Fillable SAFER Clinician Communication General Instructions Safety Assurance Factors (Office of the National Coordinator)

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SAFER Clinician Communication General Instructions Safety Assurance Factors (Office of the National Coordinator)

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SAFER
Safety Assurance Factors
for EHR Resilience
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Self-Assessment
Clinician
Communication
General Instructions
for the SAFER Self-Assessment Guides
The SAFER Guides are designed to help healthcare
organizations conduct self-assessments to optimize
the safety and safe use of electronic health records
(EHRs) in the following areas.
▪ High Priority Practices
▪ Organizational Responsibilities
▪ Contingency Planning
▪ System Configuration
▪ System Interfaces
▪ Patient Identification
▪ Computerized Provider Order Entry
with Decision Support
▪ Test Results Reporting and Follow-up
▪ Clinician Communication
Each of the nine SAFER Guides begins with a Checklist of
recommended practices. The downloadable SAFER
Guides provide fillable circles that can be used to indicate
the extent to which each recommended practice has been
implemented. Following the Checklist, a Practice
Worksheet gives a rationale for and examples of how to
implement each recommended practice, as well as likely
sources of input into assessment of each practice, and
fillable fields to record team members and follow-up action.
In addition to the downloadable version, the content of
each SAFER Guide, with interactive references and
supporting materials, can also be viewed on ONC’s
website at www.healthit.gov/SAFERGuide.
The SAFER Guides are based on the best evidence
available at this time (2016), including a literature review,
expert opinion, and field testing at a wide range of
healthcare organizations, from small ambulatory practices
to large health systems. The recommended practices in the
SAFER Guides are intended to be useful for all EHR users.
However, every organization faces unique circumstances
and will implement a particular practice differently. As a
result, some of the specific examples in the SAFER Guides
for recommended practices may not be applicable to every
organization.
The SAFER Guides are designed in part to help deal with
safety concerns created by the continuously changing
landscape that healthcare organizations face. Therefore,
changes in technology, practice standards, regulations and
policy should be taken into account when using the SAFER
Guides. Periodic self-assessments using the SAFER Guides
may also help organizations identify areas in which it is
particularly important to address the implications of change
for the safety and safe use of EHRs. Ultimately, the goal is to
improve the overall safety of our health care system.
The SAFER Guides are not intended to be used for legal
compliance purposes, and implementation of a
recommended practice does not guarantee compliance with
HIPAA, the HIPAA Security Rule, Medicare or Medicaid
Conditions of Participation, or any other laws or regulations.
The SAFER Guides are for informational purposes only and
are not intended to be an exhaustive or definitive source.
They do not constitute legal advice. Users of the SAFER
Guides are encouraged to consult with their own legal
counsel regarding compliance with Medicare or Medicaid
program requirements, HIPAA, and any other laws.
For additional, general information on Medicare and Medicaid
program requirements, please visit the Centers for Medicare
& Medicaid Services website at www.cms.gov. For more
information on HIPAA, please visit the HHS Office for Civil
Rights website at www.hhs.gov/ocr.
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SAFER
Safety Assurance Factors
for EHR Resilience
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Self-Assessment
Clinician
Communication
Introduction
The Clinician Communication SAFER Guide identifies
recommended safety practices associated with
communication between clinicians and is intended to
optimize the safety and safe use of EHRs. Processes
relating to clinician communication are complex and
vulnerable to breakdown. In the EHR-enabled healthcare
environment, providers rely on technology to support and
manage their complex inter-clinician communication
processes. If implemented and used correctly, EHRs have
potential to improve the safety and safe use of clinician
communication.
Communication is a key aspect of nearly all patient care
processes and has enormous potential to impact patient
safety.
1, 2, 3, 4, 5, 6
Communication breakdowns between
clinicians are one of the most common causes of medical
errors and patient harm. Communication processes have
become increasingly integrated into EHRs.
