Missing Clinical Information
During Primary Care Visits

(Reprinted) JAMA, February 2, 2005-Vol 293, No. 5, pages 565-571

Missing clinical data can impede primary care's information-intensive coordinating function. This cross-sectional study describes primary care physicians' reports of missing information. The state-level survey was conducted in 32 primary care clinics in Colorado. A total of 253 clinicians (about 1614 patient visits) filled out questionnaires about patient and visit characteristics between May and December, 2003. Missing information was reported in 220 (13.6%) of the 1614 visits. In 97 (44.0%) of these visits, clinicians said that missing information was at least "somewhat likely" to adversely affect patients. Laboratory results were the most common type of missing information in 99 (45%) of the visits. Clinicians or staff reportedly spent significant time unsuccessfully searching for missing information (5-10 minutes 25.6%; > 10 minutes, 10.4%). Post-adjustment, missing information was likelier among recent immigrants, new patients, or those with multiple medical problems. Missing information was less likely in rural practices and in offices with full electronic records. Clinicians believed that missing information would probably result in either delayed care or duplicated service (59.5%). Further research should focus on validating clinicians' perceptions. Prospective studies should determine causes and sequelae.