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Problem List Case Study

Support for policy and tools

This study confirmed the hypothesis that practitioners differ in their opinions over what should and should not go on the problem list, although many areas of agreement were identified. This difference in opinion is likely a key reason for the variation in the content and structure of current problem lists within and across healthcare organizations. Without consistency across problem lists, patients cannot receive the full benefits problem lists bring to patient care, namely better practitioner compliance with best practices and the complete utilization of clinical decision support and population management tools. The medical community needs to work towards standardization through the development of policies about how the problem list should be used as well as tools built into the EHR that can help practitioners comply with those policies.

Unlike prior research, one valuable component to the study is that the online questionnaire provided quantitative evidence about the size of the disagreement over actions towards the problem list. For instance, all but one vignette question held a statistically significant plurality suggesting that a large portion of practitioners are approaching the problem list in a similar manner. This result implies that it is possible for a majority of practitioners to agree on a common approach to the problem list.

The data also brings attention to possible differences among PCP’s and specialists concerning problem list “territory.” While specialists believe adding to the problem list would be an incursion on an area of the medical record owned by the PCP, the data indicates that PCP’s believe specialists should feel comfortable adding to the problem list.

The findings show that the problem list needs more functionality to help practitioners contribute to the document and also make the list more useful to their work. For instance, one specialist spoke about how when he stages a patient for breast cancer (entering data about the exact size and shape of the tumor) he is frustrated that the EHR cannot follow the logical consequence of automatically generating “breast cancer” on the problem list. Here is an instance where tools could help make the problem list a more integrated part of the practitioner’s medical practice and also make it easier to comply with any future policies.

Finally, the summary measures showed a weak correlation between opinions towards the problem list and any common grouping characteristics such as age, medical experience, or opinion on the importance of the problem list. For the completeness measure, the only significant factor with the support of a decent sample size was that residents wanted for less to be included on the problem list than non-residents. Speculation on these differences could be changes to recent training or less experience in the medical field. Although it is important to note that no significant differences were found for the completeness measure amongst the experience and age variables.

The plurality measure contained several more significant measures, specifically within the experience and importance categories. These data indicate that practitioners may approach the problem list differently than their peers based on these characteristics. Yet, with no true dose response and the smaller sample size, this premise is certainly not conclusive and requires further study. In developing a common approach to problem list, these data are not strong enough evidence to suggest value in segmenting opinions by common demographic factors.

Recommendations

Based on the in-person interviews, several issues stood out as greater challenges for practitioners than others. The following recommendations are areas that would benefit the most through the development of policies and EHR tools.

A major cause of unreliable problem lists is the general disagreement in the medical community over “Who is responsible for the problem list?” As discussed in the results section, the debate centers on the roles and responsibilities of the specialist versus the PCP. Due to the disagreement in responsibility, problems diagnosed by specialists do not have a consistent pathway onto the problem list. This process gap could be a primary cause of incomplete problem lists. An official ownership policy would bring clarity to the PCP and specialists relationship towards the problem list. For example, when asked what would need to change for the specialist to start having a more active role in the problem list, an oncologist responded:

"“If the [administration] came out and said everybody owns the problem list…if you are taking care of a problem then you need to make sure that problem is on the problem list, and then I think I would go ahead and do it.”"

Another potential cause of clutter and absent problems is the lack of guidelines for when to review the problem list and remove a cured or latent problem. A clarified policy could help specify when and who should be conducting this process and also the role the patient might play in reviewing their own problem list for accuracy. Removing inactive problem would help keep problem lists up-to-date, short, and relevant. Of note, such a policy would likely need to be closely intertwined with an ownership policy.

An additional cause of absent problems (or potentially worse offences) is the potentially murky understanding over how privacy and security regulations apply to the electronic problem list. In response to question #15 about placing sensitive questions on a problem list that can be viewed by many of the patient’s practitioners, one specialist commented:

"“I don't know what the rules are under this, but I think the diagnosis is relevant to everybody else. So the question is I don't know what the legality of mental health records is and how visible they are is, but that is where I would defer to someone and say I don't know. If there's a way where it’s not illegal to disclose that, then absolutely.”"

Concerns towards maintaining compliance with HIPAA and other privacy policies may be keeping practitioners from adding problems. Currently, HIPAA does not restrict what can be placed in the medical health record and instead regulates use and disclosure [19]. Discussions and clarification on how privacy can be maintained in the new digital age where problem lists are more readily accessed and available may help practitioners be more confident in their actions towards the problem list. The need to address this issue will likely become even more important as adoption of health information exchanges and online patient portals increases as well as the sensitivity of information evolves such as questions over listing genetic predispositions on the problem lists based on genetic testing.