7, 8
These
include sending and receiving referral and consult
communication, communication about transitioning a
patient from the inpatient to the outpatient setting, and
communicating clinical messages with the EHR. Several
attributes of EHR-based communication can result in a
disconnect between the sender and the receiver of clinical
information, including the sender’s uncertainty about
whether or when a message has been received, and a
mismatch between single patient versus multiple patient
interactions. Messages may be incomplete, misdirected, or
directed to an unavailable clinician, and may overload the
recipient.
5, 9
This self-assessment is intended to increase awareness of
practices that can improve the safety of EHR-based
communication, and support the proactive evaluation of
particular risks. It can help identify and evaluate sources of
potential communication breakdowns, with a focus on
processes related to electronic communication between
clinicians. The self-assessment specifically targets three
high-risk processes: consultations and referrals, discharge-
related communications, and patient-related messaging
between clinicians.
Completing the self-assessment in the Clinician
Communication SAFER Guide requires the engagement of
people both within and outside the organization (such as
EHR technology developers). Because this guide is
designed to help organizations prioritize EHR-related safety
concerns, clinician leadership in the organization should be
engaged in assessing whether and how any particular
recommended practice affects the organization’s ability to
deliver safe, high quality care. Collaboration between
clinicians and staff members while completing the self-
assessment in this guide will enable an accurate snapshot
of the organization’s EHR communication status in terms of
safety. Even more importantly, collaboration should lead to
a consensus about the organization’s future path to
optimize EHR-related safety and quality: setting priorities
among the recommended practices not yet addressed,
ensuring a plan is in place to maintain recommended
practices already in place, dedicating the required
resources to make necessary improvements, and working
together to mitigate the highest priority communication-
related safety risks introduced by the EHR.
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SAFER
Safety Assurance Factors
for EHR Resilience
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Self-Assessment
Clinician
Communication
Table of Contents
General Instructions
Introduction
About the Checklist
Checklist
Team Worksheet
About the Recommended
Practice Worksheets
Recommended Practice
Worksheets
References
1
2
4
5
7
8
9
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21
The SAFER Self-Assessment Guides were developed by health IT safety researchers and informatics experts:
Joan Ash, PhD, MLS, MS, MBA, Professor and Vice Chair, Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon
Health & Science University;
Hardeep Singh, MD, MPH, Associate Professor of Medicine at the Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of
Medicine and Chief of the Health Policy, Quality and Informatics Program at the Houston VA HSR&D Center of Excellence, and Director of the Houston
VA Patient Safety Center of Inquiry; and
Dean Sittig, PhD, University of Texas School of Biomedical Informatics at Houston, UT–Memorial Hermann Center for Healthcare Quality & Safety.
This guide was developed under the contract Unintended Consequences of Health IT and Health Information Exchange, Task Order HHSP23337003T/HHSP23320095655WC.
The ONC composite mark is a mark of the U.S. Department of Health and Human Services. The contents of the publication or project are solely the responsibility of the authors and do not necessarily represent the
official views of the U.S. Department of Health and Human Services, Office of the National Coordinator for Health Informatio Technology.
Self-Assessment
SAFER
Clinician Communication
About the Checklist
> Table of Contents
>About the Checklist
> Team Worksheet
>About the Practice Worksheets
> Practice Worksheets
The Checklist is structured as a quick way to enter and print your self-assessment.
Your selections on the checklist will automatically update the related section of the
corresponding Recommended Practice Worksheet.
The Domain associated with the Recommended Practice(s) appears at
the top of the column.
The Recommended
Practice(s) for the
topic appear below
the associated
Domain.
Select the level
of implementation
achieved by your
organization for each
Recommended
Practice.
Your Implementation
Status will be
reflected on the
Recommended
Practice Worksheet
in this PDF.
To the right of each Recommended Practice is a
link to the Recommended Practice Worksheet in
this PDF.
The Worksheet provides guidance on implementing
the Practice.
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SAFER
Self-Assessment
Clinician Communication
Checklist
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Recommended Practices for Domain 1 — Safe Health IT
1.1
Urgent clinical information is delivered to clinicians in
a timely manner, and delivery is recorded in the EHR.
