Missed results in EHRs were related to information overload, electronic handoffs from one provider to another, and perceptions of poor usability of the EHR

Physicians often overlook important clinical laboratory test results when they get too many alerts in a day. This was one of several findings from a study designed to see how physicians responded to alerts delivered through an electronic health record system (EHR).

These findings will not surprise most pathologists and medical laboratory managers. Daily and weekly, they see how frequently “out of normal” test results can be reported to a referring physician.

Electronic Health Record Systems Plagued by Issue of ‘Alert Overload’

Some 29.8% of primary care physicians (PCPs) participating in the study overlooked test results from an electronic health record (EHR) alert system on at least one occasion, according to researchers with the U.S. Department of Veterans Affairs Health System. The alert system was designed to inform doctors about a patient’s abnormal test results. The Journal of the American Medical Association Internal Medicine (JAMA) published this study in the April 22, 2013 issue.

Research Done by Team at Debakey VA Medical Center

Researcher Hardeep Singh, M.D., MPH, and colleagues at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, found that they could not precisely determine the cause of the failure. Singh is the Director of the Houston VA Patient Safety Center of Inquiry and an Assistant Professor of Medicine at the DeBakey VA Medical Center and Baylor College of Medicine. He is also Chief of the Health Policy and Quality Program at the Houston VA Health Services Research and Development Center of Excellence.

How physicians can be overwhelmed by alerts of critical test results was the subject of a study recently published by the Journal of the American Medical Association Internal Medicine. In a survey of more than 2,500 primary care physicians 29.8% of respondents acknowledged that they had missed important clinical laboratory test results that delayed patient care. Pictured above is Hardeep Singh, M.D., MPH, who led the Michael E. DeBakey Veterans Affairs Medical Center research team. (Photo copyright Veterans Administration.)

How physicians can be overwhelmed by alerts of critical test results was the subject of a study recently published by the Journal of the American Medical Association Internal Medicine. In a survey of more than 2,500 primary care physicians 29.8% of respondents acknowledged that they had missed important clinical laboratory test results that delayed patient care. Pictured above is Hardeep Singh, M.D., MPH, who led the Michael E. DeBakey Veterans Affairs Medical Center research team. (Photo copyright Veterans Administration.)

Having determined that many physicians did not respond to a significant proportion of alerts, Singh and his research team wrote that the survey findings suggested that missed results in EHRs might be related to three factors:

1. Information overload from alert notifications

2. Electronic handoffs of care from one provider to another

3. Perceptions among providers about poor usability of the EHR.

For the study, the authors invited 5,001 primary care physicians working in VA hospitals to complete a 105-item, Web-based survey to assess potential information overload. The study was conducted from June to November 2010. “Factors such as workflow, user behaviors, and organizational characteristics likely affect EHR-based test result follow-up,” the researchers wrote. “Thus, we examined the ‘sociotechnical’ predictors of missed test results in the setting of EHR-based alerts.”

A total of 2,590 PCPs participated in the survey. This was a response rate of 51.8%. Among these respondents, 29.8% reported having missed important clinical laboratory test results that delayed patient care.

EHR’s Make It Possible to Miss Medical Laboratory Test Results

Interestingly, the survey respondents who found the EHR system easy to use were less likely to miss results. But about 56% of respondents reported that the VA’s EHR system made it “possible for practitioners to miss test results,” reported MedPage Today.

Another finding will be no surprise to pathologists and clinical laboratory scientists. The median number of alerts the responding physicians received daily was 63, and 86.9% of respondents considered this number to be excessive, according to Medscape Today News. What’s more, 69.6% of respondents said they get more alerts than they could manage effectively, Medscape Today News added.

Survey respondents were significantly more likely to say they missed test results if they believed the number of alerts was unmanageably high, as well as if they worried about alerts being routed to other practitioners when handing off patients, reported Medscape Today News.

Even Lead Researcher Admitted to Missing Important Lab Test Results

In an interview with Time magazine, Singh said having too many alerts meant some would be missed. “If you’re getting 100 emails a day, you are bound to miss a few. I study this area, and I still sometimes miss emails. We have good intentions, but sometimes getting too many [emails] can be a problem,” he told Time.

The article in Time addressed a point that pathologists and clinical lab directors have long recognized: Even if hospitals and doctors have established alert systems, these notifications are not helpful if there is not a corresponding system for determining who is responsible for acting on the alerts.

In recent months, our sister publication, The Dark Report has provided in-depth coverage about how medical laboratories are attempting to engage physicians and medical staff to be more attentive as results of essential lab tests are reported out of the lab.  We reported, for example, on how the scientific staff at TriCore Reference Laboratories in Albuquerque, New Mexico, attends rounds at area hospitals and meets with treating physicians one day a week at the hospital and at TriCore’s core laboratory.

Further, TriCore has built alerts into its laboratory information system to allow its client services department to call physicians and nurses on hospital floors about significant lab test results. TriCore has found that the combination of lab test alerts and consultation outside the laboratory help to improve patient care and reduce costs. (The Dark Report, “TriCore Lab Adds Value With Consults, Better TAT,” June 17, 2013.)

Useful to Have Good Data about Longstanding Lab Test Reporting Issue

In conclusion, it is helpful that researchers like the team at the VA hospital in Houston are developing good data on the problem of “alert overload.” For years, clinical laboratory managers have been challenged to ensure that every critical laboratory test result is not only delivered to the appropriate clinicians in a timely basis, but that these clinicians recognize the significance of these critical results and take action on a timely basis to provide appropriate care to their patients.

-Joseph Burns

Related Information:

Information Overload and Missed Test Results in Electronic Health Record–Based Settings (JAMA Intern Med. 2013;173(8):702-704)

Survey: Too Many EHR Alerts Could Lead To Missing Test Results

One Third Of Doctors Admit to Overlooking Electronic Test Results

Many Docs Miss Test Results in VA’s EHR

Information Overload May Result in Missed Test Results

Some docs miss test results with electronic records