Problem lists are the keys to meaningful use

Feb. 1, 2011

Put the big picture on your problem list.

Joe Bormel,

Many hospitals are behind the curve in implementing a certified electronic health record (EHR) or contending with their existing data exchange platform's inadequacies. This is slowing their compliance efforts with the government's initial set of meaningful-use requirements comprised of 14 “core” objectives plus at least five “menu” objectives.

The HIMSS Analytics survey released in November 2010 underscores the industry-wide lack of readiness for meaningful-use compliance. Survey results indicate that 22 percent of 687 hospitals reported having the capability to achieve between one and four of the required core objectives. Approximately 34 percent said they can meet five to nine of the required core objectives, and 22 percent stated they can comply with 10 or more elements required for the 2011 federal fiscal year.

The survey's findings are troublesome. They suggest that few organizations will be able to achieve the Stage 1 meaningful-use criteria in the first possible year of the program. It also suggests that they will fall short in readiness to begin Stage 2 in 2013 and Stage 3 in 2015.

Although the first stage of meaningful use is the easiest to carry out, this doesn't mean that compliance success will be easily achieved. Reality is far from that outcome. Organizations are seemingly oblivious to the fact that Stage 1 requirements can pose unforeseen challenges that can easily derail even the best-laid plans. To be frank, providers failing to anticipate hardships are putting themselves at major risk.

To avoid potential pitfalls when striving to achieve meaningful-use compliance, organizations should begin by examining the big picture. In other words, consider the goals of the EHR to improve care quality and safety through efficient capture of, and support for, providers' diagnoses and treatments. Traditionally, this has been accomplished through a problem-centered approach to care delivery. In fact, it was over 40 years ago that Dr. Lawrence Weed's seminal New England Journal of Medicine established the fundamental concept behind a problem-oriented medical record. (Weed, L. L., 1968. NEJM; 278: 593-599. Medical records that guide and teach.)

Today's technological advancements have brought that vision to fruition. Leading EHR solutions have embraced a problem-centric model to enable diagnostic and treatment plans to be linked and driven by the patients' specific medical problems. This model creates a holistic view of patient data, empowering providers to quickly assess patients, document interventions and evaluate the effectiveness of the prescribed treatment while eliminating inefficient workflow processes.

The meaningful-use criteria underscore the significance of the problem-oriented EHR by requiring the creation and maintenance of an up-to-date problem list of current and active diagnoses for 80 percent of patients under Stage 1. The up-to-date problem list — the heart of a problem-centered EHR — delivers a unified view of current patient data across disparate care settings, laying the foundation for coordinated care, one of the main goals of meaningful use. In addition, the problem list can supply data for quality, performance and research initiatives that will help fulfill Stage 2 and 3 meaningful-use criteria.

Although creating and maintaining up-to-date problem lists appears deceptively simple, many institutions will find the task difficult to accomplish due to physicians' different needs and perspectives. For instance, emergency department physicians are focused primarily on addressing emergent care needs. Specialists may find that updating a problem list delivers less value to their decision-making process and see the responsibility falling squarely on primary care physicians. Unlike specialists' narrower focus of care, primary care physicians require a broader, comprehensive view of medical histories to design care plans to meet their patients' needs. Thus, they are more likely to recognize immediate benefits from an up-to-date problem list. How to reconcile and update problem lists across the continuum of care is part of the currently ongoing Stage 2 discussions within the HIT Policy Committee, HHS' official advisory committee on meaningful use.

Another challenge is that the historical approach to maintaining an up-to-date problem list was driven by organizations' needs to accurately capture charges as opposed to supporting care delivery. This led to a predominant use of cryptic billing codes associated with ICD-9 to document physicians' diagnoses and treatments. As a result, many physicians have resisted adoption of EHRs in general, and up-to-date problem lists in particular. This hurdle will be overcome when ICD-10 takes effect in 2013, which coincidentally is the expected timeline for beginning the transition to Stage 2. As facilities move to comply with Stages 1 and 2, they will be well served by seeking out EHRs that are ICD-10 compliant and offer ICD-9 to ICD-10 cross-mapping.

To be sure, maintaining an up-to-date problem list is a time-consuming and complex endeavor. One of the most important factors to maintenance success is to select an EHR technology that interoperates with legacy healthcare technologies across disparate locations, further enabling coordinated provider updates to the problem list. The alternative is retrofitting non-interoperable existing EHR solutions with custom application interfaces — a costly option that often fails to deliver the promised data exchange and its associated care improvements.

In addition to selecting the appropriate EHR technology to facilitate ease of problem list updates, organizations must also discuss problem list expectations with their health professionals, delegating and assigning maintenance responsibilities as agreed upon within the care team. After institutions achieve consensus, they can deploy and configure their problem-centric EHR according to the clinicians' expressed needs.

The importance of implementing and maintaining an up-to-date problem list can't be overstated. The problem list is the foundation for improving access to real-time clinical information, increasing care quality and patient safety while reducing wasteful spending. Specifically, an up-to-date problem list enables providers to:

• Access a centralized and concise view of the patient's medical problems;

• Associate patient problems with diagnostic/therapeutic interventions;

• Communicate and coordinate with other health professionals;

• Increase adoption of screening programs and preventive health measures;

• Enhance management of chronic conditions; and

• Improve clinical decision making.

As the cornerstone of care coordination, cost accountability and clinical effectiveness, the problem list, embedded within problem-centric EHRs, will be at the forefront of meaningful use over the next two years. Healthcare organizations that embrace the technology and its myriad benefits will be well positioned to capture maximum meaningful-use incentives, seamlessly exchange health information and efficiently navigate a reimbursement and care delivery system with an accountable care approach.

Joe Bormel, M.D., MPH, is chief medical officer and vice president,
clinical product management, QuadraMed.
For more information on QuadraMed solutions:

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