Below is an outline of issues to consider in setting up an approach to establishing and maintaining problem lists in a matter that will meet patient, clinician and organizational needs.  Meaningful use in 2011 requires ICD-9 or SNOMED coded problem lists; a thoughtful approach to the issues below will help in meeting this requirement, and in fully leveraging the problem list as a tool for optimizing CDS to enhance care delivery and outcomes.  Please edit or add comments to this outline, or in the comment section at the bottom of the page.

Context, from CMS NPRM 

p. 72 of the CMS NPRM:

EP/Eligible Hospital Objective: Maintain an up-to-date problem list of current

and active diagnoses based on ICD-9-CM or SNOMED CT®

EP/Eligible Hospital Measure: At least 80 percent of all unique patients seen by

the EP or admitted to the eligible hospital have at least one entry or an indication

of none recorded as structured data.

The capability to maintain an up-to-date problem list of current and active

diagnoses based on ICD-9-CM or SNOMED CT ® is included in the certification criteria

for certified EHR technology (to be defined by ONC in its upcoming interim final rule).

Meaningful use seeks to ensure that those capabilities are utilized. Therefore, we believe

in order to meet this objective it is not sufficient to demonstrate this capability once, but

rather to comply with the objective, an EP or an eligible hospital must utilize this

capability as part of the daily work process.

Cultural/Vision/Value

• Shared vision among stakeholders around purpose for problem lists
• Value proposition for each stakeholder; 'what's in it for me' to do the work required
  • Physician: creating list can help with note generation, especially if list can be pre-loaded into physician documentation tool
  • Hospital: if accurately maintained, will assist in billing for both POA (Present on Admission) and for appropriate levels of care (Observation vs. Amb Overnight vs. InPatient)

Use/Policy

[VA has done significant work with problem list management: a manual they've created and further details are here: VA CPRS Problem List References]

• Who can enter items onto list?
  • This has significant implications on the successful use of Problem List.
  • Who would be most accurate author vs. who would be most diligent in entering/maintaining the list. Can it be delegated to Medical Students or Residents - who may have a vested interest if they are creating the daily progress notes.
  • Should Nursing be responsible for entering the Problem List. The lexicon of Nurses is often different from physicians - this might create some issues or inconsistencies.
  • If the responsibility is the Attending physician, then there will need to be a value proposition that makes it worth the effort, as noted above. For many organizations that are not as far along on the evolutionary scale, this may be a difficult challenge.
  • How does the patient fit into this mix? (PHRs, etc.)

     

• Who is in charge of updating/maintaining the problem list for individual patients and keeping it current and relevant?
  • Process issue, not software issue

• • Similar issues inherent/analogous within medication reconciliation process - lessons learned to apply to Problem Lists, e.g.,

    who owns the medication list at different points in time during patient stay

     

  • Problem List items
    • Determine ideal items to have on problem lists, purpose for each item, and role responsibility to update/maintain
      • Per policy, distinguish items to include on past medical history vs items to include on Problem List
      • Determine ideal items per setting:   Inpatient, ED, Outpatient
        • Key issue: How can these items travel between each of these settings for continuity of care?
      • Determine ideal items per physician - general, specialty, other providers
      • Do patients have access to Problem Lists, e.g., discharge instructions?

         

      • Seeking in the "Comments Section" at the bottom of the page
        • Ideal items to be included within the Problem List
        • Share barriers and how overcome these issues 
        • Seeking model practices on process and collaboration

           

• What is the auditing capability of the Problem List? There will need to be an audit trail of who added/deleted/modified items on the list.  What are the policies for this?
• Separate lists for physicians/nurses/others?
  • Would this be a help or hinderance? This would probably decrease the likelihood that the lists will be maintained in a timely manner.

