Home » Dr. Jayne » Currently Reading:

Curbside Consult with Dr. Jayne 4/15/19

April 15, 2019 Dr. Jayne 3 Comments

I was out with a friend on Saturday, at least until he had to leave to go to a planned downtime event at work. He mentioned that in all the years he had been with his company, it was rare for a downtime or disaster-recovery prep event to go as planned.

Maybe his industry has less tolerance than we do in healthcare, but it got me thinking about the impact of downtime in the patient care environment. The Journal of the American Medical Informatics Association published an article on this recently: “Clinical impact of intraoperative electronic health record downtime on surgical patients.”

Many of us just read the abstracts, and a quick pass yielded some interesting information. Researchers looked at the impact of EHR downtime events lasting more than an hour over a six-year study window. Specifically, they looked at adult patients undergoing surgeries more than 60 minutes in length during an inpatient stay lasting longer than 24 hours. Since it’s hard to do certain kinds of controlled studies on events like this, they matched more than 4,000 patients exposed to one of 176 downtime episodes with 4,000 patients who weren’t similarly exposed.

Looking at the math superficially, this means that the facility was averaging more than 29 downtime episodes a year, each lasting more than an hour. That’s pretty striking – approximately one every 12 days. I’ve never worked in a facility that had that kind of downtime and I can’t imagine the anxiety that clinicians might feel in that situation.

The authors found that although the patients exposed to a downtime event had operating room times and postoperative length of stay that were slightly more than unexposed patients, the 30-day mortality rates weren’t any different. In short, there wasn’t an appreciable link between the length of the downtime event and significant adverse events.

I wondered whether the sheer volume of downtime episodes might have been protective in this facility and decided to dig deeper than the abstract to find out more about the study site. The devil is in the details in this scenario, especially since the data was gathered at the Mayo Clinic. The identified downtimes could have occurred in any of the seven applications considered core clinical systems in support of the operating room. These included the anesthesia information management system, PACS, CPOE, clinical documentation, an integrated clinical viewer, the surgical information recording system, and the surgical coordination system.

Researchers categorized the length of the downtime as well as its impact, whether limited functionality was available or whether it was a complete outage. Scheduled downtime events were excluded as were those less than 60 minutes long. When matching exposed and unexposed patients, the team looked at day of the week as well as time of day to control for any variation in staffing, facilities, and EHR load. The patients were also paired according to surgical specialty, emergency / non-emergent status, and physical status.

The typical downtime was on a weekday between 7 a.m. and noon and was not a complete outage. The most commonly impacted systems were the integrated clinical information viewer, PACS, and CPOE. Surgical subspecialties most commonly impacted included general surgery, orthopedic surgery, and cardiac surgery. The median age of patients was 61 years, with a range of 49 to 71.

Although 30-day mortality wasn’t impacted by downtimes, interoperative duration was about 10% longer for the procedures where there were outages or interruptions. Longer operative times have been linked to greater risks of complications and also can lead to higher costs to the facility. In my experience, this also impacts physician morale, with surgeons who feel their schedules have been delayed becoming irritated and at times agitated. The operating suite is one of the parts of the hospital where the adage about time being money is truly applicable. They also noted a 4% increase in length of stay, which also has cost implications. Both increases underscore the need to have strong plans in place to help staff contend with unplanned downtime.

The authors further conclude that there is a need for future studies looking at scheduled vs. unscheduled downtime and parsing it down to specific systems to determine impacts at a more granular level. They also note the need to look at data from different facilities and healthcare settings. They also identified a limitation in the matching, namely that procedures weren’t matched year by year. Since there are constant changes in surgical technique and significant changes in some procedures, the year could have been a confounder. They also noted that, “In this context, it is not possible to generalize the results of this study at our institution to the potential impact of resilience and specific contingency planning to other hospitals.”

I don’t see other facilities planning to line up to bare their downtime data. Additionally, investigators at other institutions may not have the robust longitudinal downtime data that these authors had access to and they may not have the full cooperation of information technology staffers. I still see hospitals where the culture of fear is alive and well and efforts to study incidents in order to improve processes may still be met with suspicion. There are also those where downtime processes are fairly disorganized and they wouldn’t be suitable candidates for study.

I got a surprise Saturday evening when my friend reappeared unexpectedly from his downtime event. His comment about his company’s events not going as planned was prophetic because they actually canceled the downtime before it even started. It was good for a chuckle, although the theoretical risk of downtime events in the patient care environment is no laughing matter.

