Not long ago, I found myself in the chaos of unexpected network downtime. With systems like the EHR, PACS, lab acquisition, and more offline, it felt like I had to switch from piloting a fancy aircraft that I knew well to flying a paper plane. Suddenly, our usual systematic workflows morphed into crude scribblings on photocopies that appeared older than me. I’ve had experience with paper charts in medical school and during planned downtimes, but in the midst of the turmoil, the pain of older processes was clear to the entire clinical team. Just as running ACLS during a code, the right preparedness could have eased the scramble. Now, ours only lasted a few hours; imagine scenarios where the downtime is extended for days, weeks, or longer!
The Pain of Unplanned EHR Downtime
Every CMIO has a nightmare scenario that keeps them up at night. In recent discussions, we found that a recurring specter of worry is the potential for extended, unplanned EHR downtime. It's like an uninvited guest that disrupts the entire system that has been meticulously planned, causing disarray.
Why this fear? EHR systems are the heartbeat of clinical informatics. More importantly, the entire clinical experience now revolves around the EHR. As a result, clinicians have come to rely on the different tooling and workflows that help them orchestrate extraordinarily complex processes. After all, the EHR holds the carefully curated design of order sets, safety checks for medication administration, documentation templates to streamline note writing, alerts for potentially buried patient risks, and so much more that clinicians depend on daily. It's no surprise, then, that an unexpected EHR outage can induce palpitations in informatics leaders.
Furthermore, research evidence underscores the real impact of EHR downtime on care delivery. For instance, a study found that laboratory testing was delayed over 60% during downtime - a clear indication of the potential fallout. Imagine the other parallel and downstream impacts that this causes.
The Power of Training and Simulations
Unplanned EHR downtime can feel like being thrown into the fire. The key to effective survival lies in preparation and adaptable strategies. All organizations have processes in place for planned downtime that rollover into unplanned downtime. In the emergency department, the white board typically becomes the trackboard replacements and paper folders with patient documentation replace the patient view in the EHR.
Interestingly, I’ve never been exposed to (and haven’t heard anything regarding) simulation training for EHR downtime. I’m the last person to want additional mandatory training modules for staff. However, a voluntary system led by departmental leadership could be powerful. Researchers, like Dr. Jeff Gold, have published extensively on EHR simulation training in domains like residency training and physician burnout. Of course, the EHR would be down, but running through these identical processes on paper would likely yield similar results for the downtime workflow.
By integrating training and simulations focused on unplanned outages, informatics leaders can equip teams with the right tools to navigate the chaos. A downtime simulation would allow staff to know their roles, get familiar with the script, and get ready to improvise if necessary. The panicked scramble can instead become a process that maintains, to the best degree possible, the continuity of care.
The Pull-vs-Push Strategy
The truth is, during EHR downtime, certain aspects of the system will inevitably falter. Alerts, as an example, rely on a "push" strategy: they are actively delivered to clinicians. It’s a mechanism that will invariably become non-operational during downtime.
Instead of solely relying on impossible-to-replicate push strategies, we can consider mimicking tools that rely on a "pull" strategy like order sets and documentation templates. The difference? These resources are pulled by the clinicians themselves when needed, rather than being pushed or delivered to them by the system. By maintaining an external repository of such tools, they can be printed and distributed to clinicians during outages. It's like keeping a first-aid kit handy; you hope you never need it, but if you do, you'll be glad it's there.
Bringing It Together
As informatics leaders, we are the captains of the ship, responsible for steering the course even in the setting of chaos. Unplanned EHR downtime can indeed be daunting, throwing workflows into disarray, but it doesn't have to spell disaster.
There might be a role for running voluntary simulations that demonstrate to teams how to transition away from the EHR while maintaining as much support as possible. By shifting our emphasis on the mechanisms that are potentially replaceable – pull rather than push strategies – we can create a safety net that protects workflows even when the main system falls.