Finally, this research gave insight into how restrictive a problem list policy should be towards allowing the addition of a broad range of problem types. As shown by the completeness measure, practitioners were more likely to want to include an item on the problem list than not. Throughout the study, practitioners did not limit themselves to the strictest definition of the problem list, namely only including chronic diagnoses. The results also indicated that any common approach to the problem list will need to leave room for the practitioners’ personal judgment. For instance, practitioner reactions during in-person interviews differed greatly to the question about the woman who was highly afraid of doctors. Some practitioners found the information irrelevant to how they would treat her and others wanted it to be the first fact they knew because it could potentially change their analysis of her health history. Variation in how practitioners use the problem list does have policy implication. Based on these findings, practitioners are not looking for a highly restrictive policy that restricts personal judgment on what should be included on the problem list.

Of course, the idea of an unrestrictive policy is not to say that problem lists should include every possible problem without regards to length. An “all inclusive” policy will not create problem lists that are easily scanned and make known the most essential health facts about patients. Further, when and what to include often depends on the patient. As one practitioner responded to the vignette about if a case of asymptomatic asthma should be listed on the problem list:

"“Yeah, that is a grey area, actually. From someone who is… you know… completely well. This is her only issue then I can see why this might make it on to the problem list. Young person. If it’s… you know… you’re going to be adding on to a list of 10 or 15 problems on a chronically ill person where this is not likely to be a big issue for her, then I could see where you wouldn’t put it on the list. The length of a list actually becomes an issue, I think, just like fatigue…attention fatigue.”"

Of course, the idea that there needs to be some moderation in the content included in the problem list was known prior to the research, this study showed that practitioners are not looking to be restricted to certain types of information such as only diagnosed diseases. They want the option to include anything, which leaves the greater challenge of how policies and tools can help prioritize information to create the most effective problem lists.

Study strengths and limitations

A key strength of the study was the usage of vignettes to help reveal practitioners’ attitudes towards the problem list. While not measured, practitioners appeared to easily comprehend, debate, and find answers to their preferred action and the resulting data did not appear hindered by the vignettes. One downside of the vignettes is that they were narrowly defined to specific clinical situations. Other limitations with the survey instrument included inconsistency of the survey instructions with the vignettes. Specifically, the initial instructions requested that respondents answer in the perspective of a PCP while some of the questions requested the specialist perspective.

The second core strength was the use of the two-pronged implementation method of the survey instrument as it brought out both breadth and depth to analyzing practitioners’ opinions towards the problem list. The main weakness was the sample. It was limited to practitioners at two affiliated, well-resourced, academic medical centers in Boston where the EHRs allow great freedom in what can be entered into the problem list (both coded and free text problems). Further weaknesses in the sample were that the respondents came from sources within the healthcare centers that were opportunistic rather than representative. This convenience sample resulted in disproportionate respondent demographics. For instance, the online questionnaire sample consisted mostly of PCPs due to the departments asked to participate, and the in-person interviews consisted mostly of specialists. The results would likely be affected by having a more representative sample of practitioners from across the United States.

In regards to the online questionnaire, it became known after the questionnaire was sent that a limited number of non-clinicians were included in the department mailings lists such as administrative assistants and they likely received emails containing links to the questionnaire. As the survey was designed to screen out non-clinicians based on the response to the first question, the responses were not impacted as long as the non-clinicians answered honestly, but the true response rate is likely slightly lower than reported.

The unavailability of demographic data for non-respondents of the online questionnaire further limited the study sample as it is unknown if the respondents held similar opinions to the non-respondents. Further, lack of significant respondents in the specialist category limited the ability to identify differential response rates based on clinician factors. Increasing the sample size would also further strengthen the findings of this study, and create a more representative collection of data. A larger sample size would also allow for further analysis of differing opinions by various demographic factors, such as clinician specialty, and inpatient versus outpatient practice settings, on clinician attitudes towards the problem list. The results of this study are also specific to the capabilities and design of Partner’s Longitudinal Medical Record system used at the study sites. Yet, a core strength of surveying this particular provider population is that the Partner’s Longitudinal Medical Record system allows for both structured and free text input. This unique environment means that providers have an active choice in what they list in their problem list on a daily basis and therefore, could readily give feedback on their preferences to this study. Providers who are only allowed structured problems may not have a strong idea of what they would prefer to include or not include on the problem list due to working in a more regulated EHR system.

  Winter 2006

An Approach to Case Analysis Winter 2006

What is a Case Study?

