HIM 480 Module 2 Capstone Milestone One Example

Capstone Milestone One: What Is on the List and What Should Be, a Proposal to Improve Problem List Accuracy at Hollis Ridge Health

[Student Name]

Southern New Hampshire University

HIM 480: Health Information Management Capstone

Capstone Milestone One

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Capstone Milestone One: What Is on the List and What Should Be, a Proposal to Improve Problem List Accuracy at Hollis Ridge Health

Background and Problem

Hollis Ridge Health's electronic record uses the problem list to trigger decision support, build quality measure denominators, identify patients for care management and show patients a summary of their conditions in the portal. When the list is incomplete or out of date, each of those uses fails quietly. A recent near miss, in which a patient with heart failure received a medication that can worsen the condition because heart failure was missing from his list, showed that the gap reaches patients. No one at Hollis Ridge has measured how complete or accurate its problem lists are, so the size of the problem is unknown.

Significance

The project matters beyond one near miss. If heart failure or chronic kidney disease is missing from a third of the lists where it belongs, then decision support rules for drug safety, dosing and monitoring are silent for those patients, quality measures undercount them, care managers never call them and risk adjustment understates how sick the population is. Improving the list is one of the few changes that helps patient safety, quality reporting, population health and revenue at the same time, which should make the project attractive to several leaders at once.

Purpose and Aims

The purpose of this capstone is to measure and improve the accuracy of problem lists in adult primary care at Hollis Ridge. It has three aims. The first is to measure completeness and currency of problem lists for six chronic conditions against a defined reference standard. The second is to identify the root causes of gaps through record analysis, clinician interviews and a review of workflow and record design. The third is to design an improvement program and an implementation and evaluation plan that leaders can adopt.

Scope

The project covers adult patients seen at least twice in the past year at the system's 12 primary care clinics. It focuses on six conditions chosen for their frequency and their role in decision support and quality measures: type 2 diabetes, hypertension, heart failure, chronic kidney disease, chronic obstructive pulmonary disease and depression. Inpatient problem lists, specialty clinics and pediatric patients are outside scope, although findings may later apply to them. Limiting scope in this way keeps the audit feasible within one term while covering conditions that affect thousands of patients.

Stakeholders

Patients are the first stakeholders, since their safety and the accuracy of their portal summaries depend on the list. Primary care physicians, advanced practice clinicians and nurses maintain the list. The clinical informatics team controls the record's design and decision support rules. Quality, population health and coding staff use the list for measures, outreach and risk adjustment. The chief medical information officer has agreed to sponsor the project, and the medical director of primary care has agreed to help recruit clinicians for interviews.

Methods

Aim one uses a chart audit. A random sample of 400 eligible patients will be drawn. For each condition, a reference standard defines when the condition should appear on the list: for example, diabetes counts as present when a clinician has documented it, when two glycated hemoglobin values reached the diagnostic cutoff or when the patient takes a glucose-lowering drug other than metformin alone. Reviewers will record whether each condition meeting the standard appears on the list, whether listed conditions are marked active when resolved and whether duplicates exist. Two reviewers will independently audit 40 charts to check agreement.

This approach follows published work. Wright et al. (2015) measured completeness across ten sites by comparing problem lists with evidence from medications, laboratory results and billing codes, and Poulos et al. (2021) audited a hospital's problem lists and found many conditions documented in notes but missing from the list. Hodge and Narus (2018), in a systematic review, identified recurring themes behind problem list success and failure, including ownership, usability and standardized terms; those themes will organize the root cause analysis for aim two, which adds semi-structured interviews with 12 clinicians and a walk-through of how problems are added and resolved in the record. Aim three will combine the findings with the literature to design interventions.

Data Access and Review

The project is framed as quality improvement for Hollis Ridge's own patients rather than as a study meant to inform the wider field. The sponsor will submit it for the system's quality improvement determination before any charts are reviewed. Reviewers will use the minimum data needed, store audit results with study numbers rather than names and delete the linking file at the end of the project. Interview participants will be told their answers are confidential and reported only in themes.

Timeline

Table 1 shows the timeline, aligned with the course milestones.

Table 1. Capstone Timeline

Note. Timeline prepared by the author for an eight-week term.

Expected Challenges

Three challenges are likely. Clinicians have heavy workloads and may see list maintenance as clerical work, which could make interviews hard to schedule and recommendations hard to adopt. The reference standard depends on structured data, so conditions described only in narrative notes may be missed. And changes to decision support require the informatics team's time, which is already committed to other projects. Each challenge will be discussed with the sponsor early so that the plan reflects what is possible.

Deliverables and Limitations

The project will deliver a baseline report of problem list completeness and currency for six conditions, a root cause summary, a proposed improvement program and an implementation and evaluation plan presented to the sponsor. Its limitations include a reference standard that may miss conditions documented only in free text, a single health system and a short timeframe that allows planning but not full implementation within the course.

References

Hodge, C. M., & Narus, S. P. (2018). Electronic problem lists: A thematic analysis of a systematic literature review to identify aspects critical to success. Journal of the American Medical Informatics Association, 25(5), 603-613. https://doi.org/10.1093/jamia/ocy011

Poulos, J., Zhu, L., & Shah, A. D. (2021). Data gaps in electronic health record (EHR) systems: An audit of problem list completeness during the COVID-19 pandemic. International Journal of Medical Informatics, 150, Article 104452. https://doi.org/10.1016/j.ijmedinf.2021.104452

Wright, A., McCoy, A. B., Hickman, T.-T. T., Hilaire, D. S., Borbolla, D., Bowes, W. A., Dixon, W. G., Dorr, D. A., Krall, M., Malhotra, S., Bates, D. W., & Sittig, D. F. (2015). Problem list completeness in electronic health records: A multi-site study and assessment of success factors. International Journal of Medical Informatics, 84(10), 784-790. https://doi.org/10.1016/j.ijmedinf.2015.06.011