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Appl Clin Inform 2019; 10(03): 495-504
DOI: 10.1055/s-0039-1692678
Research Article
Georg Thieme Verlag KG Stuttgart · New York

Continuing Patient Care during Electronic Health Record Downtime

Ethan Larsen
1   Center for Outcomes Research, Houston Methodist Research Institute, Houston, Texas, United States
,
Daniel Hoffman
2   National Center for Human Factors in Healthcare, MedStar Health, Washington, District of Columbia, United States
,
Carlos Rivera
3   Department of Health Administration, Virginia Commonwealth University, Richmond, Virginia, United States
,
Brian M. Kleiner
4   Grado Department of Industrial and Systems Engineering, Virginia Tech, Blacksburg, Virginia, United States
,
Christian Wernz
3   Department of Health Administration, Virginia Commonwealth University, Richmond, Virginia, United States
,
Raj M. Ratwani
2   National Center for Human Factors in Healthcare, MedStar Health, Washington, District of Columbia, United States
5   Department of Emergency Medicine, Georgetown University School of Medicine, Washington, District of Columbia, United States
› Author Affiliations Funding This research was supported by a grant from the Agency for Healthcare Research and Quality (AHRQ): Evidence-Based Contingency Planning for Electronic Health Record Downtime (R21 HS024350–01A1).
Further Information

Publication History

22 February 2019

13 May 2019

Publication Date:
10 July 2019 (online)

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Abstract

Introduction Electronic health record (EHR) downtime is any period during which the EHR system is fully or partially unavailable. These periods are operationally disruptive and pose risks to patients. EHR downtime has not sufficiently been studied in the literature, and most hospitals are not adequately prepared.

Objective The objective of this study was to assess the operational implications of downtime with a focus on the clinical laboratory, and to derive recommendations for improved downtime contingency planning.

Methods A hybrid qualitative–quantitative study based on historic performance data and semistructured interviews was performed at two mid-Atlantic hospitals. In the quantitative analysis, paper records from downtime events were analyzed and compared with normal operations. To enrich this quantitative analysis, interviews were conducted with 17 hospital employees, who had experienced several downtime events, including a hospital-wide EHR shutdown.

Results During downtime, laboratory testing results were delayed by an average of 62% compared with normal operation. However, the archival data were incomplete due to inconsistencies in the downtime paper records. The qualitative interview data confirmed that delays in laboratory result reporting are significant, and further uncovered that the delays are often due to improper procedural execution, and incomplete or incorrect documentation. Interviewees provided a variety of perspectives on the operational implications of downtime, and how to best address them. Based on these insights, recommendations for improved downtime contingency planning were derived, which provide a foundation to enhance Safety Assurance Factors for EHR Resilience guides.

Conclusion This study documents the extent to which downtime events are disruptive to hospital operations. It further highlights the challenge of quantitatively assessing the implication of downtimes events, due to a lack of otherwise EHR-recorded data. Organizations that seek to improve and evaluate their downtime contingency plans need to find more effective methods to collect data during these times.

Keywords

electronic health record - patient care - downtime - contingency planning - clinical laboratory

Authors' Contributions

Each author contributed to the conception or design of the work, data analysis and interpretation, critical revision of the article, and final approval of the version to be published.


Protection of Human and Animal Subjects

This study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects and was reviewed by the Institutional Review Boards of Virginia Polytechnic Institute, Virginia Commonwealth University, and MedStar Health.


 

