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Collegian 27 (2020) 542–552

Contents lists available at ScienceDirect

Collegian

jo ur nal ho me p a ge: www.elsev ier .com/ locate /co l l

riginal research

anagement of a critical downtime event involving integrated lectronic health record

eyur Davea, Rhonda J. Boormana, Rachel M. Walkera,b,c,∗

School of Nursing and Midwifery, Griffith University, Brisbane Australia Menzies Health Institute Queensland, Griffith University, Brisbane Australia Division of Surgery, Princess Alexandra Hospital, Brisbane Australia

r t i c l e i n f o

rticle history: eceived 16 December 2019 eceived in revised form 2 February 2020 ccepted 10 February 2020

eywords: lectronic health records edical informatics ealth information technology ontent analysis owntime omputer security

a b s t r a c t

Background: There are few descriptions of management of unplanned hospital-wide digital downtime and impact on patient care in health literature. Aim: The aim of this study was to undertake a qualitative review of a prolonged critical technology downtime event in an Australian hospital in 2017. Methods: Inductive content analysis was conducted on data collected through face-to-face, semi- structured, individual interviews conducted with nine hospitals employees (five nurses with direct-care/operational responsibilities, and four executive staff, including nursing) who played a role in the incident. Findings: Analysis of the data using an open-source R package led to the extraction of 139 codes, 13 first- level categories, and 4 main categories. Main categories extracted were: impact of event, response to the event, resilience and institutional reserve, and challenges and learnings. Discussion: The overall experience for interview participants was positive. Effective communication meth- ods, particularly vertical communication, enabled multi-disciplinary teams (comprising nursing, medical and pharmacy personnel) to safely transition back from downtime paper records to the integrated elec- tronic health record with no harm to patients. Participants identified teamwork contributed to a sense of comradery with clinical colleagues and executive staff. Contingency planning and training are essential

for ensuring safe and effective management of technology downtime events. Conclusion: The prolonged digital disruption and subsequent recovery was managed effectively using a face-to-face communication and support approach. This approach reduced the impact of the digital downtime and ensured patient safety. The data analysis strategy was enhanced using an computer- assisted qualitative data analysis software.

© 2020 Australian College of Nursing Ltd. Published by Elsevier Ltd.

∗ Corresponding author at: School of Nursing and Midwifery, Griffith University, Brisb el.: +61 7 3735 6463, fax.:+61 7 3176 5843.

E-mail address: [email protected] (R.M. Walker).

ttps://doi.org/10.1016/j.colegn.2020.02.002 322-7696/© 2020 Australian College of Nursing Ltd. Published by Elsevier Ltd.

ane Australia, Division of Surgery, Princess Alexandra Hospital, Brisbane Australia.

K. Dave et al. / Collegian 2

Summary of Relevance Problem or Issue Cyberbreaches represent a critical threat to integrated elec- tronic health records worldwide. Unexpected digital ‘downtime’ events – planned or unplanned periods of time when the ICT system is unavailable for use – pose a threat to patient safety, potential loss or compromise of data, and disruptions to continuity of health care delivery. What is Already Known Information and communication technology is transforming healthcare. While there is guidance in health literature on contingency planning for digital downtime, there are few descriptions on the management and impact of downtime events on health service delivery. What this Paper Adds Provides a ‘first-hand’ account of an unprecedented disruption to the integrated electronic health record of a large hospital. Informs healthcare facilities about potential inefficiencies in operational functions and suggests adaptations to enhance immunity against unplanned downtime vulnerabilities to ensure patient safety and data security.

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Nine employees who played a role in the incidence were approached by, or recommended to, the lead researcher to share

In industrialised nations, information and communication tech- ology (ICT) is transforming healthcare. Paper-based document anagement systems traditionally used in health settings are

apidly evolving to integrated electronic health records (iEHR) (Jha, oolan, Grandt, Scott, & Bates, 2008). With large-scale deploy- ent of ICT infrastructure, security and data-protection risks have

ncreased (Coventry & Branley, 2018). Cyberbreaches are an increasing threat to iEHR worldwide,

esulting in inaccessibility of critical clinical information and func- ions (Clarke & Youngstein, 2017; Healthcare Information and

anagement Systems Society, 2019). Facilities are also susceptible o sudden ICT outages due to internal disruptions such as hardware ailures (Coffey, Postal, Houston, & McKeeby, 2016), software bugs Genes, Chary, & Chason, 2013) and failed ITC upgrades (Wretborn, kelund, & Wilhelms, 2019). Unexpected system outages pose a hreat to patient safety, potential loss or compromise of data, and isruptions to continuity of health care delivery (Harrison, Siwani, ickering, & Herasevich, 2019; Larsen, Fong, Wernz, & Ratwani, 017; Wang et al., 2016; Wretborn et al., 2019).

