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BMJ Qual Saf. 2018 Mar 5. pii: bmjqs-2017-007447. doi: 10.1136/bmjqs-2017-007447. [Epub ahead of print]

Impact of a national QI programme on reducing electronic health record notifications to clinicians.

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TNT Health Enterprises, Atlanta, GA (previously Department of Veterans Affairs, Washington, District of Columbia), USA.
VA Sunshine Network, Department of Veterans Affairs, St Petersburg, Florida, USA.
VA Heartland Network, Department of Veterans Affairs, Kansas City, Missouri and Saint Louis University School of Medicine, St. Louis, Missouri, USA.
Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA.



Emerging evidence suggests electronic health record (EHR)-related information overload is a risk to patient safety. In the US Department of Veterans Affairs (VA), EHR-based 'inbox' notifications originally intended for communicating important clinical information are now cited by 70% of primary care practitioners (PCPs) to be of unmanageable volume. We evaluated the impact of a national, multicomponent, quality improvement (QI) programme to reduce low-value EHR notifications.


The programme involved three steps: (1) accessing daily PCP notification load data at all 148 facilities operated nationally by the VA; (2) standardising and restricting mandatory notification types at all facilities to a recommended list; and (3) hands-on training for all PCPs on customising and processing notifications more effectively. Designated leaders at each of VA's 18 regional networks led programme implementation using a nationally developed toolkit. Each network supervised technical requirements and data collection, ensuring consistency. Coaching calls and emails allowed the national team to address implementation challenges and monitor effects. We analysed notification load and mandatory notifications preintervention (March 2017) and immediately postintervention (June-July 2017) to assess programme impact.


Median number of mandatory notification types at each facility decreased significantly from 15 (IQR: 13-19) to 10 (IQR: 10-11) preintervention to postintervention, respectively (P<0.001). Mean daily notifications per PCP decreased significantly from 128 (SEM=4) to 116 (SEM=4; P<0.001). Heterogeneity in implementation across sites led to differences in observed programme impact, including potentially beneficial carryover effects.


Based on prior estimates on time to process notifications, a national QI programme potentially saved 1.5 hours per week per PCP to enable higher value work. The number of daily notifications remained high, suggesting the need for additional multifaceted interventions and protected clinical time to help manage them. Nevertheless, our project suggests feasibility of using large-scale 'de-implementation' interventions to reduce unintended safety or efficiency consequences of well-intended electronic communication systems.


burnout; communication; electronic health records; measurement; patient safety; quality improvement

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Conflict of interest statement

Competing interests: None declared.

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