  • References

  • 1 Henry J, Pylypchuk Y, Searcy T, Patel V. Adoption of Electronic Health Record Systems among U.S. Non-Federal Acute Care Hospitals: 2008–2015; 2016. Available at: https://www.healthit.gov/sites/default/files/briefs/2015_hospital_adoption_db_v17.pdf . Accessed December 16, 2016
    PubMedGoogle Scholar
  • 2 Blumenthal D. Launching HITECH. N Engl J Med 2010; 362 (05) 382-385
    CrossrefPubMedGoogle Scholar
  • 3 Russo E, Sittig DF, Murphy DR, Singh H. Challenges in patient safety improvement research in the era of electronic health records. Healthc (Amst) 2016; 4 (04) 285-290
    PubMedGoogle Scholar
  • 4 Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med 2010; 363 (06) 501-504
    CrossrefPubMedGoogle Scholar
  • 5 Buntin MB, Burke MF, Hoaglin MC, Blumenthal D. The benefits of health information technology: a review of the recent literature shows predominantly positive results. Health Aff (Millwood) 2011; 30 (03) 464-471
    CrossrefPubMedGoogle Scholar
  • 6 Wolfstadt JI, Gurwitz JH, Field TS. , et al. The effect of computerized physician order entry with clinical decision support on the rates of adverse drug events: a systematic review. J Gen Intern Med 2008; 23 (04) 451-458
    CrossrefPubMedGoogle Scholar
  • 7 Bates DW, Kuperman GJ, Wang S. , et al. Ten commandments for effective clinical decision support: making the practice of evidence-based medicine a reality. J Am Med Inform Assoc 2003; 10 (06) 523-530
    CrossrefPubMedGoogle Scholar
  • 8 Campbell EM, Sittig DF, Guappone KP, Dykstra RH, Ash JS. Overdependence on technology: an unintended adverse consequence of computerized provider order entry. AMIA Annu Symp Proc 2007; 94-98
    PubMedGoogle Scholar
  • 9 Larsen E, Haubitz C, Wernz C, Ratwani R. Improving electronic health record downtime contingency plans with discrete-event simulation. In Hawaii International Conference on System Sciences. Vol. 2016. Kauai; 2016
    PubMedGoogle Scholar
  • 10 Larsen E, Fong A, Wernz C, Ratwani RM. Implications of electronic health record downtime: an analysis of patient safety event reports. J Am Med Inform Assoc 2018; 25 (02) 187-191
    CrossrefPubMedGoogle Scholar
  • 11 Sittig DF, Gonzalez D, Singh H. Contingency planning for electronic health record-based care continuity: a survey of recommended practices. Int J Med Inform 2014; 83 (11) 797-804
    CrossrefPubMedGoogle Scholar
  • 12 McDermott IE. Ransomware: tales from the CryptoLocker. Online Search 2015; 39 (03) 35-37
    PubMedGoogle Scholar
  • 13 Digi tal extortion: 26 things to know about ransomware. Available at: http://www.beckershospitalreview.com/healthcare-information-technology/digital-extortion-26-things-to-know-about-ransomware.html . Accessed April 15, 2016
    PubMedGoogle Scholar
  • 14 Hollywood Presbyterian declares emergency after hackers cut off data, demand $3.4 million ransom | Healthcare IT News. Available at: http://m.healthcareitnews.com/news/hollywood-presbyterian-declares-emergency-after-hackers-cut-data-demand-34-million-ransom?platform=hootsuite . Accessed April 14, 2016
    PubMedGoogle Scholar
  • 15 MedStar attack found to be ransomware, hackers demand Bitcoin | Healthcare IT News. Available at: https://www.healthcareitnews.com/news/medstar-attack-found-be-ransomware-hackers-demand-bitcoin . Published April 2016. Accessed October 9, 2018
    PubMedGoogle Scholar
  • 16 Larsen E, Rao A, Sasangohar F. Investigating electronic health record downtimes: a scoping review of literature and news media. J Med Internet Res 2019 Doi: 10.2196/preprints.13285
    PubMedGoogle Scholar
  • 17 Office of the National Coordinator for Health Information Technology. Contingency Planning - The Safety Assurance Factors for EHR Resilience (SAFER) Guides. Available at: http://www.healthit.gov/sites/safer/files/guides/safer_contingencyplanning_sg003_form_0.pdf . Accessed September 14, 2015
    PubMedGoogle Scholar
  • 18 Sittig DF, Ash JS, Singh H. The SAFER guides: empowering organizations to improve the safety and effectiveness of electronic health records. Am J Manag Care 2014; 20 (05) 418-423
    Google Scholar
  • 19 Sittig DF, Singh H. Electronic health records and national patient-safety goals. N Engl J Med 2012; 367 (19) 1854-1860
    CrossrefPubMedGoogle Scholar
