Other issues regarding problem lists
The Problem List: Current Issues and Controversies
Lawrence Weed coined the idea of the problem list in the 1960s (1). 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” (2). The federal meaningful use program defines the problem list as “a list of current and active diagnoses as well as past diagnoses relevant to the current care of the patient” (3). A problem list may contain diagnoses, previous surgeries, social factors, and family history among other things.
Benefits of Problem lists
Problem lists provide both direct patient care benefits and secondary use benefits. Direct patient care benefits include being a rapid, concise resource for the primary care provider, covering provider, specialist, or other healthcare staff (MA, nurse, etc.) involved in patient care (4). It also can provide longitudinal data regarding the patient, enabling one to see a patient’s problem list evolve over time. Lastly, problem lists are critical for many clinical decision support applications (1) and clinical decision support when used judiciously can improve healthcare quality. In one systematic review, clinical decision support improved healthcare quality 64% of the time (5).
Secondary use benefits include the ability to collect data on populations, which allows a health system to monitor the efficacy of quality improvement initiatives and assess the quality of care (4). Quality of care can be assessed at the macro level of an entire health care system, as well as the micro level of individual providers. In addition, it can also help find patients with specific diagnoses (4) if a new treatment plan becomes available or new adverse event becomes realized. Finally, it enables research studies to detect and contact patients who may qualify for a clinical trial (with patient consent) (4).
Problem list statistics
Most commonly compiled by the primary care provider
-Primary care physicians provide more than 80% of diagnoses on the problem list despite that more than half the notes on the patient are written by other specialties (6).
-Patients who have a primary care provider have nearly three times the numbers of problems listed than those without a primary care provider (6).
Problem lists are often inaccurate
Example: One out of five patients with chronic kidney disease do not have it listed on the problem list (7). This can profoundly affect the patient’s treatment plan (or lack thereof), subsequent renal dosing of medications, as well as clinical decision support capture.
Other medical problem documentation rates for other conditions are listed below. This emphasizes that this is a more pervasive problem (8).
Benign prostatic hyperplasia – 42%
Coronary artery disease – 49%
COPD – 55%
GERD – 56%
Congestive Heart Failure – 73%
Hypertension – 73%
Hyperlipidemia – 74%
Atrial Fibrillation – 75%
Diabetes – 81%
Issues surrounding EHR problem lists
Firstly, there is no common approach or standard to the problem list (1). Many providers have different opinions on what is important to include and what not to include on the problem list. For example, one possible problem on the problem list would be family history of colon cancer. Some practitioners would say it’s important, while others would say it shouldn’t be listed as a problem since the patient doesn’t actually have the condition. Also, there can be too many options to choose from when entering a new problem in an EHR which may lead to inaccuracies or problems with minimal detail (2). Thirdly, building and maintaining accurate problem lists is time consuming and requires persistent revision. (1) (2). Many problem lists lack rigor and are either incomplete, inaccurate, or out of date or the opposite, problem lists have become too comprehensive or cluttered. Old problems that are irrelevant are not removed. In addition, duplicate problems can be listed. The problem list can become too long to quickly read; therefore, getting a good understanding of the patient medical history becomes difficult. Finally, multiple providers and other healthcare personnel (nurses, MA, coders, etc.) often use shared problem lists and have different philosophies of the ideal problem list (2), or conversely have a lack of ownership over the problem list.
In summary, the problem list is a useful tool in the EHR that can be either a blessing or a curse. Further research as well as best practices are needed to utilize this tool to its maximum potential.
1. Healthcare provider attitudes towards the problem list in an electronic health record: a mixed-methods qualitative study. Holmes, Casey, et al. 127, 2012, BMC Medical Informatics and Decision Making, Vol. 12, pp. 1-17.
2. AHIMA Best Practices for Problem Lists in an EHR Work Group. "Best Practices for Problem Lists in an EHR.". 1, January 2008, Journal of AHIMA , Vol. 79, pp. 73-77.
3. Eligible Professional Meaningful Use Core Measures Measure 3 of 14 Stage 1. EHR Incentive Program. [Online] April 2013. http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/3_Maintain_Problem_ListEP.pdf.
4. The problem List Beyond Meaningful Use Part I: The Problems with Problem Lists. Holmes, Casey. February 2011, Journal of AHIMA, pp. 30-33.
5. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. Garg AX, et. al. 10, 2005, JAMA, Vol. 293, pp. 1223-38.
6. Use of an Electronic Problem List by Primary Care Providers and Specialists. Wright, Adam, et al. 8, March 2012, Journal of General Internal Medicine, Vol. 27, pp. 968-973.
7. Under-documentation of chronic kidney disease in the electronic health record in outpatients. Chase, Herbert S., et al. 2010, Journal of the American Medical Informatics Association, Vol. 17, pp. 588-94.
8. Accuracy of Computerized Outpatient Diagnoses in a Veteran Affairs General Medicine Clinic. Szeto, Herbert, et al. 1, January 2002, Vol. 8, pp. 37-43.
Submitted by Sarah Schultz