Having issues

In my last post I described the positioning of the SRR record and I also painted it as a form that can either be predetermined in the form of a clinical guideline record or a free form record to which the doctor can add steps, or a mixture of both. Since we don’t want to keep calling this thing an “SRR”, and we can’t call it a “symptom” or a “pathology” or a “disease” for reasons I’ll soon get to, I think we need to call it an “issue”.

It would have been natural to call it a “problem”, but there’s a problem with calling it a “problem”, namely that 50 years ago or so, Wade described the Problem Oriented Medical Record (POMR) which has a lot of the characteristics of what we here describe, but still differs on some crucial points. And since I don’t want to run in to prejudices connected with POMR and get remarks like “it’s old hat”, “we know about that”, “it never worked”, and more, I prefer to call it something else. And “issue” it is for now. Especially since I can’t think of anyone calling this an “issue” up to now.

Recapping, we have a list of “issues” under the entity “patient”. Each “issue” can be a symptom, a disease, a hypothesis, a plan, or even in some cases a therapeutic regimen. Let’s run through a couple of examples just to illustrate what it is, and what it is not.

“Diabetes type 2” is an issue. It has diagnostic criteria, recommended follow-up lab tests, regular checkups and referrals, recommended therapies, diagnostic codes, and contra-indications such as “careful with some diuretics”.

“Migraine” is an issue, and so is “tension headaches”. Interestingly, “headache” is also an issue with its own recommended diagnostic steps, but it also has a list of differential diagnoses, including both “migraine” and “tension headaches”. A “headache” is not a diagnosis but a symptom, but it needs to be a first class “issue” anyway, since that is the “issue” we’re working with until we can replace it with a more definite diagnosis.

So now we encountered the “replacing” of issues. This can happen in the “headache” case, among many others. The patient presents with headaches, and immediatly gets a “headache” issue assigned, which is prefilled with a differential diagnosis including among other things “migraine” and “tension headaches”. As the physician needs to exclude “migraine” first, the issue “migraine” is attached to the main issue “headaches” and you can work through the recommendations in “migraine”. If “migraine” is confirmed, it actually is lifted a level and replaces the main issue “headache” which is then removed from the list. If, on the other hand, “migraine” is excluded after some examination, the “migraine” subissue is removed and it is marked as “excluded” in the list of differential diagnoses in the “headache” issue. And so forth.

Don’t become nervous when you see all this insertion, moving, and deletion. That is how it looks to the user, but behind the scenes, everything is saved, version controlled, listed, and is being audited like there’s no tomorrow. Except we don’t want to actually see any of that unless we ask for it.