The Office of the National Coordinator for Health Information Technology Health IT Playbook

Section 8

Quality & Patient Safety

In this section

Learn how to:

Quality healthcare means doing the right thing — for the right patient, at the right time, in the right way — to achieve the best possible results. Patient safety practices protect patients from accidental or preventable harm associated with healthcare services.

Together, care quality and patient safety improvement activities can help healthcare teams achieve the 6 aims described in the Institute of Medicine’s publication Crossing the Quality Chasm: A New Health System for the 21st Century. It states that care should be:

  • Safe
  • Effective
  • Patient-centered
  • Timely
  • Efficient
  • Equitable

Compared with paper records, electronic health records (EHRs) facilitate improvements to healthcare quality and safety. EHRs gives clinicians — as well as patients and their proxies — access to relevant patient information.

EHR systems also offer integrated best-practice support in the form of electronic clinical decision support (CDS). CDS gives care teams general and person-specific information — intelligently filtered and organized — at the appropriate times. This improves care outcomes by making timely information — that supports sound decisions — available to the care team.

A properly implemented EHR helps clinicians more easily track patients from one point of care to another and document all care they receive. It also has automated functionalities that improve patient care and safety, such as:

  • Electronic prescribing
  • Drug-drug interaction checks
  • Drug-allergy interaction checks

EHR and population health

EHR systems also play a role in improving population health. They process large amounts of aggregate health data and can support both trend and outlier analysis. This lets clinicians and public health professionals take action to improve outcomes.

As we look to improve our nation’s health, these population health activities become increasingly important. And as new care models evolve and focus on both population and patient outcomes, EHRs make meeting quality-reporting program requirements more efficient.

Clinicians can use automated EHRs to harvest performance measurements from data routinely captured in the course of care. We refer to electronic clinical quality measures (specified in standard format for automatable, interoperable electronic reporting from the EHR) as eCQMs.

Like all powerful tools, EHR systems carry risk with use. However, you can minimize unintended consequences by following best practices for the design, implementation, user training, and use of your EHR.

Planning is essential to get the most out of your EHR investment and to ensure its safe use. The resources provided throughout this playbook provide clinicians with a starting place to use their EHR to improve care quality and safety.

“Patient safety” refers to freedom from harm, injury, or loss associated with healthcare services — or close calls where harm, injury, or loss comes close to happening. An electronic health record (EHR) provides tools to help clinicians, and any staff who interact with a patient's record, improve patient safety.

EHRs play an integral role in larger systems composed of the clinical team, the patient, and the workflows that support patient care. When analyzing the safe use of EHRs, be sure to consider the sociotechnical system — how human behavior and technology interact — as a whole.

SAFER Guides

The recommendations in the Assistant Secretary of Technology Policy (ASTP) Safety Assurance Factors for EHR Resilience (SAFER) Guides illustrate evidence-based best practices to improve the safety and safe use of EHRs. The recommendations are proactive risk assessments that aim to mitigate and minimize EHR-related safety hazards. Each of the 8 SAFER Guides consists of 6 to 18 recommended practices that can be assessed on a 5-point scale, from “not implemented” to “fully implemented.” Understanding the configuration settings of your EHR and implementing recommended practices can help you improve the safety and safe use of the EHR in your practice.

The rationale for the practice and implementation guidance that accompanies each recommendation is designed to help EHR users and developers understand and meet that specific recommendation. Meeting SAFER recommendations is a team effort and requires everyone to work together, including users in your practice setting, staff responsible for setting up your EHR, and sometimes the EHR software developer. The EHR developer might also have an EHR-specific manual for those users who are responsible for configuring and implementing the EHR, which can help your team meet the recommendations.

Many recommendations relate to adjusting specific EHR configuration settings, while others involve strengthening workflows — the processes your office follows to deliver patient care. So, it can be helpful for your practice to review your internal policies and procedures against the SAFER recommendations to identify the recommendations you can implement.

For example, it's ideal for your practice to have a well-designed paper-based system for documenting your activities and ordering medications, tests, and procedures when your EHR is unavailable (see the Contingency Planning Guide [PDF — 1.8 MB]). In small practices using a remotely hosted (cloud-based) EHR solution, clinicians can ask those responsible for some EHR configuration and maintenance settings to document which of the SAFER recommendations they have implemented.

Are you looking for more guidance? The authors of the SAFER Guides have outlined a step-by-step approach for conducting an EHR safety assessment.

ASTP organizes the SAFER Guides into 3 broad groups:

  • Foundational
  • Infrastructure
  • Clinical process

You can find summaries of — and links to — the SAFER Guides in each broad group below.

