Here's a true story recently told to me by a surgeon friend. Let's call him Dr Clark:
Dr. Clark, a highly skilled and caring surgeon, receives an unexpected phone call. It's from the wife of Charlie, a patient he discharged after a successful surgery and post-operative recovery two weeks earlier. "Charlie is dead," she said.
Charlie was compliant in the hospital with the orders to ambulate after surgery. He understood the discharge instructions to progressively continue to ambulate when he got home. "Dr. Clark isn't here. I'm tired and weak. I have no intention of ambulating any more than I have to for meals and the bathroom," he told his wife.
After several days at home, Charlie stood up, gave a facial expression of "uh oh," and fell over dead from a massive pulmonary embolus.
More than a decade later, Dr. Clark still remembers Charlie vividly. As a result, at the slightest sign or suspicion of patient resistance to post op ambulation therapy, Dr. Clark goes above and beyond his peers when dealing with patients like Charlie. For example, he recently told a patient that if he didn't ambulate by noon, Dr. Clark would have his bed rolled to the far end of the long hospital hallway, have security evict the patient from the bed, and then have the bed moved back to his empty room.
The patient said, "You're kidding, right?" Dr. Clark replied, without a smile, "No."
Why am I sharing this story? As a result of the ARRA requirement (as outlined in section 170.302(c), Maintain electronic, up-to-date problem list), CIOs, CMIOs, and CMOs are planning for their ED and inpatient strategies to get these lists populated and maintained. All clinicians I've met strongly welcome this requirement. They see the value to their patients and themselves. Most of these same clinicians are, within reason, willing to enter problems directly into the EHRs themselves. Most hospitalists I've met are also highly enthusiastic about it. This attention to the complexity of real, hospitalized patients is part of what they love!
I've heard some understandable concerns as well. Suppose an emergency medicine physician documents a problem that is not directly related to a patient's reason-for-visit to the Emergency Department. Many of these physicians are recognizing that as a result of adding this problem to a problem list, they have some new, newly explicit, or perceived duties.
They have a duty to consider and be accountable for their conclusion that the problem they added is not urgent or emergent relative to this encounter. Even when they schedule follow-up for this patient's non-emergent problem, they don't feel they have necessarily relieved their obligation, even though they have addressed the newly documented problem. The reason? Like Dr. Clark, they have had their own patients like Charlie. They're highly responsible doctors who believe they cannot trust the health system, the accountable primary care physician, or the patient to close the loop and reliably address anything they add to the problem list. Heck, they have some of their own problems they haven't been able to get around to caring for, i.e. diet and exercise. I certainly struggle with that.
Conclusions:
- UTD Problem Lists are a great and necessary thing. Aside from regulatory issues, they are the right thing to do.
- Closing the loop on care processes is exactly what EHRs and MU are all about. See my prior problem list post; Stage 3 of ARRA is explicitly about improving access, care quality and accountable costs. UTDPLs are a vital link in that closed-loop chain.
- Some healthcare systems will institute new or expanded screening programs as a result of ARRA/HITECH UTDPLs out of respect for the needs of people like Charlie, and Dr. Clark, who need or want follow-up care and its coordination. UTDPL shines a bright light on that need and issue.
In closing, I would like to know what you think by asking you to answer three questions:
Who owns the Problem List?
Who owns the problem while the patient is hospitalized or visiting the ED?
Who owns the problem after the patient is discharged?
