Downtime procedures for a clinical information system: a critical issue
The article discusses the downtime plan of LDS hospital. The HELP system in the LDS hospital is known for its reliability with 99.85% uptime. A study determined the cost per minute of downtime for an average 3-hospital integrated delivery network with 1400 beds to be more than $1000. The hospital had faced a planned downtime successfully. However, after a long break, in a series of planned and an unplanned downtime the recovery was not good. A multidisciplinary software oversight committee (SOC), that included representatives from nursing, pharmacy, respiratory therapy, laboratory, information systems, hospital administration, quality, and risk management, was appointed to come up with a downtime plan.
Based on their experience the LDS hospital came up with two downtime plans for planned and unplanned events. Planned or scheduled downtime is mostly for the maintenance of the system. Based on the least activity observed, a set time was determined. Planned downtime notices were issued via several mechanisms such as logon message, email notifications, and on the evening of the downtime day overhead loudspeaker announcements were made. Unplanned downtime notifications were usually given by overhead loudspeaker announcements and the message included the type of downtime, and the potential length of the downtime if a reasonable estimate can be determined. The hospital came up with downtime documentation policies and procedures for each department, which indicate what ‘back-up’ forms and process must be used to document patient care and communicate with other departments during downtimes. Data access was not an issue in planned downtime; however, this was a big issue for unplanned downtime. During unplanned downtime physicians rely on the recent printed shift reports, any temporary worksheets or physician rounds reports that may have been printed to provide data until the system is operational again. The manually recorded downtime paper record, which has the patient information from the beginning of the downtime, is also available during this time.
In order to evaluate the effectiveness and consistency of downtime policies, the SOC conducted a drill followed by the survey and came up with the following recommendations 1. Length of the downtime was very critical, a four-hour downtime was tolerable six-hours was too long and disturbed the workflow significantly. 2. The survey confirmed that there was confusion on the part of the nursing staff as to who and what data must be entered into the computer after a downtime, especially if the downtime crosses change in shift boundaries. 3. Survey results indicated problems with laboratory communication. Therefore, it was recommended that both nursing and laboratory staff become more familiar with the downtime process for laboratory ordering and specimen identification. 4. Accessing automated medication carts was an issue for units using them. Patients admitted during downtime were not in the cart census and drugs could not be easily dispensed for those patients. Recommendations were for pharmacy to incorporate automated medication dispensing processes into the downtime plan to provide consistent access methods during downtimes.
Further changes were needed to shed clarity on the role of nurses in downtime shift especially with regard to data entry into computer after the downtime and how much and what data must be entered into computer and how to fill gap in electronic health record during this time. To overcome this confusion, clear standards on post-downtime computer data entry by nursing were charted. Merely coming up with downtime plans is not enough. In order to have a successful downtime plan, the staff must be well prepared and aware of the details of such plans to ensure this downtime drills are recommended, which is especially helpful to prepare the crew for unplanned downtime.
Although the downtime plan proposed by the LDS team seems very traditional, this back up plan has a high chance of being fool proof. Irrespective how much technology back up one comes up with, there is chance it can fail. It is important for the hospitals to have one such plan as a final safety step to ensure in-patient care during worst downtimes.
Downtimes of any application used in patient care are disruptive. It is imperative that policies are developed and staff is educated about them. The recovery period after a downtime needs to be mapped as well for managers, application specialist and informaticians to ensure patient's information, documentation and billing transactions are properly recovered.
This is a perfect example of informatics in my opinion. Downtime is inevitable with Information Systems as it is needed for updates, additions, etc., but finding a way to minimize the effect of downtime took research to identify the most impacted by the downtime, and the development of a solution. Now granite the solution is not a real big solution, but if gaining familiarity with the system minimizes the impact of downtime, then it is a solution. This article kind of got me excited for health informatics a little.
- Nelson, 2007. Downtime procedures for a clinical information system: a critical issue. http://www.ncbi.nlm.nih.gov/pubmed/17371746