Intervention to Lessen Low-Value Electronic Health Record Notifications Reduces Workload for Primary Care Physicians

BACKGROUND:
Inefficiencies from electronic health record (EHR) use have led to burnout and dissatisfaction among clinicians. There are more than 50 types of notifications (i.e., test results, referral-related information, medication-refills, and orders) they can receive. In the VA healthcare system, each facility can choose how many and which types of notifications should be "mandatory." Yet EHR-based "inbox" notifications originally intended for communicating important clinical information are now cited by 70% of VA primary care practitioners (PCPs) to be of unmanageable volume. Alarmingly, 30% of PCPs also report missing abnormal test results due to information overload from notifications. This study evaluated the impact of a national multi-component, quality improvement program to reduce low-value EHR notifications. The program involved three steps: 1) accessing daily PCP notification load data at all 148 VA facilities; 2) standardizing and restricting mandatory notification types to a recommended list of 10, with flexibility to include up to two additional types; and 3) hands-on training for all PCPs on customizing (e.g., turning a notification type off) and processing notifications more effectively. Using a nationally-developed toolkit, the Chief Medical Officer, Chief Health Informatics Officer, or a primary care leader in each of VA's 18 regional VISNs led program implementation from March through June 2017.

FINDINGS:

• Based on prior estimates of 85 seconds to process each notification, this quality improvement program potentially saved 1.5 hours per week per primary care physician to enable higher-value work. The mean number of daily notifications per PCP decreased significantly from 128 to 116, and the median of the change in mean number of daily notifications per PCP decreased from 122 to 112. However, the number of daily notifications remained high, suggesting the need for additional multifaceted interventions and protected clinical time to help manage them.
• Program impact appeared to be achieved by reducing certain types versus just the sheer number of mandatory notifications, underscoring the complexity of addressing notification burden.
• More than 50% of VISNs found it hard to deliver program implementation training within the initial project timeline. Several program leads reported lack of time and resources to support training efforts because they directly competed with providing patient care.

IMPLICATIONS:

• The QI program was originally implemented in 2017 in response to Dr. Shulkin's initiative to reduce frontline clinician burden. Findings suggest the feasibility of using large scale 'de-implementation' interventions to reduce unintended safety or efficiency consequences of well-intended electronic communication systems.

LIMITATIONS:

• Investigators were unable to correlate how and which intervention component(s) led to changes in the types and quantities of messages received.

AUTHOR/FUNDING INFORMATION:
This study was partly funded by HSR&D. Dr. Singh is part of HSR&D's Center for Innovations in Quality, Effectiveness and Safety (IQuESt) in Houston, TX.

Shah T, Patel-Teague S, Kroupa L, Meyer A, and Singh, H. Impact of a National QI Program on Reducing Electronic Health Record notifications to Clinicians. BMJ Quality and Safety. March 5, 2018; Epub ahead of print.