Original Study| Volume 22, ISSUE 5, P1009-1014, May 2021

There's a Problem With the Problem List: Incongruence of Patient Problem Information Across the Home Care Admission



      Illustrate patterns of patient problem information received and documented across the home health care (HHC) admission process and offer practice, policy, and health information technology recommendations to improve information transfer.


      Observational field study.

      Setting and Participants

      Three diverse HHC agencies using different commercial point-of-care electronic health records (EHRs). Six nurses per agency each admitted 2 patients (36 total).


      Researchers observed the admission process and photographed documents and EHR screens across 3 phases: referral, assessment, and plan of care (POC). To create a standardized data set, we mapped terms within medical diagnoses, signs, symptoms, and Problems to 5 of the 42 Omaha System Problem Classification Scheme problem terms. This created 180 problem pattern cases (5 problem patterns per patient).


      Each pattern of problem information being present or absent was observed. In 52 cases (28.9%), a problem did not appear. In 36 cases (20%), the problem appeared in all 3 phases. In 46 cases (25.6%), the problem appeared in referral and/or assessment phases and not on the POC. Conversely, in 37 cases (20.5%), the problem appeared in referral or assessment phases and on the POC. In 9 cases (5%), the problem only appeared on the POC. Within the EHRs, there were no rationale fields to clarify including Problems or not and no problem status fields to identify active, resolved, or potential ones.

      Conclusions and Implications

      Diagnosis or problem information transferred from the referral source or gathered during an in-home assessment did not appear in the POC. Because of the EHR structure, clinicians could not identify inactive problem or problem priority. Documentation or mapping of a structured problem list using a standardized interprofessional terminology such as the Omaha System coupled with identification of rationale could support the documentation of problem status and priority and reduce information loss.


