News: Disease severity linked to incomplete and duplicate EHR problem lists
A study published in the Journal of Informatics in Health and Biomedicine found that the severity of the patient’s specific diseases impact the completeness of their EHR problem list and whether or not the problem list contains duplication.
The study analyzed more than 325,000 patient records from Partners HealthCare that had any of the following common chronic diseases:
- Crohn’s disease
- Ulcerative colitis
Across the study participants, there were more than 380,000 problem list entries. Researchers looked at each patient’s problem list checking for incompleteness and duplications.
Results showed that the completeness of an EHR problem list ranged based on disease severity. Of those patients with asthma, 93% has a completed problem list, meanwhile only 73% of patients with hypertension had a completed problem list. Duplicate problem lists were an issue for 28% of diabetes patients, yet only 4.8% of patients with hypertension had duplication in their problem list.
From a CDI perspective, many professionals have firsthand experience with problematic problem lists. Because of the ease of copy/paste functionality and a lack of policies to remove old or redundant conditions from problem lists, they’re often a dumping ground of inaccurate documentation.
CDI teams looking to improve this documentation may be well served by directing special care at these high complexity patient records, as the study suggests they may contain incomplete or duplicate documentation.
Editor’s note: The Journal of Informatics in Health and Biomedicine study can be found here. To read a recent article from CDI Strategies about patients identifying errors in their own records, click here. To read about common EHR pitfalls faced by CDI professionals, click here.