Who should maintain the EHR problem list? [podcast]

20170620-22-Nordic-Sales-3454-3600.jpgA well-maintained problem list could do wonders for patient outcomes. But the problem list is often de-prioritized on an ever-growing list of provider tasks, and when it isn't cared for, its benefits are lost. 

In this podcast, Director of Optimization Solutions Rick Shepardson and Manager of Optimization Solutions Jake Aleckson discuss a potentially controversial question: Who should be responsible for maintaining and updating the problem list? (Hint: They think it may not have to be physicians). 

If you'd prefer to read rather than listen, the transcript is below. 


Show Notes

[00:00] Intros
[4:54] The history of the problem list
[9:32] Challenges with the problem list
[12:37] Who owns the problem list?
[15:55] How to build a more accurate problem list
[20:43] Benefits and risks of care manager ownership
[24:22] Where the problem list is headed


Jake: How are we doing? My name is Jake Aleckson, and I'm the manager of Optimization Solutions at Nordic and I'm joined here with Rick.

Rick: Thanks for having me, Jake. I'm the Director of Optimization Solutions at Nordic, and I'm looking forward to talking to you today.

Jake: We're going to be talking about the problem list today, and this generated from a podcast that we did on the longitudinal plan of care a few weeks ago. After that podcast, we just started talking about the problem list and how that tied into the longitudinal plan of care. Next thing you know, we had a whiteboard full of another podcast.

Rick: If I remember correctly, we were wishing that we had kept that podcast recording going and just had that conversation, but actually, it worked out pretty well. We got a chance to whiteboard a little more.

Jake: Let's see if we can kind of re-live that good conversation. Do you want to kick us off here, as far as what we want to cover today?

Rick: Sure. We were talking about longitudinal plan of care and how do you ensure that the patient problems are accurate. They are things that you can drive goals and care gaps off of and whatnot. You know, that got us thinking about how the problem list is really being used today in organizations.

We all kind of know that it's not the most well-maintained or the most loved tool in the EHR. Many organizations kind of struggle with: who is the right person to own it and maintain it? It's kind of been overloaded. All of the specialties are using it now. We want to be able to drive decision support off of it, but is it reliable? Do you know that all the patient problems are there?

We want to get into a real discussion around some of the history of the problem list, why and how it's being used, maybe how to make it a little more usable. I think we want to end with asking who really is the right person to be able to maintain this and what are some of the considerations.

Jake: Yeah, definitely. Right now, it's definitely a physician- and provider-owned problem list, but maybe based off this discussion, we'll find that there's opportunity for other roles to be owning it. Let's start with the history, as far as that problem list, going back 10 years or so. The problem list was on paper, and each specialty had their own charts, their own problem list. Now that we've all  or most organizations — are on an electronic medical record, it's a shared problem list.

Rick: Yeah, in some ways, I think you can trace the arc of the problem list to what's happening in the healthcare industry in general. Healthcare used to be provided primarily by general practitioners. They had a list of problems, you knew what problems the people in your community had. You saw Joe, who lived on Third Avenue, and took care of him, and you knew him, right? Over time, hospitals came to be more and more focused on specialty care. You needed this diverse set of documentation tools and needed to drive coding and all of these types of things. Then, all the specialties used it.

We're still largely in that space today where you have this multi-disciplinary approach and multiple different specialties weighing in. Who does a spine surgery? Is it ortho or is it neuro? Do they collaborate? You get into this kind of world. We're moving more and more into a population health world where people are trying to be healthy all the time. You have care managers, who are now in the mix, and care coordinators who are responsible for patient outreach and keeping them as healthy as possible. As we look at who's using the problem list and how they're using it, I really think that this evolution is ongoing.

Rick Jake 2.pngJake: As far as maintaining the problem list now, it's primarily done by physicians across organizations, wouldn't you say? I think the organizations that I've worked with, it's always been a provider-owned activity.

Rick: It has been. I've been doing implementations for 13 years, working at the EHR, someway, for a long time. It's always been the recommendation, historically, to have the provider or physicians maintain that problem list. I think a lot of that comes down to their licensure. They're the ones who are credited providers, they have an MPI. Their medical decision making is what's used to drive coding and billing, you need this accurate problem to drive reimbursement. That's sort of been the backbone of it.

