Strategies for problem list implementation in a complex clinical enterprise.

Although the Institute of Medicine states that a patient problem list should have a prominent place in the computer-based patient record, the design and function of the problem list is not a matter of universal agreement. Developer experience with implementation has been inconsistent, in part because of confusion on data standards, uncertain user acceptance of data entry, and minimal rewards for the clinician. I propose that necessary features of the problem list include: 1) clinical focus, 2) codification of problems, 3) support for problem resolution, 4) historicity of problems, 5) support for multiple clinical views, 6) integration of maintenance functions with workflow, 7) support for administrative reporting, and 8) integration with useful clinical tools. I describe the strategies that we employed to meet these goals while implementing the problem list in a computerized patient record serving a large, complex clinical enterprise. I further report the successful achievement of those goals based upon audits six months after implementation.