VA Providers Often Miss EHR Test Result Alerts

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VA Providers Often Miss EHR Test Result Alerts

By Brenda L. Mooney

HOUSTON – Almost a third of primary care providers missed test results received through VA’s electronic health record (EHR) notification system, possibly because of “information overload,” according to a survey conducted by researchers from the Michael E. DeBakey Veterans Affairs Medical Center in Houston.

The research letter published online by JAMA Internal Medicine was based on a survey from June 2010 through November 2010 of 2,590 VA primary care practitioners. Nearly 1-in-3, 29.8% reported missing test results notifications in the EHR.1


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“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,” according to the report. “In the Department of Veterans Affairs (VA), abnormal test result alerts are generated automatically for pre-specified abnormal laboratory values or manually by the interpreting radiologist when an unexpected finding is noted.”

Another version of the study was previously published online with open access by the Journal of the American Medical Informatics Association (JAMIA).2

Hardeep Singh, MD, MPH, and colleagues noted that respondents reported receiving a median of 63 alerts each day, and 86.9% of the primary care providers said they considered that excessive. Nearly 70% said that was more than they could handle.

In 2009, Hardeep Singh, MD, MPH, general medicine staff physician and a patient safety clinical investigator, demonstrates the computerized patient record system to veteran Clayton Murphy, right. VA Photo by Bobbi Gruner

The survey also found that:

  • More than half of the survey respondents, 55.6%, said the current EHR notification system made it possible for test results to be missed.
  • Over one-third (37.9%) reported having staff support needed for notifying patients of test results.
  • Many primary care providers relied on the patient’s next visit to notify them for normal (46.1%) and abnormal results (20.1%).
  • A majority (85.6%) stayed after hours or came in on weekends to address notifications; less than one-third reported receiving protected time to do so (30.1%).

A key problem, according to the report, was the lack of sufficient training and support for physicians using the technology. Only 45.7% of respondents reported receiving adequate training on using the EHR notification system, according to the research letter, and only 35.1% reported having an assigned contact for technical assistance with the EHR. In fact, most, 60.4%, said they sought and received help from colleagues.

“Our findings underscore the additional time burden induced by EHR-based alert systems, with the majority of respondents staying after hours, coming in on weekends, or using remote access from home to deal with notifications,” study authors wrote. “Unfortunately, there is little or no reimbursement for non-face-to-face time related to documentation, follow-up and patient notification of test results. Although the interventions proposed in the survey focused mostly on technological features and workflow, several organizational and policy interventions are also needed to improve the outcomes of EHR-based test results reporting.”

Primary care clinicians responding to the survey expressed strong support for functions to keep alert information from being lost in the EHR, including prevention of automated deletion of alerts; the ability to retrieve deleted alerts; providing a “back” button; and the preservation of alerts in inboxes for at least 30 days.

Those responding to the survey also agreed with the need for a feature to remind them at a later date of the requirement for follow-up action on the alert, while calling for ways to make the alerts more visible with a separate window and/or color-coding. They also endorsed the concept of a separate messaging system within the EHR to allow providers to communicate with each other outside of the notification system, as well as a way to display who is assigned responsibility for following up on test result alerts.

Suggesting that future EHR development should focus on better ways to facilitate patient notification of test results, the authors noted, “because most PCPs receive hundreds of test results a week, one area for potential improvement is PCPs’ resources to facilitate patient notification. Just over a third of the PCPs reported having administrative support for patient notification, presenting an opportunity to leverage the current shift towards team-based models of care (e.g., medical home teams). For

example, with appropriate task delegation and clarity of roles, other members of the team could be responsible for tracking results and notifying patients.”

In some cases, new features available through VA Blue Button initiative might pre-empt the need for staff notification, although follow-up might still be required. In January, VA announced that veterans with premium accounts will be able to access microbiology as chemistry and hematology test results. The results of pathology procedures such as surgical pathology, cytology and electron microscopy also will be available to veterans through the My HealtheVet gateway.

1. Singh H, Spitzmueller C, Petersen NJ, Sawhney MK, Sittig DF. Information Overload and Missed Test Results in Electronic Health Record-Based Settings. JAMA Intern Med. 2013 Apr 22:1-3. doi: 10.1001/2013.jamainternmed.61. [Epub ahead of print] PubMed PMID: 23460235.

2. Singh H, Spitzmueller C, Petersen NJ, Sawhney MK, Smith MW, Murphy DR, Espadas D, Laxmisan A, Sittig DF. Primary care practitioners’ views on test result management in EHR-enabled health systems: a national survey. J Am Med Inform Assoc. 2012 Dec 25. [Epub ahead of print] PubMed PMID: 23268489

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