Article 1: The Purpose and the Function of the Problem List
The concept of the patient’s problem list is not new to the ambulatory community. For decades, primary care providers have employed problem lists in both paper and electronic forms. Now, however, a revolution is afoot since, with the advent of Meaningful Use regulations, suddenly the inpatient community is being forced to use problem lists as well. This sudden change has driven inpatient and outpatient providers into a series of conversations around a central, fundamental question: what is a problem list for?
An agreement on the answer to this simple question has been harder to reach than anyone would have hoped. In the years since 1968, when Dr. Lawrence Weed wrote his landmark article outlining the concept of the problem-oriented medical record (1), opinions regarding the purpose of the Problem List have varied both between communities and also within communities over time. One divide has been between providers who use problem lists in isolation from the rest of their community versus inter-disciplinary groups of providers who share lists. Especially in the first case, some have seen the Problem List only as a checklist for individual providers to use when organizing and tracking the care of their patients. In contrast, and especially with those who share problem lists, others have seen these lists as a tool to communicate and track the essentials of a patient’s conditions across care settings. As a consequence of this divide, there have been subsequent differences regarding workflow specifics, such as how to maintain problem lists, or what types and what specificity of problems to keep on a list. To say the least, a lack of common understanding as to the purpose of problem lists has made it difficult to design widespread, common systems to use them. Fortunately there is an emerging national consensus as to a definition.
Consensus starts with Dr. Weed's supposition that, “…the primary organization of the medical record should be by medical problem and that all diagnostic and therapeutic plans be linked to a specific problem.”2 Further clarification has come with the advent of the shared Electronic Health Records (EHR), which has necessitated international definitions for those who review and certify these tools. For example, in 2008 the American Health Information Management Association (AHIMA) refined the concept of the Problem List with a Best Practices guideline, suggesting that:
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The Problem List is “…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)
A prime goal of the Problem List, according to AHIMA, is to retain information across the continuum of care.
Other authoritative sources have chimed in. In 2007, Health Level Seven suggested:
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"A problem list may include, but is not limited to: Chronic conditions, diagnoses, or symptoms, functional limitations, visit or stay-specific conditions, diagnoses, or symptoms. Problem lists are managed over time, whether over the course of a visit or stay or the life of a patient, allowing documentation of historical information and tracking [of] the changing character of problem(s) and their priority." (3)
The American Society for Testing and Materials (ASTM) too has published a congruent definition. (4)
Compiling these similar definitions, one gathers a common vision of the Problem List as a snapshot of the totality of a patient’s conditions at any given time, a snapshot with many subsequent and related sub-purposes:
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To communicate an abbreviated version of the patient’s story to the next provider of care;
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To organize care within and across visits (i.e, for both episodic and longitudinal care plans);
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To serve as a checklist, especially for complex patients, prompting timely review of all important problems;
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To prompt automated clinical decision support;
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To track and trend disease incidence, prevalence and quality of care (i.e., for public health surveillance); and
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To assist with coding and billing, although not necessarily to be definitive for either.
A key point about this vision is the shared nature of the list, for a shared list requires a common understanding of the maintenance and use of the list, within and throughout the many care settings where the patient may land.
MEDITECH’s job at this point is to make sure that its clients agree with this vision. To that end, MEDITECH staff will embark on a series of conversations with its provider community over the next several months. Only when there is a semblance of consensus on the purpose of Problem Lists can MEDITECH advance the design of its software so that providers may use them more efficiently, effectively and to the greater benefit of the patient.
Works Cited:
(1) Weed, Lawrence L. “Medical Records that Guide and Teach.” New England Journal of Medicine 278, no. 11 (1968): 593–600.
(2) “Best Practices for Problem Lists in an HER.” Journal of AHIMA 79, no. 1 (January 2008): 73-77.
(3) "Health Level Seven Electronic Health Record System Functional Model, Release 1, Chapter 3: Direct Care Functions." Page 15. February, 2007.
(4) ASTM International Standard Practice for Content and Structure of the Electronic Health Record (EHR) (E1384-02a).