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MU element: 2011 Objective --- Maintain an up-to-date problem list of current and active diagnoses

Page history last edited by Colene Byrne 11 years, 5 months ago

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.






  • 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)



[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.







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



Comments (11)

LuAnn Kimker said

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.

Charles Beauchamp said

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.

Charles Beauchamp said

at 2:25 pm on Nov 21, 2009

How about having ICD-10 coding capability?

Jerry Osheroff said

at 9:16 am on Nov 23, 2009

LuAnn, Charles: many thanks for these excellent thoughts! As you can see, since your posts Don Levick has begun to acually build on the initial seed outline above - please feel free to make additions directly within that outline as well! (I don't think ICD-10 is mentioned explicitly in the meaningful use criteria, but it's a good question)

Donald Levick, M.D., MBA said

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?

Charles Beauchamp said

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.

Richard Vaughn MD said

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.

Bob White said

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.

Ferdinand Velasco said

at 6:45 pm on Dec 31, 2009

I'll incorporate relevant elements from the CMS proposed rule for meaningful use and ONC interim final rule for HIT standards and ceritifcation in the next week or so, but wanted to go ahead and post some pertinent links:
CMS Proposed Rule
ONC Interim Final Rule
Commentary by HIT Standards Committee co-chair, Dr. John Halamka

Of relevance to this section of the Wiki, the adopted vocabulary standards for problem list documentation are ICD-9-CM and SNOMED CT in order to demonstrate Stage 1 Meaningful Use (2011). The candidate standards to support Stage 2 MU (2013) are ICD-10-CM and SNOMED CT.

greg weidner said

at 6:12 pm on Jan 27, 2010

It seems to me the central tension regarding problem List population is between ease lof entry and data integrity for the sake of downstream usefulness (CDS as well as documentation and subsequent care provision). There are multiple ways to unburden the providers from this task, via direct feeds from billing data or diagnoses or by having others assume this task despite having less familiarity with the patient and a lesser (or no) clinical skill set. CDS rules and alerts can help by introducing Problem List entry into existing work flow. Eventually NLP will allow relevant suggestions for the problem list even from unstructured data or dictation. But ultimately entry or approval of problems must be the province of the responsible provider. Without compensation for their efforts, it is often difficult to convince providers to make this effort - we must continually demonstrate the downstream benefits to the patient and eventually to provider effciency of building and maintaining a thoughtful and complete Problem List. I have heard many horror stories of sites that "opened" problem lists to multiple position types and now have lots of data with no integrity or utility. I would love to hear from some who have driven the provider-owned approach and achieved successful adoption and ideally demonstrable benefits. Would be especially interested in anyone willing to share position papers, policy or guidelines that resulted in this type of success in a large IDN or academic environment.

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