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Doctors Really Care About Their Patients and UTD Problem Lists

October 14, 2010
by Joe Bormel
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How problem lists can add quality to patient care

Here's a true story recently told to me by a surgeon friend. Let's call him Dr Clark:

Dr. Clark, a highly skilled and caring surgeon, receives an unexpected phone call. It's from the wife of Charlie, a patient he discharged after a successful surgery and post-operative recovery two weeks earlier. "Charlie is dead," she said.

Charlie was compliant in the hospital with the orders to ambulate after surgery. He understood the discharge instructions to progressively continue to ambulate when he got home. "Dr. Clark isn't here. I'm tired and weak. I have no intention of ambulating any more than I have to for meals and the bathroom," he told his wife.

After several days at home, Charlie stood up, gave a facial expression of "uh oh," and fell over dead from a massive pulmonary embolus.

More than a decade later, Dr. Clark still remembers Charlie vividly. As a result, at the slightest sign or suspicion of patient resistance to post op ambulation therapy, Dr. Clark goes above and beyond his peers when dealing with patients like Charlie. For example, he recently told a patient that if he didn't ambulate by noon, Dr. Clark would have his bed rolled to the far end of the long hospital hallway, have security evict the patient from the bed, and then have the bed moved back to his empty room.

The patient said, "You're kidding, right?" Dr. Clark replied, without a smile, "No."

Why am I sharing this story? As a result of the ARRA requirement (as outlined in section 170.302(c), Maintain electronic, up-to-date problem list), CIOs, CMIOs, and CMOs are planning for their ED and inpatient strategies to get these lists populated and maintained. All clinicians I've met strongly welcome this requirement. They see the value to their patients and themselves. Most of these same clinicians are, within reason, willing to enter problems directly into the EHRs themselves. Most hospitalists I've met are also highly enthusiastic about it. This attention to the complexity of real, hospitalized patients is part of what they love!

I've heard some understandable concerns as well. Suppose an emergency medicine physician documents a problem that is not directly related to a patient's reason-for-visit to the Emergency Department. Many of these physicians are recognizing that as a result of adding this problem to a problem list, they have some new, newly explicit, or perceived duties.

They have a duty to consider and be accountable for their conclusion that the problem they added is not urgent or emergent relative to this encounter. Even when they schedule follow-up for this patient's non-emergent problem, they don't feel they have necessarily relieved their obligation, even though they have addressed the newly documented problem. The reason? Like Dr. Clark, they have had their own patients like Charlie. They're highly responsible doctors who believe they cannot trust the health system, the accountable primary care physician, or the patient to close the loop and reliably address anything they add to the problem list. Heck, they have some of their own problems they haven't been able to get around to caring for, i.e. diet and exercise. I certainly struggle with that.

Conclusions:

  1. UTD Problem Lists are a great and necessary thing. Aside from regulatory issues, they are the right thing to do.
  2. Closing the loop on care processes is exactly what EHRs and MU are all about. See my prior problem list post; Stage 3 of ARRA is explicitly about improving access, care quality and accountable costs. UTDPLs are a vital link in that closed-loop chain.
  3. Some healthcare systems will institute new or expanded screening programs as a result of ARRA/HITECH UTDPLs out of respect for the needs of people like Charlie, and Dr. Clark, who need or want follow-up care and its coordination. UTDPL shines a bright light on that need and issue.

In closing, I would like to know what you think by asking you to answer three questions:

Who owns the Problem List?

Who owns the problem while the patient is hospitalized or visiting the ED?

Who owns the problem after the patient is discharged?

 

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Comments

Oh, and how 'bout this:
We now have 'Meaningful Use' for providers. Do it and you get a bonus (maybe), do not and you get a penalty!

So next is: Meaningful Response. The patient attests that he/she will be compliant with all practioner discharge directives. He/she must complete an online form each day attesting to his/her compliance (subject to audit of couse).

Failure to do will result in an insurance premium penalty of 10%. Adherence will get you a 10% discount!
Hey wait a minute, aren't we already doing this. I think this is what the Allstate guy says on the TV adds. Works for car insurance, so I am sure it'll work for health insurance.

Rich and Frank, Thank you both for your terrific perspectives. They certainly are helping me clarify the question. They are also making it clear that we are dealing with more of predicament (non solvable) than a problem (solvable).

Rich, the law may be follow me here, but I expect that if I go to one of the clinics (Mayo, Cleveland, Geissinger, or Hopkins), I will be directed to the best evidence or at least expert that informs my diagnostic and therapeutic plan. I expect any physician employed by such an organization, to provide such. The notion is implied by credentialing, although I appreciate the historical limitations.

