Process Improvement by Backfilling Patient Records In the Event of EHR System Downtime

1. Process Improvement by Backfilling Patient RecordsIn the Event of EHR System Downtime Molly Lagermeier Adele Golden Cathy Olson Bob Winston IPHIE June, 2010 Health Informatics Graduate Program University of Minnesota

2. Objective To survey and evaluate the EHR data backfilling processes of major Minnesota hospitals (post system downtime) and develop recommendations for best practices.

3. Problem Statement With hospital clinicians using and relying more on the information in the electronic health records, the need exists for best practice development in data backfilling and clear links to scanned documents post downtime. If not addressed, this is a patient safety issue.

4. Background: Common Themes Literature Very limited research available. Data backfilling is just beginning to be recognized for its importance in EHR. Topics found included: Downtime “kits” Different policies for planned and unplanned downtime Policies for clinical data access during downtime and backfilling patient information

5. Survey Methodology 14 Multi-part Question Survey 12 major MN health care organizations contacted 11 participated, representing 23 hospitals In person or phone interviews conducted with each participant Open format responses De-identified results to be shared with participants

6. Survey Question Categories System Environment: EHR deployment stage EHR vendor Cultural Environment: Accountable role for downtime policy/procedures Policy/procedures structure and implementation timing Process: Data Backfilling (what, by whom, when, how): Automated feeds Manual input of structured data Scanning of paper documents Prioritization (by department, data type)? Audits? Downtime Indicators and Scanned Document Links in EHR?

7. Stage of EHR Deployment (Environment)

8. Vendor (Environment)

9. Ultimate Accountability (Cultural) * CIO Equivalent includes HIM Director, Clinical Informatics Director,IS Director.

10. Level Policies/Procedures Kept (Cultural)

11. Post Downtime Policy Detail (Cultural)

12. Data Backfilled From Other Systems (Process)

13. Data Backfilling (Process) • What data will be backfilled by whom, by when, and for what frequency and duration? • Results: • ADT input by Admissions Dept as first priority • If pharmacy system had also been down, getting medications dispensed was next priority • Lab, pharmacy, radiology all input their own data ASAP • Nurses input data for their patients unless backup support needed for significant downtime recovery. Timeframe of “ASAP” or by shift end. • “Other” data backfilled included nurse initial assessment (ht/wt/allergies), start and stop of IV and catheters, and discharge orders

14. Data Prioritization (Process) • What is the prioritization of data backfilling? • Results: • Prioritization of data backfilling by type of data was found to be: • 1) ADT, 2) Medications Ordered, 3) All Other Data Types • Prioritization of data backfilling by a specific department was rare. All get input ASAP. • Quality Measures are still in their infancy in implementation in backfilling. Only one organization had detailed quality measures included in their backfilling procedures. • Some hospitals chose not to input outpatient data (“we’ll catch it on their next visit”) • Emergency Department was least likely to have data backfilling in EHR, especially if patient was not admitted.

15. Audits and Drills (Process) Few organizations audit the backfilled Downtime drills ranged in intensity Night shift was often the only shift with experience with “planned downtimes” Executive sponsorship and commitment to continuous improvement led to most effective drills

16. Common Themes… Sometimes it takes a major downtime incident before a hospital gets serious about downtime recovery Our survey prompted hospitals to internally discuss their policy and procedures; some immediately addressed gaps identified

17. Recommended Operational Best Practice for Backfilling Hours 4-6 Floor Nurses: Input vital signs, medications given, I/O, catheters/IVS added/removed, discharge orders. Review & approve device data inclusion. Hours 7-8 Hour 1 Hours 2-3 Hospital Unit Coordinators (HUCs): Input care plan orders Floor Nurses: Review and reconcile patient records after the admissions, pharmacy, HUC, lab, radiology and their own input. Add/validate downtime “memory aid” note. Pharmacy Dept: Inputs all medications ordered and dispensed (or confirms the feed if automatic) Admissions Dept: Inputs all admissions, discharges, transfers Lab Dept: Inputs lab orders and results (or confirms the feed if automatic) Note: Hours are for example only. True hours will vary depending upon amount of downtime, which systems have automated feeds, and staff availability. Ideally process will be completed within a shift from a patient safety perspective, and teams will be “all hands on deck” to complete the backfilling. Radiology Dept: Inputs radiology orders and results (or confirms the feed if automatic)

