Primary care is comprised of first contact care, longitudinal care, comprehensive care, and coordinated care.^{1, 2} Without information that is comprehensive, accessible, timely and correct, primary care physicians (PCPs) cannot deliver high quality care. Information problems do exist, ^3-7 with an extrapolation from one study suggesting that errors related to information handling account for 29% of family medicine errors. ⁸ Because information is central to the effectiveness of primary care, we propose a conceptual framework to explain the relationship between information hazards, i.e. information problems that may contribute to errors, and PCPs’ ability to provide high quality care.

This framework is especially timely given the emphasis on electronic health record (EHR) use in primary care. The patient centered medical home (PCMH) movement encourages EHR implementation to improve information handling. However, EHR systems may not meet this goal. ^9-11 Furthermore, in 2010 the “Meaningful Use” regulations brought incentives and penalties to promote EHR use. ¹² EHRs can transform the quality, comprehensiveness, timeliness, and accessibility of information in both good and bad ways. ¹³ Both the move toward PCMH and the need to adopt EHRs will have effects on information needs and the design of support systems in primary care. It is therefore important to understand how information relates to primary care.

The vignette in Figure 1 illustrates five specific information hazards that arise in primary care and how they can lead to information chaos.

The field of human factors engineering and ergonomics (HFE)^21-24 contributes to our understanding of information chaos. HFE studies and applies information about human cognitive and physical limitations, and human abilities to the design of systems, including, for example, work processes, tools, technologies, and environments, and in turn how systems impact human cognitive and physical performance. From HFE science, we hypothesize a conceptual framework for the way information chaos relates to the cognitive processes in primary care. This is presented in Figure 2.

Information chaos imposes demands on PCPs. Because of information overload, they may not be able to adequately review all the information and may miss important details. Because of information underload, scatter, and conflict, PCPs must expend effort searching for needed information through charts, phone calls, further questions to the patient and perhaps unnecessary testing. Erroneous information may lead to re-work, errors in diagnosis, or treatment decisions that threaten patient safety. The work PCPs do in response to information chaos is not value-added to the visit; it is only necessary to deal with the chaos. Importantly, it distracts the PCP from the primary work of the visit: caring for the patient.

From a cognitive point of view, information chaos, may contribute to two unwanted outcomes: impaired situation awareness (SA)^25-30 and increased mental workload.^31-33 SA is defined as a person’s awareness and understanding of his/her task-related situation. It has three levels: (1) perception of elements in the environment, e.g., patient cues/stimuli (pulse, color), chart, EHR, nurse, (2) comprehension of the meaning of those elements by integrating the disparate pieces of information and determining what is important and (3) projection of future status so that decisions can be made.^{25, 34} Whether or not accurate SA is achieved is dependent on the timing, comprehensiveness, accessibility, and quality of the information obtained. That means information chaos can directly impair SA. If SA is poor, it can result in impaired decision making.^{25, 26, 29, 30, 35}

A related variable is mental workload, which is the amount of cognitive resources required for a task. Mental workload is a function of demand, which may be increased due to information chaos, and available resources, such as time.^{31, 33} Mental workload and SA are related. Poor SA increases mental workload, and high mental workload can degrade SA.³⁶ High physician mental workload occurs when the mental demands imposed on the physician exceeds the physician’s resources cope with those demands. Both the poor SA and the high mental workload generated by information chaos can impair cognitive work^{29, 31, 33, 35} (e.g., diagnosis and treatment decisions), and may have negative impacts on safety.³⁵

At the start of an office visit a PCP will have some SA, but it is incomplete. The clinician only knows what he/she remembers from previous visits, from a brief look at the patient’s chart, and possibly from a short meeting with the nurse who roomed the patient. As soon as the clinician enters the room, SA is dynamically updated based on sensory inputs such as how the patient looks, feels and sounds and from higher level processes such as communication with the patient and searching in the medical record. Whether or not accurate SA is achieved is dependent on the timing and quality of the information obtained through sensation, perception, communication and record searching. Because of information chaos, the clinician may never fully develop SA, and, due to information underload, may not even know they are not fully or accurately aware of the situation as is suggested by work in related fields. ³⁷

During times of high mental workload which may be increased by information chaos, people involuntarily focus on fewer cues, considering fewer options and solutions because of cognitive tunneling.³² This occurs when people zoom in on a narrow set of cues or options because mentally they cannot handle more. In such situations, people are at risk for decision errors³⁸ because they miss things they should have noticed such as patient symptoms, or abnormal lab results. In other words, in situations of high mental workload, people operate with selective and reduced capacity.³² Among PCPs, higher mental workload has been positively associated with a higher perceived probability of medical error.³⁹

The magnitude of the effects of information chaos on the quality of care delivered by PCPs is affected by a variety of moderators. We highlight three that affect the relationship: interruptions, physician expertise, and time.

Reducing information chaos requires mechanisms to ensure that the necessary information is available and presented in a useable manner at the right time. Two general strategies have been proposed to calm the chaos. These include improved visit preparation and EHRs.

Our hypothesis is that appropriate practice redesign will reduce information chaos and provide the PCP with needed situational awareness during all phases of the visit, allowing him/her make better care decisions, and accomplish more (and perhaps with less fatigue) than would otherwise be the case. More research is needed to determine just what this practice redesign should be.

We propose that if progress is to be made on controlling information chaos and its effects on physician performance, the following questions, at minimum, need to be addressed:

Which aspects of information chaos are most common and which ones pose the greatest threats to patient safety?

The questions above are examples of what needs to be done to help improve primary care. Technology cannot alone solve the problems of information chaos, nor can the transformation to a PCMH. New thinking is necessary. We cannot accept that information chaos is “just the way primary care is.” If we do this, we are not taking advantage of primary care redesign and the power of information systems to maximize the quality and efficiency of patient care delivery.