'Too Much Information': Are EHRs Drowning Primary Care?

Kate Johnson

February 14, 2012

February 14, 2012 — Although electronic health records (EHRs) are intended to streamline patient care and communication between healthcare professionals, they can lead to information overload, according to results a study published in a letter in the February 13 issue of Archives of Internal Medicine.

"Strategies to improve efficiency of electronic clinician-to-clinician messaging should be pursued to avoid burdening busy frontline health care providers," recommend Daniel Murphy, MD, from the Veteran's Affairs Health Services Research & Development Center for Excellence in Houston, Texas, and colleagues.

Their study was conducted in the outpatient clinics of a large, tertiary-care Department of Veterans Affairs facility in which the EHR includes an inbox system for "additional signature request" (ASR) alerts, defined as any note requiring an electronic signature.

The researchers extracted all ASR alerts (n = 53,606) transmitted to any full-time primary care physician (PCP) during a 160-day period beginning May 2, 2009, and then randomly selected 1% (n = 536) of these alerts for further analysis.

Two PCP reviewers rated the "value" of the alerts, based on the urgency with which follow-up action was needed to avoid patient harm, the level of patient harm that might occur if the PCP missed the alert, and the subjective importance of the alert to the PCP's care.

Because each ASR alert originated from a note within the EHR, the reviewers also rated the content of the parent notes.

More Than Half the Alerts Were High Value

High-value alerts were defined as those which both reviewers rated as "urgent, potentially harmful if missed, and important."

Overall, 282 alerts (53.7%) were classified as high value, "but inefficiencies in information transfer required PCPs to read through large amounts of extraneous text to find relevant information," note the researchers.

Although parent notes contained a median of 142 words, only 28 (19.7%) of those words were considered relevant.

The 2 most frequent reasons for alerts being sent were to inform PCPs about patients' medication refill requests (40.0%) or to relay new or persistent symptoms reported by patients (18.9%).

Of these 2 main reasons for alerts, the majority were deemed high value (89.0% and 64.6%, respectively).

"Conversely, alerting about patient home events, order status updates, inpatient visits, and progress note completion (residents to supervising attending) were infrequently (<15%) of high value, even though many were rated as 'important,' " write the investigators.

"Few alerts were deemed nonessential, but in conjunction with the low percentage of relevant text in parent notes, they likely lead to a perception of information overload from ASR alerts," they note.

In addition, a previously published paper by the same group found that such alerts involve "considerable" processing time ( Am J Med. 2012;125:209.e1-209.e7).

The authors suggest that strategies to improve the situation might include having other members of the medical home team follow-up the alerts or introducing a system that allows highlighting relevant text.

"Because clinician-to-clinician messaging is likely to increase as systems become more integrated, our study might be useful to others as they explore interventions to improve outpatient communication," they suggest.

The "Smoking Gun" for PCPs

"We both hear strong complaints from [PCPs] about electronic medical records...cutting their time efficiency," write Michael H. McDonald, MD, from the Department of Surgery, University of Wisconsin School of Medicine, Madison, and Clement J. McDonald, MD, from the National Institutes of Health, Bethesda, Maryland, in an invited commentary.

"Murphy and colleagues provide the smoking gun for the internists' complaints of time theft," they write.

To get a better understanding of the issue, the commentators surveyed 7 attending physicians and 2 residents at a family practice clinic.

All respondents reported a median of 60 minutes and a mean of 48 minutes per day of free time lost to the computer.

"Electronic medical record access to patient data was faster than with the paper system (no surprise). The same was true for prescription writing. Physicians had mixed opinions about the effect of EMRs on the time to write orders and notes. Their opinions were more consistently negative about the EMR's effect on message management — such as provided by the EMR inbox," the commentators write.

"If changes are not made to reduce or eliminate these time penalties on PCPs, there will be no PCPs left to penalize," they caution.

The study was supported by the Veterans Affairs National Center for Patient Safety, Baylor College of Medicine Department of Family & Community Medicine Post Doctoral Fellowship program, a SHARP contract from the Office of the National Coordinator for Health Information Technology, and the Houston VA HSR&D Center of Excellence. The study described in the commentary was supported in part by the Intramural Research Program of the National Institutes of Health, National Library of Medicine. The study authors and the commentators have disclosed no relevant financial relationships.

Arch Intern Med. 2012;172:283-285. Letter extract, Commentary extract


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