Posted on Sept. 22, 2008

Ah, downtime. Outside the world of technology, it has a peaceful and pleasant ring to it: "I have some downtime later today, so let's meet for coffee." Or, "I can't wait until vacation next week when I finally have some downtime." It conjures images of children taking naps, women getting pedicures and men in recliners watching Sports Center.

But in the HIT environment, just hearing the word "downtime" can make an HIM director, coder, nurse manager, office administrator or CIO cringe. When the downtime is associated with a mission-critical, far-reaching system such as electronic medical records (EMRs) or document imaging, the cringe can quickly upgrade to panic. Even planned downtime can be very disruptive, impacting both clinical and operational effectiveness. A study conducted by the Journal of the American Board of Family Practice, "Impact of an Electronic Medical Record System," (http://www.medscape.com/) revealed that downtime was overwhelmingly the greatest concern related to EMR implementation.

Clearly, having rigorous downtime policies to accompany an EMR, particularly in the hybrid phase, is a must. This month, our panelists will be discussing how they changed and strengthened downtime policies and procedures to accommodate the hybrid environment and prepare for complete e-enablement.

BRANDWEIN: It's no secret that hospitals implementing EMR must have stringent downtime policies and procedures. What have you done to strengthen yours?

Glennda Gore, RHIA, vice president, corporate compliance and risk management; former HIM director, McAlester Regional Health Center, McAlester, OK:  We conduct more frequent system testing on a regular, scheduled basis. Aside from that, we've stuck to the core policies that govern all HIT systems. These downtime policies have been in place since 1999. Our philosophy is that having consistent policies for every system will help with compliance and adherence organization-wide; everyone is on the same page.

BRANDWEIN: What are some policies or procedures you've implemented that colleagues in other hospitals may want to consider?

GORE: Our chart check-out system, much like you'd see in a library, has been a real life-saver. It helps HIM staff know where charts are located at all times, including downtime. We issue each medical record a number, which gives us a permanent reference and indexing system that can work even during downtime. This manual system is stored in the same place (a wall next to a file cabinet) in the HIM department; that way, if a nurse is looking for charts with only a flashlight, he or she will know exactly where to find it.

The only challenge with our manual system has been enforcing it during after-hours downtime--which fortunately isn't very often. When this happens, we must rely upon the nurses to write down each record's assigned chart number in order for our numbering system to remain intact.

BRANDWEIN: Are any of your new policies and procedures particularly "out of the box"?

Beth Kost-Woodrow, RHIA, assistant vice president and chief privacy officer, WellStar Health System, Atlanta, GA: One of our managers took a very brave step: Almost immediately after we went live with Horizon Patient Folder, she implemented a policy that stated, "If the system goes down, staff goes home." It's patterned after nursing staffing, which correlates staffing with patient volumes. With this model, if nurses aren't needed based on the current patient load, they clock out. Similarly, if our EMR is down, then the scanners, indexers and analysts take paid time off.

BRANDWEIN: That's a pretty radical change for the HIM department. How did they adjust?

KOST: Most of our downtime has been planned, which has definitely helped employees adjust to the policy. In these cases, the staff knows they'll be asked to take time off and can plan accordingly. Regarding the department's overall reaction to the policy, it's like many other changes resulting from the EMR. It's new and it's different, but we recognize it as part of a large, strategic change that we've committed to making. Initially, not all changes are comfortable or easy, but we know they're for the best.

I haven't seen many other hospitals adapting staffing models like this one, but I'd strongly encourage at least evaluating whether it's right for your facility. By its very nature, the EMR brings about major organizational changes. This makes it a great time to examine the status quo and whether new processes make financial or operational sense.

BRANDWEIN: On that note, were any new policies and procedures particularly challenging to implement or enforce?

KOST: Along with the concept of taking PTO (paid time off) when the system is down, we also had to sell the concept of being flexible about reporting to work. If the system downtime is going into another shift, our managers call and ask staff not to come in. Yes, this can be inconvenient and a little frustrating. We did have a few employees resign. Our employee retention overall, however, is very strong. The moral of this story is that people will adapt to new policies if they are logical, well-explained and communicated in advance. 

BRANDWEIN: Are there any other "lessons learned" relating to downtime policies and procedures that you'd like to share with your colleagues?

GORE: I've noted that certain procedures have evolved as we've gained a greater understanding of our EMR. The longer our EMR has been live, the more we know about it--including how it impacts our workflow and the ability for staff to perform certain responsibilities. For instance, we originally thought that if the system was down, so was our workflow--and we couldn't do coding. However, we found another way to access the system, which has enabled coders to work uninterrupted during downtime. There's a "lesson learned" here: If you're vigilant and inventive post-implementation, you can continuously find ways to maximize your investment and improve your workflow.

Having solid policies and procedures to address system downtime--and, of course, avoiding it altogether when possible--has been a strategic initiative for hospitals since the inception of HIT. As organizations move closer to complete e-enablement, however, it takes center stage. Careful preparation, as well as ongoing evaluation, can make all the difference.

Next month, we'll be exploring the evolving relationship between HIM and IT--a topic of much discussion and scrutiny. Stay tuned, and may your downtime be planned, well-managed and short and sweet!

 Aaron Brandwein s divisional vice president for HealthPort, formerly SDS. He is responsible for HealthPort's EDMS technology division and currently serves on the AHIMA Exhibit Advisory Committee and has spoken at numerous AHIMA national and state conferences on the topic of electronic and hybrid records.