Electronic Health Records downtime
After the implementation of any information system, contingency strategies and action policies should be in place to mitigate the negative effect of a downtime on the workflow process. Same concept applies to Electronic Health Records (EHR). There are two types of downtime: scheduled and unscheduled. The unscheduled is the one that is mostly dreaded, since there are scheduled operational plans and staff readiness already in place in the case of a scheduled downtime. A recent survey of 50 health care institutions found that 96% of them reported at least one unplanned downtime (1). According to a study analyzing 76 reports related to patient safety during EHR downtime, 46% of reports indicated that downtime procedures either were not followed or were not in place(2). The magnitude of such an event could be of dire consequences such that one hospital had to shut down its ED services(3).
Plan of Action
To reduce the risk and negative impact of an unscheduled failure, the disaster recovery/business continuity DR/BR strategy should be as close as possible to the strategy of a planned interruption with always a margin for flexibility and adaptation to the new situation. The following procedures should be in place:
1. Paper templates should be available for documentation and ordering medications. Paper records should be placed in secure locations in compliance with HIPPA regulations.
2. A backup server, in the background and during uptime, should be saving all copies of medical records so it could be possible to access patients’ data in a read-only mode during downtime. This backup server should be independent of the EHR’s, so that it remains accessible in downtime.
3. For urgent medications administrations, since the pharmacy information system would not interface with the offline EHR, pharmacists and registered nurses should have procedures in place to handle paper orders in an efficient way. Pharmacists should keep a copy of the paper orders, so that they could update the electronic Medication Administration Record (eMAR) when the EHR functionality is restored.
4. Same thing should apply for radiology orders, where the ability to fax paper orders for imaging tests that could be carried out without major delays especially for urgent tests that could make a difference in patient’s outcome. Routine tests should be deferred so as not to slow down the radiology staff and divert limited resources. Those papers orders should also be saved so that updates to EHR could made later on.
5. Operating rooms schedule and workflow should remain as downtime proof as possible, especially for accommodating emergent surgery cases. A spreadsheet should be maintained and managed at all times, even during uptime, and should remain accessible (independent of the EHR) during downtime. The ADT system should also be independent of the EHR or at least operate in a safe mode independent of HER, so that patient’s registration and admissions are not delayed.
6. Communications between providers should be maintained. If physicians and providers already use HIPPA compliant platforms for communications that would be impacted by a system failure, there should be a physician’s roster with the offices’ phone and providers’ cell numbers. Also an updated hardcopy of the on-call providers should be available at all times even during uptime, so that consultations especially urgent ones could be carried out in an uninterrupted way and with minimal delay.
7. It is crucial that, during downtime, communications between the administration and management on one side and the clinical staff on the other be maintained and updates are delivered frequently to the providers, nurses, therapists and technicians regarding the current status and expected return to normalcy.
Unplanned EHR downtime should be dealt with as a probable event with potentially major negative consequences and therefore institutions have to create contingency planning; and probably run downtime simulation (4) so that the staff could learn to efficiently operate without EHR for a period of time; that would boost the readiness and preparedness for a real downtime situation.
1. Cain MV. When not if: How to prepare for EHR downtime. AAP News [Internet]. 2018 Oct 3 [cited 2018 Oct 17]; Available from: http://www.aappublications.org/news/2017/11/08/HIT110817
2. Larsen E, Fong A, Wernz C, Ratwani RM. Implications of electronic health record downtime: an analysis of patient safety event reports. J Am Med Inform Assoc JAMIA. 2018 Feb 1;25(2):187–91.
3. EHR outage forces hospital to shut down its ED [Internet]. [cited 2018 Oct 16]. Available from: http://www.advisory.com/daily-briefing/2015/03/09/ehr-outage-force-hospital-to-shut-down-its-ed
4. EHRIntelligence. How to Optimize EHR Downtime Preparedness, Reduce Slowdowns [Internet]. EHRIntelligence. 2018 [cited 2018 Oct 18]. Available from: https://ehrintelligence.com/news/how-to-optimize-ehr-downtime-preparedness-reduce-slowdowns
Submitted by Rabih Atallah '