Problem and Medication List Review: More Than Checking a Box?

Maintaining current and accurate problem and medication lists improves quality of care. Reviewing and updating these lists can be time-consuming and add to clinicians' cognitive load, thus increasing risk of clinician burnout. Maintaining these lists were core measures in the Centers for Medicare and Medicaid Services' Meaningful Use electronic health record (EHR) incentive program. It may appear that the easiest way to indicate that problem or medication lists are up-to-date is to have clinicians attest to the review by checking a box in the EHR. Yet, whether these reviews and maintenance are actually taking place or if they are merely "check-the-box" activities remains unclear. This study aimed to understand the relationship between clinician attestation of problem and medication list review and the length of these lists.

This multi-method study retrospectively analyzed EHR data from 24 Federally Qualified Health Centers to characterize problem and medication lists, and survey data to gauge the cognitive burden due to list review activities. EHR data were collected on patients with at least 2 visits between June 1, 2021 and May 30, 2022. The provides visited were from two health centers and they were surveyed from December 20, 2022 to March 3, 2023.

Our EHR data sample consisted of 362 436 patients seen by 2054 providers at 1 346 645 encounters. Eighteen percent of patients had a problem list with over 20 items; one percent had a medication list with over 20 items. Six patients had over 100 problems on their list, with the longest being 145. Twenty-three percent of patients had 1 or more duplicate diagnoses. Clinicians attested to reviewing problem and medication lists in the vast majority of encounters. There was no meaningful correlation between list lengths and attestation or between problem list duplication and attestation. Among the 49 survey respondents, the mean rating of mental effort for a comprehensive review of the problem list was 8.3 on a 9-point scale and 8.0 for medication list review.

Our findings revealed that problem and medication lists are sometimes long with unnecessary items. Attestation that the list has been reviewed does not equate to shorter and less duplicative lists. These findings may indicate that the clinician attestation process during clinical encounters is often done whether or not a problem and medication list has, in fact, been updated. Attestation may be a "check-the-box" activity imposing cognitive burden on clinicians to meet a metric while missing the goal of a focused and uncluttered list.