Despite cybersecurity concerns, adoption of iEHR is vital for ransforming the standard of patient care (Raposo, 2015). Hence,

comprehensive implementation design, along with training and reparedness for nurses and other health professionals, is vital for ffective and seamless integration of ICT in the healthcare environ- ent (Coventry & Branley, 2018; Ronquillo, Winterholler, Cwikla,

zymanski, & Levy, 2018). Equally important is contingency plan- ing for ‘downtime’ events–planned or unplanned periods of time hen the ICT system is unavailable for use (Sittig, Gonzalez et al.,

014). As health organisations become more dependent on digital ecords, technical and organisational policy and procedures need o be established to guide efficient and safe transition from digital o paper-based and back again (Kashiwagi et al., 2017). While guid- nce for contingency planning is available (Jalali, Russell, Razak, & ordon, 2018; Sittig, Ash et al., 2014), there are few descriptions f iEHR downtime in health literature (Wretborn et al., 2019). A

first-hand’ account of an unprecedented disruption to iEHR in a arge hospital can be a valuable learning resource. It can inform ealthcare facilities to potential inefficiencies in downtime oper- tional functions and suggest adaptations to enhance immunity

gainst unplanned downtime vulnerabilities (Sittig, Gonzalez et al., 014).

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The current study details an unplanned hospital-wide ICT down- time of six days at a major teaching hospital in Australia. The downtime event was precipitated by an international cyberattack in May 2017 (named ‘WannaCry’) which had significant impact upon health services in the United Kingdom (Clarke & Youngstein, 2017; Comptroller and Auditor General, 2017). Preemptive security response by ICT staff led to unexpected and undetected accessibility limits to iEHR and concurrent use of paper and electronic docu- mentation of patient care, representing significant risks to patient safety. An internal emergency response was initiated and access to inpatient iEHR suspended. Relative to source, nature, and dura- tion, the incident has no precedent in academic or grey literature. Strategies to ensure safe and effective patient care had to be quickly developed and implemented. The aim of this study was to under- take a qualitative review of the impact and management of the ICT downtime event.

1. Materials and methods

1.1. Design

The Consolidated criteria for reporting qualitative studies (COREQ) checklist was used to guide the reporting of this study (Tong, Sainsbury, & Craig, 2007). Inductive content analysis was conducted to assess the impact and management of an iEHR down- time event at 23–28 May 2017. Widely used in health research, content analysis reduces data to meaningful concepts by creat- ing categories through a process of abstraction for previously unexplored phenomena (Elo & Kyngäs, 2008; Elo et al., 2014) The method provides content-sensitivity and broad description in terms of concepts and categories.

1.2. Setting

The study was conducted in a large Australian 700-bed qua- ternary hospital providing acute medical, surgical, mental health, cancer, rehabilitation and allied health services. The hospital had 110,226 admissions in 2016–2017, employed over 5500 staff, and conducted 20,269 surgeries. Full rollout of advanced iEHR capability was completed just two months before the incident and included an established schedule of four planned down- times per annum. All patient care processes were supported and recorded within a digital environment including clinician doc- umentation, care planning, clinical decision support, diagnostic orders, discharge management, and medication administration. The management of both planned and unplanned iEHR down- time events was detailed in a number of hospital guidelines to ensure the continuation of operations and optimisation of patient safety and risk management strategies via a chain of command. These guidelines included step-by-step procedures and checklists for downtime coordinators (the nurse unit manager or delegate of each ward or service) and staff (nursing, medical, radiology, pathol- ogy and administrative) to utilise during the recovery phase. As unscheduled downtimes were classified as internal emergencies, an iEHR business continuity strategy was embedded within the hospital’s disaster management plan.