So, a codified problem on a problem under this scenario creates a fiduciary responsibility to such a clinic. A responsibility that if far more implicit today, pre UTDPL.

The patient does own the consequence of their problems, risks and duty to compliance with a shared plan being part of that.

I was interested in your bringing up the issue of the lie. The issue of why the person is lying becomes extremely relevant. Today, the payment system causes people to be silent about their role in their problem. For example, patients with bad outcomes seldom point out or acknowledge that their behavior was contributory, since it could result in the claim being denied. Frank's observations about lessons from auto insurance are highly relevant. Patient's generally expect a "no fault" paradigm.

Frank, I though your extension from Meaningful Use to an individual mandate, the patient's Meaningful Response, was understandable. It gets messy immediately in our pluralistic society. Helmets, handguns, and hair dyes comes to mind. The later assumes that there was or is a linkage to such dyes triggering auto-immune diseases.

My take is far more good than harm will come from UTDPLs. They will change our lives.

Thanks for your perspective Doc Benjamin.

I think that with time, we will come to see problem lists much the way we see accounting. There is not one correct way to do it. Accounting is based on the purpose it is being done for. Hence, there are income statements, cash flow and balance sheets, activity-based formulations and various costing approaches. The variations reflect who is doing the accounting and what work are they trying to get done.

It seems inevitable that health systems, especially those who assume financial risk, will maintain what amounts to their own problem lists for each client (previously known as patients.) Consumers will have their own explicit problem lists, in their PHRs and elsewhere (e.g. lifestyle management software for diet, exercise, mental health, etc.) Same for payers, search engine companies, and anyone using CRM systems.

Perhaps the UTDPL mandate serves most (and nothing more than) to highlight the risks already inherent in our own professions and businesses.

Dr. Joe,

Nice Post.  Two observations.

First, on the general subject of who owns the record.

This one's not so straightforward.  In my view, the patient owns the problems; the provider owns the list.  Like the accounting profession, the client owns the information; the accountant owns the book.

Which clinician manages which problem or problems?  Is that not for the patient to decide?  In a health care delivery system with many, many specialists, who sets the boundaries for where one specialist makes decisions on treatments that may or may not be his/hers to make or which overlap with treatments of other problems not within that clinician's boundaries: e.g., changing drugs?

I see where you're going with your argument: if there's a problem list in the EMR, who is accountable?  Since the list is in theory comprehensive, the treating provider(s) or institution is probably responsible for at least one problem on the list and must be cognizant of them all, but may not be responsible (or maybe not wholly responsible) for every problem on the list.  E.g., chronic problems not related to the hip replacement surgery for which patient is in the Orthopedic Hospital with the Orthopedic Surgeon.  By and large, each clinician is licensed and legally an independent entity: there is no certain method for coordination/collaboration across licensed practitioners.

If the patient "owns" the problem or list, what does that mean?  Is he/she free to add, delete, modify?  Lie? In the current world of non-linked records, the patient is clearly able to lie with impunity.  Does society need to include the right to lie in the architecture of interoperable medical records?

Too complex an issue for an easy solution.  This one will take generations.

And I note that the tone of that blog is in terms that I've heard discussed in scenarios ten years ago already.  Apparently, not a whole lot of progress has been made.


Second, the way I read your blog, it's really about a patient complying with discharge instructions and the liability/responsibility on the physician if the patient opts for non-compliance.  I don't see a strong tie to the premise of who owns the problem list; I see that as a very different problem? I.e., who owns post-op risk is a different question than who owns the data.

Rich

Reality check. In my many years in urgent care, I rarely if ever saw an up to date medication list, much less a decent problem list. And that was with an EHR (name I won't mention). One time at the VA a patient had a problem list, as most do, but this one had 73 problems. So, as physicians become more responsible managers of their patients' medical care they are responsible for an accurate medication list at every transition of care. Yes, EVERY, and the same holds true to review on at least a regular basis and updated problem list. Unfortunately, the EHR vendors have not developed a very good standardization of problem list management. Ultimately, the responsibility falls to the medical provider as I am NOT a big fan of patient maintained personal health information (my estimate is about 2-3% of patients are sophisticated enough to do this accurately much less engaged to the process, hence the plug pulling of PHRs by such big players as Revolution Health). However, I do FIRMLY believe patients should have a personal copy of their medical records either kept with them or maintained online in some fashion.

