Several of the paper-based workarounds identified in this study related to awareness of new information. Paper processes were used to notify, alert. Or prompt a clinician to take action based on new information. Many of these paper processes were redundant to electronic processes in CPRS. Several of these paper processes were used instead of, not in addition to, electronic processes. This suggests that electronic processes were either insufficient in terms of a signal to noise ratio (i.e., ability to alert clinicians reliably and consistently), a problem documented in other VA studies [17-24], or there may have been distrust in the reliance of electronic systems for transmitting this information. Designers should consider strategies to increase to increase the signal to noise ratio in the EHR, such as decreasing the overall number of EHR alerts to minimize clinicians’ desensitization.