Managing the Problem List.

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
As we progress to a fully electronic medical record, the providers are being pushed to begin using an electronic Diagnosis(problem) list. We use Cerner for our EMR and currently nurses are able to populate a problem list and physicians can then accept those problems onto their Diagnosis list (as well as add their own dx). This Diagnosis list can then be automatically loaded into the MD's daily progress note to ensure all active problems are addressed.
There have been suggestions that CDI should populate the problem lists on the patients we review. The MD's would be then responsible for accepting problems onto their diagnosis list.
I can see come pro's/con's with this process but was wondering if any other CDS's are currently doing this and what the benefits and potential problems you have seen or are anticipating seeing in the future.

Thank you!

Comments

  • robert.hodges2robert.hodges2
    edited May 2016
    Just prior to me starting here the coders used to be able to add to the problem list based on coded diagnoses. That process was put to a halt when the new HIM Chief came in. Apparently there were a number of compliance issues involved.

    Working with an EMR I would be very cautious in your implementation of a problem list where many people can make entries. We have everything on the computer here and I can look at problem lists that list the same diagnosis three different times in three different ways (i.e. chronic kidney disease, stage 3 chronic kidney disease, and chronic renal failure). We encourage providers to review and update the problem lists on an annual basis, but that takes extra work on their part. I support the pro's in that everyone can see the problem list, but be cautious on who can enter information and how many providers may automatically accept all entries.

    Robert

    Robert S. Hodges, BSN, MSN, RN, CCDS
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
     
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov
     
    "We are dealing with Veterans, not procedures; With their problems, not ours." --General Omar Bradley

  • kshumpertkshumpert
    edited May 2016
    We are implementing Cerner as well. The problem list is in Snowmed CT. If those are moved up to the diagnoses field and then populate the progress note, there is a potential to lose the ICD-9 specificity you need for the progress notes if your physicians are using power notes.

    There are 2 options.
    #1 I have been running reports by specialty on the most common diagnoses used and adding the acuity that we need:) These are placed in a folder for the physicians. The diagnoses field is not all that intuitive right now and scares the heck out of the doctors.
    #2 the is an add on product called "Intelligent Medical Objects" and it makes it much easier for the physicians to search by diagnosis get what they mean.
    For example, most document CHF, not heart failure. If you type in CHF in the diagnosis field there are two options- 428.0 CHF and 065.0 Crimean Hemorrhagic Fever (yeah, we see a lot of this:)

    Thanks,
    Kathy
    Kathy Shumpert, RN, CCDS

    Clinical Documentation Improvement Specialist
    Howard Regional Health System
    Office 765-864-8754
    Cell phone 765-432-3961
    Fax 765-453-8152

    When something can be read without effort, great effort has gone into its writing. ~Enrique Jardiel Poncela



  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Thanks for the response! I have not had a chance to play with the system much at all but your concerns are what immediately jumped out at me as well.
    My assumption is that if the provider chooses the unspecified CHF code (428.0) as the diagnosis, that would only be a problem if they did not further specify the type/acuity in the narrative. Right?
    It has also been suggested that we create a "favorites" folder with the most common DX with the appropriate acuity options. That is what it sounds like you are doing.

    Katy Good, RN, BSN
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404

  • kshumpertkshumpert
    edited May 2016
    You are correct about the CHF 428.0 as a problem. The BIG problem is that the physicians are really struggling with the whole problem identity thing!! They are used to calling the current illness a "problem". Now, not only do they have to learn CPOE and electronic documentation, but new terminology! I have had physicians call me and ask me if I would help them round when we go live. They are so confused by all this that they are uncertain they are going to cover all the elements.

    Katy- in the diagnosis field I had Cerner change something for me. In the problems and diagnoses, I had Cerner add all 4 POA options to the classification box. That way when a physician pulls a diagnosis into a progress note, if POA is addressed, it is pulled in with the diagnosis. If nursing maintains the problem list (like a care plan for example) if they document that a foley was POA or a wound was POA you info to support a query and don't have to search so deeply.

    Thanks,
    Kathy
    Kathy Shumpert, RN, CCDS

    Clinical Documentation Improvement Specialist
    Howard Regional Health System
    Office 765-864-8754
    Cell phone 765-432-3961
    Fax 765-453-8152

    When something can be read without effort, great effort has gone into its writing.  ~Enrique Jardiel Poncela

  • vdavis2vdavis2
    edited May 2016
    We are moving toward Nursing and CDS's being able to add to the problem list... When a query is answered, the CDS can then add the answer to the problem list so the handoff MD's will also know that it needs addressed/accepted/treated, etc. Our problem list will also try to separate the list into "acute" issues while we maintain a constant list of those conditions that are chronic and always present.

    Vicki S. Davis, RN CDS
    Clinical Documentation Improvement Manager
    Health Information Management Department
    Alamance Regional Medical Center
    Office (336) 586-3765
    Ascom Mobile (336) 586-4191
    Fax (336) 538-7428
    vdavis2@armc.com

    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
  • jamiedugan2012jamiedugan2012
    edited May 2016
    We have cerner and our physicians are not utilizing the problem list and
    the nurses do not populate. It Would be great if they would. But can
    you really code from a problem list in a program or just from notes? I
    am a new CDI.
    Thanks
    Jamie

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Our coders do not code from the Cerner problem list. But the Cerner problem list can be used to populate the physicians PowerNote. If they use PowerNote and they have a complete problem list, it would ensure that each identified dx is carried through to discharge.

    Katy Good, RN, BSN
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404

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