 One perspective from my real-life experience with the ED identification of non-emergent problems for later follow-up is that in our current tort system, just by identifying the problem and putting it in the record, the ED physician (and the ED institution) put itself on the hook for allegations of legal liability if for any reason that problem is not followed up on by the patient or anyone else. I.e., irrespective of the fact that treatment of the identified non-emergent condition would have been inappropriate/impossible in the ED setting, that won’t stop lawsuits from being filed. 

Not saying the plaintiff would win, but that’s a possibility and in any event both clinician and institution would have to pay costs of defending themselves. 

Of course, if the ED physician DOESN’T enter the problem into the problem list, there are both ethical and the same potential argument for tort liability for failure to diagnose/document. 

Your issue is a very real one down in the trenches and the fact that technology now enables a better response, fact is that there is not the system infrastructure in place to ensure that responsibilities are assigned and executed, whether to patient or to institution or to clinician.

IA, Rich and Bob,

Thanks for your observations.

Rich, I like your conclusion. I agree with your conclusion that, although maintaining UTDPLs dont directly fix some of healthcare delivery gaps, they do shine a bright light on actionable issues. Tactically, there's an improved opportunity to find and address needs. Strategically, there's a framework to identify and close-the-loop of processes that are currently out of control.

Dr Budman, I acknowledge your reality check and raise you one! The historical experience with problem lists that you raised are very real. One of the first challenges early-adopters have is the clean-up problem. That said, what was lacking in the past was problem-based workflow. Workflow that led to better, faster, higher quality CPOE, results review and documentation. That's the new reality going forward, and problem lists will be at the center. To your point, these wont be our fathers problem lists.

Thanks all for your great observations.

Dr. Bormel,
A thoughtful post, and truly great comments. They reflect the serious concerns of every clinician I know.

From my point of view, There are many stakeholders in a medical record, but ownership is still being debated at many levels. However, it is the patient's medical record by general definition.

While the patient is hospitalized, those providing treatment have custodial care of the record. It is their responsibility to ensure it remains current.

After discharge, any problem the patient has, once he or she is made aware of it (them) and advised what action is necessary on their part, becomes the patient's responsibility.

No matter what we do, we will not be able to prevent legal action, particularly in a society that has become so prone to file for damages. All we can do is adhere to the guidelines we're provided, and fight legal battles on a case-by-case basis. That's just a fact of life.

Doc Benjamin

I'm with Rich..the patient owns it (except post op).

Whatever happened to personal responsibility? Can we legislate /regulate it all away? I don't think so, but we sure are trying too.

And here will be the next 'documentation requirement'.
The dischage papers will have a Sarbanes-Oxley clause. A signed acknowledgement that your practioner told you in no uncertain terms that if you do not ambulate each day 100ft -YOU WILL DIE! (sign here).

I’ve been in the health care industry all of my career.  Most of the last 15 years has been in various capacities crusading for health IT: standards for administrative and clinical IT so that real data could move easily to where it is needed and useful.  But my earlier years were in various service and administrative roles in a number of hospitals.  That background goes to setting up this comment: I heartily agree with your description of the Dr. Clarks of the world and how they will gravitate to the use of new IT tools as long as they are able to see how those tools will provide tangible benefit to their patients.
 
Now as to your 3 questions on the Problem List:

1)      In the ONC-envisioned HIE world, everybody shares the problem list; nobody “owns” it.

2)      While treating the patient, each clinician has temporary custody of the problem list. He or she makes clinical decisions accordingly: act or not act; consult or not consult. Each clinician is professionally responsible for his/her decisions to act/not act.

3)      After the patient’s departure, the existence of the HIT and the Problem List make no difference: responsibility for taking action belongs to the patient.  Clinicians’ ownership/custody of the Problem List is suspended until the next encounter.  Follow-up reminders (another of the ARRA MU requirements) and calls may be useful and even important, but ultimate responsibility must reside with the patient.
 
In short, HIT and the Problem List do not change Dr. Clark’s dilemma.  IT makes clinicians more aware of the total patient picture and, at least in theory, makes information sharing and collaboration/coordination easier.  But it in no way improves assignment of clinical responsibility or shifts post-discharge/post-visit responsibility away from the patient, despite our national predilection to assign blame by suing every deep pocket within range. 

And more to the point, the HIT does not give Dr. Clark any tools he can employ to absolutely ensure patient compliance post-discharge. HIT and the Problem List are only one small step on that proverbial thousand-mile journey.

Joe Bormel

Healthcare IT Consutant

Joe Bormel

@jbormel

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