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January/February 2020

Down but Not Out
By Keith Loria
For The Record
Vol. 32 No. 1 P. 18

When the EHR is unavailable, instead of scrambling for a solution, health care organizations should have a tried and tested plan ready to go.

If an EHR goes down, there’s no waiting around for the problem to be solved. Although severely impacted, patient care continues unabated. There’s no other option. That’s why there needs to be a dedicated plan in place detailing everyone’s role during the crisis.

“The first battle is really making sure it doesn’t go down, and that’s the job of the IT service team to minimize the loss of service,” says Thomas Payne, MD, FACP, medical director of IT services for the University of Washington School of Medicine. “Inevitably, it will go down—maybe a storm came up and the power went out, or the network was disrupted—so you need to have a plan.”

Robyn Stambaugh, MS, RHIA, director of HIM practice excellence at AHIMA, says organizations must have a contingency plan in place, a requirement of the HIPAA Security Rule. “Natural disasters happen all the time, you could have system failure, and certainly cyberattacks, and then the plan really ought to be customized to address the specifics of an event,” she says. “Organizations really need to recognize that [a contingency plan] is not a stagnant document. You’re not going to create it and then touch it only when needed because [organizations] tend to get into a lot of problems if that’s the way the contingency plan is viewed.”

That means regular review, updating continuously, and identifying gaps through drills is vital to success. “If you go into downtime, you’re going to have paper-based records, and that throws everybody for a loop because you’re so accustomed to electronic and some people have never lived in that world,” Stambaugh says. “It’s another reason for drills, so everyone understands the process.”

What the plan entails will vary depending on whether it’s an operating room, a free-standing surgery center, a family medicine clinic, or some other health care setting. Regardless, there needs to be a method to carry on business.

“For example, dictation is one way to do this. It’s usually separate from infrastructure, so it may be possible to call a phone number and create your note that way,” Payne says. “If that’s not possible, people will have to go back to simple pen and paper and document brief notes—enough so the recollection of key information is aided when it comes time to make the final note.”

Health care organizations must adhere to various rules and regulations. For example, orders for scheduled substances have to be on tamper-proof paper.

Michael A. Cook, vice president of sales and national accounts at Carstens, says the best organizations are well prepared in the event they’re unable to access their EHR. “The most important thing is to make sure your facility has a paper back-up system that’s stocked, organized, and ready to go at a moment’s notice so there’s no lag time or confusion when EHR downtime occurs,” he says. “This can be as simple as always having a mobile chart rack at the ready, stocked with charts that are prefilled with dividers, forms, and any other key materials for your facility. This is something that could be easily stored away when not in use and wheeled out when necessary.”

Consistency, in this case, is vital. Cook suggests creating a templated paper charting system so everyone is working with the same materials organized in the same way, which will make it easier to train clinicians on the system and enable quicker and more efficient data entry when the EHR system is restored.

Clarity is also necessary. Cook notes that having clear and specific guidelines for when a backup system is to be implemented (eg, after the EHR has been down for 30 minutes) so there’s no guesswork on the part of clinicians eliminates a lot of the unknown about how to proceed.

“Since staff is often in flux and regular training isn’t always possible, it’s a good idea for each paper chart to include instructions for your facility’s paper documentation,” he says. “Many younger physicians have little or no experience with paper charting, so having answers and instructions in-hand is a great benefit.”

Andy Gettinger, MD, chief clinical officer for the Office of the National Coordinator for Health Information Technology, says when entities transition from paper to electronic systems, part of the process must involve thinking ahead to when an EHR might not be available.

“We have lots of people who have never experienced anything but electronic systems, but you need to have these contingencies in place,” he says. “You have to anticipate that this will happen at some point and be sure to have whatever paper or forms you need to document properly.”

Gettinger recommends organizations conduct EHR downtime rehearsals to allow staff to experience the situation in a pseudo-live setting. Some facilities couple EHR downtime drills with disaster preparedness, he notes.

Practice Makes Perfect
Colin Zick, cochair of health care practice and chair of data privacy and security practice at the Boston-based law firm Foley Hoag, says organizations should assume their EHR will go down at some point, necessitating a plan be in place. Quick, precise detection and an appropriate communication plan can reduce the effects of system downtime, he says, adding that practice runs are a must.

“The unavailability recovery plan should be tested from time to time using scheduled mock drills,” he says. “A drill usually will not affect active operations; however, if it is known that operations will be affected, the drill should be carefully scheduled such that the effect is minimal and is done during a permissible window. These activities should be regarded similarly to regular equipment maintenance activities that require operations downtime. The experience of the mock drill should be updated into the unavailability recovery plan document.”

Having a plan is one thing, but having all members of the staff be able to carry it out is something different. That’s why it’s important that a plan is drilled and put into practice, so there’s no frenzy or confusion if something does eventually occur.

