Standardizing the Problem List in the Ambulatory EHR to Improve Patient Care

Maintaining an up-to-date problem list is a core element of the Centers for Medicare and Medicaid Services (CMS) definition of electronic health record (EHR) “meaningful use” because an accurate problem list is essential to providing better individual patient care across multiple care sites, and serves as a foundation for population management. This requires healthcareo rganizations to have a standardized process in the EHR to ensure the problem list remains current, an aspect of chart management that in the past was left to individual providers. The change that standardization of the problem list represents can pose a major challenge to healthcare organizations of all sizes, and is therefore an issue best approached within the framework of change management principles.

This white paper seeks to accomplish three objectives:

  1.  Describe how the problem list can be leveraged to achieve better individual patient care andpopulation management.
  2. Understand the opportunities and barriers for a standardized problem list in the EHR.
  3. Explain in detail how the change management principles of vision, skills, incentives, resources, and action plan can be used to assist organizations with developing processes to standardize problem list maintenance.

The material in these guides and tools was developed from the experiences of Regional Extension Center staff in the performance of technical support and EHR implementation assistance to primary care providers. The information contained in this guide is not intended to serve as legal advice nor should it substitute for legal counsel. The guide is not exhaustive, and readers are encouraged to seek additional detailed technical guidance to supplement the information contained herein.

Reference in this web site to any specific resources, tools, products, process, service, manufacturer, or company does not constitute its endorsement or recommendation by the U.S. Government or the U.S. Department of Health and Human Services.

Practice Role
Care Coordinators
Health Care Mgmt - Practice Mgrs Admin
Providers (MDs, DOs, NPs, PAs, RNs, LPNs)
PSR, Schedulers, Front Desk, Med Secretaries
Providers & Professionals
Setting/Practice Type
FQHC or Community Health Center
Large Practice 11 or more
Small Practice 1 - 10
Specialty Practice
Resource Topics
Patient and Family Engagement
Quality Improvement and Practice Transformation
EHR Steps
Step 5: Achieve Meaningful Use

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