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Up-To-Date Problem Lists And MU

September 6, 2010
by Joe Bormel
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How involved is your medical staff in using problem lists

When we ranked the Meaningful Use implementation and use challenges from the Final Rule, July 28, 2010, numbers one and two were clearly CPOE and Maintain Up-to-Date Problem List. Last week, following the CCHIT jury testing process, we tested our product's Problem List capabilities (§170.302b) against the government test procedures, as well as CCHIT Inpatient test scripts.

What became immediately clear, and yet not obvious from a distance, is that the government is very serious about the "Up-to-Date" words before the "Problem List" for the inpatient setting. Clearly, creating a one problem Problem List on admission to satisfy the reporting requirement, an approach that more than one CIO asserted would be their approach, will not be "up-to-date" on hospital day two. For example, per TD170.302.c-5, there is an expectation that an acute heart attack be changed from active to inactive.

This point was made by a prominent CIO, Dr. Hal Baker, in his podcast last week as well. Dr. Baker pointed out that the challenges to turning on the Problem List capability within an EMR is easy; and getting a medical staff to use it is complex. These are entirely different issues.

Issue: Historical Reluctance to Use Problem Lists

- Demanding to maintain
- Usually incomplete – so inaccurate
- Often not maintained – results in mistrust
- Problems often linked in a casual way
- Limited classifications, types and status
- Lack of ownership

It stands to reason that, if your goal is to demonstrate Meaningful Use in 2011, creating a shared clinical vision of an up-to-date Problem List is going to be necessary, and will require a campaign and prototype.

To help you get started, here are a few of the benefits you can achieve from evolving toward an up-to-date Problem List:

- Facilitate analysis of potential interaction between patient problems and diagnostic/therapeutic interventions

- Facilitate association of clinical information to a specific medical problem

- Facilitate management of patient chronic conditions

- Support continuity of care

- Improve clinical decision making

- Increase adoption of screening programs and preventive health measures

- Improve communication between health professionals

- Provide a central and concise view of the patient’s medical problems

- Encourage an orderly process of medical problem solving and clinical judgment

- Improve provider productivity, while creating accurate and complete medical records


Installing and turning on certified software is one thing. Achieving and demonstrating Meaningful Use is something more.


What do you think?


Photo: Dr. Thomas Garthwaite, over a decade ago, led an initiative as Under Secretary for Health at Department of Veterans Affairs, driving problem list usage from 60% prevalence to over 90%, as part of a highly successful and systematic set of initiatives to improve cost, quality and access.

http://edocket.access.gpo.gov/2010/pdf/2010-17207.pdf   Page 44336, middle column.

I hope that helps, Dr Joe.

Dr Joe,

While I agree with your comments, the main purpose of ARRA is to improve the quality of care and that cannot be done with an inaccurate Problem List. One entry a year or visit does NOT reflect the patient safety risks associated with the communication between providers of care.

The CMS response provided below states "The term "up-to-date" means the list is POPULATED (meaning added to) with the most recent diagnosis" to help assist judgment in deciding what further probing or updating may be required given the clinical circumstances. If problems are maintained as they should be, then the list will reflect chronic problems that change status over time and so this assists a clinicians judgment in deciding the most appropriate level of care. In addition, the management of problems will provide a history of the patients clinical status, which additionally assists in the most effective level of care. All of this results in reduced costs.

I know this is a very difficult topic to address, but I believe as an informatics community and as clinicians, we need to deliver a clear message that if the Problem List is used appropriately, there will be less work, improved accuracy and completeness which will result in improved patient care and reduced costs.

Obviously, I am very passionate about this because I really believe there is enormous value to the patient, clinician, hospital, etc.

Thanks for helping make the stakes more explicit.

Here's a checklist for an Inpatient, MU-ready Problem List:

1. Flexible Design - ability to arrange required elements to meet varying physician workflow and contributors

* Attending Only
* House Staff (Res, PA, CRNP) + Attending
* Nurse + House Staff + Attending

2. Ability to create problem-based or systems-based problems (e.g. HP might be problem based, but it converts to systems-based if pt admitted to CC)

* ability to easily sort/move problems within the Problem List

3. MU Requirements are met

* able/searchable ICD-9 (option for ICD-10)
* SNOMED Coded elements
* Onset/Inactivated dates recorded
* last modified by date/time recorded avail for display on the note
* Present on Admission Indicator
* Status indicator (worse, improved, etc.)
* Principal/Primary indicator
* ability to sort problems

4. Incorporation of DSS - recommended courses of action and triggering of NQF quality measures

5. Carry forward flexibility options to:

* set carry forward on/off at the field level (e.g. Dx could carry forward, but force users to update the assessment/plan, etc.)
* hover or review yesterday's assessment/plan

6. Validation rules: customer can determine what fields are required option to prevent user from signing the note if fields are not completed or reviewed

7. (near future capability) Use automation (NLP) to create problem list from the HPI

8. Abstraction of problems for reports (to PCP, for HIM, or DC Summary):

* ability to create lists for display on the DC Summary Active Problems (with codes/dates, etc) vs Inactive Problems

Sure, Dr. Joe.

The vision of the stages , in lay terms, is:

Stage 1: Get them to start using an EHR.
Stage 2: Get them proficient at using an EHR.
Stage 3: Make them accountable for quality and outcomes.

My point in my comment was that stage 1 is all about getting a toe in the water not about achieving best clinical practice with problem lists.

The feds will increase the requirements in Stages 2 and 3, but we don't have any advance indication of how high the bar will be raised in either subsequent stage nor what the exact specifications will me.

My guess is that Stage 3 will see rules for 'best practice' requirements around problem lists. Backing into where they want to be in Stage 3, the feds will craft stage 2 to be some kind of midpoint between the stage 1 entry level and the stage 3 best practices level.

The high ground for vendors and provider organizations is to lead users to be using the problem list in a way that adds real and positive value, not just doing the minimum compliance thing which would likely not encourage good clinical practice.

To the original point of your post, that requires medical staff leadership. You and Dr Baker are right. Problem list roll-out is extremely complex and important. Getting it right will improve patient safety through demonstrably better communication. Getting it wrong will be evident if clinicians don't appropriately use and trust the problem list. That clearly wont happen auto-magically by turning on the functionality!

Thanks Rich and Ed.

There is a sentiment that I've heard widely; paraphrasing:

"It is really unnerving that ARRA is being looked as an opportunity to gain funding, rather as a reward for doing the right thing and being effective. "

"If practitioners use the problem list according to the federal regulation minimum and not in a way that makes sense for clinical work flow, then the MU Stage 1 problem list may well add negative value to patient care. "

Rich, I think you were getting at this with your comment "[there is a ] dichotomy in Stage 1."   Can you expand a bit?

IA, Thanks for sharing your insights and your organizations strategy. Per Ed's comment above, and yours above, anything less than maintaining a UTDPL is likely to result in patient harm through a too-blind trust in that list.


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