedure, and education you need for your team. 

C. THE SOLUTION :
Given the lack of clarity about these terms, what's the average CMIO, CNIO, or clinical informaticist to do? Fortunately, there is a strategy you can employ, and that is expanding upon a fairly simple template for functional definitions : 

[ Term: What It's Called ] - [ Functional Definition: What It Does ] 

This simple template is helpful in separating terminology for tools that have slightly different functions, e.g. : 

Term1 - FunctionalDefinition1
Term2 - FunctionalDefinition2
 ...and so on...

So if we can accept this simple template for separating terminology and function, we can then start to draft a 'conceptual map' for these common terms in healthcare (click the image below to enlarge) : 

(REMEMBER - THIS GRID IS JUST A DRAFT AND IS NOT COMPLETE!)

As you start to do this exercise, you'll see that there are some terms which have very similar functions, and other terms which don't : 

• Guidelines and Policies initially look like they might have similar functions - until you consider that policies might result in root cause analysis and disciplinary action, and guidelines don't. (Policies=rules, guidelines=suggestions).
• Protocols and Standing Orders seem to have very similar functional definitions, so we need to figure out if they are true synonyms, or if there is some kind of a difference between them.
• Procedures and Plans also have similar definitions - So we will need to figure out how to separate them. In this case, I've taken the liberty of separating them in time, suggesting that procedures describe current tasks, and plans describe future tasks. 

Given the similarities between protocols and standing orders, it's helpful to separate them by considering their risk - and thus their initiation/triggering mechanisms, FOR EXAMPLE: 

• Standing Orders = Used for common, LOW-risk clinical scenarios in which the benefit to the patient of rapid evaluation and care outweighs any known risks. Standing orders may be initiated ('triggered') by a clinical POLICY (e.g. 'All clinic patients will be screened and potentially administered for pneumonia vaccination, according to the Standing Orders for Pneumonia Vaccination.) All orders and outcomes of standing orders will be attributed to the attending provider.
• Protocols = Used for common, HIGH-risk clinical scenarios in which the benefit to the patient of improved care standardization outweighs any known risks. All protocols must be initiated ('triggered') or discontinued by an ORDER (e.g. 'Initiate Ventilator Liberation Protocol' or 'Discontinue Ventilator Liberation Protocol'). All orders and outcomes of clinical protocols will be attributed to the ordering provider.

While you undergo this exercise, it's important to look at your regional, state, and federal regulations, and to speak to experts (like Sue Dill Calloway, BSN MSN JD as I mentioned above). If there are no regulations to guide you in this grid, then you and your clinical and administrative leadership will have to make local decisions about how your organization wants to define these tools.  

As you work on these definitions, keep in mind other things you can do to improve safety and clarity, e.g. "Orders are documented instructions [ that ] must be signed within 24 hours."

As you start to build out this grid for your own organization, talk to people who use these tools, and you'll start to better understand the form, function, and other issues related to their design. And once you think your grid is complete? Bring it back to your senior leadership for review, discussion, and formal approval. Voila! You now have your own organizational glossary that will help you develop the templates, procedures, and education that create a greater understanding, and improved standardization, predictability, and efficiency, for both your clinical and administrative teams. 

Hope this is helpful in guiding you to build your own workflow glossary! If you have any other tips, suggestions, or comments, leave them in the comments section below!

Remember - This blog is for educational discussions only. Do not use any of these definitions without formal review and discussion with your own informatics, legal, administrative, and clinical teams. Have any other clinical terminology tips you'd like to share? Feel free to leave in the comments below!

Problem Lists - What exactly is the "Past Medical History"?

Hi readers,

Happy 2016! For today, I'm going to try to tackle an interesting conceptual and terminology issue around problem list management, and how it relates to the Past Medical History (PMHx).

