Executive Summary
Problem lists can become liabilities if they are not accurate. A recent study found that many problem lists aren’t complete and some of the information in the lists isn’t correct.
- A problem list figured in a recent large malpractice judgment.
- If you have a problem list policy, it must be followed.
- Moving problem lists from paper to an electronic record poses risks.
Many hospitals use problem lists as a way to catalog all health issues affecting a patient, or at least those that are particularly noteworthy for other physicians. A recent study and malpractice case, however, highlight the risk posed by having a policy on problem lists and not following it.
Researchers led by Adam Wright, PhD, a scientist at Brigham and Women’s Hospital in Boston, examined 10 healthcare organizations that use different electronic health records (EHRs) in the United States, United Kingdom, and Argentina. The study was published in the October 2015 issue of the International Journal of Medical Informatics.
To study how complete problem lists were at those facilities, they looked for patients who had hemoglobin A1c values of greater than 7%, a diagnostic indicator for diabetes, and then looked to see if diabetes was listed on the problem lists for those patients. They found the levels of completeness varied from 60% to 99% across the 10 facilities, with an average of 78%.
They reported that further investigation revealed “six success factors which may be useful for healthcare organizations seeking to improve the quality of their problem list documentation: financial incentives, problem oriented charting, gap reporting, shared responsibility, links to billing codes, and organizational culture.” (More information on the study can be found online at http://tinyurl.com/nrmdo4x. The Agency for Healthcare Rsearch and Quality has published a commentary on a case in which an incomplete problem list led to an adverse outcome. That commentary is online at http://tinyurl.com/ljyxnzm.)
A recent malpractice case also illustrates the risk from incomplete problem lists. Andrea Larkin, 35, is paralyzed from a stroke that she suffered hours after giving birth, says her lawyer, Benjamin Novotny, JD, partner with the Boston law firm Lubin & Meyer. A jury in Dedham, MA, awarded $35.4 million against defendants Dedham Medical Associates, where Larkin sought treatment for dizziness in 2004, and Jehane Johnston, MD, a physician there who examined Larkin. With interest, the jury award comes to just more than $41 million, Novotny says. Larkin’s care costs her family more than $200,000 annually.
Michael Querner, MD, Dedham Medical’s chief medical officer, issued a statement expressing sympathy for Larkin, but he said “we respectfully disagree with the jury’s finding in this case and intend to pursue all available legal measures.”
Issue? The “problem list”
The case began with Larkin’s visit to the clinic in 2004 after running the Boston Marathon and experiencing dizzy spells. Johnston ordered an MRI and a CAT scan that revealed brain abnormalities.
Dedham Medical Associates had a specific policy requiring the doctor to note such abnormal findings in a “problem list” on the inside cover of her paper medical record, Novotny says. The policy was intended to improve patient safety by bringing the conditions to the attention of any clinicians viewing the chart in the future, according to testimony.
Johnston did not enter Larkin’s abnormal brain findings in the problem list. When the health system transitioned to an electronic medical record over the next few years, any patient’s problem list notations from the paper record were entered into the electronic record. All physicians in the Dedham Medical Associates system could access the electronic record, including the problem list notations.
Because Larkin’s abnormalities were not noted in the paper record’s problem list, they also didn’t appear in the electronic record’s problem list four years later when Larkin became pregnant. The abnormal testing findings were still in Larkin’s complete record, but they were not highlighted on the problem list that clinicians routinely checked.
Policy backfired
Testimony at trial indicated that her Dedham Medical obstetrician was not aware of her brain issues and would have ordered a cesarean section if they had been on her problem list. Labor would be too risky because it could lead to a massive stroke such as the one Larkin suffered within hours of the birth.
Larkin, a former teacher, requires 24-hour care and has difficulty with speech. “She’s there cognitively, but she’s locked in her body and will need constant care for the rest of her life,” Novotny says.
The health system’s problem list backfired in terms of patient safety and malpractice defense, Novotny says. The existence of the problem list encouraged clinicians to depend on it for important alerts about a patient’s conditions, he says, which in turn made them lax about digging through the entire patient record in search of important information. When key findings were left off the problem list, the policy ended up causing the very thing it was meant to prevent.
“They actually had a policy that was right on point for trying to prevent this kind of disaster, and they didn’t follow it,” Novotny explains. “That will always come back and hurt you in court if you have a policy and procedure and don’t follow it.”
- Benjamin Novotny, JD, Partner, Lubin & Meyer, Boston. Telephone: (617) 720-4447.
