A Perfect Tool for the EHR
The healthcare industry is undergoing a digital revolution. The
result will likely be vast changes in how people interact with
The continuity in care movement, for example, is pushing
practitioners to use the EHR as the main medium for communication with other providers. Administrators are relying on
medical records to measure the success of quality improvement projects in real time. Patients are now getting a chance
to view their medical records online, gaining a new understanding of their diagnosed health. Finally, patients may have
a complete medical record across all practitioners through the
possibility of health information exchange.
With all these changes, the medical record is under stress
to serve the increasing demands of numerous stakeholders. A
record that was formerly a PCP’s personal notes is now of interest to specialists, administrators, researchers, government
officials, payers, patients, and the hospital next door. Further,
every stakeholder brings to the table a new set of demands for
information. As a consequence, tolerance for inaccurate, inconsistent, or ambiguous parts of the medical record is rapidly
decreasing and the need for standardization across the medical record is knocking at the door. The problem list exemplifies
Lawrence Weed was truly a visionary who created a perfect
tool for the EHR. Yet, the variations in today’s problem list
Available online in the AHIMA Body of Knowledge at
Casey Holmes ( email@example.com) is a master’s student at the
Harvard School of Public Health.
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Increasing demands for health
data are lowering the tolerance
for inaccurate, inconsistent, or
ambiguous parts of individual
make it unusable as a resource to further improve patient care.
In order to reap the benefits of upcoming decision support
and population management tools, as well as meet the larger
trends in medicine, healthcare centers need to address the issues in content and utilization as well as develop the policies
and tools to standardize the problem list.
Part 1 of this article, “The Problem List beyond Meaningful
Use: The Problems with Problem Lists,” appeared in the February issue. ¢
If so, contact
Director, e HIM Consulting
at 312-229-7159 or
1. Wangsness, Lisa. “Electronic Health Records Raise
Doubt.” The Boston Globe, April 13, 2009. Available online at www.boston.com/news/nation/washington/
2. AHIMA. “Best Practices for Problem Lists in the EHR.”
Appendix D. Journal of AHIMA 79, no. 1 (Jan. 2008).
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