HIM 480 Module 5 Solution Design Short Paper Example

One Fix for Each Cause: Designing a Problem List Improvement Program for Hollis Ridge Health

[Student Name]

Southern New Hampshire University

HIM 480: Health Information Management Capstone

Solution Design

[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.

One Fix for Each Cause: Designing a Problem List Improvement Program for Hollis Ridge Health

The baseline audit at Hollis Ridge Health found that roughly one qualifying chronic condition in four was missing from the list and that almost a quarter of patients carried stale entries. The root cause analysis traced these gaps to unclear ownership, the absence of any routine review, a cumbersome interface, the lack of prompts when data suggest a missing condition and the absence of policy. This paper designs a program in which each component addresses at least one of those causes, and it explains how the components work together.

Design Principles

Three principles guided the design. First, keep clinical judgment with clinicians: the list should reflect a clinician's synthesis of the patient, which Kaplan (2007) described as the list's real value, so no component adds diagnoses automatically. Second, make the right action the easy action by placing the list where clinicians already work. Third, fix the process as well as the backlog, so the list stays accurate after the project ends. Simons et al. (2016) reached similar conclusions, emphasizing agreed definitions, clear responsibility and usable design as determinants of a successful problem list.

Component 1: An Ownership Policy

A written policy will make the patient's primary care clinician responsible for the overall list, while every clinician who diagnoses a chronic condition must add it with a codable term. Specialists may add problems in their field and are expected to resolve problems they added when those problems end. The policy also defines what belongs on the list, chronic and active conditions and significant history, and what does not, such as symptoms already explained by a listed diagnosis. The medical executive committee will be asked to adopt the policy so it carries medical staff authority rather than appearing to come from health information alone.

Component 2: Reconciliation at Chronic Care Visits

At annual wellness visits and chronic disease follow-ups, the rooming nurse will open the list and ask the patient about each problem, then flag items that may have resolved. The clinician confirms or resolves them before signing the note. This builds the missing routine into existing visits instead of creating a separate task and addresses the stale problems found on 23% of lists.

Component 3: The List Inside the Note

The informatics team will add a problem pane to the primary care note template so clinicians can add, update or resolve a problem without leaving the note, and so that assessment and plan entries can be written against listed problems. This reduces the steps that interviews described as the main obstacle and ties the list to the note, as the problem-oriented record intended.

Component 4: Suggestions of Likely Missing Problems

Decision support will suggest conditions that the record's data imply but the list lacks. Wright et al. (2012) tested this approach in a randomized trial and found that clinics receiving inferred problem suggestions documented substantially more of the targeted conditions than control clinics. Hollis Ridge will start with three conditions where rules are clear and the audit gap is large. For chronic kidney disease, the rule follows the KDIGO definition summarized by Levin and Stevens (2014), which requires reduced kidney function or markers of damage persisting for more than three months: two estimated glomerular filtration rates below 60 at least 90 days apart will prompt a suggestion. For diabetes, two qualifying glycated hemoglobin results or a prescription for insulin or another diabetes drug besides metformin will prompt one. For heart failure, a reduced ejection fraction on echocardiography with a heart failure medication will prompt one. Each suggestion must be accepted, dismissed with a reason or deferred, and dismissals will be reviewed monthly to refine rules and limit alert fatigue. Suggestions will appear only in the problem pane during a visit, never as interrupting pop-ups, and a clinician who dismisses the same suggestion twice for a patient will not see it again for a year unless new data arrive.

Component 5: Feedback to Clinics

Each clinic will receive a monthly report showing completeness for the six conditions, the share of lists reviewed at chronic care visits and the rate of accepted suggestions, compared with other clinics and with targets. Clinicians told interviewers they did not know the list mattered, so each report will include one example of a decision support rule or quality measure that depends on it.

Component 6: Patients as Reviewers

Patients already see their problem list in the portal. In surveys spanning seven years of open visit notes, Walker et al. (2019) heard from patients who generally reported better understanding of their care and valued the access, which suggests patients can be partners in keeping the record accurate. The portal will add a simple option for patients to flag a problem they believe is resolved or incorrect, routed to the care team for review rather than changed automatically.

Health Information Cleanup

The health information data integrity team will run a monthly report of duplicate entries, such as the same condition listed under two terms, and send merge suggestions to the responsible clinician. It will also maintain the list of approved terms and their mappings to diagnosis codes, so that problems added through any component are codable.

How the Components Fit

Table 1 maps each component to the root causes it addresses. No single component solves the problem; together they create responsibility, a routine, an easier path, prompts, feedback and a second set of eyes.

Table 1. Components Mapped to Root Causes

Note. Mapping by the author based on Milestone Two findings.

Conclusion

The proposed program treats problem list accuracy as a shared process rather than an individual failing. By pairing a clear policy and routine with easier design, evidence-based suggestions, feedback and patient review, it addresses every root cause found at Hollis Ridge while leaving clinical judgment where it belongs. Milestone Three will plan how to implement and evaluate the program.

References

Kaplan, D. M. (2007). Clear writing, clear thinking and the disappearing art of the problem list. Journal of Hospital Medicine, 2(4), 199-202. https://doi.org/10.1002/jhm.242

Levin, A., & Stevens, P. E. (2014). Summary of KDIGO 2012 CKD guideline: Behind the scenes, need for guidance, and a framework for moving forward. Kidney International, 85(1), 49-61. https://doi.org/10.1038/ki.2013.444

Simons, S. M. J., Cillessen, F. H. J. M., & Hazelzet, J. A. (2016). Determinants of a successful problem list to support the implementation of the problem-oriented medical record according to recent literature. BMC Medical Informatics and Decision Making, 16, Article 102. https://doi.org/10.1186/s12911-016-0341-0

Walker, J., Leveille, S., Bell, S., Chimowitz, H., Dong, Z., Elmore, J. G., Fernandez, L., Fossa, A., Gerard, M., Fitzgerald, P., Harcourt, K., Jackson, S., Payne, T. H., Perez, J., Shucard, H., Stametz, R., DesRoches, C., & Delbanco, T. (2019). OpenNotes after 7 years: Patient experiences with ongoing access to their clinicians' outpatient visit notes. Journal of Medical Internet Research, 21(5), Article e13876. https://doi.org/10.2196/13876

Wright, A., Pang, J., Feblowitz, J. C., Maloney, F. L., Wilcox, A. R., McLoughlin, K. S., Ramelson, H., Schneider, L., & Bates, D. W. (2012). Improving completeness of electronic problem lists through clinical decision support: A randomized, controlled trial. Journal of the American Medical Informatics Association, 19(4), 555-561. https://doi.org/10.1136/amiajnl-2011-000521