Checking the Box: The Association between "Problem List Reviewed" and Outdated Diagnoses on the List

Problem lists are intended to support high-quality care, but are often long and outdated. Despite policy efforts to encourage their upkeep-such as the "Problem List Reviewed" attestation checkbox in electronic health records (EHRs)-many diagnoses remain on lists far longer than clinically appropriate. Clinicians often check the attestation box that problem lists have been reviewed to comply with performance measures without reviewing and modifying the list.This study aimed to assess whether attestation of "Problem List Reviewed" is associated with shorter duration of short-term (acute and billing-related) diagnoses on problem lists.Multi-method study including retrospective EHR data from 892,329 patient visits at 24 Federally Qualified Health Centers across the United States and chart review data. Participants included adult patients with 2+ primary care visits during the study period. The primary outcome was the duration that short-term diagnoses remained on the problem list. The secondary outcome was the relationship between duration and attestation of review.Diagnoses persisted on problem lists far beyond their expected clinical duration (e.g., acute pharyngitis: median 343 days; urinary tract infection: 443 days). For 6 of 12 conditions, attestation was associated with significantly longer duration (e.g., pharyngitis: 371 days with attestation vs. 302.5 without, p < 0.001). Only one code ("Encounter for Screening") was associated with shorter duration when attested (p = 0.016). Chart reviews revealed minimal evidence of problem list management during visits.Checking the "Problem List Reviewed" box is not associated with the appropriate removal of short-term diagnoses and may paradoxically contribute to their persistence. Incentive structures focused on clinician attestation of problem list review are counterproductive. Improving the design and functionality of problem lists is likely a better way to maintain concise, up-to-date lists that drive care and focus attention. Expecting clinicians to keep problem lists clean by adding an attestation check box is likely misguided.