Jake: Yeah, you mentioned the coding piece. Patients get admitted; patients see multiple specialties. Providers really just don't have the time during those visits, maybe five, 10 minutes, to really reconcile, update, and make sure that it's accurate. A lot of times, they're concentrating on the problems that they are focused on.

Rick: Yeah, that's part of the concept or the thought of where this problem list means a lot of different things to a lot of different people. In the outpatient space, the provider has to document. They get to see a patient for five or 10 minutes. They're reviewing the reasons why the patient is there. They may not be thinking about all the problems that the patient has over time. You get into the inpatient world, or let's talk about the ED first.

You have a constant differential diagnosis or a reason for admission. Why is the patient there, and does that go in the problem list, and in what format? How does it correlate? If the patient gets admitted, then you have other groups who are involved. You have the physicians who are documenting their medical decision making and an HNP, or their progress notes. You have a CDI team that is monitoring those patients. Hopefully you have a CDI team that's monitoring those patients concurrently and trying to work up a suspected DRG, diagnosis-related group, which is just another version of a problem.

Providers are supposed to document and follow up on any of the queries. Some of them do so in a timely manner, some of them don't. They're not necessarily looking at or needing the information directly in the problem list, they really just need to document it into their notes somewhere or somewhere in the chart because ultimately, at the end of the inpatient visits, you end up with a coded diagnosis, or a coded DRG, or ICD codes. When that coding happens at the end, there isn't a straightforward reconciliation process that happens with a problem list. It's a tool that's used in the inpatient realm, but it doesn't actually derive the final coding.

Jake: There're a lot of people touching the problem list. It's hard to maintain. Some of the reasons  or the importance of maintaining that problem list  really have to do with decision support that's driven off of the problem list. Providers want that evidence-based medicine.

Rick: Providers may want the evidence-based medicine, you know who really wants evidence based medicine? Two groups. Patients. Patients want to get the best possible care, the best possible outcomes. They want to know that the care plan that they're going down is going to make them healthy faster. You know who else wants evidence-based medicine? All those folks worried about cost.

Jake: Mmm-hmm.

Rick: Evidence is shown to provide the best outcomes, in the quickest amount of time, at the lowest cost. A lot of these are standards of care. As we look in this new world, where we're trying to reduce costs. We're trying to standardize care. Standardizing around evidence allows the organization to buy in. It allows the providers to buy in. We're not just standardizing some care protocol because XYZ doctor says this is the way to go. No. We're standardizing care because there's evidence that points that this is the best way to provide that care.

Jake: For organizations to be successful with evidence-based medicine, decision support driven at the point of care, a lot of it comes back to that problem list being accurate.

Rick: Right, the problems that the patient has is the foundation of a decision support strategy. You want to be able to see what are the problems we're trying to address so that you have the right interventions or care pathways in place? Those problems end up driving what type of education the patient might need to receive or what to put into their care plan. Certainly, the problems themselves are going to be what those care plans or education require are going to be, not just based on the diagnosis, but also problems, or procedures that are going to be performed, or lab tests, or special considerations for a given patient, right? A lot of it comes down to diagnosing the problems, but leveraging that problem is so critical to decision support. If you have more problems documented for the patient, or you don't have all the right problems documented for the patient, it's really hard to be able to rely on that problem to drive your decision support, be they order sets or recommended interventions.

Jake: OK, what are some ways that organizations can have a more accurate problem list?

Rick: Well, that's a great question. A lot of that comes down to governance, right? You've gotta make somebody own the problem list.

Jake: Clear responsibility.

Rick: Clear responsibility. If you don't have that clear responsibility, then no one updates it, right? No one makes sure that it's cleaned up. I think that the other part about making that problem, you want to make it efficient and easy for the providers to see the problems and to do that sort of maintenance. I know there is some functionality within the systems to help make that a reality.

Jake: Yeah, I know that over time, Epic has improved the filters within the problem list, being able to filter by specialties, being able to filter by systems. Making sure that your providers and staff have those filters implemented, I think is important, just to help with the clearness and the organization of that problem list.

