EHR problem lists: Docs say more info is better

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Physicians are more likely to want more conditions on the patient problem list in electronic health records even though that information might be duplicated elsewhere in the record, according to a study published at BMC Medical Informatics and Decision Making.

Problem lists are subjective, involve multiple providers and lack overall standards or policy as information is shared among healthcare organizations, the authors note. 

"When problems are left out or hidden within a long and cluttered list, the problem lists' effectiveness is compromised. …To improve patient care and reap further benefit from the problem list as a data resource, the medical community needs to create clear, consistent, complete, and accurate problem lists. Unfortunately, the medical community's current approach to the problem list makes inconsistency and error the standard," they wrote.

The research was carried out at Brigham and Women's Hospital and Massachusetts General Hospital in Boston, both of which allow coded as well as free-text diagnosis on the problem list. It gleaned information from 97 survey responses and 14 partial responses as well as eight interviews. The survey had two parts--one on provider characteristics and theother made up of vignettes in which respondents had to determine whether a condition should be on the problem list.

Among the findings:

  • Characteristics such as age or medical experience had little effect on the results.
  • A strong majority wanted family history (76 percent) and surgeries (73 percent) included. Latent chronic diseases (82 percent), undiagnosed long-term symptoms (96 percent), multiple occurrences of transitive illnesses (93 percent), and resulting problems (100 percent) got the thumb's up as well.
  • Providers were split 50/50 on including hospitalizations.
  • Most practitioners (92 percent) rejected adding an occupation.
  • Non-medical conditions such as inclusion of a women's fear of doctors was controversial as were adding sensitive information, since some of the respondents were unsure about the HIPAA standards for that.

Who "owns" the problem list was a big issue, with some specialists deferring there to primary-care physicians. Another was who has authority to list conditions there. While few had problems with a nurse practitioner adding to the list, 61 percent said an inpatient nurse should not do so, but should alert the physician to the condition.

A "murky understanding" of how privacy and security regulations apply to the electronic problem list increases the likelihood that problems that merit attention could be left off, the authors note.

A recent article in Hawai'i Journal of Medicine and Public Health addresses the charting problems in EHRs associated with a residency-training program, including the temporary nature of the jobs and the number of part-time faculty.

The ability to maintain a current problem list has been among the proposed improvements in EHRs in Meaningful Use Stage 3.

To learn more:
- read the research

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