Problem, Issue, Diagnosis and Concern

POMR / Problems / Issues / Diagnosis/ Concerns/ Conditions/ Reason for encounter/ History/ Story etc

On reviewing the very helpful comments on the existing Clinical Knowledge Manager (CKM) Problem/diagnosis archetype, it is clear that we need to resolve some concept definitions in this difficult area, before we move on to the even more heated question of how to name these concepts.

As a start point, we have tried to tease out the various 'evaluative' elements of a patient encounter and in problem-orientated health issue/concern threads.

We would be grateful for some feedback on these concepts, prior to incorporating them into related CKM archetypes.

The focus for now is on identifying separate concepts, rather than getting embroiled in naming.

Please use the CKM discussion area from the 'Problem/diagnosis' archetype to make any comments as this will lead to a more interactive discussion. You will need to register (free) with CKM here , if you have not done so already.

At high-level we have identified three general aspects of the record where these kind of concepts appear:

1. Patient Contact: The individual patient encounters where the prime recordings are made (encounter/ progress note).

Synonyms: Encounter, Contact, Progress note, Consultation.

2. Unmanaged Health Issue list:   The computed generation of a summary of the concepts (originally entered via a patient contact),by mean of a query and some rules e.g. In date order, only active problems, group by term code. Any grouping, ordering, hiding of entries is fundamentally computed, though the summary may finally be tidied up manually or annotated e.g. prior to sending a referral or lab request. An unmanaged heath summary may be generated ' on-the-fly' by a query or the summary returned by a query may be stored in a persistent composition.

Synonyms: Problem summary, Problem list.

3. Managed Health Concern thread: The generation of a structured, ordered tree-like thread, essentially by manual means. This is the typical problem orientated summary (POMRS) or HL7 health concern summary where the clinician continually groups and re-groups the list of concerns into some sort of tree structure, to best reflect the patient's current health picture. This is then effectively a meta-evaluation of the entries made originally within a patient contact to give a more accurate and understandable picture of the patient's health.This structure would be represented by a Persistent Composition within an openEHR record.

Synonyms: Heath issue threads (CEN), health concern list (HL7), problem-oriented summary (UK), episode-oriented summary (NL).

All clinical applications will support the Patient Contact, most will support Unmanaged query-based summaries. Only POMR/Episode-oriented applications generally support the Managed health concern thread, and these may also support unmanaged query/rule based lists.

Health Summaries

 The concept of a 'health summary' itself merits some discussion, since there is considerable overlap and confusion with the Health concern lists and threads above.

A Health summary may be defined as an extract of patient health-information originally defined by a record of primary entry e.g in a consultation. Normally a subset of this 'primary' information is extracted for a specific purpose, to communicate of an overview of the significant aspects of the patient's current health status. Examples of summaries can be seen in Referral letters, Discharge summaries, investigation requests, and of course, generic patient problem lists or threads within health records, like the 'GP summary' or 'Significant problem list.

The key function of the summary is to re-evaluate and re-present the primary information to reduce the complexity of that data in a way that is helpful to the consumer of the summary. Usually this involves filtering out unimportant detail, and/or re-ordering/ re-structuring the information to make the important aspects of the patient's health story more obvious. Summarising may also protect the patient from the transfer of insignificant but personally sensitive information. 

Both the Unmanaged health list and Managed health thread often act as the basis for the creation of specific summaries e.g for a referral, but they act as a form of summary themselves for the originator, by giving an overview of the patient's health. 

Individual Concepts

In the following discussion the following phrases are used:

- a brief, (commonly coded) piece of text to identify the concept. e.g 'Asthma'

- a longer piece of free text or structured content to give more details about the concept.

Concepts in 'Patient Contact'

1. Label of the reason for contact from an administrative perspective:

There is some cross-over of labelling patient contacts for administrative purposes with labels used for clinical purposes. e.g. The concept 'Reason for Encounter' is sometimes used to hold a broad administrative category such as 'Inpatient care, follow-up', rather than a more precise clinical label.

