“The most important 30 second communication tool nobody uses.”
That’s the medical problem list in a nutshell, according to one frustrated CMIO.
As healthcare becomes more interconnected, care delivery increasingly atomized, and communication across care teams grows more crucial than ever, the primary tool for communicating the patient’s most important health problems remains largely underutilized.
Indeed, it’s a distressing reality given that medical problem list data serves as the foundation for a variety of critical workflows within the electronic health record (EHR) – such as initiating billing workflows, driving clinical decision support, creating cohorts for population health efforts, and feeding quality reporting.
So why are clinicians neglecting the problem list if it’s so impactful to patient care?
The phantom of the problem list is here
There are a number of reasons for this practice (or lack thereof), but they mostly come down to usability. The problem list today is not a 30-second workflow. It’s unorganized, cluttered, out-of-date, and shared across multiple providers from various specialties. As clinicians are inundated with more and more data, they simply don’t have time to sift through it all to distinguish the signal from the noise.
EHRs are recognizing the need for better tooling to make the problem list not just usable, but useful to the provider as the entry point to the patient encounter. Major EHRs are adopting solutions from third party software vendors to help organize the problem list, remove out-of-date or redundant entries, prioritize conditions of particular interest to the provider, and link problems to other relevant and related clinical data like tests and treatments.
As problem list tooling improves, barriers to adoption diminish. Indeed, more and more health systems are creating workgroups focused on improving engagement with the problem list. But ensuring these lists accurately reflect the entirety of a patient’s chronic, ongoing conditions remains a challenge.
Of particular concern are phantom or “undocumented” problems, though this label may be a misnomer. Often, they are documented somewhere on the patient’s chart, just not where they belong.
For instance, a patient may have had renal insufficiency documented as a billing diagnosis during a hospitalization, but it was never added to the problem list. Or perhaps it was dictated into a chart note or plan, but never added to the structured problem list. Either way, the outcome is the same: to the computer, that problem does not exist, and to the harried clinician at their next encounter, it’s easily overlooked.
Enhancing EHR workflows with embedded apps
There are many solutions in the market that claim to deliver clinical insights and improve the accuracy of clinical data, but administrators are rightfully skeptical of programmatic, back-end changes without a provider’s review. Natural language processing (NLP) may be able to find and structure meaningful clinical data found in unstructured notes, but also may be constrained by the target terminology to which this data is matched. While these technologies show promise, a solution ultimately needs to be easy to use and embed directly into the providers’ existing EHR workflow.
With the rise of SMART on FHIR, a standards-based, interoperable apps platform being widely adopted across all major EHR vendors, developers are able to create applications that embed directly into the EHR to supplement native functionality. Indeed, applications exist today that can identify unnecessary problems – “clutter” in common clinical parlance – and embed into the encounter workflow to facilitate streamlined removal by the provider. These applications can serve a dual purpose of not just identifying records for removal, but also those for inclusion, making them a semi-automated “problem list wizard” that does the hard work of combing through the patient’s chart for these suggestions; providing streamlined workflows for review; and updating the list based on the provider’s sign-off.
As EHRs develop more problem-oriented workflows, and as more health systems create policies to encourage wider adoption, it will be incumbent upon providers to routinely engage with the problem list. Tooling that organizes and prioritizes relevant problems will facilitate this transition, and contextualizing the problem list with other clinical data will enrich the experience. But to ensure appropriate communication of the patient’s most pressing health concerns, and to optimize outcomes in use cases ranging from revenue cycle to decision support, accuracy is the key. And to do so in 30 seconds, it will be incumbent upon their software vendors to assist.