Following initial review by the health service Human Research Ethics Committee, the project was considered to be exempt from full ethical review (HREC/17/QPAH/451; HREC/17/QPAH/539).

1.3. Participants

their experience during this time. While all individuals were free to refuse, all agreed to participate. Nursing participants’ roles included

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nurse executive, three nurse leaders responsible for clinical and perational matters, and two direct-care nurses. Other participants omprised a senior executive officer with organisational responsi- ilities, a medical and iEHR specialist, and a pharmacy team leader. our participants with organisation responsibilities were members f a larger incident team specifically assembled to manage the vent.

.4. Data collection

Face-to-face, semi-structured, individual interviews were con- ucted at participants’ workplaces between 19 July–31 August 017, and digitally recorded and transcribed verbatim by a profes- ional transcription service. Each interview lasted 20–66 minutes M = 42 min). Open-ended questions guided the interviews, includ- ng: “Can you tell me about your experiences during the recent hut-down of the iEHR?”; “What were the positive and negative spects of how this critical event was managed?; “What level of upport did you receive from nursing, medical, allied health col- eagues in your work environment?”; “What level of support did ou receive from the division of surgery and the organisation during his critical event?”. All participants were provided the opportunity o review and make changes to their transcribed interview before nalysis.

.5. Data analysis strategy

Analysis utilised data corpus from nine interview transcripts nd an inductive content analysis approach based on emergent ain categories to describe the phenomenon (Elo & Kyngäs, 2008).

omputer-assisted qualitative data analysis software (CAQDAS) an be a valuable tool to enhance transparency, validity, rigor and rustworthiness of qualitative research projects (Woods, Macklin, & ewis, 2016). An open-source R package (R Qualitative Data Anal- sis, RQDA: Huang, 2016) was used for this study (see Supplement

for RQDA application).

.6. Coding

Transcribed interview files were imported to RQDA. Every inter- iew was read multiple times to construct a general understanding f content and meaning. After each interview, preliminary impres- ions were coded. As more interviews were read, new codes ere added, renamed, and merged reiteratively to refine codes to

est represent the contextual information (Elo & Kyngäs, 2008). ime-related text was indexed to allowed post-hoc extraction of hronology of events.

.7. Categories (Code abstraction)

Codes were aggregated into first-level and then main categories sing a process of abstraction. Similar to the coding process, cate- ories were refined reiteratively to identify higher-order groupings nd contextualisation (Elo & Kyngäs, 2008). The process of deriv- ng meaningful understanding of categories was augmented by etwork analysis and visualisation carried out using R (refer Sup- lement 1) (R Core Team, 2013).

. Results

Analysis of the data led to extraction of 139 codes, 13 first-level ategories, and 4 main categories. Examples of the formation of ategories from codes by inductive content analysis is shown in able 1. A representation of the broad chronology of events was

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produced by reviewing and consolidating time frame of events between participants (Fig. 1).

2.1. Occurrence of codes

Codes were segregated by role of participants involved in senior organisation responsibilities (executive) and operational/direct care nursing staff (nurses). The frequency of codes provided a global picture of the content of these groups (Fig. 2). For exam- ple, timelines and codings associated with strategising were better represented in the executive group, while operational/direct care nursing staff emphasised teamwork, supportive network and pos- itives from the experience. Codes representing safety were equally distributed across both groups.

2.2. Main categories

Four main categories extracted were: impact of the event; response to the event; resilience and institutional reserve and; challenges and learnings.

2.2.1. Impact of the event This category captures the initial difficulties of iEHR access dis-

ruption, taskforce involved, and the chronology of events (Fig. 3). At the point of impact, the situation was challenging with

intermittent login difficulties and multi-layered problems with a transient sense of recovery (false-alarms).

