The recent passage of the American Recovery and Reinvestment Act of 2009 stimulus package is putting tremendous pressure on physicians in small practices and larger healthcare organizations to implement state-of-the-art electronic health record (EHR) systems within the next 5 years. Incentive payments, beginning as early as 2011, will be allocated to healthcare facilities that meet the “meaningful use” EHR certification criteria, released by the CMS at the end of 2009. Currently, fewer than 20% of hospitals and less than 10% of physicians in private practice meet these criteria.

Ideally, implementation of EHR systems should result in lower costs, less duplication, and greater quality of patient care. Hardeep Singh, MD, MPH, and I developed eight essential recommendations to ensure that EHRs are used safely and effectively. Published as a commentary in the September 9, 2009 JAMA, the “eight rights” were based on a systems engineering model for patient safety to realize the full potential of EHRs. These rights include:

1. Hardware or Software. The EHR system must have proper hardware and software to function correctly and ensure efficient workflow.
2. Content. Standardized terms used to describe clinical findings are necessary to ensure that information is shared effectively.
3. User Interface. User interface should allow clinicians to efficiently grasp a complex system in a way they can rapidly recognize and respond to problems.
4. Personnel. Trained and knowledgeable software designers, developers, trainers, and implementation and maintenance staff are essential for EHRs to work safely.
5. Workflow and Communication. Prior to system implementation, there should be careful workflow analyses and testing that account for EHR use.
6. Organizational Characteristics. Continual improvement relies on an ongoing surveillance system to report errors and identify obstacles to appropriate care.
7. State and Federal Rules and Regulations. Policies must address the safety and effectiveness of health information exchange across organizational boundaries.
8. Monitoring. Ongoing monitoring and oversight after implementation are critical to the success of the EHR system.

Ensuring the Basics               

Foremost, a back-up system must be in place to restore all information if necessary before EHR implementation. The consequences of not having back-up systems could be devastating and result in complete loss of patients’ medical records. Because it’s common for computers to have functional problems, physicians should also understand the procedures that occur if EHRs or servers break down. A process should also be established to allow physicians to continue to see patients during times when computers are unavailable.

Proper user interfaces that are well configured will also reduce the risk of inadvertent errors. The physical aspects of interfaces (eg, keyboards, the mouse, or touch screens) can contribute to errors during input or selection. For example, patients or medications listed along side each other can lead to a “juxtaposition error” if physicians unintentionally select the wrong option.

Systems that don’t fit physicians’ workflows can slow down a practice, making it cumbersome to see patients, document appointments, and hand out prescriptions and patient education material in a timely manner. While EHR systems are intended to improve safety, quality, and efficiency of healthcare, they can also hinder these goals if they’re not implemented correctly and with caution.


Sittig DF, Singh H. Eight rights of safe electronic health record use. JAMA. 2009;302:1111-1113. Available at:

Sittig DF, Ash JS. Clinical information systems: overcoming adverse consequences. Sudbury, MA: Jones and Bartlett. 2010.

Yackel TR, Embi PJ. Unintended errors with EHR-based result management: a case series. J Am Med Inform Assoc. 2010;17:104-107.

Klein K. So much to do, so little time. To accomplish the mandatory initiatives of ARRA, healthcare organizations will require significant and thoughtful planning, prioritization and execution. J Healthc Inf Manag. 2010;2:31-35.

Boyd AD, Funk EA, Schwartz SM, et al. Top EHR challenges in light of the stimulus. Enabling effective interdisciplinary, intradisciplinary, and cross-setting communication. J Healthc Inf Manag. 2010;24:18-24.