August 2015

Documentation During EMR Downtimes
By Robert N. Mitchell
For The Record
Vol. 27 No. 8 P. 10

The headlines jump off the page: "Network Glitch Brings Down EMR," "Nurses Want Probe Into EMR Failure," "Setback After EMR Crashes," "What to Do When IT Disaster Strikes," and "Lessons Learned From an Extended EHR Outage."

When the EMR goes down what happens next is as important as what happened moments before, including a potential transition to manual documentation. In all likelihood, an EMR will go down at some point, but such an occurrence should never send an organization into chaos. Instead, there should be a methodical shift from electronic to manual documentation.

With patient care being intertwined, EMR technology is indispensable at many facilities. Unexpected downtime is rare, but when the EMR does go down, processes must be in place that enable staff to quickly access an alternative.

Effective Communication
DocuCOMP CEO and executive physician educator Betty B. Bibbins, MD, BSN, CHC, CI-CDI, CPEHR, CPHIT, says EMR downtime—whether planned or unexpected—can be less stressful if organizations are properly prepared.

"Education is important in all of this," she says. "It's important to know what EMR downtime is and how it's communicated within the organization."

To help avoid frustration and panic, contingency plans must explain the process of shifting from electronic to paper. Training should occur before it's needed, exposing all staff to the manual processes, Bibbins says, adding that reference materials must be readily available to serve as quick reminders on how to document on paper.

Mitch Morris, MD, vice chairman and US/global health care providers sector leader at Deloitte Consulting, says only foolhardy organizations would not consider the possibility of an EMR failure, noting they must be prepared for various possibilities. "Today, there are different levels of an EMR being down. It can be a minor glitch, such as being unable to print from the EMR, certain functionality within the EMR being unavailable, or a catastrophic event such as a tornado, power outage, or flood," he says.

If an EMR is down for longer than a few hours, Bibbins says batches of folders should be available for manual documentation and stored securely in accordance with HIPAA regulations. When the EMR is back up and running, any paper documentation must find its way into the system. "Physicians will not be the ones who bring out the manual charts. Someone else needs to be responsible for this," Bibbins says. "There should be a few people responsible for each hospital in a health system that may be affected."

Brina Hollis, MHHS, PhD, CBRS, a health informatics faculty member at Kaplan University, says hospitals must revert to continuity plans, which include disaster recovery and a business impact analysis, should the EMR go down. "It's important to communicate that the EMR is down, whether it's at a large hospital or a small physician practice," she says. "Everyone should know that manual procedures are being followed. Everyone should know their role because some EMR functions may not be available."

Downtime Planning
Documentation can get tricky during EMR downtimes, making it imperative to have policies and procedures in place to address such circumstances. "Precautions, such as filing the documented chart on a shelf, and having paper charts available and ready beforehand, all need to be in place so the chart can simply be slipped under a physician's hands and documentation can continue," Hollis says.

Preparation includes cross-training current staff on both electronic and paper documentation. In addition, new hires should know how to chart on paper. "This is particularly important for providers who have learned primarily how to document electronically. They must know how to document on paper," Hollis says, adding that it's a good idea to also make sure physicians are familiar with documenting on paper, including what steps to take if the EMR's functionality is limited.

Understanding workflows both within and between systems is important, says Mike Dow, CIO at Galen Healthcare Solutions, an HIT consulting firm. "Everyone must know the workflows in a downtime situation. Having a business continuity solution helps to ensure familiar workflows during downtime," he says. "Most business continuity solutions will provide a copy of the patient's chart, and the good ones will also allow for basic documentation that flows back into the patient's electronic chart once the EMR is available again."

Don't neglect other critical functions, such as ordering medications and lab tests, Dow says. "Groups should provide paper prescription pads, order requisitions, and other key resources at the point of care to ensure all workflows are covered during a downtime event," he says.

Back to the Electronic Chart
When the EMR is brought back up, there's the matter of making sure anything documented on paper is entered into the system. "If it's a large hospital or health system, there should be personnel responsible for getting that information into the system," Hollis says, adding that there's typically no mandate on who should handle this function.

She notes that during this time there may be lapses in what patient information is available. However, quickly entering the data—whether scanning them or entering them by hand—should not be the organization's priority. "Accuracy of what's in the EMR is more important than getting it into the system quickly," Hollis says.

Dependencies Create New Issues
As digital advances continue throughout the health care industry, providers have become more dependent on technology, which adds to the urgency during EMR downtimes. "It would be very difficult to maintain an EMR without lab results, radiology, or pharmacy. We really can't function because everything is connected," Morris says. "It can really become an issue not having the EMR. While most physicians can document on paper, this paradigm will change as physicians write less and less and we depend more on technology. It's like if you've never done online shopping before, you'd be lost on Amazon."

Fortunately, unplanned EMR downtime is something that occurs less frequently these days. "It's a much more stable environment, which includes remote hosting and application management," Morris says. "That's one of the things Evergreen, a business Deloitte started a year ago, provides. There are two aspects of Evergreen. We help clients manage their systems at a lower cost using a global delivery model. Dedicated teams work with the client and the quality of customer service improves. This includes remote hosting, redundant systems and servers, or mirrored servers."

Dow says the best-case scenario is to have processes similar to those of the EMR in place. "That's why you need to understand current workflows in the EMR. You should know that if the EMR goes down, you have the right combination of technology and paper-based workflows to continue seeing patients," he says.
"Ultimately, patient care is still the most important aspect, regardless of whether documentation occurs electronically or manually. The downtime scenario shouldn't be all that different. It should be straightforward, allowing us to keep our focus on continuing to care for the patient."

— Robert N. Mitchell is a freelance writer based in King of Prussia, Pennsylvania.