HIMSS Clinical Informatics Insights
Isn’t it funny that when you implement a computer system, everyone hates it, but after about six months, the same staff doesn’t know how they will survive when the system goes down? Really thinking through how you will manage when your systems goes down is critical and unique to your institution.
How long has your institution been using their electronic processes?
There are younger staff members who have never documented their notes on paper and will struggle as much using paper as your original staff did converting to electronic documentation. Do you have a process in place to periodically review your downtime documents to make sure they match or are similar to the electronic equivalents? You either need a structured change control process that includes updating downtime document with every change, or a structured periodic review of downtime documents to compare to current electronic ones.
Are you able to address unscheduled downtime the same way you address planned downtime?
Many institutions have downtime applications that take periodic snapshots of key parts of the electronic record and make them available to staff when the system goes down. In our recent past, we had laptops in our disaster control area that took hourly snapshots of the patient information. If the system went down, these laptops were distributed to the units so the staff had recent clinical data to aid in providing care. This information included orders, results, the MAR and progress notes. More recently, we upgraded our systems so that we now have PCs on each unit that takes a similar snapshot every three minutes; this provides more recent information and allows the staff quick access to the most up to date data. Both will work if the downtime is planned or unplanned, but the later solution is better for unplanned downtimes.
Is there information that you need to “function” that is not part of the clinical snapshot?
In our institution, we have a large ambulatory care service and need to be able to pull a clinical picture for patients who may not have been at the clinic recently. How much clinical data will be needed to care for an urgent care visit for a patient that drops in? We back up basic clinical data to secure flash drives on all of our active ambulatory patients including the protocol and roadmap they are enrolled on where they are on that roadmap, recent ambulatory clinic notes, their take home medication profile and their most recent lab values, among other things. This clinical picture is updated daily on the flash drives. For our inpatient population, we also have flash drives that contain the oncology protocols for each patient on the unit, policy and procedure manuals and copies of blank downtime forms.
How critical is it to get data collected while the systems were down back into the medical record?
Because we are a research institution, we determined that all clinical data is relevant and must be re-entered into the EMR when the system comes up. It is important for the researchers to be able to mine the data and for chart abstracting to be accurate. For this reason, all orders and documentation are transcribed back into the system when it comes back, regardless of how long it has been down. Does this decision influence if you implement a failover version of your system that is used if the downtime becomes extended? At what point do you failover? Are your downtime documents designed so that those who transcribe the information have all the details they need to answer required fields? How do you handle illegible paper documents? Do you flex your staffing levels when the system comes up to allow time for transcription? Who is authorized/required to transcribe? These questions are all answered in our downtime policy and are unique to each institution.
Do you have a plan for a major disaster?
After Hurricane Katrina, we reviewed our disaster plan and implemented a process in which a bank of flash drives are updated with the same information that we need for downtime patient care; the recent labs, medications, nursing documentation, problem list, progress notes and protocol/roadmap data. These flash drives are password protected and encrypted. We are able to pull a flash drive and attach one to each patient with an armband that contains the password. If that patient is flown to another location to receive care in the event of a disaster, the team that receives that patient would have the basic information needed to care for that patient.
Having a strong downtime plan in place is a great start. Reviewing that plan periodically, especially after you have experienced a downtime, will allow you to address lessons learned. Downtime drills are a great way to make sure your staff is comfortable with the plan. Preparing for the inevitable is the best way to get through it.
About the Contributor
Tina Dieckhaus, MSN, RN-BC, NE-BC, CPHIMS, is the Director for Patient Care Informatics at St. Jude Children’s Research Hospital in Memphis, TN. She has been an Informatics Nurse Specialist since 1997 and in her current role at St. Jude since 2000. Tina Dieckhaus’ undergraduate degree is from Mississippi University for Women and her Masters in Nursing Informatics is from Tennessee State University.