‘Information overload’ may cause missed EHR alerts

Electronic health records (EHRs) routinely alert clinicians to abnormal test results, but there is potential for these alerts to be missed, according to a new study.

To examine what factors might predict missed test results in an EHR, researchers performed a cross-sectional survey of primary care clinicians working in the Veterans Affairs system from June through November 2010. The clinicians were asked their perceptions of the technical aspects of their EHR, such as ease of use and content of alerts, and about relevant social factors that might affect EHR use, such as workflow. Clinicians were asked if they received more alerts than they considered effectively manageable or too many alerts, obscuring those that were considered most important.

The study's primary outcomes were based on clinicians' answers to two survey items reflecting potential for missed results (“The alert notification system in Computerized Patient Record System as currently implemented makes it possible for practitioners to miss test results”) and personal history of missed results (“In the past year, I missed abnormal lab or imaging test results that led to delayed patient care”). Correlation coefficients were examined for significant relationships between social and technical factors and the primary outcomes, and multivariate analysis was then performed. The study results were published online in a research letter by JAMA Internal Medicine on March 4.

A total of 5,001 practitioners were invited to participate in the study, and 2,590 (51.8%) responded to the survey. The respondents reported receiving a median of 63 EHR alerts each day, and 86.9% said that the number of alerts they received was excessive. A total of 69.6% said they received more alerts than they could manage effectively, and 55.6% said that the current EHR notification system was structured to allow clinicians to miss results. Personally missed test results that resulted in delayed care were reported by 29.8% of respondents.

The authors found that clinicians who perceived their EHR as easy to use were less likely to report a potential for missed results and a personal history of missed results (odds ratios, 0.52 [95% CI, 0.32 to 0.86] and 0.64 [95% CI, 0.43 to 0.96], respectively). Clinicians who were more concerned about electronic handoffs, defined as “routing alerts to the EHR of a surrogate covering practitioner,” were more likely to report potential for missed results and personal missed results (odds ratios, 2.00 [95% CI, 1.38 to 2.39] and 1.86 [95% CI, 1.28 to 2.69], respectively). Missed results leading to delayed patient care were more likely in clinicians who reported receiving more alerts than were manageable (odds ratio, 2.20 [95% CI, 1.37 to 3.52]). The authors noted that neither of the primary outcomes were related to the number of alerts clinicians reported receiving each day.

The authors stressed that the data on alerts received were self-reported and that their study could not assess causation. However, they concluded that their results may indicate EHR “information overload” among clinicians, which could cause important clinical information to be missed. They also noted that both social and technical factors affected the primary outcomes and said that both should be considered in future studies. “An isolated reduction in alert numbers without attention to the broader [primary care practitioner] experience related to information overload might be insufficient to improve outcomes,” they wrote.