Rick: Yeah, making sure that it's organized can really sort of help serve all the different roles, inpatient, outpatient, home care.

Jake: The other piece of functionality that comes to mind is problem-oriented charting. There's a few pieces to that, but the first is making sure that there's an overview note for that problem: A quick synopsis that's up-to-date, as far as for that problem, what's going on. The other piece of the problem, where I did charting, is that assessment and plan. Being able to actually chart the specific assessment and plan for those problems.

Rick: Yeah, problem-oriented charting sounds great. I love it. I love it, in theory. It's been very hard to operationalize because providers are not necessarily thinking about the patient in problems. They don't always know what problems the patient has until they get to the end of the visit, and then it's kind of too late, right? They may be thinking about a problem. They might think the patient has this problem. They're kind of ruling things out by ordering lab tests or other diagnostics, but they don't actually know.

There's a lot of hesitancy to document the inpatient. The culture is similar from the ED, where they're working off a differential, and they're used to documenting the differential diagnosis. In the inpatient world, they're not as used to that and they're kind of going down that same process, but they're not comfortable documenting it just quite yet. The other problem with some of the problem-oriented charting is it just feels like you have to document things in one more place. Providers never want to see some of those inefficiencies.

Jake: There are some tools to try to be able to  if you documented first in the problem list, you can pull that back into your notes. I've seen it done successfully for some providers, but usually those are your more tech-savvy providers. Like you said, it just hasn't taken off.

Rick: Well, the other key that you said is you can't just implement problem-oriented charting in a bubble and think it's going to work. You have to really focus on the deep integration of the notes or the documentation that's there and make sure that it flows into the progress notes, and into the discharge summaries, into all the other locations. I think that if you do that, there is tons of value in documenting against problems because that's what your care gaps are related to, right? You get your rich information, right? You want to know how you've treated that patient for their hypertension so that you know what to do with them down the line with the hypertension.

Jake: Yeah, last comment about the problem oriented charting that we've kind of gone on a tangent about that is that the ability to see all of those assessment in plans for a specific problem, over time, is very beneficial for some care managers and some clinicians.

Rick: Oh yeah. It just creates such a richer timeline for specific challenges that a person has, a patient has.

Jake: Those are some ways that we can make the problem list more accurate, more useful to clinicians. Let's get back to that responsibility or that ownership of the problem list. We've seen that some organizations  and Epic even recommends this now from a population health standpoint  but it is to maybe shift some of that responsibility to care managers. What are some of the benefits and risks of organizations going down that road?

Rick: I'm going to save the big reveal for later on what I think would be the best route, but let's talk about some of the considerations. I see you rolling your eyes over there, Jake. That's great, this isn't like Extreme Home Makeover. There isn't that big of a reveal but because the problem list has historically been your source for diagnoses, for coding, right? They've been used as suspected diagnoses that you're ruling out. You associate them. Doctors associate the diagnosis with a procedure order, and that is the billing justification for that problem or for that procedure.

There is a risk that you have a non-licensed professional that doesn't fully understand how to diagnose patients, or they haven't gone through medical school in the same way or had the same level of training as an MD has had, and if a care manager, who's often a nurse, is owning or updating that problem list, then maybe they add a problem that wasn't reviewed or vetted by a provider. Maybe that problem ultimately ends up being used by coders, or maybe it's being used to drive decision support in recommending procedures or interventions that aren't actually valid. Maybe it ends up being used by other providers downstream, as they're reviewing the patients chart and trying to figure out what kind of care to provide. These are some real risks, and there's a reason why providers, physicians, are the ones who've owned it for a long time and why organizations have done that, and it's because of that medical decision making, and that licensure, and the power that is behind it.

Jake: One of the benefits of shifting some of that responsibility to the care managers could be then, at least there is somebody that has a closer eye on it. It's difficult for some providers to possibly spend the time that it needs to maintain those 20-plus problems.

