The Doctor’s Advocate | Second Quarter 2014
Director's Forum

SAFER Guides for Electronic Health Record Implementation and Use

David B. Troxel, MD, Medical Director, Board of Governors

Problems with electronic health record (EHR) implementation and use are common. Examples include the following:

Image Dr. David Troxel
  • Unwillingness by vendors to modify their systems to meet the complex workflows of the real-world practice setting.
  • Failure to use a team approach involving physicians and other healthcare professionals in leadership positions to ensure that their clinical concerns are met.
  • Not adequately addressing known problems with EHR use, e.g., “alert fatigue” as a result of too many alerts, problems locating where lab and x-ray results are filed (or misfiled), difficulty correcting progress note entry errors, and unnecessary operational complexity.

The Office of the National Coordinator for Health Information Technology recently released the Safety Assurance Factors for EHR Resilience (SAFER) Guides. They are a practical, useful, and comprehensive suite of tools developed to assist healthcare institutions, medical groups, and physician offices with EHR implementation.

I recommend that all physicians, medical groups, and healthcare institutions that are considering implementation or replacement of an EHR visit the SAFER Guides website and spend an hour becoming familiar with those guides that address the areas of greatest interest or concern. The free guides—which can be downloaded as PDF files or used online—provide a well-organized work plan for tackling the organizational complexities of EHR implementation and use. In order to ensure that clinically important considerations are addressed, the guides apply a structured team approach involving everyone whose professional life will be permanently affected by the EHR.

The SAFER Guides are designed to help healthcare organizations conduct self-assessments to optimize the safe use of electronic health records in nine areas. The last three in the following list are of particular importance to physicians:

  • High Priority Practices
  • Organizational Responsibilities
  • Contingency Planning
  • System Configuration
  • System Interfaces
  • Patient Identification
  • Computerized Provider Order Entry with Decision Support
  • Test Results Reporting and Follow-Up
  • Clinician Communication

Each of the nine SAFER Guides begins with a Checklist of recommended practices that indicates the extent to which each recommended practice has or has not been implemented.

Links embedded in each Checklist open the corresponding practice Worksheet that gives the rationale for each recommended practice, examples of how to implement each practice, likely sources of input into the assessment of each practice, and fields to record team members and follow-up actions.

You can download the content of each guide (with all of its interactive references and supporting materials) as individual PDFs or download all of the guides in a single zip file by going to A link to this website is also posted on our EHR and Telemedicine Resource Center at

The guides are based on a literature review, expert opinion, and field testing at a wide range of healthcare organizations—from small ambulatory practices to large health systems. The recommended practices are intended to be useful for all EHR users. However, every organization is unique and will implement a particular practice differently. As a result, some of the recommended practices may not be applicable to every organization.

The SAFER Guides are designed to help deal with safety concerns created by the continuously changing landscape that healthcare organizations face. When using the guides, changes in technology, clinical practice standards, Meaningful Use, and/or HIPAA Security Rule requirements should be taken into account.

Order Enter ChartBecause the guides are designed to help organizations prioritize EHR-related safety concerns, clinician leadership in the organization should be engaged to assess whether and how any recommended practice affects the organization’s ability to deliver safe, high-quality care. To optimize EHR-related safety and quality, collaboration between clinicians and staff should lead to a consensus about the organization’s future path.

At right, see our examples of the Checklist and practice Worksheets from the SAFER Guide for Computerized Provider Order Entry with Decision Support. This Checklist has 29 recommended practices (only number 12 is shown here), and there is a Worksheet for each recommended practice.


The SAFER Self-Assessment Guides were developed by the following team of health IT safety researchers and informatics experts:

Joan Ash, PhD MLS, MS, MBA, Professor and Vice Chair, Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University.

Hardeep Singh, MD, MPH, Associate Professor of Medicine at the Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine and Chief of the Health Policy, Quality and Informatics Program at the Houston VA HSR&D Center of Excellence, and Director of the Houston VA Patient Safety Center of Inquiry.

Dean Sittig, PhD, University of Texas School of Biomedical Informatics at Houston, UT-Memorial Hermann Center for Healthcare Quality & Safety.


The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.

The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.

The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

The Doctor’s Advocate is published quarterly by Corporate Communications, The Doctors Company. Letters and articles, to be edited and published at the editor’s discretion, are welcome. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of The Doctors Company. Please sign your letters, and address them to the editor.

Second Quarter 2014

Director's Forum
SAFER Guides for Electronic Health Record Implementation and Use

An Ounce of Prevention
Why Accuracy Matters

Politically Speaking
MICRA Update

Sign Up for Complimentary CME

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Industry and Company News: Second Quarter 2014

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