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It sounds foolish: planning for something you hope never occurs. But in the world of health care, few are willing to throw the proverbial dice. So plan--and spend--they do.
But how much is a different story. Large hospitals have the budget to contract disaster recovery/business continuity solutions--and the caseload to justify such precautionary spending. Smaller facilities have fewer funds, but still run the risk of electronic health record (EHR) downtime, especially those in areas prone to severe weather or poor telecommunications. Fortunately, there's a range of business continuity options, so facilities can find a fit for most needs.
Paper Primer
The most basic downtime procedures involve an old stand-by: paper. When HIM departments go electronic, they're often eager to toss paper forms. But hold on to that processed pulp, document storage experts and downtime survivors advised. Paper can play a crucial role in the event of an unexpected system failure, allowing documentation and caregiving to continue. "With computers, no matter how hard you try, an outage is still not 100 percent preventable," said Scot Silverstein, MD, a medical informatics consultant and adjunct professor of health care informatics and IT at the College of Information Science and Technology, Drexel University, Philadelphia, so keeping paper on hand is "a no-brainer."
Hard copies for orders, progress notes and registration should be in stock and easily accessible, and both clinical and HIM staff should know where to find what they need.
More importantly, they should know how to use them. When Fletcher Allen Health Care's EHR system went down abruptly, some new staff members had no clue how to handwrite an order. The teaching hospital had gone electronic a few months earlier, and the most recent round of residents hadn't been trained on paper. "A few of them looked at the nursing staff and said, 'I don't know how to do that,'" recalled Sandra Dalton, RN, chief nursing officer at Fletcher Allen.
Now, the hospital plans to use scheduled downtime as a chance to review paper protocols.
Executives at Concord (NH) Hospital learned a similar lesson last June, when its systems went down following a storage upgrade. Some nurses were not familiar with manual documentation practices and were at a loss without the EHR. Since then, the CEO has vowed to implement training and procedures for paper-based response.
Call for Back-up
If an EHR goes down, facilities will most likely wind up using paper. But whether they're working in the dark or with full patient records depends on their back-up. Document management companies take the burden of scanning off facilities and their servers, and in an emergency situation, give providers access to valuable records. "We do become a defacto offsite back-up for a lot of facilities," said John King, chief operating officer, EvriChart, White Sulphur Springs, WV.
If a hospital's EHR software goes down, a point-person can request imaged records from the document management vendor, which can be sent instantly through its Client Portal, which is distinct from (but interfaces with) the facility's EHR. That way, clinicians would have foundational information needed for patient care. There are even plans in the works to back up the whole record, including point-and-click data, instead of just paper-based documents.
According to Christine Rys, RHIA, HIM consultant, Cardone Record Services and Midwest Medical Records Association, one of her client hospitals scanned entire paper records for legal purposes and wound up using those scanned images to keep registration, the master patient index and documentation on track when its EHR went down. But even with that back-up system in place, the facility prepared for an entire outage. "They had a plan B [in case] their network or infrastructure went down. Then that would be a totally manual process," she said. "So they had an A, B and C plan."
Having read-only access to records can be helpful in an emergency, Dr. Silverstein agreed, but the preventive measure might not seem worth the pricetag, especially at low risk and low budget organizations. "You don't want to have physicians working in the dark," he said. "On the other hand, the cost of having that capability might be excessive."
Ditch the Load
For some, downtime is best avoided by washing their hands of software altogether. Cloud computing is gaining clout as a way facilities can have an EHR without the IT headaches, but it's a decision that needs to be made from the outset.
Fort Lauderdale, FL, office manager Jose Hernandez chose a Web-based program for his latest EHR implementation. Two months in, the system has yet to falter. "I've worked at other practices that used server-based systems and experienced downtime at least once a week," Hernandez recalled.
Cloud-based EHRs put the technology burden on the vendor, so providers can skirt the need for IT staff and the costs that go along with it. It's especially helpful for small practices, which can't afford to spend thousands of dollars on traditional software, Hernandez added.
When information's held in clouds, providers are shielded from many of the quirks that affect local systems, including hardware failure and system crashes, according to Ryan Howard, CEO of Practice Fusion, a Web-based EHR vendor. "With cloud computing, you can go to any computer with an Internet connection and log in to the system immediately," he explained. "We had a practice whose office burned down; they were up and charting the next day from a hotel room."
But that still leaves providers at the mercy of their Internet connection. Systems often have redundant or back-up connections, even reverting to prepaid wireless cards in the event of a failure, according to Howard. If a computer or modem goes kaput, however, staff could have a hard time accessing patient records--or they'll go on the prowl for a working connection.
No matter the systems in place, a facility can never be fully guarded against downtime, the experts agreed. Whether it's a computer glitch, power failure or human snafu, something can throw the EHR off track. Training and drills help, especially when emergency procedures are practiced during planned downtimes, Rys said, but even the best-laid plans can stumble. "A scheduled downtime is just routine and typically affects just one shift," she said. "An unscheduled one is what you really have to prepare for."
Cheryl McEvoy is an assistant editor with ADVANCE.
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