Measure 3 Maintain Problem List
Measure 3 of 15 Core
Stage 1
|
Maintain Problem List
|
|
|
Objective
|
Maintain an up-to-date problem list of current and active diagnoses.
|
|
Measure
|
More than 80 percent of all unique patients seen by the EP have at least one entry or an indication that no problems are known for the patient recorded as structured data.
|
|
Exclusion
|
No exclusion.
|
Definition of Terms
Problem List - A list of current and active diagnosis as well as past diagnosis relevant to the current care of the patient.
Unique Patient - If a patient is seen by an EP more than once during the EHR reporting period, then for purposes of measurement that patient is only counted once in the denominator for the measure. All the measures relying on the term " Unique Patient" relate to what is contained in the patient's medical record. Not all of this information will need to be update or even be needed by the provider at every patient encounter. This is especially true for patients whose encounter frequency is such that they would see the same provider multiple times in the same EHR reporting period.
Up to Date - The term "up to date" means the list is populated with the most recent diagnosis known by the EP. This knowledge could be ascertained from previous records, transfer of information from other providers, diagnosis by the EP, or querying the patient.
Attestation Requirements
NUMERATOR / DENOMINATOR
-
DENOMINATOR: Number of unique patients seen by the EP during the EHR reporting period.
-
NUMERATOR: Number of patients in the denominator who have at least one entry or an indication that no problems are known for the patient recorded as structured data in their problem list.
The resulting percentage must be more than 80 percent in order for an EP to meet this measure.
Additional Information
-
The Medicare and Medicaid EHR Incentive Programs do not specify the use of ICD-9 or SNOMED-CT in meeting the measure for this objective. However the Office of the National Coordinator for Health Information Technology (ONC) has adopted ICD-9 or SNOMED-CT for the entry of structured data for this measure and made this a requirement for EHR technology to be certified. Therefore, EP's will need to maintain an up to date problem list of current and active diagnosis usien ICD-9 or SNOMED-CT as a basis for the entry of structured data into the certified EHR technology in order to meet the measure for this objective.
-
For patients with no current or active diagnosis, an entry must still be made to the problem list indicating that no problems are known.
-
An EP is not required to update the problem list for patients seen during the EHR reporitn period, and that at least one peice of information is presented to the EP. The EP can then use their judgement in deciding what further probing or updating may be required given the clinical circumstances.
-
The initial diagnosis cn be recorded in lay terms and later converted to standard structured data or can be initially entered using standard structured data.
