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Promoting the Safe Use of Electronic Health Records

August 24, 2021

Takeaway: Guides developed by HSR&D researchers to promote the safe use of electronic health records are part of a new federal policy on Medicare reimbursement to hospitals. The new policy is scheduled to take effect in 2022 and calls for hospitals to use  extensive guides and checklists, based on extensive research conducted by HSR&D investigator Hardeep Singh, MD, MPH, and his collaborator Dean Sittig, PhD.

Emerging evidence suggests that the electronic health record (EHR) can lead to patient safety concerns as well as burnout and dissatisfaction among clinicians. Through a series of studies, HSR&D investigator Hardeep Singh, MD, MPH, and his Houston VA Patient Safety Center team at the Michael E. DeBakey VA Medical Center, along with his main collaborator, Dean Sittig, PhD, a professor at UTHealth School of Biomedical Informatics, developed a comprehensive compendium of safety checklists known as the SAFER Guides. “SAFER” stands for “Safety Assurance Factors for EHR Resilience.” The guides are sponsored by the Office of the National Coordinator for Health Information Technology within the Department of Health and Human Services. The guides cover areas such as communication among clinicians, test results reporting and follow-up, patient identification, and contingency planning. They walk hospital personnel through detailed steps to ensure they are using EHRs in the safest way. Use of the SAFER Guides is one of several requirements and measures included in the new Medicare rules.

Dr. Singh is Chief of the Health Policy, Quality & Informatics Program at HSR&D’s Center for Innovations in Quality, Effectiveness and Safety (IQuEST) in Houston, TX. His research focuses on understanding and reducing diagnostic errors; using health information technology to improve health care; and improving the safety of electronic health records. In 2022, Dr. Singh received the Eisenberg Patient Safety and Quality Award, which recognizes major individual, local, and national achievements in healthcare that improve patient safety and healthcare quality. In 2016, he and his team received HSR&D’s Health System Impact Award, which honors HSR&D- and QUERI-funded research that has had a direct and important impact on clinical practice or clinical policy within the VA health care system. His team's impact on policy and practice in the VA healthcare system includes initiatives to measure and improve communication of diagnostic test results to patients and clinicians. For instance, Dr. Singh co-developed the national VA policy on communication of test results to patients and providers that is in place at all VA facilities and impacts care for millions of Veterans.


With the new Medicare payment rules, all U.S. hospitals eligible for reimbursement will have to attest annually that they assessed their electronic health record use based on the SAFER Guides.

This new measure will stimulate hospitals to self-assess various aspects of their EHR-related patient safety proactively, without posing much additional measurement or reporting burden. We see this as a landmark development in EHR safety policy that impacts all US hospitals. –Dr. Singh

Adoption of the SAFER Guides should help healthcare organizations achieve safety and quality improvements that were promised by state-of-the-art EHRs. – Dr. Sittig


Dr. Singh’s team includes experts from cognitive psychology, human factors engineering, social sciences, clinical medicine, and clinical informatics – and is additionally supported by the VHA National Center for Patient Safety


Sittig DF, Ash JS, Singh H. The SAFER guides: empowering organizations to improve the safety and effectiveness of electronic health records. American Journal of Managed Care. May 2014;20(5):418-23.

Sittig D and Singh H. Toward more proactive approaches to safety in the electronic health record era. The Joint Commission’s Journal on Quality and Patient Safety. October 2017;43(10):540-547.

Sittig D, Salimi M, Aiyagari R, et al., and Singh H. Adherence to recommended electronic health record safety practices across eight health care organizations. Journal of the American Medical Informatics Association. July 2018;25(7):913-918.

Sittig D and Singh H. Policies to promote shared responsibility for safer electronic health records. JAMA. 2021;326(15):1477-1478.

Sittig D, Sengstack P, and Singh H. Guidelines for US hospitals and clinicians on assessment of electronic health record safety using SAFER guides. JAMA. 2022;327(8):719-720.


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