September-October 2020

Eliminating the Problems From Problem Lists
By Elizabeth S. Goar
For The Record
Vol. 32 No. 5 P. 20

These tools can live up to their moniker in more ways than one. Learn how to get them back on the right path.

Problem lists play an integral role in health care, providing a single source documenting the illnesses, injuries, and other factors impacting a patient’s health. Typically, they list the time of occurrence or identification and the approach to resolving the issue, making them an important communication tool across the care continuum. However, in today’s electronic environment, many problem lists have fallen victim to information overload.

“I consider the problem list the ‘index’ to the ‘book’ about the patient. It serves as the roadmap of where the patient ‘traveled’ in their health history. Each of these analogies require it to be accurate or we won’t be able to determine what is important about the patient at the time the patient is treated,” says Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, chief operating officer at First Class Solutions.

However, when problem lists are not properly maintained, they become cluttered with outdated or redundant information of little clinical value, which quickly diminishes their usefulness.

For example, an outdated problem list “may reflect the problem for which the patient is being treated today but also all the prior conditions, many of which may no longer be pertinent although they are all appearing as ‘active.’ If a thorough assessment of the patient is to occur, the provider should be addressing all active conditions. The fact that I had multiple bee stings four years ago is no longer relevant,” Dunn says.

The Problem List’s Importance
The problem list was first defined and created by Lawrence Weed in the 1960s as part of a problem-oriented medical record (POMR). Today, problem lists are widely used as a basis for problem-oriented charting and to meet accreditation standards and EHR incentive payment requirements.

Considered by many to be the centerpiece of the POMR, the problem list was designed to include all of a patient’s past and present medical problems, as well as those related to social and psychiatric difficulties.

Today’s problem lists allow physicians to quickly review a patient’s ongoing health problems, says Rae Freeman, RHIA, CHPS, CDIP, CCS-P, senior manager of consulting with Healthcare Coding & Consulting Services. “The lists can be utilized for multiple reasons, such as to identify which of the physician’s patients have a specific disease or condition, and may benefit from specialized information such as a new medication,” she says.

Dunn says a clean problem list will save time in a clinician’s initial exam and assessment or reassessment. It can also be used “as a ‘feed’ for artificial intelligence clinical data messaging, to offer options for consideration to the provider for provisional diagnosing, medications, and treatment to address the maladies presented,” she says, adding that it can also serve as “the source of truth for the claim.”

In its practice brief “Problem List Guidance in the EHR,” AHIMA notes that accurate problem lists “are an important communication vehicle used throughout the entire health care continuum. … Well-designed problem lists provide a clear picture of patient issues requiring consideration or intervention and frequently serve as a table of contents for more comprehensive health record details. In addition, problem lists offer a data source for research studies, quality measures, and other secondary data reporting requirements.”

However, despite their role in advancing care quality and safety, problem lists have presented challenges over the years for various reasons.

A List of Problems
As the role of problem lists expands in patient care, so too does the challenge of keeping them current. Among these, Freeman says, are physicians or other providers forgetting to include a diagnosis or condition and no policies or procedures to standardize the information within the problem list. However, EHR design often creates the most significant challenges, typically around the utilization of free text, drop-down menus, data entry, and abbreviations.

“EHR designs can make the problem worse—for example, by not allowing the option to add a condition or diagnosis from the physician documentation to the problem list, which [would make it] much easier to keep updated,” Freeman says. “Sometimes, having a drop-down selection is actually more difficult for the physician since they do not think in coding terminology.”

Dunn identifies several additional issues that can be traced back to EHR design, starting with the challenges of adding or deleting a problem. The process of doing so is often cumbersome and may not be consistent with the approach of the provider’s exam. For example, if the physician needs to flip from one screen to another to add a problem to the list, it is less likely to happen.

Furthermore, EHRs often allow just two statuses: active and resolved. Dunn surmises that some clinicians leave the status as active to monitor for any recurrences of a listed condition. It’s an approach that “creates an unwieldy list of conditions that often exceeds the allowed number of conditions and loses the value of important past conditions that are truncated from the list and trends of other conditions,” she says, adding that the inclusion of a third “recurring” status option could resolve this problem.