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        • Anderson Helms L.B.
        • Black S.
        • Myers D.K.
        A rural perspective on home care communication about elderly patients after hospital discharge.
        West J Nurs Res. 2000; 22: 225-243
        • Institute of Medicine
        To Err Is Human: Building a Safer Health System.
        National Academies Press, Washington, DC2000
        • Kripalani S.
        • LeFevre F.
        • Phillips C.O.
        • et al.
        Deficits in communication and information transfer between hospital-based and primary care physicians: Implications for patient safety and continuity of care.
        JAMA. 2007; 297: 831-841
        • The Joint Commission on the Accreditation of Healthcare Organizations
        National Patient Safety Goals Effective January 2017: Home Care Accreditation Program.
        (Available at:)
        • Brody A.
        • Gibson B.
        • Tresner-Kirsch D.
        • et al.
        High prevalence of medication discrepancies between home health referrals and Centers for Medicare & Medicaid Services home health certification and plan of care and their potential to affect safety of vulnerable elderly adults.
        J Am Geriatr Soc. 2016; 64: 5
        • Ferranti J.M.
        • Musser R.C.
        • Kawamoto K.
        • Hammond W.E.
        The Clinical Document Architecture and the Continuity of Care Record: A critical analysis.
        J Am Med Inform Assoc. 2006; 13: 245-252
        • Medicare Payment Advisory Commission
        Home Health Care Services.
        • Wright A.
        • Pang J.
        • Feblowitz J.C.
        • et al.
        Improving completeness of electronic problem lists through clinical decision support: A randomized, controlled trial.
        J Am Med Inform Assoc. 2012; 19: 555-561
        • Hartung D.M.
        • Hunt J.
        • Siemienczuk J.
        • et al.
        Clinical implications of an accurate problem list on heart failure treatment.
        J Gen Intern Med. 2005; 20: 143-147
        • Romagnoli K.M.
        • Handler S.M.
        • Ligons F.M.
        Home-care nurses perceptions of unmet information needs and communication difficulties of older patients in the immediate post-hospital discharge period.
        BMJ Qual Saf. 2013; 22: 324-332
        • Shih A.F.
        • Buurman B.M.
        • Tynan-McKiernan K.
        • et al.
        Views of primary care physicians and home care nurses on the causes of readmission of older adults.
        J Am Geriatr Soc. 2015; 63: 4
        • Vaidya S.R.
        • Shapiro J.S.
        • Papa A.V.
        • et al.
        Perceptions of health information exchange in home healthcare.
        Comput Inform Nurs. 2012; 30: 7
        • Arbaje A.
        • Hughes A.
        • Werner N.
        • et al.
        Information management goals and process failures during home visits for middle-aged and older adults receiving skilled home healthcare services after hospital discharge: A multisite, qualitative study.
        BMJ Qual Saf. 2019; 28: 111-120
        • Jewell S.E.
        Discovery of the discharge process: A study of patient discharged from a care unit for elderly people.
        J Adv Nurs. 1991; 18: 1288-1296
        • Bowles K.H.
        • Pham J.
        • O'Connor M.
        • Horowitz D.A.
        Information deficits in home care: A barrier to evidence-based disease management.
        Home Health Care Manage Pract. 2010; 22: 278-285
        • Monsen K.A.
        • Westra B.L.
        • Oancea S.C.
        • et al.
        Linking home care interventions and hospitalization outcomes for frail and non-frail elderly patients.
        Res Nurs Health. 2011; 34: 160-168
        • Westra B.L.
        • Solomon D.
        • Ashley D.M.
        Use of the Omaha System data to validate Medicare required outcomes in home care. Journal of healthcare information management.
        JHIM. 2006; 20: 88-94
        • Sockolow P.
        • Le N.
        • Yang Y.
        • et al.
        Incongruence of patient problem information across three phases of home care admission: There's a problem with the problem list.
        Stud Health Technol Inform. 2019; 264: 803-807
        • Sockolow P.S.
        • Wojciechowicz C.
        • Holmberg A.
        • et al.
        Home care admission information: What nurses need and what nurses have. A mixed methods study.
        Stud Health Technol inform. 2018; 250: 164-168
        • Centers for Medicare & Medicaid Services
        Outcome and Assessment Information Set.
        (Available at:) (Published 2020)
        • Martin K.S.
        The Omaha System: A Key to Practice, Documentation, and Information Management.
        2nd ed. Health Connections Press, Omaha, NE2005
        • The Omaha System
        The Omaha System: Solving the clinical data-information puzzle. Recognition/Electronic Health Records.
        (Available at:)
        Date accessed: December 11, 2019
        (Published 2018)
        • The Omaha System
        Omaha System: Solving the clinical data-information puzzle. Omaha System overview.
        (Available at:)
        Date accessed: April 7, 2020
        • Omaha System Community of Practice
        Learning about the Omaha System.
        (Available at:) (Published 2020)
        • Marek K.D.
        Nursing diagnoses and home care nursing utilization.
        Public Health Nurs. 1996; 13: 195-200
        • Coenen A.
        • Marek K.D.
        • Lundeen S.P.
        Using nursing diagnoses to explain utilization in a community nursing center.
        Res Nurs Health. 1996; 19: 441-445
        • Bowles K.H.
        The Omaha System: Bridging hospital and home care.
        Online J Nurs Inform. 1999; 3: 4
        • Monsen K.A.
        • Kapinos N.
        • Rudenick J.M.
        • et al.
        Social determinants documentation in electronic health records with and without standardized terminologies.
        West J Nurs Res. 2016; 38: 1399-1400
        • Austin R.R.
        • Monsen K.A.
        • Schulz C.
        An informatics approach to interprofessional management of low back pain: A feasibility study using the Omaha System.
        J Innov Health Inform. 2017; 24: 929
        • Helleso R.
        • Lorensen M.
        • Sorensen L.
        Challenging the information gap—The patients transfer from hospital to home health care.
        Int J Med Inform. 2004; 73: 12
        • Aguirre E.
        • Woods R.T.
        • Spector A.
        • Orrell M.
        Cognitive stimulation for dementia: A systematic review of the evidence of effectiveness from randomised controlled trials.
        Ageing Res Rev. 2013; 12: 253-262
        • Sockolow P.S.
        • Bowles K.H.
        • Wojciechowicz C.
        • Bass E.J.
        Incorporating home health care nurses’ admission information needs: Informing data standards.
        J Am Med Inform Assoc. 2020;
        • Forster A.J.
        • Murff H.J.
        • Peterson J.F.
        • et al.
        Adverse drug events occurring following hospital discharge.
        J Gen Intern Med. 2005; 20: 317-323
        • Park Y.S.
        • McNaughton D.B.
        • Mathiason M.A.
        • Monsen K.A.
        Understanding tailored PHN interventions and outcomes of Latina mothers.
        Public Health Nurs. 2019; 36: 87-95
        • Sockolow P.S.
        • Rogers M.
        • Bowles K.H.
        • et al.
        Challenges and facilitators to nurse use of a guideline-based nursing information system: Recommendations for nurse executives.
        Appl Nurs Res. 2013; 27: 25-32
        • Kim J.
        • Yao Y.
        • Macieira T.G.R.
        • Keenan G.
        An examination of the coverage of the SNOMED CT coded nursing problem list subset.
        JAMIA Open. 2019; 2: 386-391
        • Fischer G.
        Context-aware systems: The “right” information, at the “right” time, in the “right” place, in the “right” way, to the “right” person. Paper presented at: AVI '12: Proceedings of the International Working Conference on Advanced Visual Interfaces.
        2012 (Capri Island, Italy)
        • Centers for Medicare & Medicaid
        IMPACT Act of 2014 Data Standardization & Cross Setting Measures.
        (Available at:) (Published 2018)
        • Bowles K.H.
        • Potashnik S.
        • Ratcliffe S.J.
        • et al.
        Conducting research using the electronic health record across multi–hospital systems: Semantic harmonization implications for administrators.
        J Nurs Admin. 2013; 43: 355-360