Clinician Communication

Download Guide *

Download the PDF guide to access the checklist of recommended practices for self assessment and a supporting worksheet to identify action steps to achieve those recommended practices.

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.1-6 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 vs. 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), and even more importantly, 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.

*Persons using assistive technology may not be able to fully access information in this file. For assistance, contact ONC at onc.request@hhs.gov.

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