The format of problem lists within the EHR also leaves much to be desired, Dunn says. However, the most serious issue with EHR design is that “some EHRs automatically send the codes associated with the list of conditions in the problem list to the claim. If the problem list is not accurately maintained to truly represent active conditions for which the patient is being treated, then the claim will falsely represent conditions associated with the services the provider provided,” she says.

Dunn adds, “Practitioners in active practice have clearly not been involved in the design of some EHRs. The workflow is not consistent with the practicing provider’s approach to examining and diagnosing the health of patients.”

Maintaining the List
If problem lists are to deliver on the promised benefits of improved patient care, regular pruning is a necessity to enable physicians to “see at a glance what the problems are for the patient, but any reports that are prepared with these data are more likely correct and current,” Freeman says.

The problem, according to AHIMA’s practice brief, is that many organizations struggle to assign accountability for problem list maintenance and even what content is required for an accurate, updated problem list. The organization recommends establishing clear policies and guidance on the structure and use of problem lists, which will help ensure reliability and integrity.

The responsibility of maintaining the problem list typically falls upon the attending physician, which can be problematic if the process doesn’t integrate smoothly into the clinician’s workflow. AHIMA notes, “If the functionality for adding and removing active problems is difficult or awkward to accomplish, the list can become overwhelming and unreliable as a current data source.”

For this reason, Dunn advocates for putting maintenance in the hands of a certified/credentialed coding professional. Coding professionals are fully qualified to review physician-provided documentation on what conditions are being treated or assessed. If the status cannot be ascertained by the coder, a query can be sent to the physician.

“If a change in the status of a problem is initiated by the coder, then perhaps there could be an option for the EHR to trigger an ‘acceptance’ by the provider at the time of the next examination. The trigger would need to be easy to address or it, too, will be bypassed by the provider,” Dunn says. “Alternatively, the nurse assisting the provider could do it at the time of the nurse’s interview with the patient prior to being seen by the provider.”

The latter approach is less attractive for financial reasons, Dunn says, noting that the use of higher-paid individuals to manage tasks other than clinical is impractical at a time when reimbursement is minimal.

“However, the flipside of this approach is that the patient may be more willing to disclose conditions to the nurse and, therefore, the problem list would actually be enhanced,” she says. “To that end, the front-end collection of the complete and accurately statused problem list will facilitate the physician’s assessment.”

Success Strategies
Once accountability has been assigned, there are several strategies hospitals and physician practices can take to keep problem lists problem-free. Freeman recommends conducting annual reviews, breaking the tasks into sections to make the process more manageable.

She also suggests involving patients in the maintenance process by providing a channel for them to report any errors they may see on their problem list when reviewing it via a patient portal. That action could be triggered by conducting “a survey of the patients to determine if they have viewed their problem list.”

For physician practices, Dunn recommends implementing an “at or after every visit” maintenance policy in which a nurse or other member of the health care team updates the problem list at the time of the patient’s visit or the coding team does so after the fact.

“An additive measure that can be beneficial is to have the receptionist ask whether the patient is seeing any other physicians. If the patient is seeing another physician and agrees to allow that physician to release their records to this physician, then, when the records are received, additional problems or conditions may be identified for which this physician may wish to query the patient about upon the next visit,” she says, adding that “this requires a staging of the conditions for the patient’s next visit and can also be done by the coding team based on scheduled visits.”

Dunn notes that this additional documentation will help the physician evaluate the interaction of conditions that were known with those that may not have been known because they were being treated by another provider. It will also allow the physician to assess the new conditions and associated medications to avoid any treatment contraindications.

Finally, under this approach, physicians reimbursed under hierarchical condition categories may see an increase in the number achieved.

First, however, Dunn recommends undertaking a one-time cleanup in which the coding team assesses the problem lists of patients seen the same month the prior year and updates them based on the documentation present for that patient during that month’s and any subsequent visits during the prior year. As the year progresses all patients seen the prior year will have been assessed, and, if they return during the current year, their problem list would have been updated as well. Going forward, only patients not seen since two or more years ago would require problem list review.

“When we consider the hospital setting, I would propose that the ‘after-the-visit’ approach is used with an automated query to the physician to assess the statuses applied by the coding professional or an indicator to show that the problem’s status has been modified by the ‘role’ of coder,” Dunn says. “Will EHR vendors accommodate either of these features? We need to push them to do so.”

— Elizabeth S. Goar is a freelance writer based in Wisconsin.