Worksheet 1.1
Implementation Status
Fully
in all areas
Partially
in some areas
Not
implemented
reset
1.2
Policies and training facilitate appropriate use of
messaging systems and limit unnecessary messaging.
Worksheet 1.2
1.3
The EHR includes the capability for clinicians to look up
the status of their electronic communications (e.g., sent,
delivered, opened, acknowledged).
Worksheet 1.3
1.4
Messages clearly display the individual who initiated the
message and the time and date it was sent.
Worksheet 1.4
Recommended Practices for Domain 2 — Using Health IT Safely
2.1
The EHR facilitates provision of all necessary
information for referral and consult request orders prior
to transmission.
Worksheet 2.1
Implementation Status
Fully
in all areas
Partially
in some areas
Not
implemented
reset
2.2
The EHR facilitates accurate routing of clinician-to-
clinician messages and enables forwarding of
messages to other clinicians.
Worksheet 2.2
2.3
Clinicians are able to electronically access current
patient and clinician contact information (e.g., email
address, telephone and fax numbers) and identify
clinicians currently involved in a patient’s care.
Worksheet 2.3
2.4
Electronic message systems include the capability to
indicate the urgency of messages.
Worksheet 2.4
2.5
The EHR contains a copy of clinician-to-clinician
communications.
Worksheet 2.5
2.6
The EHR displays time-sensitive and time-critical
information more prominently than less urgent
information.
Worksheet 2.6
2.7
Both EHR design and organizational policy facilitate
clear identification of clinicians who are responsible for
action or follow-up in response to a message.
Worksheet 2.7
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SAFER
Self-Assessment
Clinician Communication
Checklist
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Recommended Practices for Domain 3 — Monitoring Safety
3.1
Mechanisms exist to monitor the timeliness of
acknowledgment and response to messages.
Worksheet 3.1
Implementation Status
Fully
in all areas
Partially
in some areas
Not
implemented
reset
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SAFER
Self-Assessment
Clinician Communication
Team Worksheet
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
reset page
A multi-disciplinary team should complete this self-assessment and evaluate potential health IT-related patient safety risks addressed
by this specific SAFER Guide within the context of your particular healthcare organization.
This Team Worksheet is intended to help organizations
document the names and roles of the self-assessment team, as
well as individual team members’ activities. Typically team
members will be drawn from a number of different areas within
your organization, and in some instances, from external sources.
The suggested Sources of Input section in each Recommended
Practice Worksheet identifies the types of expertise or services to
consider engaging. It may be particularly useful to engage
specific clinician and other leaders with accountability for safety
practices identified in this guide.
The Worksheet includes fillable boxes that allow you to document
relevant information. The Assessment Team Leader box allows
documentation of the person or persons responsible for ensuring
that the self-assessment is completed. The section labeled
Assessment Team Members enables you to record the names
of individuals, departments, or other organizations that
contributed to the self-assessment. The date that the self-
assessment is completed can be recorded in the Assessment
Completion Date section and can also serve as a reminder for
periodic reassessments. The section labeled Assessment Team
Notes is intended to be used, as needed, to record important
considerations or conclusions arrived at through the assessment
process. This section can also be used to track important factors
such as pending software updates, vacant key leadership
positions, resource needs, and challenges and barriers to
completing the self-assessment or implementing the
Recommended Practices in this SAFER Guide.
Assessment Team Leader
Assessment Completion Date
Assessment Team Members
Assessment Team Notes
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SAFER
Self-Assessment
Clinician Communication
About the Recommended
Practice Worksheets
> Table of Contents
>About the Checklist
> Team Worksheet
>About the Practice Worksheets
> Practice Worksheets
Each Recommended Practice Worksheet provides guidance on implementing a specific
Recommended Practice, and allows you to enter and print information about your self-assessment.
The Rationale section
provides guidance
about “why” the
safety activities are
needed.
Enter any notes about
your self-assessment.
Enter any follow-up
activities required.
Enter the name of
the person
responsible for the
follow-up activities.
The Suggested
Sources of Input
section indicates
categories of
personnel who can
provide information to
help evaluate your
level of
implementation.