Foundational guides:


High Priority Practices.

High Priority Practices [PDF — 1.8 MB]*: This guide is for front-line clinicians. It highlights the 16 most critical recommendations selected from among the other 7 guides because of their relevance and importance for practicing clinicians.

Organizational Responsibilities.

Organizational Responsibilities [PDF — 1.9 MB]*: This guide provides a framework for managing the responsibilities associated with the safe use of EHRs and artificial intelligence (AI)-enabled systems. It addresses human behavior, relationships, organizational structures, and collaborative processes to help healthcare organizations assess and improve EHR-related safety.

Infrastructure guides:


Contingency Planning.

Contingency Planning [PDF — 1.8 MB]*: This guide offers recommended safety practices for planned or unplanned EHR unavailability (downtime) — instances when clinicians or other end users can’t access all or part of the EHR.

System Management.

System Management [PDF — 1.7 MB]*: This guide is designed to be worked through collaboratively by a multidisciplinary team of clinicians, technical staff, administrative specialists, frequent end users, and relevant subject matter experts. It provides guidance on the configuration, validation, and maintenance of EHR hardware, software, and application programming interfaces (APIs). It also outlines recommendations for policies, monitoring protocols, and collaboration strategies to enhance system safety and effectiveness.

Clinical process guides:


Patient Identification.

Patient Identification [PDF — 1.8 MB]*: This guide looks at safety practices associated with accurate patient identification to ensure that the information entered into — and presented by — the EHR represents the correct person. It offers recommended practices to help prevent, detect, and mitigate problems caused by duplicate records, patient mix-ups, and commingled (or “overlay”) records.

Computer Provider Order Entry (CPOE) with Decision Support.

Computerized Provider Order Entry with Decision Support [PDF — 1.4 MB]*: This guide offers recommendations to improve safety related to clinician orders for medications, testing, procedures, referrals, or transitions of care — and to ensure that clinicians who electronically order diagnostic tests and consultations remain in the communication loop.

Test Results Reporting and Follow-Up.

Test Results Reporting and Follow-Up [PDF — 1.8 MB]*: This guide covers recommended safety practices for electronically communicating, managing, documenting, reporting, and following up on test results. The recommendations aim to ensure that an EHR's design and implementation help close the loop on test results to minimize the potential for errors and delays.

Clinician Communication.

Clinician Communication [PDF — 1.6 MB]*: This guide can help your practice use an EHR to reliably send and receive referrals and consultations, inpatient-to-outpatient transition communications, and clinical messages.

Agency for Healthcare Research and Quality's (AHRQ's) National Action Alliance Webinar

Overview
A recording of the “Engineering Safety into Practice through Implementation of the 2025 SAFER Guides” webinar featuring the authors of the SAFER Guides discussing the guides' contents and use for self-assessment

Who it’s for
Clinicians and healthcare practitioners, front desk staff, health IT implementers, practice owners and administrators

When it’s used
To learn about the need the SAFER Guides fill, what information the guides contain, and how healthcare organizations can use them to enhance the safety and safe use of their EHR

Watch the National Action Alliance Webinar: Engineering Safety into Practice through Implementation of the 2025 SAFER Guides

What's the Big Deal About Patient Demographic Data?

Registrar and Front Desk Patient Registration Training Module

Overview
Patient identification is essential to patient safety — but neither can be achieved without accurate demographic data in the patient record.

Today's healthcare settings usually handle high patient volumes. Front desk staff manage a large number of rapid check-ins and registrations each day, and they play a key role in collecting and maintaining accurate demographic data.

This training module illustrates common pitfalls associated with incorrect demographic data. It also suggests ways front desk staff can minimize issues. It provides information about how to use patient demographic data for matching patient records, the issues that can occur with incorrectly matched data, and best practices for accurately capturing patient demographic data.

Who it’s for
Registrars, front desk staff, and practice managers

When it’s used
To train staff who collect patient demographic data on a regular basis

Check out Chapter 1: What's the Big Deal About Patient Demographic Data?

The term “usability” comes up frequently during discussions about software, and it’s a very important part of a successful electronic health record (EHR) implementation. The International Organization for Standardization (ISO) defines usability as:

“The extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use.”

In health IT, usability refers to how well the system supports the end user’s work and how much the user interface design helps people complete tasks while minimizing human error.

