• Patient safety
• Healthcare quality improvement
• Quality improvement

For decades we have looked hopefully to electronic health records (EHRs) to aid efforts to make healthcare safer.1 Early research gave basis to this hope: automated alerts and reminders were shown to improve preventive and chronic illness care,2 electronic records could be better organised and more easily delivered where needed,3 automated computerised decision support (CDS) can help make diagnoses4 and plan treatments,5 and computerised practitioner order entry (CPOE) was shown to reduce risk for serious adverse drug events.6

Since 2009, the USA has joined other countries in broadly adopting EHRs.7 ,8 Through the meaningful use programme, and other efforts, use of CPOE has also grown tremendously. This transition has not been easy and has uncovered weaknesses in EHRs, including problems with usability,9 interruption of workflow,10 and concerns for altered interaction with patients.11 We are discovering that the transition from paper to electronic records is a long, difficult journey that is far from complete. There is an enormous need for improvements in EHRs, and efforts to do so are reinvigorated by evidence that we have made not made as much progress in patient safety in the last decade as we had hoped.12

The difficult question is how to make these improvements. In part, the answer is that we get better …