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The Examples section
lists potentially useful
practices or scenarios
to inform your
assessment and
implementation of the
specific
Recommended
Practice.
SAFER
Self-Assessment
Clinician Communication
Recommended Practice 1.1
Worksheet
Domain 1 —
Safe Health IT
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Recommended Practice
1.1
Urgent clinical information is delivered to clinicians in a timely
manner, and delivery is recorded in the EHR.
Checklist
Implementation Status
Rationale for Practice or Risk Assessment
If active measures are not taken to inform clinicians of the
presence of critical information, this information may be
missed by clinicians resulting in delays in care.
10, 11
If
primary care physicians (PCPs) do not receive a timely
discharge summary they may incorrectly restart or change
medications for which contraindications have been identified
during hospitalization.
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
EHR developer
Health IT support staff
Examples of Potentially Useful Practices/Scenarios
▪ The organization has a policy for verbal delivery of critical
information that supplements use of the EHR.
▪ Hospitals have policies and procedures to address timely
electronic delivery of important clinical information. For
example, hospital discharge summaries are delivered to
clinicians responsible for follow-up within two business
days.
▪ Messages are automatically forwarded to an alternate
clinician if not responded to within a time period
appropriate to the time-urgency of the message.
▪
▪
The EHR allows automatic forwarding of messages to
a designated surrogate clinician during a specific time
period or circumstance, such as when the clinician is
absent.
Messages that are delivered to a pool that several
clinicians are held accountable for should have clear
individual responsibilities and a hierarchy for follow-up, as
well as a means for escalating messages that are not
dealt with in a timely manner.
12
▪ When a patient transitions to another setting, a clinician
provides a summary of care record to the receiving
hospital or clinician in a timely manner. The summary
record should include, at a minimum, the Common
Meaningful Use Data Set.
13
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
reset page
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SAFER
Self-Assessment
Clinician Communication
Recommended Practice 1.2
Worksheet
Domain 1 —
Safe Health IT
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Recommended Practice
1.2
Policies and training facilitate appropriate use of messaging
systems and limit unnecessary messaging.
Checklist
Implementation Status
Rationale for Practice or Risk Assessment
Information overload is a significant problem in EHR
systems. When a large amount of information that is not
clinically relevant is transmitted through the same
channels as information with high urgency, the latter
may be missed, leading to potential patient harm.
5, 9, 14, 15
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
Examples of Potentially Useful Practices/Scenarios
▪ The organization implements a comprehensive policy on
clinician-to-clinician messaging that specifies what should
and should not be transmitted.
▪ Messages are sent only to persons who may need to act
on them. “Reply all” is used only when necessary.
▪ Mechanisms are in place to allow communication of non-
clinical information (e.g., appointment requests) in a way
that does not impact communication of clinical information
(e.g., abnormal laboratory results).
▪ The organization ensures that clinicians have sufficient
non-face-to-face time built into their daily schedules to
safely manage the clinical information delivered.
15
▪ Clinics employ a team-based strategy to manage non-
face-to-face activities, assigning tasks to other team
members where physician decision making is not needed.
▪ EHR messaging systems allow sorting of messages by
urgency and type.
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
reset page
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SAFER
Self-Assessment
Clinician Communication
Recommended Practice 1.3
Worksheet
Domain 1 —
Safe Health IT
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Recommended Practice
1.3
The EHR includes the capability for clinicians to look up the
status of their electronic communications (e.g., sent, delivered,
opened, acknowledged).
1
Checklist
Implementation Status
Rationale for Practice or Risk Assessment
Delays in care may result from referrals, consults, and
clinician-to-clinician messages that do not receive timely
attention.
1, 16, 17, 18
Suggested Sources of Input
EHR developer
Health IT support staff
Examples of Potentially Useful Practices/Scenarios
▪ A real-time tracking system allows referring clinicians to
determine the status of all their referrals and consults
transmitted and allows specialists to identify all their
referrals and consults that are pending.
19, 20, 21
▪ Clinicians and specialists are able to create a report of all
their referrals and consults including the status of each.