     

• Approach to coding? ICD-9 vs. SNOMED? Migration path? 
  • To be effective as the basis for CDS, entries in the Problem List must be represented as discrete data rather than free text
    • This can be accomplished using an existing classification system (e.g., ICD9 or SNOMED CT) or one developed internally. In the Meaningful Use matrix approved by the HIT Policy Committee on August 14, 2009, there are specific references to ICD9 and SNOMED. At the subsequent meeting of the HIT Standards Committee on August 20, 2009, the committee endorsed the Clinical Operations Workgroup's recommendation that SNOMED CT as defined by HITSP be adopted as the vocabulary for clinical problems and procedures. For 2011-2012, ICD-9, CPT-4, and/or local codes (mapped to one of the terminologies) were accepted as allowable alternatives. For 2013, ICD-10 was positioned as the ony allowable alternative to SNOMED-CT.
    • One of the benefits but also one of the challenges with SNOMED CT is its breadth. Wasserman (2003) identified 8,378 clinical terms. To better support the use of SNOMED CT for Problem List documentation, a subset of the terminology has been developed specifically for this use case and made available by the National Library of Medicine.
  • The taxonomy of the Problem List  may need to be based on how it will be used. Physicians are accustomed to standard descriptions of problems, which are not always the same as those needed for POA billing.
  • Should the clinicians be able to create entries in the problem list from a standard list. And then the back-end systems should semantically translate the entries based on the use or recipient of the information.

     

• Distinction between Problem List and Encounter Diagnoses
  • Encounter diagnoses are typically important for medical records coding and reimbursement, whereas the Problem List tends to be utilized for clinical applicatoins. In many EHRs, there are challenges in the overlap between the legacy use of encounter diagnoses for coding/billing and the clinical requirements related to the Problem List.
  • This disctintion has potentially important implications for the definition of the legal medical record

Infrastructure (CCHIT Criteria for problem lists provides important context for this)

• Pertinent capabilities needed within EHR/related tools
  • Robust coding capablities ICD9 or SNOMED
    • Ability to handle rule out diagnoses given limitations of coding schemes
  • Ability to handle fact that different users (e.g. specialists) have different perspectives/needs for list, with needs for different granularity
    • Some organizations desire hierarchical problem lists, e.g. nesting so subspecialist-specific details can be hidden/rolled up to others where they may not be as useful
    • Ability to reorganize and present other views of the list to meet different user needs
    • Preference lists (for data entry)
    • Organize problem list according to different organ systems
    • Problem list for inpatient vs. outpatient encounters differ in terms of granularity, etc. - need to manage accordingly
    • Manage differing needs/use of problem list: Nursing problem wiht special needs/uses, e.g., "don't use arm b/c of dialysis"
  • Ease problem list creation/additions
    • Linked w/in CPOE, e.g. so that as diagnoses are entered into OS, they can be automaticallly added to problem list  
  • Ease use of problem list for other purposes
    • Order sets prompt when new condition entered on problem list
    • Problem list can drive diagnosis [JO: I can't remember what this meant]
  • Problem list admin/management
    • What is the auditing capability of the Problem List? There will need to be an audit trail of who added/deleted/modified items on the list.
  • Handling problem lists across settings
    • Ability to integrate problem list between the in-patient and out-patient systems: this is critical to its use and success. Ideally, it should be a shared document, with full audit capability. If it is not integrated, then there needs to be the ability to view the problem list in a shareable environment (such as with several of the current data aggregator systems) and then 'import' the acceptable items into the active system.

Leverage/CDS

• How can available problem list capabilities and usage be leveraged (e.g. via CDS) to optimize care delivery processes and outcomes?
• Having a Problem List as accessible discrete data creates many opportunities for CDS:
  • Development of rules that can alert based on diagnosis-drug interactions
  • Rules based on diagnosis and presence/absence of appropriate tests or medications (Core Measure data)
• Using CDS in a CPOE system can enhance completion and use of Problem Lists:
• http://www.ncbi.nlm.nih.gov/pubmed/18599342?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=4
•  

Click here to go to: "MU Element - Problem List: Archived Comments"