“We were getting some reports through of difficulties logging in, but in fact people who were already logged in were okay and it was only really as new people came in that they were having difficulty in accessing.” (E1 Aug24 2017) “Then we thought it was back up and running and we started to reconcile all the patients and then it went down again.” (N1 July19 2017)

Regular updates to staff were critical but difficult at the exec- utive level due to size of the campus and functionally segregated staff. Despite availability of a variety of communication tools, no single tool was able to get across all staff members simultaneously. Verbal communication was more effective than emails:

“You could ring everybody and get people to filter it down but that takes time, or you could send emails. Well half the people are work- ing clinically, they’re not actually looking at their emails. Or you could do a run around but to get around the organisation this big, that would take some time.” (E1 Aug24 2017) “So verbally first and then executive were sending out emails that weren’t accessed, so staff wouldn’t have had time to read their emails.” (N4 July24 2017)

Multilayered challenges included limited life of downtime printouts, false alarms, and unpredictability of downtime.

“So, we got to a point in the downtime where the medica- tions that were in the downtime viewer were going to expire.” (N6 Aug3 2017) “we weren’t sure of the period of time we were going to be down for.” (N2 July19 2017)

A large taskforce was involved to deal with the impacts felt dur- ing iEHR disruption and provide expert support and rapid response during the critical event (Fig. 3, ‘TaskforceInvolved’).

2.2.2. Response to the event

Defines response by strategic planning, communication tools

used, patient safety, and identification of solutions (Fig. 4). Communication tools such as text messages, face-to-face,

phone, emails, social platforms, and the emergency public

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Fig. 1. Timeline of activities during the downtime event (WannaCry: ransomware attack; Code Yellow: internal emergency; Downtime: access to inpatient iEHR suspended).

Fig. 2. Barplot of coding frequency between interviews. Coloured by groups, executives (4 interviews) and direct-care nurses (5 interviews).

546 K. Dave et al. / Collegian 27 (2020) 542–552

Table 1 Sample data extract containing “Example text”, initial “Code”, developed “First Level Categories”, and overarching “Main Categories”

Example text Code First-level Category Main Category

In fact, people are pretty good in saying look maybe you should take a couple of hours off. Go and sit in the sun

Supportive Human values and relations

Resilience and institutional reserve

There are some lessons learned but there was no patient harm. No patient harm Focussing on safety Response to adverse event

This was obviously unscheduled, it was unpredictable and also it was partial. . .

Access disruption Experiencing difficulties

Impact of the Event

I think this is going to be a problem for the future in where people move between hospitals, between a digital hospital and another — they’ve going to have to re-school themselves in or at least have an orientation to how to write in paper records just as much as we have to orient people coming in in how to use the electronic record.

Orientation for paper Lessons for future Challenges and learnings

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ig. 3. Network visualisation of codes and categories representing ‘Impact of the eve ategories, and node colour corresponds to main category.

nnouncement (PA) system were deployed. Task-specific mobile evice carried by nursing staff proved to be efficient in rapid updat-

ng. Use of the PA system was successful, however all participants escribed ‘face-to-face’ communication most effective, direct, and eassuring.

“. . .it’s easy to have a very quick conversation . . . I think that per- sonal approach and the reassurance for anybody who had concerns . . .” (E1 Aug24 2017) “He walked around and checked up on the teams . . . Even a repre- sentative from that company walked around and - couldn’t really

do too much to help out but walked around to make sure people were doing okay.” (P1 Aug23 2017)

ge links are weighted by code frequency, edge line colours correspond to first-level

The PA system was considered carefully despite its effectiveness in updating as there may be potential implications in a healthcare setting and patient care.

“I think it’s necessary, for the people who didn’t catch the other forms of communication.” (P1 Aug23 2017) However, initially they failed to use the loudspeaker system because I believe they worry about causing distress to the patients and family members in the hospital.(̈N4 July24 2017)

Proactive measures in preparation for a potential cyberattack

was suggested to have inadvertently caused the issue.

“. . .as a result of preparing for the potential cyberattack that in fact created our problem. It was one of those hundreds of

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ig. 4. Network visualisation of codes and categories representing ‘Response to t rst-level categories, and node colour corresponds to main category.

patches that we put in that saw our own staff logins as a threat.” (N6 Aug3 2017)

Consequently, a solution in terms of a new firewall was insti- uted.

Participants noted that successful recovery was due to organisa- ional responsiveness in terms of strategic resource allocations to

aintain critical infrastructure without interruption and with no mpact on patients.