Clinicians are able to identify whether their sent messages
have been opened (e.g., “read receipt”).
▪ The EHR automatically notifies the ordering clinician or
team when referrals or consults are canceled or completed.
Clinicians are notified if a message they sent has not been
opened within a pre-specified number of days.
▪ The EHR can track whether a message was received or
not.
▪ Outpatient practices with messaging systems that are not
fully integrated into the EHR use additional tracking
strategies to enable follow-up.
▪ The organization implements policies to encourage
closed-loop (i.e., in-house or in-practice) referral and
consult tracking.
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
reset page
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Self-Assessment
Clinician Communication
Recommended Practice 1.4
Worksheet
Domain 1 —
Safe Health IT
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Recommended Practice
1.4
Messages clearly display the individual who initiated the
message and the time and date it was sent.
Checklist
Implementation Status
Rationale for Practice or Risk Assessment
In order to make informed and appropriate decisions,
clinicians need to know the source and timing of a message.
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
EHR developer
Health IT support staff
Examples of Potentially Useful Practices/Scenarios
▪ The EHR message interface prominently shows the date,
time, and sender's name, physical address, telephone
number, and electronic contact information.
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
reset page
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Self-Assessment
Clinician Communication
Recommended Practice 2.1
Worksheet
Domain 2 —
Using Health IT Safely
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Recommended Practice
2.1
The EHR facilitates provision of all necessary information for
referral and consult request orders prior to transmission.
1, 22, 23
Checklist
Implementation Status
Rationale for Practice or Risk Assessment
Referral and consult processing and routing may be
delayed if information provided with the request is
inadequate, resulting in care delays. Referral and
consultation requests without certain fields filled, such
as “specialty” or “reason for referral,” might be delayed.
Suggested Sources of Input
Clinicians, support staff, and/or
clinical
administration
EHR developer
Health IT support staff
Examples of Potentially Useful Practices/Scenarios
▪ Templates are used to facilitate completion of electronic
referrals and consults to meet specialists’ requirements.
▪ The EHR enables automatic pre-population of fields in
the referral template when possible (e.g., demographic
data, current medication list, recent relevant laboratory
test results).
1
▪ Referral template user interfaces should be designed to
minimize cognitive load on the provider making the
referral.
21
▪ Clinicians are prompted when certain key fields, such as
the “reason for referral” or “specialty” field, are left
blank.
17, 20
▪ Organizational policies and procedures facilitate the
creation of collaborative care agreements that define
both primary care (or referring) provider and specialist
physician expectations and accountability about referral
content, required information, and shared care. These
types of collaborative efforts between referring providers
and specialists that facilitate communication and clarify
referral expectations can reduce referral denials.
▪ Referral requests should include, at a minimum, the
Common Meaningful Use Data Set.
24
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
reset page
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SAFER
Self-Assessment
Clinician Communication
Recommended Practice 2.2
Worksheet
Domain 2 —
Using Health IT Safely
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Recommended Practice
2.2
The EHR facilitates accurate routing of clinician-to-clinician
messages and enables forwarding of messages to other
clinicians.
Checklist
Implementation Status
Rationale for Practice or Risk Assessment
Delays in patient care may result when important
information is inadvertently transmitted to an incorrect
recipient and cannot be redirected to the correct one.
Suggested Sources of Input
EHR developer
Health IT support staff
Examples of Potentially Useful Practices/Scenarios
▪ In the EHR, “To:” and “From:” fields are visible on the
message inbox and at the top of message content.
▪ The EHR supports forwarding of incorrectly routed
messages to other clinicians.
▪ Clinicians can forward messages they received incorrectly
to the correct recipients.
▪ Mechanisms exist for tracking acknowledgment and
acceptance of forwarded notifications.
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
reset page
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SAFER
Self-Assessment
Clinician Communication
Recommended Practice 2.3
Worksheet
Domain 2 —
Using Health IT Safely
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Recommended Practice
2.3
Clinicians are able to electronically access current patient and
clinician contact information (e.g., email address, telephone
and fax numbers) and identify clinicians currently involved in
a patient’s care.
