Background:
The Centers for Medicare and Medicaid Services (CMS) provide financial incentives to hospitals that demonstrate meaningful electronic health record (EHR) implementation. The American Recovery and Reinvestment Act of 2009 specifies meaningful use; for hospitals, there are 24 objectives of which 14 are mandatory, including maintaining an up–to–date problem list. For stage one of meaningful use, the problem list requirement states that at least one active problem must be present on 80% of all admitted patients.
Purpose:
We present our initiative to use the EHR at a tertiary teaching hospital to achieve problem list meaningful use compliance. The baseline usage at our hospital was 20%, although the EHR had been fully implemented for more than 2 years. No department initially met CMS meaningful use requirements, while the ED, orthopedic, psychiatry, and intensive care units started at 0%.
Description:
The hospital’s Physician Informatics Team (PIT) created a task force to investigate and implement the use of problem lists. Members included hospitalists, primary care physicians, specialists, medical residents, nurses, and representatives from the IT department and EHR vendor. The IT department suggested several solutions, but physician members found them cumbersome. Physicians designed alternatives with attention to work flow. These options were explored in a small group with hospitalist, IT, and EHR vendor representatives. Following response from the task force, mockups in a “sandbox” environment, and feedback from the PIT, a step–wise process was enacted. Best practice advisories (BPAs) alerted physicians that a problem list had not been completed. When initiating the order–writing process, a soft–stop alert would pop– up. Both of these alerts provided a quick link to the problem list screen. When attempting to sign orders without a documented active problem, an order–validation pop– up would alert the physician to document a problem. This order validation was initially a soft–stop, with the option to switch to a hard–stop. This initiative was coupled with efforts to inform and educate physicians. Physician education, BPAs, and soft–stops improved problem list compliance from 20% to 50%. The hard–stop option immediately improved problem list use to 95%. Physician response (as assessed by help–desk calls, inquiries to IT, and physician critique), was generally favorable. Conclusions: Instituting a hard–stop in the EHR can be an effective tool to improve problem list meaningful use compliance. Our task force closely examined physician work flow to identify a process that minimized interference with patient care. While a hard–stop does not guarantee an informative and high–quality problem list, it can facilitate a change in hospital opinion and culture regarding problem lists.