A case study is a description of an actual administrative situation involving a decision to be made or a problem to be solved. It can a real situation that actually happened just as described, or portions have been disguised for reasons of privacy. Most case studies are written in such a way that the reader takes the place of the manager whose responsibility is to make decisions to help solve the problem. In almost all case studies, a decision must be made, although that decision might be to leave the situation as it is and do nothing.

The Case Method as a Learning Tool

The case method of analysis is a learning tool in which students and Instructors participate in direct discussion of case studies, as opposed to the lecture method, where the Instructor speaks and students listen and take notes. In the case method, students teach themselves, with the Instructor being an active guide, rather than just a talking head delivering content. The focus is on students learning through their joint, co-operative effort.

Assigned cases are first prepared by students, and this preparation forms the basis for class discussion under the direction of the Instructor. Students learn, often unconsciously, how to evaluate a problem, how to make decisions, and how to orally argue a point of view. Using this method, they also learn how to think in terms of the problems faced by an administrator. In courses that use the case method extensively, a significant part of the student's evaluation may rest with classroom participation in case discussions, with another substantial portion resting on written case analyses. For these reasons, using the case method tends to be very intensive for both students and Instructor.

Case studies are used extensively thoughout most business programs at the university level, and The F.C. Manning School of Business Administration is no exception. As you will be using case studies in many of the courses over the next four years, it is important that you get off to a good start by learning the proper way to approach and complete them.

How to do a Case Study

While there is no one definitive "Case Method" or approach, there are common steps that most approaches recommend be followed in tackling a case study. It is inevitable that different Instructors will tell you to do things differently, this is part of life and will also be part of working for others. This variety is beneficial since it will show you different ways of approaching decision making. What follows is intended to be a rather general approach, portions of which have been taken from an excellent book entitled, Learning with Cases, by Erskine, Leenders, & Mauffette-Leenders, published by the Richard Ivey School of Business, The University of Western Ontario, 1997.

Beforehand (usually a week before), you will get:
  1. the case study,
  2. (often) some guiding questions that will need to be answered, and
  3. (sometimes) some reading assignments that have some relevance to the case subject.
Your work in completing the case can be divided up into three components:
  1. what you do to prepare before the class discussion,
  2. what takes place in the class discussion of the case, and
  3. anything required after the class discussion has taken place.
For maximum effectiveness, it is essential that you do all three components. Here are the subcomponents, in order. We will discuss them in more detail shortly.
  1. Before the class discussion:
    1. Read the reading assignments (if any)
    2. Use the Short Cycle Process to familiarize yourself with the case.
    3. Use the Long Cycle Process to analyze the case
    4. Usually there will be group meetings to discuss your ideas.
    5. Write up the case (if required)
  2. In the class discussion:
    1. Someone will start the discussion, usually at the prompting of the Instructor.
    2. Listen carefully and take notes. Pay close attention to assumptions. Insist that they are clearly stated.
    3. Take part in the discussion. Your contribution is important, and is likely a part of your evaluation for the course.
  3. After the class discussion:
    1. Review ASAP after the class. Note what the key concept was and how the case fits into the course.
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Preparing A Case Study

It helps to have a system when sitting down to prepare a case study as the amount of information and issues to be resolved can initially seem quite overwhelming. The following is a good way to start.

Step 1: The Short Cycle Process
  1. Quickly read the case. If it is a long case, at this stage you may want to read only the first few and last paragraphs. You should then be able to
  2. Answer the following questions:
    1. Who is the decision maker in this case, and what is their position and responsibilities?
    2. What appears to be the issue (of concern, problem, challenge, or opportunity) and its significance for the organization?
    3. Why has the issue arisen and why is the decision maker involved now?
    4. When does the decision maker have to decide, resolve, act or dispose of the issue? What is the urgency to the situation?
  3. Take a look at the Exhibits to see what numbers have been provided.
  4. Review the case subtitles to see what areas are covered in more depth.
  5. Review the case questions if they have been provided. This may give you some clues are what the main issues are to be resolved.
You should now be familiar with what the case study is about, and are ready to begin the process of analyzing it. You are not done yet! Many students mistakenly believe that this is all the preparation needed for a class discussion of a case study. If this was the extent of your preparation, your ability to contribute to the discussion would likely be limited to the first one quarter of the class time allotted. You need to go further to prepare the case, using the next step. One of the primary reasons for doing the short cycle process is to give you an indication of how much work will need to be done to prepare the case study properly.

