A key to achieving meaningful use of the electronic health record (EHR) is to establish a functional problem list to aid decision support. We sought to establish the necessary components of a problem list to manage patients. Three use-cases were developed and tested; a clinic patient with the new onset shortness of breath, a post-heart transplant patient with chest pain and a patient presenting to the emergency room with chest pain. First, all identifying information was removed from the record; two authors then independently reviewed the notes and dictations and temporally identified problems and decisions. We compared the evaluation of the use cases with the Veterans Administration classification schema for problems (ICD-9 codes with modifiers, date and status) as compared with our proposed schema. That proposed schema includes the use of SNOMED-CT and the following attributes: 1) Problem status; active, inactive, historic, resolved and changed to, as well as remove/error 2) Ambiguity, 3) Relevance/severity, 4) Episode and time within episode, 5) defined problem modifiers and 6) Role of the provider/consultant. Using the VAMC schema we were unable to accurately code the patients problems in a manner that would facilitate decision support. The limitations included the inability to prospectively classify problems, the limited utility of a status of active or inactive and the inherent weakness of ICD-9 coding to support ambiguity. Conversely, we were able to accurately code the patient's clinical scenario using our problem list modifiers. Specifically, the support of ambiguity by SNOMED-CT, especially "definite and definitely not" are important in evaluating and refining a differential diagnosis. Further, this schema supports defined problem modifiers such as paroxysmal, persistent and permanent. Finally, the administrative support of the problem list should include the ability to define problems in real time. Additionally, roles help define the ownership of problems, i.e. separating glaucoma from heart failure. In conclusion, to achieve meaningful use of the EHR adoption, a more robust schema for problem list management is required. This candidate schema satisfies those requirements.
McCormick, M., Windle, T. A., & Windle, J. R. (2010). A NEW SCHEMA FOR PROBLEM LISTS: TOWARDS REAL-TIME DECISION SUPPORT. Journal of the American College of Cardiology, 55(10), A132.E1241. https://doi.org/10.1016/s0735-1097(10)61242-9