The EHR Explainer: Decoding the Problem List

What I hear often when visiting physicians who are using the problem list in an electronic health record (EHR) is “it doesn’t give me any information.” When I ask why, is it empty? They say, “No, there are a hundred things on it. It’s filled with lots of stuff.” The problem is that you really don’t have an accurate snapshot of a patient when people are just throwing problems on the problem list.

Physicians have to start de-duplicating and doing work on the problem list because it’s not accurate, tight, up-to-date and reflective of the patient’s acuity and status today. And so, they get uninvolved with the problem list and the issues get increasingly worse.

How does the problem list get to this point?

You might wonder, how does a problem list get to the point where there are 20 things on it but the patient is essentially healthy? Consider this common scenario: A patient comes in to the emergency department saying, “I’ve had headaches for the last two months.” The emergency medicine physician puts headache on the problem list (which I think is completely appropriate for the emergency medicine physician to interact with the problem list in this manner).

A week later, the patient goes for follow-up to his primary care doctor. The primary care doctor has more time, is dealing with fewer issues than in the emergency room, and does a more thorough investigation. The physician says these aren’t really headaches; these are migraines, puts migraine on the problem list, and comes up with a plan.

Several months later the patient comes back and the migraines are getting worse. The physician says, “You need to see a specialist – the child neurologist.” The child neurologist sees the patient and says, “This is not just a migraine, but a classic migraine - a specific kind of migraine that requires a specific kind of treatment.”

The child neurologist adds classic migraine to the problem list. So, now we have:

• Headache
• Migraine
• Classic Migraine

When someone looks at that they likely say, “I don’t know what’s going on here.”  As a result, they will start to ignore the problem list, and that’s when you start going downhill.

What’s the right way to use the problem list?

How could that have been handled? Well, in Epic there’s a button called “Change Diagnosis.” If the physicians would have been using the “Change Diagnosis” button, assuming that the project team has enabled the button to be there, things would be much better.

For example, you could actually go back and see that the emergency room doctor put headache on the problem list, then the pediatrician or family doctor clicked the “Change Diagnosis” button and changed it to a migraine. Then the neurologist, who had even more information than the other two physicians, changed that diagnosis once again to a classic migraine. Now there’s only one problem on the problem list: classic migraine. If someone wanted to see the history they could by looking at the appropriate report, and view the entire progress of that issue, including how it started in a generic way and moved into a specific one.

Doctors are smart. So, why does this behavior persist?

I have had physicians tell me “I don’t want to touch that problem” or “I don’t want to modify that diagnosis because that’s Dr. Smith’s diagnosis and I don’t want to offend Dr. Smith.” I remind physicians that they actually don’t have problems on the problem list. It’s actually the patient’s problem. So, physicians don’t have problems on the problem list and they don’t own problems on the problem list. Physicians want to have an up-to-date problem list and the only way they get that is with other physicians modifying, updating and keeping information as current as possible.

Is there a rule for what goes on the problem list?

Here’s a general philosophy: What information do you want the emergency room physician to know when that patient is rolled into their trauma bay? That really is the number one decision that I would use in order to determine if something should go on the problem list or not.

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