The lack of standards for creating and adding to patient problem lists essentially limits the effectiveness of them in improving patient care. A set of standard guidelines for problem lists would help to reduce confusion, medical error and overload of information for clinicians when deciding on the best treatment for a patient.
The role of a problem list is to make clinicians aware of the most important health issues they should know about a patient. By providing clinicians with a centralized and effective resource for decision support, a standardized approach to the problem list would improve patient care through an up-to-date record of the patient’s critical information.
A study that looked into clinicians’ preferred actions toward a problem list provided an important contribution to the discussion around how best to approach a problem list. It revealed differences in the actual management of problem lists but also in how long certain problems should stay on the problem list for. Another study into the implications of an inaccurate problem list showed that if a patient had heart failure displayed on their problem list, they were much more likely to be prescribed the appropriate medication and treatment than those without the issue listed correctly on their problem list.
How can the approach to problem lists be improved?
Step one: Agreement on what should and shouldn’t be included in a problem list
Being a healthcare professional, it’s drilled into us to focus on the domain in which we’re trained. We typically believe that the content of a problem list and the data that we want to attribute to each problem are unique to our specialty. While elements of this are true, there is significant overlap of which specialty should be aware of particular conditions.
Some may see value in including family history to prompt more frequent testing of hereditary conditions, whereas others may see that this duplicates information in the section for family history and therefore clutters the list. Some might see benefits for including procedures in the problem list so healthcare professionals can see what treatment the patient has received. Other perspectives might see this as unnecessary clutter or not applicable to their scope of practice.
There is no wrong argument here, it all depends on the purpose and context of use in combination with the individual’s special needs and preferences. These things need to be considered when creating a standard for what to include on the problem list.
Step two: Ensure nothing gets missed off the list
Part of the risk associated with a paper problem list that healthcare professionals have to manually copy over is major problems not being recorded in the latest problem list. This occurs when key clinical information isn’t recorded in the appropriate place at the appropriate time. This relates to the current ‘five rights’ of clinical decision support:
The right information
To the right person
In the right format
Through the right channel
At the right time in the workflow
An electronic platform is essential to ensure things are not missed off the problem list. As shown in the study, there is a difference in opinion on who is responsible for the problem list. Another issue is around patient privacy and security, as many clinicians will often have access to the patient’s electronic health record (EHR) and consequently, their problem list. By editing and viewing a problem list inside a clinical portal, these concerns could be mitigated. For instance, access could be controlled by checking a user’s permission when signing on, and it would be digitally recorded who edits or views a problem list.
Step three: Avoid clutter on the problem list
In a bad case, a problem list could turn into a steaming pile of problems that have accumulated over time and have not been properly reconciled. These are problems that are no longer current, not appropriate for inclusion in the problem list, and/or incorrectly recorded.
Avoiding clutter on a problem list is tricky, due to different perceptions of what is important. A lack of guidelines results in confusion, not only around what to include, but also when a problem should be removed from the list. Who decides that it is no longer a problem or insignificant enough to remove from the problem list?
All of these things pose a problem to a health system that has a multitude of doctors, nurses and other healthcare professionals building on a patient’s electronic health record together. The need for a standardized approach to problem lists is crucial if we are going to succeed at building a connected health system and provide better care to patients.
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