Problem List Norms

A list of active health conditions (“Problem List”) appears in all Connect Care charts in all contexts. Problem List entries are signs, symptoms, presentations, disorders or diseases that have an impact on, or could be impacted by, a patient’s current care. All prescribers share responsibility to update and manage health problems, especially those they have entered themselves. Problem List management (resolve, revise or promote) occurs at first encounter, care transitions or appropriate intervals.

Impact

A patient’s health problems determine which ordering tools (Order Sets, SmartSets, Protocols, etc.), documentation aids (templates, flowsheets, forms, etc.), coordination guides (Express Lanes, Therapy Plans, Care Paths, etc.), decision supports (alerts, reminders, etc.), patient resources (handouts, questionnaires, etc.) and professional billing shortcuts are offered to speed workflows. Problem lists are pulled into documentation templates. Patient registries, reporting tools, quality metrics and chronic disease management reports often depend upon accurate problem lists.

Messy problem lists impede workflows. Good problem lists provide the scaffolding for a clear, concise and impactful health record. They connect workflows within Connect Care, as well as beyond through system interfaces to community EMRs and patient and provider portals.

Accountability

Problem list management is a core clinical competency. It is also a prescriber responsibility with profound effects on health record quality and function. Effective problem list management all ensures that charting is efficient and effective for all, and that no one prescriber group bears a disproportionate information burden within the Connect Care community. That is why problem lists are central to documentation and minimum use norms:

Minimum Expectations

Problem List review and validation (reconciliation) should be done at every care transition, including admission, transfer and discharge. It should also be done for every new outpatient encounter and periodically thereafter. Within encounters, the timely addition, revision and resolution of problems makes for faster documentation that more clearly shares clinically important information across the continuum of care.

Simply dictating a problem list into a note or letter does not meet a prescriber's problem list responsibilities. It is essential that the actual Problem List be revised to reflect current active problems. The list is then easily pulled in to documentation with one or more SmartTools.

Sharing Etiquette

Each patient has but one Problem List within their Connect Care chart. Shared across the continuum of care, it requires diverse clinicians to work to a shared understanding of a patient's problems. This represents a paradigm change for clinicians accustomed to independent framing of patients' issues.

Different prescribers may have different notions about how specific a problem is characterized (e.g., “Chronic Obstructive Lung Disease” vs. “Emphysema”), or whether a problem is active and relevant to ongoing care. It can help to think of the Problem List as belonging to the patient. It reflects the patient's condition and not the perspective of any one provider or specialty doing documentation. In this way, if the patient is diagnosed with a chronic condition, the diagnosis should be included on the problem list. The problem should be resolved only if the patient no longer has the condition, not because a particular provider is no longer taking accountability for that problem.

Use of a digital health record does not absolve one from professional courtesy. When editing an existing health problem, or when consolidating a number of problems into one unifying diagnosis, it is important to help other prescribers recognize changes and appreciate the reason(s) for changes.

Finding Focus

Given that the Connect Care Problem List is patient-centric, the tally of active problems for a patient can grow, especially if some clinicians break-out problems into a sub-issues (e.g., both "Chronic Obstructive Pulmonary Disease Exacerbation" and "Respiratory Failure"). Keeping lists lean is achieved through problem reconciliation, where inactive problems are resolved or moved periodically.

Finding focus within long lists is achieved through options for how lists are filtered, categorized and sorted (which can be saved as a personal preference). Problems can be grouped by:

  • Priority
    By tagging problems as high, medium or low priority, individuals can bring the problems of greatest interest to the top of a list, with each user having the ability to manage priorities independently.

  • Context
    Problems can be filtered to display or hide past problems, multidisciplinary problems and/or hospital problems.

  • Status
    Lists can be grouped according to whether problems are chronic (long-term) or not.

  • System
    Lists can be grouped by the body system (e.g., nervous) so that the problems relate to a particular specialty are easier to recognize.

Best Practices