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Publication Briefs

VA Primary Care Physicians Using Electronic Health Records May Miss Important Information Due to Information Overload

Electronic health record (EHR)-based alerts are often used to notify practitioners of abnormal test results, but follow-up failures (missed results) continue to occur in outpatient settings. In VA, abnormal test result "view alerts" are generated automatically for pre-specified abnormal laboratory values, or manually by the interpreting radiologist, when an unexpected finding is noted. Factors such as workflow, user behaviors, and organizational characteristics likely affect EHR-based test result follow-up. This study examined potential predictors of missed test results in the setting of EHR-based alerts. Between 6/10 and 11/10, investigators conducted a cross-sectional survey of 2,590 VA primary care practitioners (PCPs). The survey content included items that assessed PCPs' perceptions of technological factors (e.g., EHR notification software, ease of use, content of alerts received, EHR user-interface), as well as social factors (e.g., workflow, people, organizational policies and procedures) related to alert follow-up. Moreover, investigators assessed potential information overload by asking if PCPs received more alerts than they could effectively manage — or received too many alerts to focus on the most important ones related to patient care.


  • The median number of alerts VA PCPs reported receiving each day was 63; 87% of PCPs perceived the quantity of alerts to be excessive, and 70% reported receiving more alerts than they could effectively manage (marker of information overload).
  • More than half (56%) of the PCPs reported that the EHR notification system, as currently implemented, made it possible for them to miss test results. Almost a third (30%) reported having personally missed results that led to delays in care for their patients.
  • Further analyses showed that the perceived ease of EHR use by PCPs was related to a lower likelihood of both study outcomes: 1) the perception of potentially missing results, and 2) reporting missed results that led to delays in patient care. Greater concern over electronic hand-offs (i.e., routing alerts to the EHR of a surrogate covering-practitioner) was also related to the potential for and personal history of missed test results.
  • PCPs who reported receiving more alerts than is manageable (information overload) were more likely to report having missed results that led to delayed patient care. Notably, the number of alerts that respondents reported they received per day was unrelated to either outcome.


  • Because this was a cross-sectional survey, causation could not be determined.

NOTE: Using findings from this study and others, investigators worked with VHA program offices to develop the Communication of Test Results Toolkit to help achieve VA policy requiring notification of all test results to patients within 14 days. The toolkit was approved for national distribution to all VA facilities in June 2012.

This study was partly supported by HSR&D. Drs. Singh, Petersen, and Sawhney are part of HSR&D's Houston Center for Quality of Care and Utilization Studies. Dr. Singh is the Director of the Houston VA Patient Safety Center of Inquiry funded by the VA NCPS.

PubMed Logo Singh H, Spitzmueller C, Petersen N, Sawhney M, and Sittig DF. Research Letter: Information Overload and Missed Test Results in EHR-Based Settings. JAMA Internal Medicine April 22;e-pub ahead of print.

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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