Experts outline five steps for clinicians to assess their electronic health records

Researchers with UTHealth Houston outline five steps for clinicians to assess their electronic health records (EHR) using the SAFER guidelines.

The study was published in the Journal of the American Medical Association JAMA.

“Organizations that follow these guides should have a much safer and more efficient EHR,” said Dean Sittig, PhD, professor at UTHealth Houston School of Biomedical Informatics.

The SAFER Guides were developed in 2014 by Sittig and Hardeep Singh, MD, MPH, a professor of medicine at Baylor College of Medicine and researcher at the Center for Innovations in Quality, Effectiveness and Safety and Michael E. DeBakey VA Medical Center. It consists of nine guides that each fall within three different categories.

In August of 2021, the Centers for Medicare & Medicaid Services (CMS) issued a final rule mandating annual attestation of SAFER assessment completion for eligible hospitals. Having clinicians participate in the EHR safety evaluation process outlined within the SAFER assessment significantly aids organizations in enhancing both clinical and patient care.

Through comprehensive review and study, Sittig and Singh crafted concrete assessments that focus on reducing as many safety risks as possible. “The guidelines for using the SAFER Guides presented in the JAMA article are the result of years of work by many people across multiple organizations,” Sittig said.

Within the paper, the co-authors outline suggest health care organizations include build a SAFER team, determining what recommendations need EHR vendor support, bringing the team together to track progress, documenting and communicating about the status of implementation, and finally, prioritizing unmet recommendations to make needed changes.

Because the CMS rule impacts almost all hospitals, the researchers understand how impactful the assessment steps are in enhancing clinical safety practices.

“We think of the SAFER Guides Assessment as a major step in a hospital’s journey towards high reliability health care” said Singh. “Hospitals should also provide assessment results to their governing board and engage them in EHR safety improvement efforts.”

Patricia Sengstack, DNP with Vanderbilt University School of Nursing is an additional author on the study.