FOLLOWING several key federal initiatives, reliance on the electronic health record (EHR) for recording clinical observations during patient encounters and providing archival storage for patient personal health informatics has grown exponentially. In 2009, the HITECH (Health Information Technology for Economic and Clinical Health) Act required the use of EHRs to achieve and receive incentive payments for Meaningful Use. While this, in and of itself, did not include implementation of the EHR, the incentives cannot be received unless an organization uses a certified application. Beginning in January 2017, Medicare payments will be reduced to health care systems who do not comply with the Centers for Medicare & Medicaid Services program to report electronic Clinical Quality Measures (eCQMs) for 2017. This means that organizations must use a certified EHR and populate a special Quality Reporting Document Architecture form with selected quality measures. To further embed the EHR use, these quality measures must be submitted from the EHR directly, not from human abstraction (as in the past).
These measures result in expectations by health care organizations for highly reliable and nearly always available EHR systems. Ponemon Institute (an organization that conducts independent research on privacy, data protection, and information security policy) has performed surveys on the effects of downtime. It reports that there is a profound effect on our increasing reliance on technology in our workplace.1 In its Sixth Annual Benchmark Study on Privacy and Security of Healthcare Data report in 2016, it notes that the negative financial effect to an organization is from $7000 to upward of $17 000 per minute of downtime.2 This does not include a consideration on how EHR downtimes affect the organization's community reputation or influence patient choice for clinical care.
It is clear that when there are large or profound national disasters, such as hurricanes or tornadoes, the resulting change can be very devastating. This applies to the communities and also to the ability of care providers to care for community members. Health care organizations need to be prepared for dealing with these. In the 2011 Joplin, Missouri, tornado, for example, off-site data centers allowed clinical access to patient information, although the hospital building was destroyed.3 In addition, paper processes were immediately activated for triage care. During Hurricane Katrina (2005), New Orleans hospitals experienced greater challenges because the major hospitals in the community had on-site data centers. These flooded, making access to patient information impossible.
What preparation will nurse executives need for adequate downtime planning in both large natural disasters and internal downtime events? This area of planning has been often overlooked or delayed because during implementation of EHRs, the first priority is to make sure the system is usable and functioning for clinical users during routine delivery of care. Given the reality of potential disasters, adequate planning that includes downtime drill practice must be part of every health care organization's standard operating procedure. The goal must be that clinicians can continue to give safe and effective care to our patients even in crisis situations.4
Elements of downtime planning include the following areas:
Downtime governance: It is critical to understand when and who is authorized to formally move the clinical documentation of care from the EHR to paper. Downtimes are not always as clear as one might expect. Scheduled or planned downtimes usually occur with regularity. These are often weekly or monthly to allow the technical team an opportunity to update the system. The event is known in advance, and clinical users are usually prepared. Unplanned downtime results in the EHR being unavailable suddenly and unexpectedly. This can disrupt care and can result from many reasons. Whatever the downtime cause, the end result is immediate inability for clinicians to access clinical information. This may include all or parts of clinical documentation, medication administration, physician orders, revenue cycle, and scheduling for care. Formal governance will verify downtime work flow processes and policies are in place, ensure downtime tools are available and updated as needed, and will review any downtime event for root cause. This last step (root-cause analysis) is essential so that steps can be taken to mitigate the potential for future unplanned downtimes.
Downtime access to selected components of the EHR: Many systems with EHRs have provided dedicated computers and programs that offer selected components of the EHRs for use in downtime. Placement of these devices is usually done during the EHR implementation period. They are often powered by dedicated "red" (emergency) plug-in sources for electricity continuity. (The organization's emergency electric supply, usually provided through gas generators, is the power source for these red plugs.) Downtime viewer can offer a snapshot in time that can be printed by the clinical users. Available chart elements often include orders from the past 24 hours, as well as medication administration records (MARs) with currently ordered medications and administration schedules; general patient information, including allergies; and planned schedules for ambulatory settings.
Downtime documents for clinical use: Downtime documents are forms that may include flow sheets for clinical charting. Usually included are assessment forms, admission history intake forms, MARs, order sheets, and general notes flow sheets. These documents may be blank and can be stored on the care unit or in a central location. They are often distributed prior to a planned downtime. During unplanned downtimes, they need to be quickly circulated to clinical users.
Definition of documentation elements that must be transcribed when system is restored: As previously noted, many regulatory agencies are requiring clinical information for financial reimbursement. Not only is the clinical information important for payment but also the information must be discrete for both Meaningful Use and eCQM submissions. This means that there will be a need to do clinical data entry of the downtime data. Frequently affected areas include pharmacy, laboratory, charges, and significant clinical events. Organizations need to carefully consider the effect of this manual effort. While critically necessary to restore clinical encounter information (continuity of medication administration, for example), it requires resources in addition to "normal" staffing. Simply scanning the downtime forms would seem to be a logical procedure, but ongoing clinical review of the scanned documents does not always occur. This poses potential risk to the safety of our patients. Best practice is the manual entry of critical clinical and financial information from the paper record to the EHR.
Downtime drills: Downtime practice drills are necessary to ensure readiness for continuity of clinical care. Drills are scheduled to allow clinical users (as well as our Information Technology colleagues) an opportunity to practice what will be needed in a real downtime situation. As clinicians rely more and more on electronic sources of information, lack of access can result in immediate confusion or lapses in patient care. It is uncomfortable for nurse leaders to consider that professional clinicians might "forget" to critically think but it can and does occur. Critical thinking is a core nursing competency, but habitual reliance on the EHR (such as the task list) can result in lapses in care that might have been intuitive in the pre-EHR days. Having downtime drills can not only allow clinicians to be ready for the downtime event but also serve as a reminder and activation of deeper clinical thinking. That is a benefit to our patients, and nurses, even if crisis (disaster) downtimes do not occur.
CONCLUSION
Dependence on EHRs has quickly become the "norm" for nurses and other clinicians. Emergencies and disaster events will disrupt the norm. It is important that nurse leaders prepare their teams to provide care without this tool, for the good of our patients.
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