18. Conclusions Open response interviewing was useful in uncovering not only the culture and readiness for system downtime but the value placed on data backfilling Wide variation found in EHR adoption and hence backfilling not only across health care organizations but across hospitals within an organization Opportunities discovered for improvements in policy/procedures, training, systems, and EHR vendor software

19. Acknowledgements • Brian Patty, MD Executive Sponsor, CMIO HealthEast • Skip Valusek, PhD Champion, Director Clinical Analytics HealthEast • Survey Participants from: • Allina Abbott Northwestern • Children’s • Fairview (8 hospitals) • HCMC • HealthEast (4 hospitals) • HealthPartners Regions • Mayo Rochester (2 hospitals) • North Memorial (2 hospitals) • Park Nicollet Methodist • St. Luke’s Duluth • VA Midwest

20. References 1 ASTM E2682 - 09 Standard Guide for Developing a Disaster Recovery Plan for Medical Transcription Departments and Businesses, http://www.astm.org/Standards/E2682.htm 3 Hurley, Brenda, CMT, “ASTM Introduces Disaster Recovery Standard -- New standard could make HITECH compliance a little easier,” Advance For Health Information Professionals, January 20, 2010 http://health-information.advanceweb.com/Features/Article-2/ASTM-Introduces-Disaster-Recovery-Standard.aspx 3 Certification Commission for Health Information Technology, http://www.cchit.org/about 4 Drazen, Erica, CSC (formerly First Consulting Group), Gilboard, Bethany, MPA, Massachusetts Technology Collaborative; Metzger, Jane , CSC; Welebob, CSC; Massachusetts Technology Collaborative / New England Healthcare institute, “Saving Lives, Saving Money In Practice: Strategies for Computerized Physician Order Entry in Massachusetts Hospitals,” January 2009 http://web3.streamhoster.com/mtc/cpoe2009.pdf 5 McEvoy, Cheryl, “The Highs and Lows of Downtime Solutions. There's a spectrum of technology and cost options to keep facilities afloat,” Advance For Health Information Professionals, January 2010 http://health-information.advanceweb.com/Editorial/Content/PrintFriendly.aspx?CC=213667 6 Getz, Lindsey, Dealing With Downtime — “How to Survive If Your EHR System Fails,” November 9, 2009, For The Record, Vol. 21 No. 21 P. 16 http://www.fortherecordmag.com/archives/110909p16.shtml 7 McEvoy, Cheryl, “EHR Downtime: The Aftermath What to Do Once the System Comes Back Up,” January 18, 2010, ADVANCE, for Health Information Professionals, Vol. 20 • Issue 1 • Page 12 8 http://vitalcenter.galenhealthcare.com/ 9 http://www.bostonworkstation.com/

21. Thank You Questions?

22. Appendix

23. Project Gantt Chart

24. Stage (0-7) of the HIMSS EMR Adoption ModelSM(Environment) At what stage (0-7) of the HIMSS EMR Adoption ModelSM are your cumulative capabilities? Circle stage. (Reference http://www.himssanalytics.org/stagesGraph.html) 0 - All three ancillaries (lab, radiology, pharmacy) not installed 1 - All three ancillaries (lab, radiology, pharmacy) installed 2 - CDR; controlled medical vocabulary; CDS; may have document imaging; HIE capable 3 - Nursing/clinical document (flow sheets); Clinical Decision Support System CDSS (error checking); PACS available outside of radiology 4 - CPOE; CDSS (clinical protocols) 5 - Closed loop medication administration 6 - Physician doc(structured templates); full CDSS (variance & compliance); full R-PACS 7 - Complete EMR; CCD transactions to share data; data warehousing; data continuity with ED, ambulatory, and OP