title: Missing clinical information during primary care visits.
abstract: BACKGROUND
  The coordinating function of primary care is information-intensive and may be impeded by missing clinical information. However, missing clinical information has not been explicitly investigated in the primary care setting.
  
  
  OBJECTIVE
  To describe primary care clinicians' reports of missing clinical information.
  
  
  METHODS
  Cross-sectional survey conducted in 32 primary care clinics within State Networks of Colorado Ambulatory Practices and Partners (SNOCAP), a consortium of practice-based research networks participating in the Applied Strategies for Improving Patient Safety medical error reporting study. Two hundred fifty-three clinicians were surveyed about 1614 patient visits between May and December 2003. For every visit during 1 half-day session, each clinician completed a questionnaire about patient and visit characteristics and stated whether important clinical information had been missing. Clinician characteristics were also recorded.
  
  
  METHODS
  Reports of missing clinical information frequency, type, and presumed location; perceived likelihood of adverse effects, delays in care, and additional services; and time spent looking for missing information. Multivariate analysis was conducted to assess the relationship of missing information to patient, visit, or clinician characteristics, adjusting for potential confounders and effects of clustering.
  
  
  RESULTS
  Clinicians reported missing clinical information in 13.6% of visits; missing information included laboratory results (6.1% of all visits), letters/dictation (5.4%), radiology results (3.8%), history and physical examination (3.7%), and medications (3.2%). Missing clinical information was frequently reported to be located outside their clinical system but within the United States (52.3%), to be at least somewhat likely to adversely affect patients (44%), and to potentially result in delayed care or additional services (59.5%). Significant time was reportedly spent unsuccessfully searching for missing clinical information (5-10 minutes, 25.6%; >10 minutes, 10.4%). After adjustment, reported missing clinical information was more likely when patients were recent immigrants (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.06-2.99), new patients (OR, 2.39; 95% CI, 1.70-3.35), or had multiple medical problems compared with no problems (1 problem: OR, 1.09; 95% CI, 0.69-1.73; 2-5 problems: OR, 1.87; 95% CI, 1.21-2.89; >5 problems: OR, 2.78; 95% CI, 1.61-4.80). Missing clinical information was less likely in rural practices (OR, 0.52; 95% CI, 0.29-0.92) and when individual clinicians reported having full electronic records (OR, 0.40; 95% CI, 0.17-0.94).
  
  
  CONCLUSIONS
  Primary care clinicians report that missing clinical information is common, multifaceted, likely to consume time and other resources, and may adversely affect patients. Additional research on missing information is needed to focus on validating clinicians' perceptions and on conducting prospective studies of its causes and sequelae.
authors.affiliation: Department of Family Medicine, University of Colorado Health Sciences Center, Denver, USA. peter.smith@uchsc.edu
authors.forename: Peter C
authors.initials: PC
authors.lastname: Smith
authors.forename: Rodrigo
authors.initials: R
authors.lastname: Araya-Guerra
authors.forename: Caroline
authors.initials: C
authors.lastname: Bublitz
authors.forename: Bennett
authors.initials: B
authors.lastname: Parnes
authors.forename: L Miriam
authors.initials: LM
authors.lastname: Dickinson
authors.forename: Rebecca
authors.initials: R
authors.lastname: Van Vorst
authors.forename: John M
authors.initials: JM
authors.lastname: Westfall
authors.forename: Wilson D
authors.initials: WD
authors.lastname: Pace
mesh_terms: D003142:Communication; D003430:Cross-Sectional Studies; D005194:Family Practice / Q000458:organization & administration*; D006801:Humans; D008499:Medical Records; D011320:Primary Health Care / Q000458:organization & administration*; D014481:United States