Rick: Yeah, I think the role of the care manager is ... certainly it's a new role with the shift to population health and some value based care, but it's very much an evolving role, and it's a role that has a lot closer touch to the patient. At times they have more time. They're not limited to your five- or 10- or 15-minute office visits. In some ways, if you think about going all the way back, earlier we were talking about some of the history, and you're being cared for by your general practitioner back in the 50s or whatever, right? The role of the care manager is actually not that much different than those roles, right? It's actually not that much different.

As we kind of look at how we progress this forward, I think one of the real important things to think about is the care manager, right? Are they really going to add problems to the problem list if they're not confident that that's a problem? Are they really going to be irresponsible stewards with the patient's chart? I don't know that they are. The nurses that I've talked to, the care managers I've talked to, they understand their role relative to providers, right? They understand their role. They understand, really, they're there to act on the patient's behalf and make sure that their health is accurately represented. I think they might have the most amount of time. They might be the best positioned to keep this up to date.

Jake: What are your thoughts, Rick, on the problem list housing certain social determinants as a place to document social determinants or other care management-related problems? That may not be your typical diabetes, congestive heart failure, but using the problem list as a tool to that full picture of the patient's health.

Rick: I think that's ultimately where we're going. The problem list has gone through evolution. It started out being something to document the different considerations that the patient has that are chronic problems, or chronic considerations, that need to be addressed throughout the patient's lifetime. As it's evolved, as we're evolving into a population health world, those social determinants oftentimes could be chronic, right? The patient may  the person may not have access to food. They may not have shelter. That's going to be a problem until it's not. If they get an apartment, they get a job, they get off the streets, or they have access to food, then that should be resolved, right? Really, the value of keeping all these things in the problem list is for that continuity of care. It's for all the providers to weigh in and then use it to drive decision support.

Jake: Yeah, I bring it up because it is a hot topic as far as where they are important pieces of the comprehensive medical record. Finding a home, an appropriate home for those important factors, has been a challenge. The problem list is definitely an option and that's going to be the main piece of that plan of care, which is shared across multiple organizations, multiple areas of the patient's care.

Rick: Yeah, I think what we're going to see is a shift. EHR is a technology, and sometimes we build technology for technology's sake. Sometimes we use technology, or we use tools that seem like the most useful tool, but we use them to mask other problems or other opportunities. I don't know how far we'll go down this path or not, but ultimately, I think it's about getting back to its functional use. What do we need to do, right? What's the problem list for?

The problem list, in some ways, is asking: What are all the patient considerations that are going to persist over time that a caregiver should be considering? That a patient, as they see in their MyChart portal or otherwise, what are things that they need to be looking out for? What should be driving care pathways, or protocols, or care options? That's what the problem list really is. How do we look at that, not from the sake of a technology or a tool, but from the sake of, how do we accurately represent patient care needs?

Jake: Yeah, Rick, you had mentioned earlier, the big reveal.

Rick: I told you, we weren't going to like pull aside some giant piece of paper, but I think the care manager really, in the year of 2018 maybe, right? I don't know. I think that we're going to see a bigger shift to the care managers being the ones who are maintaining the problem list. We're going to see a process by which those problems are reviewed and vetted by the primary care provider within an annual wellness visit or something of the like. I would hope that, on the inpatient side, will eventually start to see more teams using it as a differential diagnosis tool to help drive some of the decision support within an inpatient stay, but I think we're further off from that. That might be a few more years down the line.

I really think that in the next year or two, we're going to see a lot more organizations shifting to care managers. We're going to see shifts in policy, and procedure, and government structure around that so that coders and the like are going to understand where and who's documenting these. I think it's going to be necessary to shift that way if we're going to accurately represent patient risk, and we're going to do a good enough job to capture all the patient problems and maintain that over time as the patient condition changes.

Jake: Yeah, I would agree. I think it's going to take a few organizations to jump and to try this and then to share with the rest of the community, as far as having a more accurate and useful problem list is possibly driven by that care manager.

Rick: I can see it. You heard it here first, right? Someone else has said it?

Jake: We didn't come up with the idea, but we're definitely on board with it.

Rick: I'm on board.

Jake: Awesome. Thanks, Rick.

Rick: Thank you, Jake. Good talk.

Jake: Yeah, you too.

Topics: population health, quality measures, Performance Improvement

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