2. Label of the initial clinical assessment of the reason for contact:

The information provider's brief initial assessment of the reason for the patient contact, prior to any further observation or evaluation. Often termed 'Reason for Encounter/Chief complaint/Presenting problem'. There may be multiple reasons.

The CEN Contsys model separate each of these into an individual Contact Element i.e. one Reason per element. Care must be made to separate this clinical idea of a reason for contact from the more administrative categorisation defined above.

3. Details of the initial assessment of reason for contact:

This is the traditional patient history or subjective assessment. Currently captured by various CKM 'Story' and 'Symptom' archetypes but CKM also has a 'Patient Issue' archetype which is modelled as a possible component of the Story archetype. It represents a short patient-defined reason for the contact and is more akin to a brief synopsis of an issue.

4. Label representing a concluding assessment of the reason for contact:

This is variously described as the problem. heath Issue, condition, opinion or assessment. It is often coded. This concept is currently represented in CKM as 'Problem' .

5. Label representing a concluding biomedical assessment of the reason for contact:

Where the reason for a patient contact can be identified as being due to a recognised biomedical pathology, it is often referred to as a diagnosis and may require specific definitional criteria to be recorded. This concept is currently modelled as a specialisation of the 'Problem' archetype to 'Diagnosis' .

6. Narrative description of the concluding assessment:

A complete narrative overview of the whole contact is sometimes given in a 'clinical synopsis', though a synopsis may equally apply to only one aspect of the contact.  This is currently published in CKM as a 'Clinical Synopsis' archetype. 

7. Other 'findings':

Legacy systems may allow the undifferentiated recording of simple clinical findings e.g. Date + Code + Free Text. Many of these will be Observations but some may be Evaluations which are not felt to merit the 'status' of an Issue, Problem or Diagnosis.There is currently no comparable concept in CKM.

Concepts in 'Unmanaged Health Issue Lists'

Unmanaged lists simply retrieve, order and filter the Patient Contact concepts according to a set of rules, generally creating an Event Composition for a particular purpose e.g. a Referral document or lab request, or just displaying the query results on screen. There may be occasional requirement to 'save' a Health Issue list as a Persistent composition.

Concepts in 'Managed Health Concern Threads'

The defining feature of a Managed thread is that it is manually adjusted to reflect the relationship between related entries, originally recorded as part of a series of patient contacts. This generally results in the creation of a tree or thread-like structure with parent 'concerns/problem headers' acting as containers for multiple occurrences or episodes of the same condition, or of related entries such as causative or consequential conditions or key observations. It is generally accepted that such structuring is impossible to construct reliably via computing and has to be performed manually, though perhaps with some decision support.

This kind of construct is described variously as a Problem-oriented summary (UK-GP), Episode-oriented summary (NL-GP), Concern Tracking (HL7), and Health Issue Thread (CEN-CONTSYS).

In general it seems to be implemented as a container object with links to the original entries created by patient Contacts.

1. Grouping of related entries, originally recorded in Patient Contacts.

The prime role of the managed summary is to group  and re-group related record entries to best represent the patient's current state of heath. Related entries may be supporting observations, re-occurrences, causative, or simply represent the emergence of a more accurate diagnosis e.g. Wheeze Bronchitis->Asthma, grouped under asthma.

2. Temporal groupings of related entries

Temporal grouping is also possible via episodes or nested sub-episodes of care which reflect a clinical view of their start and end date, rather than one defined by administrative events such as admission or discharge from a particular clinical service e.g outpatient clinic or hospital admission.

3. Status of groupings

Managed summaries generally allow some sort of status to be accorded to the grouping e.g Active / Inactive to signify that certain problems of issues merit less immediate attention. This may be used both to influence screen display and decision support. e.g. Drug prescribing support may ignore 'inactive' conditions when doing disease-drug checking.

 Mindmap of concepts

Please use the CKM discussion area from the 'Problem' archetype to make any comments as this will lead to a more interactive discussion. You will need to register (free) with CKM here , if you have not done so already.


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