- Healthcare organizations looking to improve EHR safety and usability can look toward ONC SAFER Guides that were updated in 2017. However, a recent study found that adherence to recommended EHR safety practices is low, even with recommendations on how to improve EHR use being widely available.
Healthcare organizations are more likely to follow technical recommendations with EHRs than those that “require workflow and process enhancements related to clinical areas of concern or recommendations to use technology to reduce safety concerns,” according to Sittig, et al.
“Uptake of the remaining SAFER recommendations will likely increase as organizations become more confident in their abilities to develop new policies, procedures, clinical workflows, and configure and maintain their EHR implementations,” researchers continued. “Finally, full implementation of the SAFER recommendations will require organizational prioritization, resource allocation, policy changes, and vendor participation.”
ONC SAFER Guides were initially released in January 2014, but were updated in 2017. Providers can take self-assessments of personal EHR system safety vulnerabilities through a checklist of evidence-based practices that experts recommended.
There are nine focus areas in the Guides, which are organized into foundational, infrastructure, and clinical-process groups.
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For the study, researchers conducted risk assessments of eight organizations that were of varying size, complexity, EHR, and EHR adoption maturity.
Just 25 of 140 SAFER recommendations – 18 percent – were fully implemented at the eight organizations, while the mean percentage of “fully implemented” SAFER recommendations ranged from 94 percent for the System Interfaces guide down to 63 percent for the Clinician communication guide.
None of the recommendations from the Clinician Communication, Organizational Responsibilities, or High Priority guides were fully implemented across all eight sites, the research team found.
“Of the 11 recommendations most likely to be ‘not Implemented,’ most (9 of 11) were from 3 guides: Test Results Reporting, Communication and CPOE/CDS, with 4 from the CPOE/CDS guide alone,” researchers wrote. “Conversely, all System Interfaces and Contingency Planning guide recommendations were implemented by at least one site.”
Researchers noted that most of the fully implemented recommendations at all sites either represented requirements of the meaningful use program, requirements to ensure proper patient identification and registration (a Joint Commission priority), or requirements for proper maintenance of hardware, network, and other technical systems.
It is “reassuring” that healthcare organizations are responsive to technical safety requirements, more drastic EHR safety improvements will need “a much more comprehensive and proactive approach to deal with emerging EHR safety hazards,” researchers explained.
“While we did not systematically evaluate why implementation of all the SAFER recommendations varied across organizations, anecdotal evidence and informal discussions suggest budgetary limitations, personnel skill mix, organizational strategy and priorities, EHR design or implementation configuration decisions, and leadership commitment as possible contributing factors,” the team wrote.
The SAFER Guides could provide a useful platform to healthcare organizations with being able to effectively benchmark EHR safety, researchers proposed. Organizations can also use SAFER recommendation rates’ mean value as fully implemented to judge their own level of EHR safety as a whole.
CMS could even utilize SAFER scores as conditions of participation or part of the Joint Commission’s accreditation procedures. Having such policy changes in place could also stimulate wider SAFER Guide adoption.
“The guides may also assist in driving culture change regarding organizational learning related to evaluation and improvement of the EHR,” researchers wrote. “This has historically been seen as the sole responsibility of the IT department rather than as shared responsibility among stakeholders across the entire organization in conjunction with EHR vendor.”
Healthcare organizations should perform a SAFER self-assessment once per year, the team recommended. A national Health IT Safety Center could also be beneficial because SAFER scores “could be de-identified, aggregated, and displayed to enable refinement” of the guides and help organizations compare themselves to others in the industry.
There is room for future research into details as to why certain recommendations were less fully implemented than other recommendations. For example, with only 18 percent of all the recommendations being fully implemented, some organizations may be recognizing and acknowledging their own limitations.
Cost, degree of difficulty, and expertise required to adhere to the least implemented recommendations were also not reviewed, the researchers explained. Additionally, there were not enough respondents to determine whether the EHR vendor or time since EHR implementation had any influence on SAFER recommendations.
“It is typically the [healthcare organization] that is mostly responsible for configuring and implementing the various EHR features, functions, and workflow processes to satisfy the SAFER recommendations, and the EHR vendors are only responsible for ensuring that their systems have the capability to meet recommendations,” researchers stated.
EHR usability problems has previously been cited as a factor potentially leading to patient safety issues.
A study published in JAMA earlier this year found that 1.956 of the 1.7 million reported safety events that were reviewed included direct mention of a health IT company or EHR system. Approximately 550 patient safety events also suggested EHR usability was a contributing factor that led to the incident of potential patient harm.
Data entry, interoperability, and availability of information were some of the EHR usability problems found that could contribute to patient harm.
“EHR usability may have been a contributing factor to some possible patient harm events,” researchers explained. “Only a small percentage of potential harm events were associated with EHR usability, but the analysis was conservative because safety reports only capture a small fraction of the actual number of safety incidents, and only reports with explicit mentions of the top 5 vendors or products were included.”