Step 2: The Long Cycle Process

At this point, the task consists of two parts:
  1. A detailed reading of the case, and then
  2. Analyzing the case.
When you are doing the detailed reading of the case study, look for the following sections:
  1. Opening paragraph: introduces the situation.
  2. Background information: industry, organization, products, history, competition, financial information, and anything else of significance.
  3. Specific (functional) area of interest: marketing, finance, operations, human resources, or integrated.
  4. The specific problem or decision(s) to be made.
  5. Alternatives open to the decision maker, which may or may not be stated in the case.
  6. Conclusion: sets up the task, any constraints or limitations, and the urgency of the situation.
Most, but not all case studies will follow this format. The purpose here is to thoroughly understand the situation and the decisions that will need to be made. Take your time, make notes, and keep focussed on your objectives.

Analyzing the case should take the following steps:
  1. Defining the issue(s)
  2. Analyzing the case data
  3. Generating alternatives
  4. Selecting decision criteria
  5. Analyzing and evaluating alternatives
  6. Selecting the preferred alternative
  7. Developing an action/implementation plan

Defining the issue(s)/Problem Statement

The problem statement should be a clear, concise statement of exactly what needs to be addressed. This is not easy to write! The work that you did in the short cycle process answered the basic questions. Now it is time to decide what the main issues to be addressed are going to be in much more detail. Asking yourself the following questions may help:
  1. What appears to be the problem(s) here?
  2. How do I know that this is a problem? Note that by asking this question, you will be helping to differentiate the symptoms of the problem from the problem itself. Example: while declining sales or unhappy employees are a problem to most companies, they are in fact, symptoms of underlying problems which need to addressed.
  3. What are the immediate issues that need to be addressed? This helps to differentiate between issues that can be resolved within the context of the case, and those that are bigger issues that needed to addressed at a another time (preferably by someone else!).
  4. Differentiate between importance and urgency for the issues identified. Some issues may appear to be urgent, but upon closer examination are relatively unimportant, while others may be far more important (relative to solving our problem) than urgent. You want to deal with important issues in order of urgency to keep focussed on your objective. Important issues are those that have a significant effect on:
    1. profitability,
    2. strategic direction of the company,
    3. source of competitive advantage,
    4. morale of the company's employees, and/or
    5. customer satisfaction.
The problem statement may be framed as a question, eg: What should Joe do? or How can Mr Smith improve market share? Usually the problem statement has to be re-written several times during the analysis of a case, as you peel back the layers of symptoms or causation.

Analyzing Case Data

In analyzing the case data, you are trying to answer the following:
  1. Why or how did these issues arise? You are trying to determine cause and effect for the problems identified. You cannot solve a problem that you cannot determine the cause of! It may be helpful to think of the organization in question as consisting of the following components:
    1. resources, such as materials, equipment, or supplies, and
    2. people who transform these resources using
    3. processes, which creates something of greater value.
    Now, where are the problems being caused within this framework, and why?
  2. Who is affected most by this issues? You are trying to identify who are the relevant stakeholders to the situation, and who will be affected by the decisions to be made.
  3. What are the constraints and opportunities implicit to this situation? It is very rare that resources are not a constraint, and allocations must be made on the assumption that not enough will be available to please everyone.
  4. What do the numbers tell you? You need to take a look at the numbers given in the case study and make a judgement as to their relevance to the problem identified. Not all numbers will be immediately useful or relevant, but you need to be careful not to overlook anything. When deciding to analyze numbers, keep in mind why you are doing it, and what you intend to do with the result. Use common sense and comparisons to industry standards when making judgements as to the meaning of your answers to avoid jumping to conclusions.

Generating Alternatives

This section deals with different ways in which the problem can be resolved. Typically, there are many (the joke is at least three), and being creative at this stage helps. Things to remember at this stage are:
  1. Be realistic! While you might be able to find a dozen alternatives, keep in mind that they should be realistic and fit within the constraints of the situation.
  2. The alternatives should be mutually exclusive, that is, they cannot happen at the same time.
  3. Not making a decision pending further investigation is not an acceptable decision for any case study that you will analyze. A manager can always delay making a decision to gather more information, which is not managing at all! The whole point to this exercise is to learn how to make good decisions, and having imperfect information is normal for most business decisions, not the exception.
  4. Doing nothing as in not changing your strategy can be a viable alternative, provided it is being recommended for the correct reasons, as will be discussed below.
  5. Avoid the meat sandwich method of providing only two other clearly undesirable alternatives to make one reasonable alternative look better by comparison. This will be painfully obvious to the reader, and just shows laziness on your part in not being able to come up with more than one decent alternative.
  6. Keep in mind that any alternative chosen will need to be implemented at some point, and if serious obstacles exist to successfully doing this, then you are the one who will look bad for suggesting it.
Once the alternatives have been identified, a method of evaluating them and selecting the most appropriate one needs to be used to arrive at a decision.

