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Authors: Hardeep Singh, Dean Sittig
Journal: JAMA Internal Medicine (2013)

In Reply We thank Dr McDonald for his observations on our studies and agree that primary care practitioners (PCPs) deserve more signal and less noise through their electronic health record (EHR)-related alerts.Primary care practitioners must also agree on the signal itself-what types of information they want or need to receive.We have found that physicians often disagree about the importance or urgency of alert content. 1 Dr McDonald's example (ie, transmission of abnormal vs all test results) offers one possible point of consensus.However, in our experience of developing policy on communicating test results within the Department of Veterans Affairs (VA), 2 we found this rather challenging to operationalize.For instance, an alert should be generated for abnormal findings that are likely unexpected (eg, when the history given to the radiologist is "rule out cancer" or "cough"), but PCPs need not be alerted to abnormalities that are clearly known to them (eg, unchanged cancer metastases on a computed tomography request for "follow-up of metastatic lung cancer").Conversely, certain "normal" laboratory results are essentially not normal in the given patient's context (eg, normal international normalized ratio in a patient receiving warfarin).Thus, "normal" and "abnormal" as conventionally defined do not necessarily map onto a simple protocol for efficient use of alerts.Physicians need to come to an agreement on what defines an "alert worthy" result and how to most effectively handle the inevitable exceptions to the rule.Moreover, PCPs must be given flexibility to customize receipt of certain types of alert notifications that are not considered "alert worthy" by others.Competing external policy and operational demands often require more information to be pushed to PCPs.Although there is some merit to the "wait until next visit" strategy for normal or insignificant results, this needs to be weighed against competing policies requiring patients' rapid access to test results. 3Primary care practitioners must also receive protected time to process and act on alert information, which was available to only about a third of the PCPs in our survey. 4inally, the complexities of the social environment and workflow of primary care also need to be adapted to reduce information overload. 5For example, the culture of sending "FYI" messages directly to the PCP just to have it "covered" needs to evolve in this information-rich era.We believe that with appropriate task delegation and clarity of roles and responsibilities, other members of the medical home team are ideal recipients of administrative and even certain types of clinical information. 6Senders should be socialized to think carefully before sending information when no response or action is needed from the PCP and perhaps to redirect the information to other members of the PCP's medical home team.One lesson from the needless "reply all" and spam e-mails we all still receive is that it will take the entire neighborhood of PCPs to solve this communication challenge.The technology to overload PCPs with information is here.However, with innovations such as those suggested by McDonald, we need to develop or use existing technologies, coupled with other systemic changes, to now unburden PCPs.