Both requiring and fostering data capture, problem lists are a Meaningful Use objective. A current and accurate problem list serves as “a catalyst for many other objectives within Meaningful Use,” according to Michelle Consolazio Nelson, MPA, of the Office of the National Coordinator of Health IT’s Office of the Chief Medical Officer, such as patient engagement, information exchange and care coordination.
The problem list is a required element of the care summary. “The goal is for sharing information in the summary of care to improve care coordination,” she said during a recent webinar. It’s also an element within the view, download and transmit requirements.
“We’re at a point where providers are entering their data and starting to use the problem list,” she says. “For quality measures, almost everything is based upon that problem list.”
The problem list has been around since paper records but offers more benefits within the EHR including scheduling, identifying patients with specific conditions and determining appropriate visit intervals, says Jerry Fingerut, MD, medical director of Blackstone Valley Community Health Care in Pawtucket, R.I. Blackstone has been a patient-centered medical home since 2011 and conducts about 60,000 annual visits.
The diagnoses and codes in the problem list are needed to trigger clinical decision support (CDS), Fingerut says. Diagnoses should correlate with medications and are needed to initiate alerts and stops for items such as drug-disease interactions.
There are numerous challenges to having up-to-date and accurate problem lists, Fingerut says. For example, it’s not unusual to have more than a dozen problems on the list. If the list is too long and “can only be seen by scrolling down, use may be diminished and some problems overlooked. Also, the list must be accurate or it will fall into disuse.” There are policy issues as well, such as the problem list’s location within the EHR relative to workflow and how to print or send confidential information.
Blackstone uses a clinical data warehouse to crate single patient reports which are used for previsit planning, says COO Christine Grey. To coordinate team-based care, the report breaks down items by role “so each team player can easily see what to address,” she says. Reviewing problems and medications is a top priority to plan for each day’s patients. The report can be expanded to show patient details, allowing clinicians to track uncompleted labs and imaging tests and reach out to patients who have not kept appointments.
Accuracy begets proactive care
“It’s so critical to have that active problem list,” says Jose Polanco, MD, assistant medical director and CMIO. During morning huddles, the care teams can see which patients need a reminder call or whether consult reports have been received. “We can know in an instant who is missing different tests and screenings. We go through the highlights, particularly for our high-risk patients.”
Meanwhile, patient registries “make it possible for us to participate in incentive programs because we can manage our patient populations proactively,” says Grey. “Without diabetes diagnoses reported as structured data, the creation and accuracy of registries would be difficult, if not impossible.”
An abundance of data
Before a problem list can be used to improve care, problems must be entered—but not all healthcare organizations’ clinicians keep their patient’s problem lists up to date. ABQ Health Partners, a multispecialty medical group based in Albuquerque, tied problem lists to bonuses to combat the problem, says Robert White, MD, medical informatics director. They were so successful that they recently dropped the bonus so they could move on to other issues.
“When we started this process, we wanted to make sure something was on the problem list,” says White. Between tying in bonuses and requiring problems to be entered in order for charges to go through, he says it wasn’t difficult to get more content on the lists. However, they ceased the bonuses because, if anything, they got too much information, he says. “We had problem lists with 20 terms on them and one-third were no longer accurate or were never accurate.”
White says he hopes ICD-10 will drive greater accuracy of the problem list because “we’ll be working in a new system that will force clinicians to be more exact. I’m hoping that, in that process, they’ll eliminate problems that are no longer accurate. No one other than the clinicians is going to address clinical content. The harder part is making sure they’re upping their level of documentation and diagnostic accuracy. That’s the part there’s no IT solution to.”
White has considered other ways to improve the quality of the problem list. His organization has a compliance audit team that goes through records looking for accuracy. “The problem is, they’re mainly looking for errors of omission. If lists are too long, no one outside of a conscientious physician who realizes some can be cut is going to solve the problem. It is hard to figure out how to reward people to really make an accurate problem list truncated and trimmed down to those things that are important.”
Whether through Meaningful Use, ICD-10 or another initiative, the use and importance of the problem list is only going to increase.