“The practicing should not be limited to those on the night shift because these events occur any time in the 24-hour period, and when circumstances occur, everyone should know what to do. This is standard practice in most organizations, but reviewing it is very important,” Payne says, adding that any review of the downtime procedures should be conducted as a team.

Stambaugh says staff must be prepared to manually assemble discharge records into paper folders, conduct analysis, and organize any deficiencies by provider. Additionally, coders will need access to the paper records and be trained to enter data into the abstracting system when it’s online.

“They’re going to have a backlog. You have to think not only about what’s happening now but [also about] when your system comes back up online,” Stambaugh says. “You have to think about how that’s going to impact productivity overall, and you’re going to have to do a lot of prioritization. You’re going to be looking at overtime, so having a good plan in place is important.”

Assign Leaders
In some cases, an EHR is down for such a brief period of time that it’s not worth activating the plan, Payne notes. Therefore, it’s vital to have staff leaders assigned who can make such decisions. From there, communication can travel over the proper channels.

“Assign specific people from each department to function as communication leads throughout the process,” Cook says. “Of course, everyone should be communicating with each other, but having specific individuals who will spearhead the dissemination of information and be the go-tos for status updates will help minimize any miscommunication.”

Consider forming a committee or using an existing one that will be responsible for launching the activation phase, Zick says. The committee should be well informed about the geographical, political, social, and environmental events that may pose threats to the EHR’s operations.

“It should have trusted information sources in the different agencies to forestall false alarms or overreactions,” Zick says. “The activation phase involves notification procedures, impact assessment, and recovery activation planning.”

Dangers of Being Unprepared
Organizations ill prepared for EHR downtime scenarios face the strong possibility of documentation and process errors. These can often result in inaccurate or incorrect prescriptions, missed treatments, and, in the worst cases, patient harm.

“If clinicians are spending a lot of time compiling paper charting materials or working through the confusion of an EHR downtime, they’re missing out on vital time to be spending with patients,” Cook says. “It ultimately decreases the quality of care you’re able to provide.”

For example, consider this scenario: A medication order is submitted, but, seconds later, the system goes down. Did anyone see the order? Was the medication given?

“The documentation isn’t available, and that leads to confusion and could lead to big problems,” Payne says. “There is the risk of omission or commission, whereby you might give it twice or you might not give it at all. Keep in mind that in a big organization, we may be giving 10,000 orders a day, and the odds of getting it perfect are not 100%.”

In addition to patient safety concerns, Stambaugh says downtime can affect privacy and security, compliance, and an organization’s overall financial picture.

Cook adds that some EHR vendors may sell a false sense of security, creating an overconfidence in digital back-up solutions. It can take a great deal of time to access these systems, rendering the technology virtually useless in a medical emergency and leaving facilities in a bind when downtime strikes hard.

Furthermore, the variance in the back-up systems designed for EHR downtime can create unnecessary confusion and further dependency on digital software that is still potentially susceptible to natural disasters, network maintenance, and hacking downtime events.

“The vulnerability of the facility’s clinical staff and patients in all of these situations of downtime directly correlates to increases in medical errors and legal liability,” Cook says. “It seems each facility comes up with their own workarounds to troubleshoot the issues that arise but many lack a standardized process and procedure to maintain quality patient care without confusion and disruption.”

Preparation should extend to having a plan in place for when the EHR eventually does return online. “You need to have a plan as to who documents what was provided on paper,” Gettinger says. “You can go back and transcribe it all and throw away the paper, or maybe scan the paper in. I have seen institutions do it both ways.”

How Often Does It Happen?
According to a recent survey of 50 health care institutions conducted by the International Journal of Medical Informatics, 96% had at least one unplanned EHR downtime in the past three years. Additionally, 70% reported at least one downtime of more than eight hours.

Based on these findings, it seems clear that EHR downtime is a common occurrence.

“The most challenging thing about unplanned EHR downtimes is that they’re just that—unplanned,” Cook says. “Some of the main causes are natural disasters, power outages, software/hardware/network failures, and, most alarmingly, cyberattacks. While natural disasters typically come with forewarning, the other causes can spring on a facility at any moment. That’s why being prepared and trained for EHR downtime is so vital.”

Payne says that while the outlook is improving, it’s not a perfect system. There are numerous factors beyond the control of health care organizations that can thwart even the best of intentions and the best-laid plans. Still, a sharp focus on preparedness is essential.

“What [success] should not depend on is awareness in preparation and planning—that should be the same for every location of care,” Payne says. “Everyone should plan for this and keep in mind that system availability is job No. 1 for the IT groups. But as a trend, over the last 20 years, this is happening much less than it used to.”

— Keith Loria is a freelance writer based in West Virginia.