In this controversy, AHIMA recommends that accountability for maintaining accurate problem lists be assigned to the
PCP. However, if a medical record is shared, mechanisms allowing specialists to provide recommendations for problem
list additions would be preferred. 2 While this is happening
through informal communication between PCPs and specialists, the process is not a medical standard and the multiple
steps to actually placing a problem on the problem list perpetuates inaccuracies.
To reduce the potential for error, organizations should implement policies clearly delineating the responsibilities of
both PCPs and specialists. They also need to create methods
through which clear communication can occur. In the case
of recommendations from a specialist to a PCP, an EHR application that supports such a process (e.g., a prompt within the
specialist’s encounter note to supply a suggestion to the PCP)
would streamline this process, ease the responsibility question, and increase accuracy.
Promoting All Problems
Even practitioners who pay excellent attention to the problem
list are prone to mistakes, such as forgetting to add a problem.
The persistence of human error is another area where the digital problem list can surpass its paper counterpart. Decision
support tools that increase the completeness of problem lists
can help avoid simple mistakes.
One such tool under development at Brigham and Women’s
Hospital is the Maintaining Accurate Problem Lists Electronically project. MAPLE is an EHR application that alerts physicians to potential problem list gaps during the documentation
process based on the diagnoses, vitals, medications, and tests
entered in the encounter note. MAPLE is currently under a
nonblinded cluster randomized clinical trial. 3
Stéphane Meystre and Peter Haug at the University of Utah
also worked to address the inconsistencies in problem lists by
studying the use of natural language processing (NLP) to draw
out potential medical problems from free-text medical documents within an EHR. Their study, published in 2006, reported
achieving high, but not perfect, rates of recall and precision
for identifying a set of 80 medical problems. 4 Further development of tools like MAPLE and NLP likely will be the key to reducing human errors in problem lists.
Of course, not all providers will welcome computer involvement in clinical documentation. As with the debate over
documentation templates for patient encounters, some practitioners argue strongly against the computer guiding the practitioner in the decision-making process. This is an important
debate that requires more testing and experience to properly
weigh the costs and benefits.
A more immediate and addressable concern when considering these tools is that such applications can be the impetus for
tremendous clinical documentation errors.
On paper, documentation errors remain isolated to that particular patient encounter. With EHRs a glitch in a program,
misinterpretation of information, or disregard of instructions
can lead to rampant error in medical documentation that if
continued unchecked could pose a risk to patient care. Thus
any EHR system that suggests diagnoses to providers for the
problem list must be monitored for accuracy.
The next defense against inaccuracies in the problem list is
regular review. PCPs typically review problem lists during
physicals. Yet, the high portion of the population without a
dedicated PCP combined with many people not receiving annual physicals makes this review process unreliable for creating up-to-date problem lists across the entire patient population. Patient review of problem lists can help increase accuracy. But allowing patients to review their own problem lists is
controversial among providers.
In particular, some providers are concerned that patients
may not understand the medical jargon and react badly to diagnoses they perceive as insulting, such as obesity or alcohol
abuse. This situation could strain the patient-doctor relationship.
Yet, while these concerns are valid, the emergence of online
patient portals significantly eases the process of a patient reviewing a problem list for errors. For instance, portals allow
patients to review their information in their home, not the
doctor’s office; patients will have more time to look up disease
definitions and other information.
Further, portals can be designed for the patient. Portals can
be programmed to show definitions when the patient scrolls
over or clicks on a problem, or they can include language
translation tools to aid non-native speakers.
Problem lists have been accessible to patients online at
New tools being developed for
the EHR are showing promise in
helping identify and promote all
problems to the problem list.
medical centers such as Beth Israel Deaconess Medical Center for some time without serious issue in regards to patient-practitioner relations. While some practitioners remain concerned that a shareable problem list will lead to controversy
that adds to their already stretched appointment times, that
same controversy can serve as the impetus for productive
conversations between practitioners and patients about the
Right now, Tom Delbanco, MD, at Beth Israel Deaconess
Medical Center is conducting Open Notes, the largest study
ever undertaken on the effects of patients viewing their full
medical records via online portals. 5 The results will be very
informative about the adoption of patient-viewed portals and
consequently the online review of the problem list.