25
Checklist
Implementation Status
Rationale for Practice or Risk Assessment
Patient care delays result from time spent searching for
correct clinician contact information, a patient’s treating
clinician, or a provider’s care team members. Care
delays may also result from incorrect message routing
based on inaccurate contact information.
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
EHR developer
Examples of Potentially Useful Practices/Scenarios
▪ The EHR system is updated at least monthly with a contact
list of all practicing clinicians, and, for hospitals, includes
clinician coverage schedules.
▪ A procedure exists for clinicians and staff to flag missing
and incorrect contact information for review by individuals
who can investigate and make corrections.
▪ The organization has a process for maintaining current
contact information for the EHR provider directory.
▪ The organization should maintain up-to-date patient care
team information within the EHR.
▪ The organization has a process for patients to review and
correct their contact information listed in the EHR, including
their preferred method of communication.
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
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Clinician Communication
Recommended Practice 2.4
Worksheet
Domain 2 —
Using Health IT Safely
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Recommended Practice
2.4
Electronic message systems include the capability to indicate
the urgency of messages.
Checklist
Implementation Status
Rationale for Practice or Risk Assessment
Communicating the urgency of a message, such as a
referral or consult, is necessary to facilitate triaging and
ensure timely follow-up.
Suggested Sources of Input
EHR developer
Examples of Potentially Useful Practices/Scenarios
▪ The EHR has functionality to allow clinicians to flag
referrals or consults as urgent when needed.
▪ High urgency messages are presented in a manner that
makes the urgency level immediately apparent to the
recipient.
▪ There are escalation processes for high priority or urgent
messages that are not responded to within the specified
time period, including an alternate communication
method.
▪ Specialists have immediate access to all their referral
and consult requests, and can triage patients and
schedule appointments based on urgency.
▪ Messages that are administrative in nature are clearly
differentiated from clinical alerts.
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
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Clinician Communication
Recommended Practice 2.5
Worksheet
Domain 2 —
Using Health IT Safely
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Recommended Practice
2.5
The EHR contains a copy of clinician-to-clinician communications.
Checklist
Implementation Status
Rationale for Practice or Risk Assessment
Clinicians may miss important information related to a
particular patient because it is hidden in secondary data
repositories or in paper-based record storage. Delays in
care may result when specialist recommendations (e.g., to
order further testing) are not received by the ordering
clinician.
Suggested Sources of Input
EHR developer
Examples of Potentially Useful Practices/Scenarios
▪ Written clinician-to-clinician communication that contains
any information about a patient's diagnosis, treatment, or
care is documented into or scanned into the EHR.
▪ If clinical messaging systems external to the EHR are used,
copies of patient-related messages are stored in the EHR.
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
reset page
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Clinician Communication
Recommended Practice 2.6
Worksheet
Domain 2 —
Using Health IT Safely
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Recommended Practice
2.6
The EHR displays time-sensitive and time-critical information
more prominently than less urgent information.
Checklist
Implementation Status
Rationale for Practice or Risk Assessment
Clinicians may miss urgent information when it is
commingled with other less urgent messages, resulting in
delayed care. A clinician may miss a small section of
relevant and important information within several pages of
a referral or consult note sent to him or her.
Suggested Sources of Input
EHR developer
Examples of Potentially Useful Practices/Scenarios
▪ Messages with critical or urgent information are made
visually distinct (e.g., visually highlighted).
▪ The EHR allows sorting of clinician-to-clinician messages
by urgency.
▪ When sending notes/documentation to other clinicians
(e.g., for co-signing), the EHR allows the sender to add
recipient-specific explanatory messages, highlighting, or
markup.
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
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Clinician Communication
Recommended Practice 2.7
Worksheet
Domain 2 —
Using Health IT Safely
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Recommended Practice
2.7
Both EHR design and organizational policy facilitate clear
identification of clinicians who are responsible for action or
follow-up in response to a message.
