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at 11:26 pm on Dec 2, 2009
I believe it is the single MOST important EHR document we have, but it takes work. Someone has to own the problem list and it really has to be the primary in/outpatient doctor who is responsible for the diagnoses and management. Specialists should add content through the PCP or be very careful to add only content that does not clutter the list. I do not think there is a significant role for nurses. Stimulating users to update lists can be accomplished by audits (e.g. dates of last entry change), comparisons of active problems with lab/meds/reports (e.g. pathology reports of cancer not reflected on the problem list), peer review (e.g. congestive heart failure diagnosis support by accepted definitions and data), and auditing visit/hospital and problem list diagnosis synchrony. An effective electronic problem list should become the registry for every disease worthy of organizational attention and performance measurement. Running CDS off the problem list, as much as possible, reduces complaints about non-pertinence of the CDS (i.e. "the reminder is based on YOUR problem list, so make sure it is accurate"). Converting to ICD10 and/or snomed will be much easier we focus on converting an existing, trustworthy ICD9 list based on clinician ownership. We all know converting to 10/Snomed must involve clinicians refining their diagnoses, because they are the only ones who know the patients well enough to determine the new level of detail. I am now noting our ICD9 diagnoses which will need revision to more complex descriptions: pathway to 10/Snomed. Inpatient and outpatient problem lists are too different to be synonymous, but they should overlap and be "reconciled." As with everything else, it would be nice to be paid to comprehensively describe a patient in their problem list so their C32/CCD/Summary patient document would have real value to the whole medical community.
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at 11:08 pm on Dec 2, 2009
1. Stakeholders listed should include the patient
2. Consider case managers and coders for proxies for problem list entry; however I would argue that all problems must be verified or 'mark as reviewed' by a physician. The audit trail must show who entered the problem and who has modified, reviewed and approved.
3. Consider adding 'organ system' filter that would allow consultants to manage 'their problems'. The appreciate the importability of the problem list into their documentation but get frustrated when the patient has a ton of problems that don't concern them.
4. Consider rank ordering of the list - should be flexible and customizable for each clinician that wants to use the list. We need a drag drop prioritization function.
5. Cross functionality - we should be able to select problems offered directly in disease/condition specific order sets that automatically populate the problem list. Every physician has to order in a CPOE system - that is when we have their attention. Filling out an admission for AMI order set should include a seamless way to to enter AMI on the problem list. At the same time we should offer high frequency comorbidities - HTN, chol, DM, chronic kidney disease, etc.
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at 7:52 am on Nov 27, 2009
Consider the following quote I obtained for implementing VA VisTa in EVERY clinical practice and hospital in North Carolina: 120 Million Dollars.
Now estimate the amount of money that is being wasted trying to "integrate" and "coordinate" the health care data that the VA has been "integrating" and "coordinating" for decades. I would venture that it is in the hundreds of millions of dollars per year in North Carolina alone. Over a six year time period Duke replaced its "Pharmacy Module" five times. What is the cost of retraining alone? And that was after the Durham VA offered to assist Duke in the implementation of its VisTa system and assist in training ALL of its employees in using it (versus training just the ones that come to the Durham VA from Duke). The anwer of the Dean at that time (Sandy Williams): "Anything that costs 250 dollars cannot be worth it." Duke IT people do not want to implement VA VisTa either. Why? Because most of them would lose their jobs because the personnel cost of maintaining VA VisTa is MUCH LESS than the personnel cost of maintaining and "integrating" multiple separated modules. All I can say for those who struggle with integration and have bloated IT staff is get a life, get VA VisTa.
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at 3:29 pm on Nov 26, 2009
For hospitals that are not fully automated, do you think that they will be able to fully integrate the use of Problem List ? Is this an achievable goal? At our hospital, the only thing that is not online are the physician progress notes and problem list (full CPOE, eMAR, Bar Code meds, nursing assessments). I am not sure how we are going to make the transition to online Problem List unless we can fully integrate with our ambulatory EMR, or if we install an in-pt progress notes application.
How do others feel about the realistic nature of this requirement?
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at 2:23 pm on Nov 21, 2009
One should be able to annotate the Problem List as in the VA. The Annotation should have a date and time stamp added automatically. One should be able to annotate the Problem List in a simple step from a snippet in the clinical note. One should be able to annotate the Problem List as a "linked list" from an Intervention List (multidisciplinary as exists in Sweden). One should be able to annotate the Problem List as a "linked list" from a Nurse Diagnosis List and from a Nurse Intervention Outcome List. One should be able to annotate a Problem List as a "linked list" from the Medication List. This allows for documentation of various observations and interventions that relate to the Problem List. For a provider seeing a patient in a new visit having this information available gives one an instant overview of what has been happening to a patient ala the views that VA providers had of New Orleans VA post-Katrina patients spread across the country to many different inpatient and outpatient VA sites. Surely the private sector can do as well as the VA, 20 years post-VA implementation of an annotatable Problem List.
How about having ICD-10 coding capability?
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at 9:45 am on Nov 21, 2009
Who can enter items onto the list - I would advocate for an integrated problem list; separate lists is reminisicent of a segregated chart and does not promote collaboration necessary for the team.
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