A new AHIMA thought leadership paper, “Problem Lists in Health Records: Ownership, Standardization, and Accountability,” calls for the problem list to be a dynamic section of the health record that is used primarily for the provision of care.
The paper, written by a group of volunteers and AHIMA staff experts, calls for innovation and new thinking within the healthcare industry to enable efficient and appropriate use of problem lists, as well as to implement changes that enhance the utility of problem lists for patient engagement.
In order to achieve success through these changes, the industry must standardize its policy, process, and application principles, according to the report.
Problems included on the list include health, psychiatric, nursing, dental, social, and preventive care. Events are added to the list such as procedures, allergic reaction, complications from treatment, and others.
The paper calls for problem lists to become three-dimensional, meaning that more than one view of the list is available to problem list users in electronic environments.
According to the authors, factors driving the change to a three-dimensional list include:
- Accountable care organizations’ (ACOs) call to engage patients in their care
- Communication necessary for care delivered across the care continuum
- Health information exchange becoming more widespread
- Patients becoming more aware of health information and increasingly wanting to see their health records
- Financial incentives have changed to include measurements of value and population health outcomes
- The American Recovery and Reinvestment Act is driving broad EHR implementation
- Automated disease registries are a central tool for care management
- Increased functionality of clinical decision support technology adds new uses for the problem list
In addition, the authors write that policy should be based on defining the role of the problem list as a tool to support patient care, workflow efficiency and organization requirements, and defining the philosophy about patient involvement in their care.
The paper goes into detail with analysis of current problem list models and recommendations for best practices in future problem list development. Click here to review the paper in full.