1
Checklist
Implementation Status
Rationale for Practice or Risk Assessment
On messages addressed to multiple recipients, each
recipient may incorrectly assume that the other recipient(s)
will take follow-up action, leading to no action being taken
at all.
Suggested Sources of Input
Clinicians, support staff, and/or
clinical
administration
EHR developer
Examples of Potentially Useful Practices/Scenarios
▪ The EHR supports the ability to assign and track actions
and responsible parties for inbound messages.
▪ Message screens display a “responsible clinician” indicator.
▪ The system supports forwarding and accepting
responsibility for follow-up.
▪ The EHR is able to capture and display when responsibility
for follow-up action is accepted by a clinician.
▪ A comprehensive policy outlining responsibility for follow-up
action for certain situations (e.g., no-shows) is
implemented.
17
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
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Recommended Practice 3.1
Worksheet
Domain 3 —
Monitoring Safety
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Recommended Practice
3.1
Mechanisms exist to monitor the timeliness of acknowledgment
and response to messages.
1, 26
Checklist
Implementation Status
Rationale for Practice or Risk Assessment
System problems related to delayed acknowledgment of
clinician-to-clinician messages may go unnoticed if
monitoring systems are not in place and checked regularly.
Suggested Sources of Input
Clinicians, support staff, and/or
clinical
administration
EHR developer
Health IT support staff
Examples of Potentially Useful Practices/Scenarios
▪ Referring clinicians, specialists, and/or leadership are
electronically notified when no action is taken on a referral
or consult request or a clinician-to-clinician message within
a set number of days (e.g., 14).
▪ The organization conducts several process measurements
related to important communication (e.g., completed
referrals, no-shows/missed appointments, denied or
canceled referrals).
▪ Referrals and consult response times are tracked by
organization leadership, and feedback is provided to each
service involved.
21, 27
▪ Messaging is periodically monitored to understand and
improve quality of communication.
▪ Policies and procedures are in place to prevent messages
from getting lost in the system, such as messages sent to
clinicians no longer employed by the organization.
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
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Safety Assurance Factors
for EHR Resilience
References
1. Esquivel, A., Sittig, D. F., Murphy, D. R., & Singh, H. (2012). Improving the effectiveness of electronic health record-based referral
processes. BMC Medical Informatics and Decision Making, 12(1), 107.
2. Gandhi, T. K., Sittig, D. F., Franklin, M., Sussman, A. J., Fairchild, D. G., & Bates, D. W. (2000). Communication breakdown in the
outpatient referral process. Journal of General Internal Medicine, 15(9), 626-631.
3. Saxena, K., Lung, B.R., Becker, J.R. (2011). Improving patient safety by modifying provider ordering behavior using alerts (CDSS) in
CPOE system. AMIA Annual Symposium Proceedings, 1207-1216.
4. McDonald, C. J. (1976). Protocol-based computer reminders, the quality of care and the non-perfectibility of man. New England
Journal of Medicine, 295(24), 1351-1355.
5. Murphy, D. R., Reis, B., Kadiyala, H., Hirani, K., Sittig, D. F., Khan, M. M., & Singh, H. (2012). Electronic health record–based
messages to primary care providers: valuable information or just noise? Archives of Internal Medicine, 172(3), 283-285.
6. Sittig, D. F., & Singh, H. (2009). Eight rights of safe electronic health record use. JAMA, 302(10), 1111-1113.
7. Chaudhry, B., Wang, J., Wu, S., Maglione, M., Mojica, W., Roth, E., ... & Shekelle, P. G. (2006). Systematic review: impact of health
information technology on quality, efficiency, and costs of medical care. Annals of Internal Medicine, 144(10), 742-752.
8. Saleem, J. J., Russ, A. L., Neddo, A., Blades, P. T., Doebbeling, B. N., & Foresman, B. H. (2011). Paper persistence, workarounds,
and communication breakdowns in computerized consultation management. International Journal of Medical Informatics, 80(7),
466-479.
9. Murphy, D. R., Reis, B., Sittig, D. F., & Singh, H. (2012). Notifications received by primary care practitioners in electronic health
records: a taxonomy and time analysis. The American Journal of Medicine, 125(2), 209-e1.
