The SAFER Guides: Empowering Organizations to Improve the Safety and Effectiveness of Electronic Health Records
Published Online: May 21, 2014
Dean F. Sittig, PhD; Joan S. Ash, PhD, MLS, MBA; and Hardeep Singh, MD, MPH
Electronic 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 (HITECH), 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 better access to information,4,5 clinical decision support,6 and more reliable provider-to-provider communication.7 Nevertheless, in the early stages of an EHR-enabled healthcare system, benefits thus far have been difficult 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 flows in real- world practice settings.9-11 To respond to these challenges, the Office of the National Coordinator for Health Information Technology (ONC) commissioned the 2012 Institute of Medicine Report, “Health IT and Patient Safety: Building 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 implementation are nonetheless scarce, and frontline clinicians and healthcare organizations (HCOs) are often unaware of best practices for safe EHR implementation and use. For example, they often have minimal guidance to handle problems 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 concerns embedded in flawed interfaces between various components of EHRs and in the way EHRs are configured. Solutions to these problems are often multifaceted, requiring analysis and redesign of work flows and organizational processes and procedures that cannot be addressed through improvements in technology alone.
Addressing EHR-related safety concerns is inherently complex and requires a comprehensive and multifaceted systems-based approach. We propose that HCOs equipped with EHRs should consider the strategy of “proactive risk assessment” of their EHR-enabled healthcare to identify and address EHR-related safety concerns.17 Herein, we describe the conceptual underpinnings of an EHR-related self-assessment strategy to provide clinicians and HCOs a foundation upon which they could build their safety efforts.
CONCEPTUAL FOUNDATION OF SELF-ASSESSMENT
With support from the ONC, we used rigorous, iterative methodologies to develop 9 self-assessment tools to optimize the safety and safe use of EHRs (Table 1).18 These tools, the Safety Assurance Factors for EHR Resilience (SAFER) guides, are designed to help clinicians and HCOs self-assess the safety and effectiveness of their EHR implementations, identify specific areas of vulnerability, and create solutions and culture change to mitigate risks.
The goal of SAFER guide-based proactive risk assessment is to eliminate or minimize EHR-related safety hazards to build system resilience, defined as “degree to which a system continuously prevents, detects, mitigates, or ameliorates hazards or incidents so that an organization can bounce back to its original ability to provide care.”19
Each SAFER guide consists of between 10 and 25 “recommended practices,” which can be assessed as fully implemented, partially implemented, or not implemented. Recommended practices help the clinic or organization know ‘what’ to do to optimize the safety and safe use of the EHR. The recommended practices address principles (Table 2) that represent ‘why’ the recommended practices are needed, although any given recommended practice may support several principles that support health IT safety.
The methods used to identify risk areas and associated practices have been described elsewhere, but are briefly summarized here.18 To develop the content of the guides, we consulted subject matter experts in informatics, patient safety, quality improvement, risk management, and human factors engineering and usability. To ensure generalizability, we conducted site visits at both small and large practices and hospitals. We also reviewed literature to identify existing EHR-related assessment items, which we validated and refined during site visits. To ensure that the guides would be useful to our intended audiences (eg, clinicians, EHR developers, IT professionals, and quality improvement leaders), we engaged with a broad range of stakeholders, such as professional organizations representing diverse groups of intended users. We undertook multiple revisions of items in the guides to increase their applicability and interpretability by individuals with differing degrees of expertise. We also considered the perspectives of those working within organizations at different points in their EHR adoption journey. Thus, we ensured that the SAFER guides are based on best evidence and expertise currently available, as well as on field research and iterative testing.20 To facilitate wide implementation and use, the SAFER guides have been made available free of charge from ONC’s website (http://www.healthit.gov/safer/).
PDF is available on the last page.