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Electronic Health Records

Problem lists are the keys to meaningful use

Put the big picture on your problem list. By Joe Bormel, M.D., MPH


any hospitals are behind the curve in imple- menting a certifi ed electronic health record (EHR) or contending with their existing data exchange platform’s inadequacies. This is slowing their compliance efforts with the government’s initial set of meaningful-use requirements comprised of 14 “core” objectives plus at least fi ve “menu” objectives. The HIMSS Analytics survey released in November 2010 underscores the industry-wide lack of readiness for meaningful-use compliance. Survey results indicate that 22 percent of 687 hospitals reported having the capabil- ity to achieve between one and four of the required core objectives. Approximately 34 percent said they can meet fi ve to nine of the required core objectives, and 22 percent stated they can comply with 10 or more elements required for the 2011 federal fi scal year. The survey’s fi ndings are troublesome. They suggest that few organizations will be able to achieve the Stage 1 meaningful-use criteria in the fi rst possible year of the program. It also suggests that they will fall short in readi- ness to begin Stage 2 in 2013 and Stage 3 in 2015. Although the fi rst stage of meaningful use is the easiest to carry out, this doesn’t mean that compli- ance success will be easily achieved. Reality is far from that outcome. Organizations are seemingly oblivious to

Joe Bormel, M.D., MPH, is chief medical offi cer and vice president, clinical product management, QuadraMed. For more information on QuadraMed solutions:

the fact that Stage 1 requirements can pose unforeseen challenges that can easily derail even the best-laid plans. To be frank, providers failing to anticipate hardships are putting themselves at major risk. To avoid potential pitfalls when striving to achieve meaningful-use compliance, organizations should begin by examining the big picture. In other words, consider the goals of the EHR to improve care quality and safety through effi cient capture of, and support for, providers’ diagnoses and treatments. Traditionally, this has been ac- complished through a problem-centered approach to care

40 February 2011

delivery. In fact, it was over 40 years ago that Dr. Law- rence Weed’s seminal New England Journal of Medicine established the fundamental concept behind a problem- oriented medical record. (Weed, L. L., 1968. NEJM; 278: 593-599. Medical records that guide and teach.) Today’s technological advancements have brought that vision to fruition. Leading EHR solutions have embraced a problem-centric model to enable diagnostic and treatment plans to be linked and driven by the patients’ specifi c medi- cal problems. This model creates a holistic view of patient data, empowering providers to quickly assess patients, document interventions and evaluate the effectiveness of the prescribed treatment while eliminating ineffi cient workfl ow processes.

The meaningful-use criteria underscore the signifi cance of the problem-oriented EHR by requiring the creation and maintenance of an up-to-date problem list of current and active diagnoses for 80 percent of patients under Stage 1. The up-to-date problem list – the heart of a problem- centered EHR – delivers a unifi ed view of current patient data across disparate care settings, laying the foundation for coordinated care, one of the main goals of meaning- ful use. In addition, the problem list can supply data for quality, performance and research initiatives that will help fulfi ll Stage 2 and 3 meaningful-use criteria. Although creating and maintaining up-to-date problem lists appears deceptively simple, many institutions will fi nd the task diffi cult to accomplish due to physicians’ different needs and perspectives. For instance, emergency department physicians are focused primarily on addressing emergent care needs. Specialists may fi nd that updating a problem list delivers less value to their decision-making process and see the responsibility falling squarely on pri-


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