Recommended reading: Better EHR: Usability, Workflow and Cognitive Support in Electronic Health Records. This book — available as a free download in PDF or iBook format — addresses the usability and cognitive support issues related to EHRs. It was created by the National Center for Cognitive Informatics & Decision Making in Healthcare at the University of Texas, with funding support from the Office of the National Coordinator (ONC).

Quality improvement is an important, established practice in healthcare, and you can find opportunities to merge electronic health records (EHRs) with quality improvement throughout all phases of care. Here are three examples:

  • Clinical decision support tools can help clinicians manage actionable information and make it available during care
  • Electronic clinical quality measures (eCQMs) can help clinicians assess the proportion of their patients with well-controlled hypertension over time
  • EHR systems can help streamline or even automate data sharing with clinical data registries that use the information to help clinicians choose the best courses of treatment

Below, we explain these capabilities and discuss how you can use your EHR to reach your quality improvement goals.

Clinical Decision Support

“Clinical decision support” (CDS) refers to information and tools that support clinicians and patients as they make clinical decisions at the point of care. CDS could be as basic as using a reference text to double-check a treatment algorithm.

Within an EHR, CDS tools offer more sophistication. They can present both general and person-specific information, filtered and organized, at appropriate times to appropriate people, including clinicians, practice staff, and patients.

Examples of CDS tools in EHRs include:

  • Health maintenance reminders
  • Drug-drug and drug-allergy interaction checks
  • Electronic presentation of clinical guidelines
  • Condition-specific order sets
  • Focused patient-data reports and summaries
  • Documentation templates
  • Diagnostic support such as differential diagnosis tools
  • Contextually relevant reference information

It’s important to think about which CDS tools will help your practice the most. If you’re selecting an EHR, carefully review its CDS capabilities to see if it fits your needs. If you already have an EHR, work with your EHR developer to enable and optimize the available CDS tools that benefit your patients the most.

Clinical Decision Support and Diagnostic Imaging

Clinical decision support (CDS) helps physicians talk with patients about which imaging tests are appropriate for their situation. These tools can help avoid unnecessary medical tests, resulting in higher-quality patient care at a lower cost.

Go to the AMA STEPS Forward™ Clinical Decision Support and Diagnostic Imaging module

Clinical Quality Measures

Clinical quality measures (CQMs) gauge and track the quality of healthcare services to help find areas that need improvement, and payers are increasingly examining them. A practitioner’s CQM results are typically expressed as a ratio with a numerator and a denominator.

For example, a quality measure focusing on hypertension control for one doctor might have a denominator of “all patients with hypertension” and a numerator of “patients at target blood pressure.” CQMs also generally have a target percentage and are built on evidenced-based, professional guidelines.

A variety of quality improvement and public reporting programs, including the Centers for Medicare & Medicaid Services (CMS), rely on eCQMs. The Office of the National Coordinator (ONC) certifies the capability of health IT, including EHRs, to accurately calculate and report specified eCQMs.

Properly implemented EHR systems can calculate quality measures, and results can help clinicians with practice improvement. Results can also be transmitted to payers, thus streamlining quality reporting.

Properly implemented EHR systems can also help clinicians — especially those who participate in a clinical data registry — to measure and improve their care quality performance. EHRs extract and transmit data that is collected during normal care and documentation. Compared with manual methods, this makes it easier to abstract data, calculate measurements, and provide feedback.

Electronic Clinical Quality Improvement

Electronic clinical quality improvement (eCQI) uses a variety of processes, including health IT tools, to help improve care and to support better health. It uses technology effectively to sustain a continuous improvement cycle, and at its core is the traditional quality improvement process model.

Steps in the continuous improvement cycle include:

  • Deliver care
  • Measure care safety, quality, and outcomes
  • Plan and implement interventions
  • Monitor intervention results
  • Adjust as needed to improve results

The next stage of healthcare quality includes advanced CDS and increased end-to-end electronic quality measurement and reporting. Rather than limiting quality improvement to retrospective measurement, CMS and ONC are working to provide standards that will incorporate evidence-based medicine and the patient’s own history, preferences, and data into CDS — for truly customized care.

Resources

Use the following tools and links to further your understanding of electronic clinical quality improvement.

Million Hearts®: Facilitating quality care with EHRs

Million Hearts. Logo.

Million Hearts® is a national initiative created by the Department of Health and Human Services, the Centers for Disease Control and Prevention, and CMS to fight cardiovascular diseases, which kill more than 800,000 Americans every year. Composed of 120 official partners and 20 federal agencies, its continuing mission is to optimize care, keep people healthy, and improve outcomes for priority populations.

The Million Hearts® website contains a wide range of resources to help medical professionals educate, motivate, and monitor their patients. Under the site’s Tools menu, for example, you’ll find a section dedicated to health IT where you can download EHR optimization guides developed by ONC.

You’ll also find other health IT guides and resources including:

  • Clinical Quality Measures Alignment
  • EHR Innovations for Improving Hypertension Challenge
  • Guide for Implementing e-Referral Using Certified EHRs
  • Guide to Improving Care Processes and Outcomes in Health Centers for Disease Control and Prevention
  • Population Health Management Software: An Opportunity to Advance Primary Care and Public Health Integration
  • “What Is a Patient Portal?” FAQ
Million Hearts Website Screen Shot.

Learn more about how you can use electronic health records (EHRs) to improve the quality of patient care. These resources will help you:

  • Implement or optimize EHRs in your practice
  • Understand how eCQI can help to improve care and support better health
  • Use data to improve quality of care and outcomes
  • Plan quality improvement goals and enhancements

eCQI Resource Center

Overview
Access to extensive eCQI resources and connections to professionals dedicated to clinical quality improvement for better health, including introductory material describing the basic technical aspects of eCQM reporting in addition to in-depth technical details. (Note: because of its technical information, this may not be as useful as an introductory resource)

Who it’s for
Quality improvement professionals, health IT professionals, and clinicians who want to understand the technical specifications for eCQM reporting

When it’s used
To plan an EHR implementation and to decide — or improve — upon clinical quality measures

Check out the eCQI Resource Center

Please see the Health Resources and Services Administration’s Guide to Improving Care Processes and Outcomes for additional resources. This webpage provides strategies and tools that health centers and their partners can use to enhance care that’s targeted for improvement, such as hypertension and diabetes control and preventive care.

Hypertension Control Change Package

Hypertension Control Change Package

Overview
Process improvements designed for ambulatory clinical settings looking for optimal hypertension (HTN) control and information on how to use EHR systems to improve processes

Who it’s for
Ambulatory practices

When it’s used
To implement population health initiatives

Download Hypertension Control Change Package [PDF — 680 KB]

eCQI: What It Is and How It Can Help You

Overview
Explanation of eCQI and how medical and health professionals can use this approach to optimize health IT applications in support of continuous quality improvement

Who it’s for
Clinicians and health IT professionals

When it’s used
To understand what a practice or organization needs to do to continuously improve clinical quality measures

Visit eCQI: What It Is and How It Can Help You website

Guiding Principles for Big Data in Nursing

Guiding Principles for Big Data in Nursing

Overview
Information about the role nurses play in strategic planning and implementation of health IT, which includes capturing health and care data in a structured manner for care management and quality improvement purposes

Who it’s for
Nurses, nursing leaders, and hospitals

When it’s used
To plan and implement health IT or to consider big data and population health strategies

Download Guiding Principles for Big Data in Nursing [PDF — 503 KB]

Health IT-enabled eCQI (Ambulatory)

Health IT-enabled eCQI (Ambulatory)

Overview
A template for documenting and analyzing approaches to quality improvement in the ambulatory setting

Who it’s for
Ambulatory clinicians and health IT implementers

When it’s used
To plan quality improvement goals and enhancements

Download Health IT-enabled eCQI (Ambulatory) [PDF — 2.5 MB]

Health IT-enabled eCQI (Inpatient)

Health IT-enabled eCQI (Inpatient)

Overview
A template for documenting and analyzing approaches to quality improvement in the inpatient setting

Who it’s for
Inpatient clinicians and health IT implementers

When it’s used
To plan quality improvement goals and enhancements

Download Health IT-enabled eCQI (Inpatient) [PDF — 2.7 MB]

Learning Guide: Capturing High Quality Electronic Health Records Data to Support Performance Improvement

Learning Guide: Capturing High Quality Electronic Health Records Data to Support Performance Improvement

Overview
Important considerations and implementation steps to help physician practices and communities improve EHR data quality

Who it’s for
Physician practices, hospital systems and affiliated practices, and other clinician organizations responsible for delivering high-quality care to specific patient populations

When it’s used
To implement EHR or to optimize EHR to improve the quality of data stored in EHR systems

Download Learning Guide: Capturing High Quality Electronic Health Records Data to Support Performance Improvement [PDF — 386 KB]

Section 8 Recap

Provide safe, effective, patient-centered, timely, efficient, and equitable care.

  • Use health IT to improve patient safety
  • Improve the usability of your EHR
  • Improve healthcare quality with EHR technology

Content last updated on: May 7, 2025