Opportunity for Improvement

Downtime.

It's not if, it's when..

Downtime is a period where the Information System is not available. Downtime, whether scheduled or unscheduled is a reality for every organization using an electronic health record (EHR). Hospitals across the country have experienced sustained periods of EHR downtime in 2019, with some taking days to resolve and other systems being brought back online within a few hours. According to Walsh, Borychi & Kushniruk (2019) in the last three years 70% of organizations who reported experiencing unplanned down time indicated they had at least one downtime that lasted longer than eight hours. It's critical to note that most downtime planning does not consider an all system shut down. Most organizations plan for a read only mode of the EHR. However, in a cyber attack the entire system would need to be unavailable during repair time. Downtime is frustrating for clinicians as they lag of workflow is apparent and it can be difficult to navigate a system with poor planning and communication. Patients and their families expect we deliver the same quality of care regardless of technology variances. 

The daughter of a septic patient admitted to a hospital is Arizona experienced a three day downtime unexpectedly occurred reported serious concerns with the care her father received during this period. According to this family they were not notified of the incident, but noted clinicians were unable to administer anti-emetics for six hours and that antibiotics were skipped and some tests were not administered for several hours (EHR Intelligence, 2019). Clinicians at the bedside struggle to revert to downtime procedures especially considering some clinicians have only practiced in technology rich environments and don't have knowledge or training to effectively navigate paper documentation and ordering. Moreover clinicians are relying on technology to deliver safety in their cares such as alerts for drug dosing, interactions and other prompts for safety. It's critical to review the resources available to guide safe care in downtime. According to my own search and that of several authors literature in acute hospital settings is in it's infancy (Walsh, Borychi & Kushniruk, 2019). Particularly a gap exists in training and preparedness for downtime for clinicians and hospital systems (Walsh, Borychi & Kushniruk, 2019). The entity SAFER (Safety Assurance Factors for EHR Resilience) publishes a contingency planning guide which makes thirteen recommendations and for each domain a planning worksheet helps guide stake holders to plan and lead operations (SAFER, 2016). 

Communication is Key

Organizations should spend time planning with executives and key stake holders how downtime will systematically be handled. Downtime procedures should be formal, documented plans that are reviewed for relevance periodically.

• Standard communication to clinicians whether it be overhead announced or sent via email shall occur during downtime
• Department managers should be advised in advance or as soon as possible and implement staffing variances to support the process and ensure patient safety
• Rounding by IT team members and executives shall occur during the period to facilitate any issues resulting from down time and ensure patient safety and resources are optimized
• A command center or central call station shall be in place for end users to communicate necessary information or issues occurring
• After the incident a debriefing period should be available. The purpose is to review procedures and informal workflows occurring so that improvement suggestions can be facilitated and changes take place.

Training for Downtime

Health systems should implement training for downtime during on boarding. Effective paper documentation should mirror the electronic flow sheets to minimize confusion. New nurses should simulate hand written physician orders in order to ensure they can effectively interpret, clarify and recognize a complete order. They must also learn to transcribe orders. Departments should be prepared with symmetry in the organization with clearly accessible "black boxes" that include kits for managing downtime. These should include lab ordering forms, Medication Administration Records, Ordering Forms, Nursing flow sheets, and Provider progress note form. A clearly laminated process map should guide the user on what to print from the read only application. Also on this guide should be the expectations of what to do after downtime which may include Medication administration and relevant assessment points be entered to the EHR. This will allow more senior nurses to trouble shoot problems and ensure care is meeting the standard.

Downtime Drills

Consider downtime drills to increase preparedness and evaluate systems before the events occur and to keep users familiar with practices required.

Just in Time Education

Consider readily available videos of education that can successfully guide the end user on how to navigate down time effectively and efficiently. The concept would include a QR code link visible at the start of downtime which links to a flight attentantesce video introducing the downtime, recognizing inherent frustrations, but calming clinicians by describing the plans for downtime and how to proceed. This video link would likely be available to personal smart phones and would add the element of reassured direction in an otherwise usually chaotic environment. 

Improve Outcomes

Studies on safety of patient during down time are limited by design. Single center reviews can be confounded by various levels of organizational preparedness and experience in downtime which make translating to each center difficult. Further, the SAFER (Safety Assurance Factors for EHR Resilience) are not comprehensive in recommendations for downtime and not tested against regulatory requirements. While no study was identified to increase mortality during downtime it was clear that downtime is "disruptive" and "chaotic" (Harrison, Siwani, Pickering & Herasevich, 2019). This research also demonstrated that intraoperative time and surgical recovery is lengthened when downtime of >60 minutes occurs for surgical patients and their providers (Harrison, Siwani, Pickering & Herasevich, 2019). 

Healthcare today is dependent on technology. The risk for error and harm is clear to clinicians though the mechanisms by which to prevent this when technology is down is limited. Questions of how disruption in technology will influence workflow and patient outcomes is unclear, but important to identify in future studies. 

Will downtime always be so limiting?

 

Theoretical Technology Based Solution

Back documentation causes frustration and increased labor requirement and while is it currently the solution to most organizations downtime there may be advanced technology capabilities in our future. A proposed solution is the availability of cloud based dictation notes. The cloud is becoming the infrastructure for most electronic health systems due to being highly capable, cost effective and secure in terms of data privacy (Deshmukh, 2017). Dictation capability could serve as an alternative workflow to ensure efficiency of technology driven healthcare is maintained during downtime. Companies like "enotes" provide programs to allow dictation to continue during downtime and when systems are restored the notes integrate into the EHR. Currently EPIC is developing a dictation application for nursing that uses voice-driven assistant with artificial intelligence that could record the statement of "blood pressure is 120 over 80 directly into a flowsheet." A cloud based version of this could be developed to store information until systems are restored thus reserving the need for paper documentation for downtime in catastrophic situations whereby internet and all computers are unavailable. Cloud based dictation has the ability to limit the interruption in the pace during downtime for providers, nurses and therapists. 

Reference

Conn, J. (2015). Nurses Turn to Speech-Recognition Software to Speed Documentation. Modern HealthCare. Retrieved from https://www.modernhealthcare.com/article/20151212/MAGAZINE/312129980/nurses-turn-to-speech-recognition-software-to-speed-documentation

Deshmukh, P. (2017). Design of cloud security in the EHR for Indian healthcare services. Journal of King Saud University - Computer and Information Sciences, 29(3), 281-287.

Harrison, A., Siwani, R., Pickering, B., & Herasevich, V. (2019). Clinical impact of intraoperative electronic health record downtime on surgical patients. Journal of the American Medical Informatics Association : JAMIA, 26(10), 928-933.

Safe Assurance Factors for EHR Resilience (SAFER). (2016). Contingency Planning Self Assessment. Retrieved from https://www.healthit.gov/sites/default/files/safer/guides/safer_contingency_planning.pdf

Walsh, J., Borycki, E., & Kushniruk, A. (2019). Strategies in Electronic Medical Record Downtime Planning: A Scoping Study. Studies in Health Technology and Informatics, 257, 449-454.