418 n www.ajmc.com n MAY 2014
TRENDS FROM
THE FIELD
© Managed Care &
Healthcare Communications, LLC
E
lectronic health records (EHRs) have the potential
to improve the quality and safety of healthcare.
1
Since the enactment of the Health Information
Technology for Economic and Clinical Health Act (HI-
TECH),
2
organizations have been adopting EHRs at an
unprecedented rate.
3
While the challenges of rapid EHR
implementation can be numerous and disruptive, EHRs
have clear potential to improve quality and safety with bet-
ter access to information,
4,5
clinical decision support,
6
and
more reliable provider-to-provider communication.
7
Nev-
ertheless, in the early stages of an EHR-enabled healthcare
system, beneits thus far have been diicult to achieve and
unintended consequences have emerged.
8
Clinicians have
experienced safety concerns from EHR design and usability
features that are not optimal for complex work lows in re-
al-world practice settings.
9-11
To respond to these challenges,
the Oice of the National Coordinator for Health Informa-
tion Technology (ONC) commissioned the 2012 Institute
of Medicine Report, “Health IT and Patient Safety: Build-
ing Safer Systems for Better Care”
12
and recently released
the Health Information Technology Patient Safety Action
and Surveillance Plan that lays out their response to these
issues.
13
National initiatives to improve the safety of EHRs must
be accompanied by practical and helpful strategies for those
on the front lines of EHR-enabled care delivery. Strategies to
address unintended consequences borne from EHR imple-
mentation are nonetheless scarce, and frontline clinicians
and healthcare organizations (HCOs) are often unaware of
best practices for safe EHR implementation and use. For ex-
ample, they often have minimal guidance to handle prob-
lems such as too many alerts,
14,15
a slow EHR, or an EHR
that requires an excessive number of “clicks” to complete
tasks. These are not skills routinely expected of healthcare
providers in the past.
16
Clinicians are also not privy to safety
The SAFER Guides: Empowering Organizations
to Improve the Safety and Efectiveness
of Electronic Health Records
Dean F. Sittig, PhD; Joan S. Ash, PhD, MLS, MBA; and Hardeep Singh, MD, MPH
Electronic health records (EHRs) have potential to improve quality
and safety of healthcare. However, EHR users have experienced
safety concerns from EHR design and usability features that are
not optimally adapted for the complex work low of real-world
practice. Few strategies exist to address unintended consequenc-
es from implementation of EHRs and other health information
technologies. We propose that organizations equipped with EHRs
should consider the strategy of “proactive risk assessment” of
their EHR-enabled healthcare system to identify and address
EHR-related safety concerns. In this paper, we describe the con-
ceptual underpinning of an EHR-related self-assessment strategy
to provide institutions a foundation upon which they could build
their safety efforts. With support from the Ofice of the National
Coordinator for Health Information Technology (ONC), we used a
rigorous, iterative process to develop a set of 9 self-assessment
tools to optimize the safety and safe use of EHRs. These tools,
referred to as the Safety Assurance Factors for EHR Resilience
(SAFER) guides, could be used to self-assess safety and ef-
fectiveness of EHR implementations, identify speciic areas of
vulnerability, and create solutions and culture change to mitigate
risks. A variety of audiences could conduct these assessments,
including frontline clinicians or care teams in different practices,
or clinical, quality, or administrative leaders within larger institu-
tions. The guides use a multifaceted systems-based approach to
assess risk and empower organizations to work with internal or
external stakeholders (eg, EHR developers) on optimizing EHR
functionality and using EHRs to drive improvements in the quality
and safety of healthcare.
Am J Manag Care. 2014;20(5):418-423