Problem lists drive CDS systems and population health management

Policy experts say problem lists can amp up clinical decision support systems as well as population health management.

As stage 3 requirements loom and accountable care organizations plug in to payer programs reimbursing population health management, IT leaders recommend providers extend the reach of their problem lists sooner rather than later, integrating them with CDS systems to see better – and faster -- outcomes.

Historically, the structure of problem lists has varied widely among providers who opt for different methods of recording a patient's medical history. Meaningful use stages 1 and 2 require providers to maintain a list of current and active medical conditions. In addition, stage 2 requires problem lists be interoperable with EHRs across numerous healthcare facilities. The common language is SNOMED CT (Systematized Nomenclature of Medicine -- Clinical Terms), a coding system that standardizes diagnoses within different vendors' EHR systems.

In the past, we kept these in paper form. Now this is structured data, and we're able to use it a lot more effectively.

Jose Polanco,
assistant medical director and CMIO, Blackstone Valley Community Health Center

In the Health Resources and Services Administration webinar, Using an EHR to Create Patient Problem Lists, Michelle Consolazio Nelson, meaningful use analyst with the Office of the Chief Medical Officer, said providers should start thinking about improving quality of care with electronic data capture and interoperability. She said that could mean correlating SNOMED-generated problem lists with clinical decision support (CDS) systems, so physicians are entering the right codes and diagnoses needed to trigger CDS measures. In turn, CDS systems can initiate alerts and "stops" for drug-disease interactions, for example.

"The idea is that moving forward ... providers can work with contractors to walk through their workflow and identify places for intervention," Nelson said. "The first area being, 'What is the patient diagnosed with?' And all those diagnoses relate back to the problem list."

Moreover, Nelson touted the potential for problem lists to benchmark clinical quality measures in a hospital's patient population. Physicians could see how their problem lists fared compared to other physicians' at the same facility.

"Providers always love a little healthy competition, so it's a nice way to embark on a quality improvement program and to see what others are doing; to touch base within the practice and to learn from each other," Nelson said.

Blackstone Valley Community Health Center in Pawtucket, R.I. attested for meaningful use stage 1 just this year, but uses its problem lists for population health management as well. IT leaders take structured data generated by problem lists to create registry reports of patients with chronic conditions, then they run searches to scope out missing medications or misdiagnosed illnesses.

"I mostly see adult patients with many chronic medical problems on multiple medications -- so this topic is of great interest to me," Jose Polanco, M.D., assistant medical director and chief medical information officer at Blackstone, said in the webinar. "In the past we kept these in paper form. Now this is structured data, and we're able to use it a lot more effectively."

The Office of the National Coordinator for Health Information Technology (ONC) offers a tool called popHealth to streamline the automated generation of quality measure reports for a provider's patient population. The ONC is working on a template for implementing CDS as well, expected this July.

Polanco said from a clinician perspective, the potential benefits of problem lists cannot be realized unless information is kept updated, structured and is used efficiently.

"Regardless of your EHR, the workflows are the same," he said. "The uses are the same and what we can do with these lists, the principles, are the same across the board."

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