Learning From Primary Care EHR Exemplars About Health IT Safety

The rapid increase in electronic health record (EHR) use has raised concerns about the potential for new types of errors in healthcare. In response, the Office of the National Coordinator for Health Information Technology (ONC) incorporated safety requirements into the certification criteria for health information technology (IT) products. Additionally, ONC developed Safety Assurance Factors for EHR Resilience (SAFER) guides to enable EHR users to evaluate and improve safety issues within their organizations.

This study assessed perspectives about a set of the SAFER recommendations and explored approaches taken to adopt them among exemplar clinics participating in the primary care practice-based research network (PBRN). PBRNs are groups of primary care clinicians and practices working together to answer community-based healthcare questions and translate research findings into practice. A multi-method study design combined quantitative assessment to identify exemplar practices in EHR safety with focus group interviews among physicians to explore their perspective about and adoption of the SAFER recommendations.

The specific aims of this project were as follows:

• Conduct focus group interviews with primary care clinicians from 20 small exemplar primary care practices to identify their perspectives on recommended practices from the SAFER guides, their adoption of these practices, and their impact on EHR safety. 
• Conduct key informant interviews with EHR vendor experts to reflect on the findings from the focus groups and provide additional perspectives on strategies associated with safe health IT. 
• Use qualitative, transcript-based analyses to develop a taxonomy of pragmatic key strategies and best practices for safe EHR use in small primary care practices. 

Exemplar practices are those that have been found to achieve high performance on a broad set of clinical quality measures. The focus groups of physicians found widespread agreement with most of the SAFER recommendations discussed, despite participants’ lack of familiarity with them. Participants cited numerous examples of safety issues that had occurred prior to their use of EHRs or adoption of related SAFER recommendations. Strategies to adopt the SAFER recommendations varied due to limitations of the EHR, participants’ understanding of their EHR functionality, and office staffing. Physicians expressed that EHRs are expensive and time-consuming to maintain, that clinical judgement was often required to supplement EHR recommendations, and that greater assistance with optimal EHR use and maintenance from their vendor was needed. The consensus, however, was that these difficulties were outweighed by the quality of care that EHR use provided.

Vendor representatives largely agreed with the findings from the focus groups and added their perspectives about the challenges they face meeting some of the SAFER recommendations. They strongly concurred with the physicians’ view that it would be desirable to be able to focus on product updates that help clinicians and patients, rather than the regulatory requirements that consume many of their resources. The research team noted that as the health IT field continues to develop, it will be important to continue to assess the relevance of EHR safety recommendations and their implementation in “real-world” practice.