10. El-Kareh, R., Roy, C., Williams, D. H., & Poon, E. G. (2012). Impact of automated alerts on follow-up of post-discharge microbiology
results: a cluster randomized controlled trial. Journal of General Internal Medicine, 27(10), 1243-1250.
11. Sittig, D. F., & Singh, H. (2012).
Improving test result follow-up through electronic health records requires more than just an
alert. Journal of General Internal Medicine, 1-3.
12. Yackel, T. R., & Embi, P. J. (2010). Unintended errors with EHR-based result management: a case series. Journal of the American
Medical Informatics Association, 17(1), 104-107.
13. Meaningful Use Stage 2 criteria. (n.d.). Center for Medicare and Medicaid Services.
14. Singh, H., Spitzmueller, C., Petersen, N. J., Sawhney, M. K., & Sittig, D. F. (2013). Information overload and missed test results in
electronic health record–based settings. JAMA Internal Medicine, 173(8), 702-704.
15. Murphy, D. R., Meyer, A. N., Russo, E., Sittig, D. F., Wei, L., & Singh, H. (2016). The burden of inbox notifications in commercial
electronic health records. JAMA Internal Medicine, 176(4), 559-560.
16. Hysong, S. J., Esquivel, A., Sittig, D. F., Paul, L. A., Espadas, D., Singh, S., & Singh, H. (2011). Towards successful coordination of
electronic health record based-referrals: a qualitative analysis. Implementation Science, 6(1), 1.
17. Singh, H., Esquivel, A., Sittig, D. F., Murphy, D., Kadiyala, H., Schiesser, R., ... & Petersen, L. A. (2011). Follow-up actions on
electronic referral communication in a multispecialty outpatient setting. Journal of General Internal Medicine, 26(1), 64-69.
18. Walsh, C., Siegler, E. L., Cheston, E., O'Donnell, H., Collins, S., Stein, D., ... & Stetson, P. D. (2013). Provider-to-provider electronic
communication in the era of meaningful use: a review of the evidence. Journal of Hospital Medicine, 8(10), 589-597.
19. Keely, E., Liddy, C., & Afkham, A. (2013). Utilization, benefits, and impact of an e-consultation service across diverse specialties and
primary care providers. Telemedicine and e-Health, 19(10), 733-738.
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Safety Assurance Factors
for EHR Resilience
References
20. Gandhi, T. K., Keating, N. L., Ditmore, M., Kiernan, D., Johnson, R., Burdick, E., & Hamann, C. (2008). Improving referral
communication using a referral tool within an electronic medical record. Advances in Patient Safety: New Directions and Alternative
Approaches.
21. Barnett, M. L., Mehrotra, A., Frolkis, J. P., Spinks, M., Steiger, C., Hehir, B., ... & Singh, H. (2016). Implementation science
workshop: implementation of an electronic referral system in a large academic medical center. Journal of General Internal Medicine,
31(3), 343-352.
22. Sittig, D. F., Gandhi, T. K., Franklin, M., Turetsky, M., Sussman, A. J., Fairchild, D. G., ... & Teich, J. M. (1999). A computer-based
outpatient clinical referral system. International Journal of Medical Informatics, 55(2), 149-158.
23. Chen, A. H., Murphy, E. J., & Yee Jr, H. F. (2013). eReferral—a new model for integrated care. New England Journal of Medicine,
368(26), 2450-2453.
24. Meaningful Use Common Data Set. (n.d.). The Office of the National Coordinator for Health Information Technology (ONC).
25. Hiltz, F. L., & Teich, J. M. (1994). Coverage list: a provider-patient database supporting advanced hospital information services.
Proceedings of the Annual Symposium on Computer Application in Medical Care (p. 809). American Medical Informatics Association.
26. 2014 Clinical Quality Measures (CQMs): adult recommended core measures. (2012). Centers for Medicare and Medicaid
Services.(Pamphlet)
27. Hoffman, J. (2012). Managing Risk in the Referral Lifecycle. CRICO.
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