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Decluttering the problem list in electronic health records.

Austin R Brown1, Allison B McCoy2, Adam Wright2

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American Journal of Health-System Pharmacy : AJHP : Official Journal of the American Society of Health-System Pharmacists
|October 1, 2021
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Summary

Problem list maintenance at an academic medical center shows significant issues with duplicate and inconsistent entries. Improvements are needed to ensure accurate patient problem lists for better care.

Keywords:
information systemsmedical record systemsproblem listproblem-oriented medical records

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Area of Science:

  • Medical Informatics
  • Clinical Documentation
  • Healthcare Quality Improvement

Background:

  • Accurate patient problem lists are crucial for effective clinical decision-making and care coordination.
  • Maintaining up-to-date and accurate problem lists in electronic health records (EHRs) presents ongoing challenges for healthcare institutions.

Purpose of the Study:

  • To evaluate the current state of problem list maintenance within an academic medical center.
  • To identify specific areas of deficiency in problem list accuracy and completeness.

Main Methods:

  • Analysis of problem list data from 546,510 patients with at least two encounters between 2018-2019.
  • Utilized frequency of additions, resolutions, deletions, and identified duplicate or inconsistent problem entries as markers.
  • Included assessment of problems documented elsewhere in the EHR, such as family history and allergies.

Main Results:

  • 0.7% of patients had exact duplicate active problems, while 10.5% had SNOMED CT code duplications.
  • Inconsistencies were found in 2.5% of asthma and 6.4% of chronic kidney disease (CKD) problem lists.
  • Significant numbers of patients had family history (3.1%) or allergies (7.2%) inappropriately listed as active problems.

Conclusions:

  • The study highlights significant areas for improvement in problem list maintenance processes.
  • Further research into semantic duplication and the development of clinical decision support tools for problem list deduplication are recommended.