Having access to all pertinent clinical information is a key component of providing quality medical care. But sometimes, barriers such as privacy regulations, inadequate communication between doctors, decentralized medical systems, the transfer of patients’ care within and across settings, and the high turnover of patients’ insurance plans, interfere with the smooth transfer of information. This can make it difficult for clinicians to correctly assess a patient and provide appropriate treatment recommendations.

Missing clinical information has been associated with adverse patient outcomes and is a frequent cause of medical error. To date, however, only one study has directly examined the occurrence of missing clinical information. In this study, which looked at a Canadian emergency department, physicians reported that in 15% of visits, missing information could have resulted in patient harm.

A study in the February 2, 2005 issue of the Journal of the American Medical Association set out to examine the extent of this problem among primary care physicians. The study found that missing clinical information during primary care visits is common, multifaceted, likely to consume time and other resources, and may adversely affect health outcomes.

About the Study

In the study, 253 physicians, nurse practitioners, and physician assistants, representing 32 primary care clinics within the State Networks of Colorado Ambulatory Practices and Partners (SNOCAP), completed surveys for every patient visit during a half-day period between May and December 2003; about 1,614 patient visits were surveyed.

The survey consisted of two parts: the first focused on patient demographics and clinical information, the second asked participating clinicians about themselves (such as demographic data, type of clinician, etc). Questions on the first survey included:

  • Was any existing information, important for the care of this patient, unavailable at the time of the visit?
  • How likely is this missing information to adversely affect the patient’s well-being?

If information was missing, clinicians answered additional questions regarding the type of information that was missing; whether the missing information was most likely inside or outside their clinical system; whether the patient was likely to have a delay in care or require additional medical services as a consequence; and how much time, if any, had been spent searching for the missing information.

The Findings

Clinicians reported information missing in 220 (14%) of the visits. The type of missing information varied, but included laboratory results (6% of visits), letters/dictation (5%), radiology results (4%), history and physical examination (4%), and medications (3%).

Among the visits with missing clinical information, clinicians reported that:

  • In 44% of visits, the missing information was at least somewhat likely to adversely affect the patient.
  • In 57% of visits, the missing information was outside of the clinical system.
  • In 57% of visits, someone—either the clinician or another staff member—spent time trying to find the missing information.
  • In 60% of visits, the missing information was likely to result in delayed care or at least one duplicate medical service.

In addition:

  • Clinicians were more than twice as likely to report missing information for first visits, compared with repeat visits.
  • Rural clinicians were less likely to report missing information than non-rural clinicians.
  • Clinicians with full access to electronic medical records were less likely to report missing information.
  • Patient who recently immigrated and those having a greater number of active medical problems where more likely to have information missing at the time of their visit.

How Does This Affect You?

This study found that primary care physicians routinely lack important clinical information during patient visits. This is no small matter, since these physicians are supposed to be responsible for gathering together this information from its various sources, reviewing it with patients, and using to coordinate appropriate treatment plans.

Importantly, the study suggests that switching to electronic medical records may help alleviate the problem. Since one of the main reasons for missing information is that a patient is new to the system, having electronic access to information on every patient—in and out of the system—would be ideal. Even a nationwide network of medical information, however, would not completely eliminate the problem of missing information.

Because you will never be able to control how effectively your medical care providers manage your records, the best way to prevent the loss of vital information is to manage it yourself. Keep an updated file of all your medical records, especially previous hospitalizations, current medications, test results, and letters from your doctors. Sometime in the future, all of this information may be available on a credit card sized magnetic strip that you keep in your wallet. Until then, paper and ink will have to do.