The patient problem list, a key component of the electronic health record (EHR), is a list of the important illnesses, injuries, and other factors impacting a patient’s health. American Health Information Management Association (AHIMA) defines the problem list as “a compilation of clinically relevant physical and diagnostic concerns, procedures, and psychosocial and cultural issues that may affect the health status and care of patients”. The list usually states the time that the illness or injury occurred as well as when it was identified and addressed. Medical transcription companies help healthcare providers maintain dynamic problem lists that include all of a patient’s past as well as present medical problems.
A well-maintained problem list would provide the physician with a clear idea of a patient’s health problems that require medical attention or intervention. However, according to AHIMA, many organizations face challenges when it comes to defining what should and should not be included, responsibilities, and accountability for maintaining an accurate, updated problem list.
Uses of Problem Lists
The concept of the problems list was put forward by Lawrence Weed in the 1960s as part of a problem-oriented medical record (POMR). Today, problem lists are used for problem-oriented charting purposes, to meet accreditation standards and for EHR incentive payment requirements. The problem list:
- helps physicians provide customized care based on the most important health factors for each patient
- can be used to recognize disease-specific populations by identifying all patients with a common illness through ICD-10 codes in the EHR
- is useful for quality improvement programs – helps health centers identify disease-specific patient populations, provide follow-up care, and ensure best practices in patient-centered care
- serves as the basis for determining standard measures for practitioners and healthcare institutions.
- can be used to identify patients for potential research studies
Problems with Problem Lists
- Natural Human Errors: Problem lists often fail when it comes to complete accuracy because of natural human errors such as: forgeting to include a diagnosis or condition, describing a condition using incorrect terms or adding a condition that never occurred on the patient’s problem list.
- Confusion about the Content to include the Problem List: Another major point of debate is regarding what diagnosed illnesses should be included in the problem list. Practitioners generally have their own opinions about what diagnosed illnesses should be included in the problem list. For instance, one study noted that practitioners may have differing opinions about listing a family history of breast cancer directly on the problem list. While one provider may consider this important to promote frequent testing, another may argue that this can clutter the problem list by repeating the family history section. (www.bmcmedinformdecismak.biomedcentral.com). As many organizations leave this decision to their practitioners, a shared EHR system may have differing problem lists.
- Comprehensibility: While all of a patient’s health concerns could be included in the problem list, clarity can become a problem if the patient gets sicker. The problem list of a relatively healthy patient may include only less than five nontransitive illnesses, but that of a sicker patient may be a long document with a lot of text, making it difficult to obtain a clear picture of the patient’s health.
- Challenges Posed by EHR Design: Utilization of free text, drop-down menus, data entry, and abbreviations in EHRs is another challenge. If the physician documents a condition or diagnosis and the EHR design does not offer the option to add this to the problem list, it will be difficult to maintain an updated list. EHR design issues that can cause information overload include the challenges of adding or deleting a problem and absence of a ‘recurring’ status option for a listed condition in addition to the existing ‘active’ and ‘resolved’ options.
- Inclusion of Sensitive Information: A key debate is about how much behavioral health information can be shared across the organization. In some cases, access to psychiatry notes is restricted to the psychiatry department. state and federal patient privacy requirements should be considered for clarity on what problems should or should not be included on a problem list.
One serious issue, according to a For the Record article is that some EHRs are designed to automatically send the codes associated with the list of conditions in the problem list to the claim. If the provider does not maintain an accurate problem list that clearly represents the active conditions for which the patient is being treated, the claim will be an inaccurate representation of conditions associated with the services provided by the physician. Fraudulent medical billing attracts stiff penalties and expensive fines.
Creating Problem-Free Problem Lists
A trouble-free problem list is one that will provide the physician with a clear picture of the patient’s problems at a glance. Here are some solutions to maintain accurate problem lists:
- AHIMA recommends that, to ensure integrity and reliability, organizations should establish clear policies and guidance about the structure and use of problem lists.
- Having qualified medical coders review physician documentation can provide clarity about the conditions that are being assessed and treated. Coders can query the physician about any condition that cannot be ascertained.
- Conducting annual reviews
- Involving patients by encouraging them to review their problem list on a patient portal and report any errors they notice.
Outsourcing medical transcription can take care of EHR data entry tasks and allow physicians to focus on their primary goal of patient care.