  • 20 Institute of Medicine National Research Council, Institute of Medicine, Committee on Patient Safety and Health Information Technology IOM, et al. Health IT and Patient Safety Building Safer Systems for Better Care. Washington, DC: National Academies Press; 2012 . Available at: http://cci.drexel.edu/faculty/ssilverstein/patientsafetyandhealthitprepub.pdf . Accessed May 22, 2017
    PubMedGoogle Scholar
  • 21 Office of the Federal Register. Public Welf 2007 CFR 45 § 164.308(a)(7)(ii)(C). Doi: 10.1037/018747
    PubMedGoogle Scholar
  • 22 Silverstein MD. An Approach to Medical Errors and Patient Safety in Laboratory Services: A White Paper Prepared for the Quality Institute Meeting Making the Laboratory a Partner in Patient Safety Atlanta, April 2003. Atlanta; 2003
    PubMed
  • 23 Plebani M. Errors in laboratory medicine and patient safety: the road ahead. Clin Chem Lab Med 2007; 45 (06) 700-707
    PubMedGoogle Scholar
  • 24 Wagar EA, Tamashiro L, Yasin B, Hilborne L, Bruckner DA. Patient safety in the clinical laboratory: a longitudinal analysis of specimen identification errors. Arch Pathol Lab Med 2006; 130 (11) 1662-1668
    CrossrefPubMedGoogle Scholar
  • 25 Sciacovelli L, Plebani M. The IFCC Working Group on laboratory errors and patient safety. Clin Chim Acta 2009; 404 (01) 79-85
    CrossrefPubMedGoogle Scholar
  • 26 Plebani M, Ceriotti F, Messeri G, Ottomano C, Pansini N, Bonini P. Laboratory network of excellence: enhancing patient safety and service effectiveness. Clin Chem Lab Med 2006; 44 (02) 150-160
    PubMedGoogle Scholar
  • 27 Howanitz PJ. Errors in laboratory medicine: practical lessons to improve patient safety. Arch Pathol Lab Med 2005; 129 (10) 1252-1261
    CrossrefPubMedGoogle Scholar
  • 28 Hallock ML, Alper SJ, Karsh B. A macro-ergonomic work system analysis of the diagnostic testing process in an outpatient health care facility for process improvement and patient safety. Ergonomics 2006; 49 (5-6): 544-566
    CrossrefPubMedGoogle Scholar
  • 29 Astion ML, Shojania KG, Hamill TR, Kim S, Ng VL. Classifying laboratory incident reports to identify problems that jeopardize patient safety. Am J Clin Pathol 2003; 120 (01) 18-26
    CrossrefPubMedGoogle Scholar
  • 30 Straub WH, Gur D. The hidden costs of delayed access to diagnostic imaging information: impact on PACS implementation. AJR Am J Roentgenol 1990; 155 (03) 613-616
    CrossrefPubMedGoogle Scholar
  • 31 Wagar EA, Yuan S. The laboratory and patient safety. Clin Lab Med 2007; 27 (04) 909-930
    CrossrefPubMedGoogle Scholar
  • 32 Bonini P, Plebani M, Ceriotti F, Rubboli F. Errors in laboratory medicine. Clin Chem 2002; 48 (05) 691-698
    CrossrefPubMedGoogle Scholar
  • 33 Lippi G, Plebani M. The importance of incident reporting in laboratory diagnostics. Scand J Clin Lab Invest 2009; 69 (08) 811-813
    CrossrefPubMedGoogle Scholar
  • 34 Oral B, Cullen RM, Diaz DL, Hod EA, Kratz A. Downtime procedures for the 21st century: using a fully integrated health record for uninterrupted electronic reporting of laboratory results during laboratory information system downtimes. Am J Clin Pathol 2015; 143 (01) 100-104
    CrossrefPubMedGoogle Scholar
  • 35 Blanchfield B, Fahlman C, Pittman M. Hospital Capital Financing In The Era of Quality and Safety: Strategies and Priorities for the Future – A Survey of CEOs. Robert Wood Johnson Found 2005; 1-27
    PubMedGoogle Scholar
  • 36 Hollensead SC, Lockwood WB, Elin RJ. Errors in pathology and laboratory medicine: consequences and prevention. J Surg Oncol 2004; 88 (03) 161-181
    CrossrefPubMedGoogle Scholar
  • 37 Corbin JM, Strauss A. Grounded theory research: procedures, canons, and evaluative criteria. Qual Sociol 1990; 13 (01) 3-21
    CrossrefPubMedGoogle Scholar
  • 38 Pope C, Ziebland S, Mays N. Qualitative research in health care. Analysing qualitative data. BMJ 2000; 320 (7227): 114-116
    CrossrefPubMedGoogle Scholar
  • 39 Creswell JW. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. 4th ed. In Knight V. , ed. Los Angeles: SAGE Publications Inc; 2014
    Google Scholar
  • 40 Ratwani R, Fairbanks T, Savage E. , et al. Mind the Gap. A systematic review to identify usability and safety challenges and practices during electronic health record implementation. Appl Clin Inform 2016; 7 (04) 1069-1087
    Article in Thieme ConnectPubMedGoogle Scholar
  • 41 Ott RL, Longnecker M. An Introduction to Statistical Methods and Data Analysis. Australia, United States: Brooks/Cole Cengage Learning; 2010
    Google Scholar