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Key Decision Criteria

A very important concept to understand, they answer the question of how you are going to decide which alternative is the best one to choose. Other than choosing randomly, we will always employ some criteria in making any decision. Think about the last time that you make a purchase decision for an article of clothing. Why did you choose the article that you did? The criteria that you may have used could have been:
  1. fit
  2. price
  3. fashion
  4. colour
  5. approval of friend/family
  6. availability
Note that any one of these criteria could appropriately finish the sentence, the brand/style that I choose to purchase must.... These criteria are also how you will define or determine that a successful purchase decision has been made. For a business situation, the key decision criteria are those things that are important to the organization making the decision, and they will be used to evaluate the suitability of each alternative recommended.

Key decision criteria should be:
  1. Brief, preferably in point form, such as
    1. improve (or at least maintain) profitability,
    2. increase sales, market share, or return on investment,
    3. maintain customer satisfaction, corporate image,
    4. be consistent with the corporate mission or strategy,
    5. within our present (or future) resources and capabilities,
    6. within acceptable risk parameters,
    7. ease or speed of implementation,
    8. employee morale, safety, or turnover,
    9. retain flexibility, and/or
    10. minimize environmental impact.
  2. Measurable, at least to the point of comparison, such as alternative A will improve profitability more that alternative B.
  3. Be related to your problem statement, and alternatives. If you find that you are talking about something else, that is a sign of a missing alternative or key decision criteria, or a poorly formed problem statement.
Students tend to find the concept of key decision criteria very confusing, so you will probably find that you re-write them several times as you analyze the case. They are similar to constraints or limitations, but are used to evaluate alternatives.

Evaluation of Alternatives

If you have done the above properly, this should be straightforward. You measure the alternatives against each key decision criteria. Often you can set up a simple table with key decision criteria as columns and alternatives as rows, and write this section based on the table. Each alternative must be compared to each criteria and its suitability ranked in some way, such as met/not met, or in relation to the other alternatives, such as better than, or highest. This will be important to selecting an alternative. Another method that can be used is to list the advantages and disadvantages (pros/cons) of each alternative, and then discussing the short and long term implications of choosing each. Note that this implies that you have already predicted the most likely outcome of each of the alternatives. Some students find it helpful to consider three different levels of outcome, such as best, worst, and most likely, as another way of evaluating alternatives.

Recommendation

You must have one! Business people are decision-makers; this is your opportunity to practice making decisions. Give a justification for your decision (use the KDC's). Check to make sure that it is one (and only one) of your Alternatives and that it does resolve what you defined as the Problem.


Structure of the Written Report

Different Instructors will require different formats for case reports, but they should all have roughly the same general content. For this course, the report should have the following sections in this order:
  1. Title page
  2. Table of contents
  3. Executive summary
  4. Problem (Issue) statement
  5. Data analysis
  6. Key Decision Criteria
  7. Alternatives analysis
  8. Recommendations
  9. Action and Implementation Plan
  10. Exhibits

Notes on Written Reports:

Always remember that you will be judged by the quality of your work, which includes your written work such as case study reports. Sloppy, dis-organized, poor quality work will say more about you than you probably want said! To ensure the quality of your written work, keep the following in mind when writing your report:
  1. Proof-read your work! Not just on the screen while you write it, but the hard copy after it is printed. Fix the errors before submitting.
  2. Use spell checker to eliminate spelling errors
  3. Use grammar checking to avoid common grammatical errors such as run on sentences.
  4. Note that restating of case facts is not included in the format of the case report, nor is it considered part of analysis. Anyone reading your report will be familiar with the case, and you need only to mention facts that are relevant to (and support) your analysis or recommendation as you need them.
  5. If you are going to include exhibits (particularly numbers) in your report, you will need to refer to them within the body of your report, not just tack them on at the end! This reference should be in the form of supporting conclusions that you are making in your analysis. The reader should not have to guess why particular exhibits have been included, nor what they mean. If you do not plan to refer to them, then leave them out.
  6. Write in a formal manner suitable for scholarly work, rather than a letter to a friend.
  7. Common sense and logical thinking can do wonders for your evaluation!
  8. You should expect that the computer lab's printer will not be functioning in the twelve hours prior to your deadline for submission. Plan for it!
  9. Proof-read your work! Have someone else read it too! (particularly if english is not your first language) This second pair of eyes will give you an objective opinion of how well your report holds together.

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