September 2013

Create Trouble-Free Patient Problem Lists
By David Yeager
For The Record
Vol. 25 No. 12 P. 8

The gradual shift toward customized care has led many providers to look at patient problem lists in a new light. Since they provide a snapshot of a patient’s medical condition, the lists typically are used as point-of-care tools, but they could potentially play a more transformative role. Many HIT professionals believe problem lists will not only be useful for decision support but also for developing best practices and improving the care of entire health populations.

In their most basic form, problem lists chronicle a patient’s medical issues. In addition, they provide historical context to any previous medical encounters that may be affecting the patient’s current status. Rita Scichilone, MHSA, RHIA, CCS, CCS-P, AHIMA’s senior advisor for global standards and coauthor of a white paper on problem list best practices, says the tool offers a convenient overview of a patient’s medical record. “It’s like the table of contents to the health record because it’s succinct and it’s usually front and center in the record to alert clinicians to existing health problems or allergies, even in electronic records,” she says. “And that makes it unique from other types of documentation captured during the episode of care. Physicians keep track of the historic factors that impact a patient’s care, and problem lists are useful reminders.”

What a Provider Wants
Still, there’s much work to be done regarding these lists. Although interest in using problem lists for a broader range of functions has been increasing, there is no consensus on how they should be constructed, populated, or maintained. This ambiguity makes it difficult to share them among providers and, sometimes, within a health care system. A basic challenge with problem lists is defining them; health care organizations tend to apply Justice Potter Stewart’s axiom “I’ll know it when I see it.”

William Holland, MD, director of clinical informatics at Banner Health, a Phoenix-based health system encompassing 24 hospitals and 125 clinical locations in seven states, says providers need to be specific about what constitutes a problem list. “I think what we’ve all wrestled with over the past few years is clearly defining what is meant by ‘problem list.’ I would say that’s probably the most important step, and a lot of organizations miss that initial step or don’t clearly define it,” he says. “In the past, organizations were happy to define the problem list in the ambulatory space for one particular purpose and a problem list in the inpatient space for a slightly different purpose. And I think the times of us being able to do that are probably past.”

Holland says organizations must determine how they intend to use problem lists. Providers typically have looked at them as point-of-care tools, but many now are considering them for decision support, registries, and identifying best practices. Narrow the list’s focus, and it’s easier to decide the type of information to include.

Once the list has been defined, it’s essential to establish who has access and who is responsible for maintenance. In ambulatory settings, a primary care physician typically is responsible for managing the list, while a hospitalist usually handles the task in a hospital setting. However, because specialists often see patients while they’re in the hospital, maintaining an effective workflow can be challenging. Specialists focus on the problem-list items that pertain to them, increasing the chances of important information falling through the cracks.

Ownership issues relating to problem lists especially are challenging because patient information can change frequently. There must be a clearly defined process for adding and updating information. One common problem is that temporary conditions often are not removed when they no longer apply. Holland says developing a consistent problem-list workflow requires a significant amount of buy-in from all stakeholders involved in patient care.

Learning to Share
Because problem lists are one of the objectives covered by meaningful use rules, more are being digitized. This has presented providers with an interesting set of new problems.

As with other paper records, simply converting text to a digital format has limited value; what’s needed is the ability to search the text. For that, structured data are necessary. Structured data also make it possible to autopopulate parts of the medical record and the problem list, which can provide workload relief to clinicians. It’s also a meaningful use requirement. Meaningful use rules stipulate that problem lists include “all past and existing diagnoses, pathophysiological states, potentially significant abnormal physical signs, and laboratory findings, disabilities, and unusual conditions.”

To meet the objective of maintaining an up-to-date problem list of current and active diagnoses, the Centers for Medicare & Medicaid Services requires that more than 80% of a provider’s patients have at least one structured data entry on their problem list or an indication that there are no problems.

However, structured data require standard terminology, meaning diagnoses will most likely need to be coded. Holland says physicians traditionally have resisted using codes for problem lists, but most now accept the need to do so. While there is no industry consensus for how to encode problem lists, AHIMA supports the use of SNOMED CT in EHRs.

In addition to medical uses, coded problem lists also can help reimbursement coders. AHIMA recommends that problem lists be used only as an adjunct to reimbursement coding and not as a final diagnosis set because the recording of problems may be slightly different than completed diagnostic statements because of the timing of entries.

Fresh Ideas
While physicians have long been employing problem lists to guide patient encounters, newer uses with the potential to greatly improve patient care have emerged. Take decision support, for example. Rules can be programmed into an EHR to remind providers of important preventive, diagnostic, and therapeutic considerations, such as when certain vaccinations are due for a condition on the problem list, what test may be required to follow up on a listed condition, or when certain therapies may be contraindicated because of a condition on the problem list.

Hardeep Singh, MD, MPH, an informatics researcher at the Houston VA Health Services Research and Development Center of Excellence and an associate professor of medicine at Baylor College of Medicine, says these types of functions are highly dependent on accurate problem-list data and structured data in a computer-recognizable format. “If the data are accurate, the computer can really help us make better clinical decisions,” he says.

Although excessive alerts and reminders can cause workload fatigue, Singh says designing workflows that get everyone on the health care team involved in the maintenance and use of problem lists can alleviate some of the burden on physicians. In addition to nurses and allied health staff, the team can be expanded to include patients. Scichilone, who considers patient involvement to be health care’s “missing link,” believes patients are an untapped resource.

Because patients are visiting more providers than ever before and the majority of problem-list maintenance is performed at the time of the encounter, it is increasingly important to get patient input to ensure accurate records. Patients often can recognize problem-list inaccuracies before clinicians, which can improve care and reduce medical errors. Also, discharge instructions are based on the problem list, and meaningful use rules mandate greater transparency and patient access to medical data.

Beyond the benefits of treating individual patients, problem lists may help improve care among entire populations. Patients with the same medical condition, such as diabetes or high blood pressure, can be grouped into registries that allow providers to target specific therapies to specific populations through EHR programming rules. For example, Singh cites a study that found patients with heart failure on their problem lists received more effective treatment for that condition.

Researchers also are looking at ways to data mine problem lists to track treatment and outcomes. Such information could potentially revolutionize best practices as well as catch problems sooner and reduce complications. However, it will be practical only when interoperability reaches a point where more systems in and out of the hospital are connected.

Lee Lemelson, vice president of clinical applications at Banner Health, says the ability to compare treatment outcomes among a large group of similar patients eventually may allow physicians to determine which tests and treatments are most effective. “If the problem lists are clearly defined and they have been standardized, either within the organization or across the country, to assist us with implementing the best standards of care, we have a better chance of handling it at the point of care,” he says. “And then, obviously, that patient is discharged or they’re seen by their primary care physician who can use those lists to look at the population in general and say, ‘What’s working and what’s not?’ You can have continuous process improvement if you’ve got that available.”

It may take a while before problem lists can be widely used for process improvement, but the experts agree that there are steps to make the tool more useful right now. Clearly defining what goes on the list, who can contribute content, and who is responsible for its management are solid first steps. Greater standardization and interoperability are also essential; the lists need to be available to all providers as well as patients to achieve maximum benefit.

“If we can have a very nice, clean problem list within our organization for each patient, then when we look to merge data that we’re getting from outside sources, either through claims data, HIE [health information exchange], or other EHR systems with direct feeds, then we have something to compare that against,” Holland says.

— David Yeager is a freelance writer and editor based in Royersford, Pennsylvania.