HIMSS Clinical Informatics Insights
The term “downtime” could essentially have various definitions, most commonly planned and unplanned. Planned usually includes activities involving ongoing requirement with the many upgrades, special updates, patches and various other reasons needed from equipment and/or vendors. These are often best handled with communications to the end users using “messages of the day” functionality upon accessing the systems, emails to leadership and involving key staff present during event like a house or nursing supervisor. However, should a planned downtime be long enough to require significant periods without access or functionality as well as recovery/validation time, the procedures mimic some of the unplanned downtime steps.
With unplanned downtime, communication to clinicians may include overhead pages and/or physical pages or calls to key staff. This could be caused by not only system failures but also environmental failures (e.g. power outages) or equipment failure (e.g. wireless network).1 These procedures are often hardest to solidify as many are aware of the need for development, but find it the lowest priority and least valued until an actual downtime occurs or is required. When planning any downtime procedure, include key downstream areas that would be impacted, such as admission/discharges/transfers (ADT) functionality, billing, interfaces, charge capture, coding and reporting, among others. A certain order for each function must be followed during recovery to ensure health of system upon the recovery process.
In a brief search of the literature surrounding clinician perspectives, one article specifically discussed physician attitudes (which might align with nurses), and reported that the downtime instances were found to be very hectic and troublesome, and should be avoided. They also felt that not having information available might jeopardize patient safety in certain cases.3 Similarly, nurse’s attitudes were often found negative around lapses in system performance or downtime. However, it was suggested that while frustrated with performance and system downtime, nurses did not desire returning to paper. With more workflows transitioned to an electronic format, the impact of a downtime to an organization is becoming more nuanced and more challenging, possibly crippling if the downtime is severe. Returning to paper may not be an option or it may be exceedingly complex to support.
While guidelines must be tailored to each organization a self-assessment guide for all individual EHR users as well as the organizations responsible for implementing them should be developed.5 This guide for users should include, at a minimum, approximately 25 common actions that a user should be capable of performing (e.g. look up a patient by name, medical record number or review the three most recent laboratory test results), the organization's EHR downtime and reactivation procedures and any EHR-related adverse events or potential hazards the user has been directly involved in. This self-assessment tool could be developed and implemented similar to the EHR clinical decision support assessment tool provided by AHRQ/LeapFrog.6
Downtime events are here to stay and while it is irrefutable that unplanned ones are not desired, planned ones will always be required. In planning for downtime, some key functions nursing informaticists should consider include the following:
- WHO is impacted: Remember that the entire care team is impacted and understanding the impact to the team is crucial.
- WHAT is happening: Ensure the proper amount of communication is provided.
- WHERE and WHEN are the impacts: Plan the best time for a planned downtime by collaborating with the users most impacted by the outage and agreeing upon a time with minimal impact.
- WHY is this happening: Don’t forget to communicate the why so end users understand reasons for outage.
- HOW does this impact me: Ensure clinicians know where to go for references and how to access patient information and specific workflows during the downtime, as well as recovery. Upon recovery, always debrief to learn how to optimize the solutions in place and improve on the process.
While downtimes are a process that is often very systems-focused, ironically, it is very similar to the nursing process whereby one must assess, diagnose, plan, implement and evaluate. Future research efforts should analyze the various types of downtimes and their impact on patient care and quality outcomes, as well as on the financial performance of an institution.
- J Nurs Manag. 2010 Jul;18(5):606-12. doi: 10.1111/j.1365-2834.2010.01084.x. Factors influencing nurses' attitudes towards healthcare information technology. Huryk LA.
- Kilbridge PM, Welebob EM, Classen DC. Development of the Leapfrog methodology for evaluating hospital implemented inpatient computerized physician order entry systems. Qual Saf Health Care. 2006;15(2):81-84
- Downtime procedures for a clinical information system: a critical issue Nancy C. Nelson, RN,MS Journal of Critical Care. Volume 22, Issue 1, March 2007, Pages 45–50
About the Contributor
Sandy Ng, MSN, RN-BC is a former pediatric nurse with experience at various children’s hospitals in Texas and California. Currently, she is a Nursing Informaticist at the University of California Medical Center, where her role has included implementation and clinical transformation experiences since 2005. Recent projects have involved converting data into information and knowledge in the form of dashboards and business intelligence tools.