Many people, working to optimize their EMRs, work hard to try to 'curate the problem list' - WIthout good curation, problem lists can become very lengthy, and include issues like "Cough" under Past Medical History - 

1. Some people see this as a failure of HealthIT ("Why is cough under the Past Medical History, when it's not a diagnosis?") - 
2. Other people see this as a failure of the doctors using the system ("Why didn't anyone remove cough from the Past Medical History?") - 

What I find particularly interesting about this discussion is the wide variation in practice, when I read admission history and physicals. I think most docs, billers, and coders believe that, on admission, the doctor should document whatever the 'acute medical issues' or 'active medical issues' are - But what do these terms mean, exactly?

1. If a patient with stable diabetes is now admitted with cellulitis, and the doc continues the diabetic medication - Should diabetes be on the active medical issues list?
2. Or should the doc only code for the cellulitis?

In discussing this many times over the years, I find that many docs use the terms 'active medical issues' and 'acute medical issues' almost interchangeably. Are they really interchangeable?

So I Googled the terms "Active Medical Issue" and "Acute Medical Issue", and found a number of good articles, including this 2010 post by A Country Doctor on Kevin MD and this excellent 2005 discussion on Past Medical History by John Gazewood, MD. Finally, the US National Library of Medicine offers this good explanation of acute versus chronic conditions.

But how are acute and active medical issues different? While these are are all good treatises on medical issues, I was wondering if I could approach this from a design standpoint, as a physician informaticist, with good conceptual definitions for the terminology, to make sure there is real clarity around the discussion. 

So, in trying to tackle this informational design issue, I've hammered out the following DRAFTED definitions, depicted on the following two slides, for your examination and discussion (the same concepts are on both, but each is displayed slightly differently) :

Slide 1 - "Bucket" depiction

Slide 2 - Same concepts, different depiction

I created these slides to try to create conceptual 'buckets' that problems/issues could easily fall into, allowing physicians to move items from one bucket to another as the patient moves from one provider to another - And then labeled them with terminology (and synonyms) that I believe best fit the concepts. (Please use your own judgment before adopting any of this terminology.)

What these slides do, however, is shed some light on why maintaining the problem list is more challenging than you might expect. It requires enormous clarity just to discuss the issues, and then when you examine the concepts in detail, there seems to be some breakdown in the definition of "Past Medical History". 

For example, in the scenario where the patient with stable diabetes is admitted for cellulitis - On writing the admission H&P, a doctor might code for both the Unstable (Acute) issue ("Cellulitis"), and the Stable (Chronic) Issue ("Diabetes, Type 2, Controlled"), since he/she has made the active medical decision to continue the diabetic medication while treating the cellulitis. 

However, on discharge, what do you do with these two Current(Active) issues (Stable and Unstable) in the EMR? 

• The cellulitis might be moved to the Prior(Inactive, Resolved) Issue list, but 
• the diabetes is still a Stable (Chronic) issue - which falls under the category of Current(Active) issues - 

So the problem is that, I suspect, most doctors would conceptually define "Past Medical History" as the items found in these three buckets : 

1. Prior Procedures
2. Prior (Inactive, Resolved) Issues
3. Stable (Chronic) Issues - which conceptually falls under the category of Current (Active) Issues - 

It's the incongruence between "Past Medical History" and "Current (Active) Issues" that I find most interesting - Past isn't really in the past, if it's still in the present. 

It's also interesting to note that the commonly-used term "Reason for Admission" typically only includes issues that would fall under the Unstable (Acute) issues bucket - But the Admission H&P typically includes more issues, especially if they involve active medical decision-making (E.g. both Unstable (Acute) issues + Stable (Chronic) Issues)

In practice, I find many docs will only include as many Stable (Chronic) issues as time (and patient census) allows - It's interesting to ponder how this impacts coding and billing on the national level.

Finally - I believe these slides support the argument that the terms "Active Medical Issues" and "Acute Medical Issues", although related, are in fact not interchangeable. (I suspect that Acute is really a sub-type of the concept of Active medical issues.)

While my post today doesn't have any great answers, I hope these slides, and this discussion, have at least shed some light on the concepts and terminology surrounding problem list management, and how they impact EMR usage, coding, and billing on the national level.

Have any thoughts about problem list management? Leave them in the comments section below!