We recently practiced an EHR downtime at our hospital. [We've practiced downtimes previously, this one was designed to be more challenging.] After weeks of intensive review of our downtime procedures, we took the EHR down and practiced using our downtime procedures. It was a relatively short drill, to be sure, but it was a drill. At the end of the downtime, we went into recovery mode to ensure all data was updated in the right order, at the right time to produce complete patient records. All went basically to plan. That doesn't mean it was easy...
That said, there were some key learnings that I think are worth sharing. Here is some of what we learned:
1. There is never a good time to perform a drill, so pick a date and stick to it.
2. If you haven't practiced your downtime procedures in a while, spend time reviewing them. Identify and address gaps.
3. Realize that many of your nurses and physicians may never have learned to chart on paper. Many don't have good penmanship (made worse by lack of practice in our electronic world), many don't know what the clinical workflow is if there's not an electronic path to follow. This is not a criticism, but a reality, of our current environment. Acknowledge this reality and address it in planning.
4. If a full downtime drill is too much to take on, perform intensive table top drills with complicated, realistic use cases.
For example, patient Mary Smith arrives in the ED with x, y, z symptoms. How do you register her? Room her? How do you get labs? Imaging? How do you note food allergies? How do you document meds? Mary then needs emergency surgery. How do you notify the OR? How does the OR know Mary's current medical history? How do you transfer her from ED to the OR? When she is ready to leave recovery, how do you find an open bed? How do you transfer her? The questions go on and on, but having all responsible parties including food services, environmental services, infection control, quality, pharmacy, IS, supply chain (etc.) in these meetings is crucial to successfully identifying gaps in process.
5. Document your findings, create an action plan, remediate and test again. From a Lean perspective, it's the basic plan-do-check-act.
6. At some point, you have to perform a real test. If you don't, you will not stress your systems (people, process and technology) in a realistic manner. Not testing at all creates a bigger risk than controlled testing.
7. Nurses rock (we knew that, we were simply reminded, again, of that fact).
An Unfortunate Reality
It's an unfortunate reality that we face in healthcare (and elsewhere) that electronic systems are under constant attack. Beyond malicious intent, there is basic human error, which accounts for 95% of the security incidents. Electronics fail, people make mistakes, bad guys use social engineering ingeniously. The reason for the failure is less important than the plans that address the variety of failures that can occur - from ransomware to network downtimes, system misconfigurations to hardware failures and beyond.
No Matter What
EHR systems have become vital to providing the best possible patient care. However, in the end, our job is to care for patients, no matter what. So, whether we have computers or printers or interfaces or automated alerts or not, we must be prepared to provide safe, effective patient care. Whether the network is up or down, whether we're using electronics or paper, we have a job to do. Practicing that patient care under carefully crafted downtime parameters can help everyone become more competent in dealing with a variety of circumstances. No matter what.