I’d be interested to hear what readers think about this EHR downtime study and whether they believe their institutions would be willing to undertake that type of analysis of their own data.

Got downtime? Leave a comment or email me.

button

Email Dr. Jayne.

View/Print Text Only View/Print Text Only


HIStalk Featured Sponsors

     

Currently there are "3 comments" on this Article:

  1. As a former CIO, I don’t think I would have had my job very long with that frequency of down times, particularly unscheduled ones happening from 7 AM to Noon. I caught hell for scheduled annual EHR upgrades, in the middle of the night, lasting more than a few hours.

  2. Just slightly off-topic, but I recently heard an interesting downtime rule-of-thumb: Every hour of downtime requires 2 hours of catch-up work.

    I’m a grizzled healthcare veteran at this point and I’d never heard this particular guideline. If you wanted to cost-justify maintenance, infrastructure, procedures, processes and all the rest, you could do worse than to use this standard.

    We have always avoided downtime as a moral good. Downtime is bad for the clients. Downtime causes reputational damage to IT. Of course you minimize downtime!

    But to have a standard by which you could actually assign a cost to downtime? Or to quantify how much work the downtime would cause? Never.

  3. Thanks for (actually) reading our paper. I enjoyed the story of your friend, as well as the translation of numbers to emotions such as anxiety, morale, and fear. As for your concluding question/comment, in my opinion, as you also wrote, the devil is in the details. It is also my opinion there is an increasing (false) conflation within clinical and biomedical research in general that quantitative equals objective and qualitative equals subjective. In this sense, I can argue this paper is merely an attempt to make clinical anecdotes concrete. In the case of your friend, if medicine and/or health care proper are approached as “just another industry”… I think it remains to be seen if physicians and other health care leaders are ready to move from anecdotes to numbers, the concept “numbers do not lie”. I have already commented upon the conflation of quantitation, plus emotions, and also enjoyed your reference to one of our (many) limitations. Ultimately, it is my personal opinion modern society is currently seeking too many answers, placing too much hope, in so-called AI/ML. I also believe “magic” AI/ML solutions may produce serious answers, some decade. However, in (current) reality, there is simply limited data granularity access for research, in the context of an increasing number of mixed/blurred physical & electronic “threats” in major news headlines. I think some of these headlines are hype, a form of Security Theater. In some of these cases, I also think Security Theater “solutions” can create a sense of “false security” and thus potentially *increase* danger. In other words, I hope other institutions attempt to reproduce our results. Likewise, compare our results between institutions. We tried our best to capture the downtime phenomenon, which is already understood on some anecdotal & emotional levels, but perhaps not easily appreciated until the (real) danger manifests. Thanks again, Andrew







Subscribe to Updates

Search


Loading

Text Ads


Report News and Rumors

No title

Anonymous online form
E-mail
Rumor line: 801.HIT.NEWS

Tweets

Archives

Founding Sponsors


 

Platinum Sponsors


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  type='text/javascript'>OA_show('Platinum108');

 

Gold Sponsors


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reader Comments

  • Grahame Grieve: "Until the vendors are required to align to a standard" That's not enough. The vendors ship very configurable systems...
  • FRANK POGGIO: Looks like McGee skewered all the bad actors except the one primary culprit. He has not seen the enemy that is US! "We" ...
  • Woodstock Generation: Hey, I have nothing against 90s or any other music from the circa 50s to the present. And shout-outs to great album musi...
  • Randy Bak: I think the comment may have (too?) quickly stepped through single payer on the way to the ultimate worthy conclusion. ...
  • Consumerfriendly: These primary care physicians are highly paid compared to the average worker, international averages, etc. People expect...
  • David Perlmuter: Bravo! Those grown people find “adulting” tiresome and unpalatable in the context of their own health and every o...
  • TheAmericanNightmare: Politicians already take large amounts of money from corporate healthcare companies. It is really strange to hear someon...
  • Van Sims: After reading the article I feel for clinicians that are experiencing burn out. I can only imagine what it is like to ge...
  • Dan Cook: NYT op-ed piece. Generally EXTREMELY sympathetic to clinicians and the burdens placed on them, but, out of touch much O...
  • Mr. HIStalk: I try not to repeat "Listening" recommendations to expose readers to new musicians, so I last recommended Veruca Salt in...

Sponsor Quick Links