The United States of America's (USA) Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 [1] has led to increased adoption and use of health information technologies (HIT), particularly use of electronic health record systems (EHRs) [2] in previously paper-based healthcare systems. As such, healthcare processes are increasingly dependent on availability of HIT. However, HIT is not infallible and is subject to disruptions and downtimes that may threaten the continuity of operations [3] and cause adverse patient care outcomes, both of which can lead to financial and operational difficulties for healthcare organizations [4].
Over the last several years, there have been several highly publicized, widespread (i.e., affecting multiple facilities simultaneously), extended (i.e., lasting greater than 12 h) EHRs downtimes in the USA and Canada [5], [6], [7], [8], [9], [10], [11], [12]. EHRs downtimes have also been reported in China [13]. However, there is little published description of practices that institutions are using to maintain the safety and effectiveness of continuous healthcare delivery while EHRs are unavailable. Our study goal was to describe EHRs downtime practices across a variety of healthcare institutions and identify practices that could be useful for planning for and dealing with EHRs unavailability. By describing and highlighting important elements of contingency plans across a variety of EHRs-enabled healthcare systems, our goal was to provide healthcare organizations with more comprehensive information to prepare for the risks of potential operational disruptions and avoid harm to patients.
Before survey development, we reviewed the existing literature and did not find any previous survey that systematically described or assessed EHRs downtime practices within healthcare organizations. Therefore, we developed a survey for the purposes of the present study. The conceptual foundation for the survey was Sittig and Singh's eight-dimension sociotechnical model of safe and effective HIT use. Although not specific to EHRs downtime, this model describes the complex interactions within
We received survey responses from representatives of 50 of the 59 (84%) institutional members of the Scottsdale Institute (i.e., unit of analysis was the institutional member), although not all respondents answered all questions on the survey. Respondents were either chief information officers or other personnel directly responsible for maintaining the organization's HIT infrastructure. Most (96%) represented non-profit organizations, and 80% were affiliated with large (>600 bed) hospital
We surveyed representatives of large integrated healthcare systems that were members of a professional organization created to share EHRs-related practices. The vast majority of these organizations were advanced EHRs users as indicated by their mean HIMSS EMRAM score of 4.6. Almost all of our respondent organizations had experienced an unplanned downtime, and most had experienced an unplanned downtime exceeding 8 h in the last 3 years. Three organizations reported patient injury had resulted
The major limitation of the survey was that respondents were from a relatively small number of USA-based, large, integrated, hospital-centric, healthcare delivery systems with significant experience in implementation, use, and ongoing optimization of their HIT and EHRs infrastructures. There were no small, self-contained ambulatory medical practices involved. We do not know how the survey findings on compliance with the practices identified in the survey would differ if the respondents were
Extended EHR-related downtimes occurred in the majority of organizations surveyed. Most institutions had only partially implemented comprehensive contingency plans to maintain safe and effective healthcare during unexpected EHRs downtimes. Preparing for these unexpected downtimes should be a part of every EHR-enabled healthcare organization's overall patient safety strategy. The best practices identified in this survey and in the SAFER Guide on Contingency Planning could help the EHR-enabled
Dr. Singh is partially supported by the Houston VA Health Services Research & Development Center of Innovation (CIN 13–413). The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
All authors made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; and drafting the work or revising it critically for important intellectual content; and final approval of the version to be published; and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
The authors have no conflicts of interest. Summary points What was already known on the topic Reliable health information technology (HIT) in general, and electronic records (EHRs) in particular are essential to a high-performing healthcare system. When the availability of EHRs are disrupted, alternative methods must be used to maintain the continuity of healthcare. What this study added to our knowledge Unexpected downtimes related to EHRs appear to be fairly common among healthcare institutions.
We thank Shelli Williamson, Executive Director of the Scottsdale Institute and Ricki Levitan for their help and support of our survey, as well as all the Scottsdale member organizations who participated in the survey.
This failure to invest in IT hardware and software was clear in this analysis, with around 30% of safety incidents directly related to infrastructure failures. Despite 96% of organisations having had unplanned downtime as a result of IT failures in the past 3 years, most have only partially implemented comprehensive contingency plans to maintain safe and effective care when their IT systems are disrupted,44 despite clear best-practice guidance being available, such as the Contingency Planning SAFER Guide in the USA.45 The failure to invest in appropriate support services and develop resilient contingency plans was also evident in our study.
The views expressed in this article are those of the authors and do not necessarily represent the views of the University of Texas, St. Luke's Health System, or Department of Veterans Affairs.
