following requirements for an EHR system and its use:
x Capable of electronically exchanging key clinical infor-
mation (e.g., problem list, medication list, allergies, and
diagnostic test results) among care providers and patient-
x Provides patients with an electronic copy of their health
information (including diagnostic test results, problem
list, medication lists, and allergies) upon request.
x Provides patients with timely electronic access to their
health information (including lab results, problem list,
medication lists, and allergies).
x Provides clinical summaries, including problems, to pa-
tients for each office visit.
x Generates lists of patients by specific conditions for qual-
ity improvement, reduction of disparities, research, and
outreach. The user will be able to electronically select,
sort, retrieve, and generate lists of patients according to,
at a minimum, the data elements included in the problem
list, medication list, demographics, and laboratory test re-
x Sends reminders to patients per patient preference for
preventive or follow-up care based on data elements in-
cluded in the problem list. 7
The objectives clearly emphasize the importance of using a
problem list within EHRs to facilitate communication, enhance
documentation, and serve as input for the patient’s engagement
in the care planning and use within personal health records.
Problem list interoperability facilitates patient engagement,
health information exchange, and other secondary data use.
Achieving interoperability requires the use of terminology and
messaging standards such as those maintained by HL7 and
Clinical document architecture (CDA) is a document mark-up
standard used to express many different document types. CDA
supports the implementation of ASTM International’s Standard
Specification for the Continuity of Care Record (E2369-05).
The resulting standard, developed collaboratively by ASTM
International and HL7, is the Continuity of Care Document
(CCD), a standard format for the exchange of basic patient information. 8 These emerging structured document standards
were developed by ASTM International and HL7 in a standard
format for the exchange of basic patient information.
Standards based on database architecture such as CDA—
rather than proprietary, closed systems with custom database
architectures—serve interoperability best. Standards enable interoperability as all the technical functionality can be used by all
systems, not just one. If one system’s functionality is based upon
a proprietary or “closed” architecture, then only that system is
working on that functionality.
The CCD specifies SNOMED CT as the terminology standard
for use in defining problems and vital signs. The CCD standard
interface transaction format is the method envisioned to migrate data between EHR applications and eventually to personal health records accessible by the patient or their designated
EHR products in use today vary in their ability to export and
import according to the CCD transaction format, so it is important for HIM professionals to monitor and inform their organizations about the use of this emerging standard for interoperability.
Incorporating a problem list in EHRs offers a powerful tool for
clinical decision making and quality improvement initiatives
because it provides a concise view of patient conditions and
creates a source for data mining. Without proper structure and
oversight it is also a potential source of clinical and administrative error if the data lack integrity or the encoding results in inaccurate representation.
Problem lists are dynamic tools to be co-managed by multiple
care providers who frequently collaborate to manage complex
clinical issues. The structured lists provide a “working” list of
conditions subject to refinement during an episode of care.
They require flexibility in recording and careful monitoring for
Since care providers generally have different opinions on what
should and should not be included on the problem list, organizations must develop and implement clear policies regarding
problem list content as well as governance for failure to comply with organizational directives. Major challenges associated
with managing problem lists include policy development, policy compliance, and difficulty maintaining an accurate, current,
comprehensive, and reliable problem list.
The issues with problem lists are as much related to process,
policy, and enforcement as they are to software system design
A problem list must be maintained in order to ensure the integrity of the list. In problem lists, current problems should be
documented, and the resolved problems should be easily identified.
HIM professionals are uniquely skilled candidates for spearheading policy development since the resulting documentation
from the problem list drives other entries in the patient’s record.
However, it is also critical to include a clinical champion to co-sponsor the policy. All clinical stakeholders should be involved
in the policy development process, along with representatives
from information systems, medical staff, nursing service, quality management and clinical departments, and all other personnel contributing or affected by problem list data management.
To most effectively use and manage problem list data, organizations must create policies that address the following:
Determine the purpose and scope of the problem list in the
healthcare enterprise or setting. Examples of purpose inlcude: