The Office of the National Coordinator for Health Information Technology Playbook

Section 8

Quality & Patient Safety

In this section

Learn how to:

Quality health care 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 health care services.

Together, care quality and patient safety improvement activities can help health care teams achieve the 6 aims described in the Institute of Medicine’s publication . It states that care should be:

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

Compared with paper records, electronic health records (EHRs) facilitate improvements to health care 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 accidental or preventable injuries associated with health care services, and an electronic health record (EHR) system provides tools to help clinicians improve patient safety.

EHRs play an integral role in larger systems composed of the clinical team, the patient, and the daily supporting workflows. When analyzing EHR safety, be sure to consider the entire system as a whole.

The Office of the National Coordinator for Health Information Technology (ONC) and Research Triangle Institute International (RTI) together produced a focused on health IT safety. Example topics include:

  • Medication management
  • Electronic ordering
  • Documentation
  • Usability

These webinars provide a great introduction to the various ways you can improve patient safety with health IT.

SAFER Guides

The ONC Safety Assurance Factors for EHR Resilience (SAFER) Guides recommendations illustrate what you need to do to achieve safe and effective EHR implementation and use. The recommendations should be considered proactive risk assessments that aim to mitigate and minimize EHR-related safety hazards. Each SAFER Guide consists of between 10 to 25 recommended practices that can be assessed as “fully implemented,” “partially implemented,” or “not implemented.” Implementing recommended practices helps you ensure safe use of the EHR.

Examples accompanying each recommendation are designed to help EHR users and developers meet each recommendation. Meeting SAFER recommendations is a team effort and requires users in your practice, those responsible for setting up your EHR, and, sometimes the EHR software developer to work together. The EHR developer might also have an EHR-specific manual for those responsible for configuring and implementing the EHR that can help your team meet the recommendations.

Many recommendations require adjusting specific EHR configuration parameters, and others involve strengthening workflows — the steps your office takes to deliver care to your patients. So, your practice should review your internal policies and procedures to ensure that you are addressing the SAFER recommendations directly under your control. For example, you should make sure that your practice has a well-thought-out paper-based system for documenting your activities and ordering new medications, tests, and procedures when your EHR is unavailable (see the Contingency Planning Guide [PDF — 13.2 MB] ). In small practices that use a remotely hosted (cloud-based) EHR solution, the clinicians should ask those responsible for configuring and maintaining their EHR to document which of the SAFER recommendations they have implemented.

ONC organizes SAFER Guides into 3 broad groups:

  • Foundational
  • Infrastructure
  • Clinical process

Foundational guides:

High Priority Practices. PDF. Click to download.

High Priority Practices [PDF — 4.5 MB]*: This guide helps you assemble and equip a safety team to determine the safety practices you need to address first — and then decide which SAFER Guides to use next.

Organizational Responsibilities. PDF. Click to download.

Organizational Responsibilities [PDF — 4.3 MB]*: This guide, designed primarily for larger health care organizations, focuses on human behavior and relationships. It’s organized differently than the other guides and includes principles that apply to people who have responsibility for patient safety in EHR-enabled health care organizations.

Infrastructure guides:

Contingency Planning. PDF. Click to download.

Contingency Planning [PDF — 13.2 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 Configuration. PDF. Click to download.

System Configuration [PDF — 3.4 MB]*: This guide provides recommended safety practices for setting up (configuring) EHR hardware and software. Configuration includes the EHR system’s physical environment, the hardware and software infrastructure, and the maintenance processes. Configuring an EHR — which involves many decisions that profoundly influence performance and safety — must be handled by the configuration team.

System Interfaces. PDF. Click to download.

System Interfaces [PDF — 3.7 MB]*: This guide covers recommended safety practices for optimizing system-to-system interfaces between EHR-related software applications. Maintaining enterprise- or community-wide clinical information systems involves integrating different software applications, often from different system developers. This guide helps organizations prioritize interface-related safety concerns.

Clinical process guides:

Patient Identification. PDF. Click to download.

Patient Identification [PDF — 4 MB]*: This guide looks at safety practices associated with accurate patient identification. These safety measures ensure that the information entered into — and presented by — the EHR represents the correct person. Technology configurations alone can’t ensure accurate patient identification.

Computer Provider Order Entry (CPOE) with Decision Support. PDF. Click to download.

Computerized Provider Order Entry (CPOE) with Decision Support [PDF — 4.2 MB]*: This guide offers recommendations to improve medication safety and to ensure that clinicians who electronically order diagnostic tests and consultations remain in the communication loop.

Test Results Reporting and Follow-Up. PDF. Click to download.

Test Results Reporting and Follow-Up [PDF — 4 MB]*: This guide covers recommended safety practices for the electronic communication and management of diagnostic test results. Failure to appropriately follow up on diagnostic test results can lead to misdiagnosis, patient harm, and liability. These recommendations aim to improve diagnostic test reporting, documentation, and follow-up of test results.

Clinician Communication. PDF. Click to download.

Clinician Communication [PDF — 2.5 MB]*: This guide will help your practice use an EHR to reliably send and receive referrals and consultations, inpatient-to-outpatient transition communication, and clinical messages.

* Individuals using assistive technology may not be able to fully access information in this file. For assistance, ONC at .


Patient identification is essential to patient safety

Patient identification is essential to patient safety, and you can’t achieve either if you don’t have accurate demographic data in the patient record.

Today’s health care settings usually handle high patient volume. A clinician’s front-desk staff manages a large number of rapid check-ins and registrations each day, and they play a key role in creating and maintaining accurate demographic data.

The following training module illustrates common pitfalls associated with incorrect demographic data. It also suggests ways front-desk staff can minimize issues.

Registrar and Front Desk Patient Registration Training Module

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 the Registrar and Front-Desk Patient Registration Training Module

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: . 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 health care, 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.

Clinical Quality Measures

Clinical quality measures (CQMs) gauge and track the quality of health care 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 health care 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.


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.

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

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

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

Please see the Health Resources and Services Administration’s 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

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

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

Guiding Principles for Big Data in Nursing

Guiding Principles for Big Data in Nursing

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] eCQI (Ambulatory) eCQI (Ambulatory)

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 eCQI (Ambulatory) [PDF — 2.5 MB] eCQI (Inpatient) eCQI (Inpatient)

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 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

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 health care quality with EHR technology

Join the conversation.

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Content last updated on: May 31, 2019