“So, we said we’re going to go completely to downtime for our inpa- tient areas. We’ll try and maintain our emergency department and our outpatient functions and see if that helps the overall numbers.” (E1 Aug24 2017)

Furthermore, strong leadership presence, clear decisions, and leading by example’ helped recovery and motivated recovery eams.

¨That just makes you feel like I want to do it too because. . .they were both so engaged and ‘what can we do’, and energised with the whole process, I think that just leads by example. It’s just so strong and such a good presence.(̈N1 July19 2017)

Establishing a checklist was one of the strategies implemented or recovery, which proved useful according to the participants.

¨We had a checklist that was given to us to say, the nurse does - iden- tifies patients that are for conversion. . .I think having the checklist made it really clear what we needed to do. . .(̈N3 July19 2017)

The primary focus was to ensure transition back to digital with- ut duplication of records or compromising safety in medication

nt’. Edge links are weighted by code frequency, edge line colours correspond to

administration. Participants discussed activities of assessing risks and proactively managing patient care:

". . .we also had a two-step process of transcribing the medications that were given that day, the last medication that was given, for continuity to make sure that the patient didn’t receive a double dose for example within a certain time frame." (N3 July19 2017)

2.2.3. Resilience and institutional reserve Defines adaptiveness and resilience of the organisation based on

positive experiences, core human values, and preparedness (Fig. 5). According to participants, core human values such as support-

ive, camaraderie, positive teamwork and strong trusting relations were motivating factors in successful recovery from this event.

". . . one of the key words that was used was comradery. . .I think it brings people together. There’s no doubt when you are forced in a situation where you need a high degree of cooperation ..." (E1 Aug24 2017) "I was just proud to be a part of it to be honest. It just showed that it doesn’t matter how bad things get, if we can work together you can get through it pretty much really. I love my job, I love where I work. . ." (N5 July25 2017)

Converting the medication records back to digital was a com- plex procedure. A clear plan (checklist) of transcription checking by three healthcare professionals (nursing, medical, pharmacy)

working as a team helped transition back to normal operations. Transcription back to digital records was the most crucial period with a huge bearing on patient safety. One participant explained the actual process in more detail:

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ig. 5. Network visualisation of codes and categories representing ‘Resilience an orrespond to first-level categories, and node colour corresponds to main category.

". . . how we did that physically is we got charts from patients’ bedsides. We worked room by room and allocated charts to the residents or the medical officer that was present for transcription. Once they were done, we handed it to the pharmacist to review the chart. They would put a digital hospital sticker and then identify with us to let them know that this patient has been converted. So, it would go on the record to say this person has been converted. Then we would go to the bedside and communicate with the nursing staff and on to the patient as well to say that they’re now back on the digital record." (N3 July19 2017)

Overall, the participants described this event as a positive xperience where teams worked together supportively without ffecting critical aspects of hospital function:

"There are some lessons learned but there was no patient harm. . .we’ve just shown that we can have a downtime and it doesn’t affect patient harm and it doesn’t affect too much the busi- ness of a big hospital." (M1 Aug31 2017)

A number of participants noted that due to the downtime con- ingency plans that were in place it was easier to deal with iEHR ccess failure in a calm and controlled manner.

"One of the positives was our staff were well prepared and versed in the downtime procedures." (N6 Aug3 2017)

.2.4. Challenges and learnings

Defines the overall challenges and learnings based on key

ependencies and negative experiences (Fig. 6). Some participants noted that key dependencies such as the

mergency departments and outpatient functions are heavily

itutional Reserve’. Edge links are weighted by code frequency, edge line colours

reliant on iEHR. Furthermore, familiarity with the efficacy and ease of electronic records meant that staff were dependent on iEHR access. Consequently, the impact of disruption to electronic sys- tems was commensurate with the extent of reliance.

". . .Just the familiarity with medications and all of the things that are associated with clinical care is just so much easier with the elec- tronic record and people become used to that. . . You don’t realise how automated things are now with the electronic record and the checking and all those things that go on within the record are not available in the paper system." (E1 Aug24 2017)

Some participants recognised instances when a staff member inexperienced in paper-based records were finding it difficult to prescribe medication on paper:

"The interesting part in that is I had a couple of staff going, what does that mean?. . . Because they had never not worked in the digital system. . ." (N2 July19 2017)

Another participant felt that not knowing the cause of the dis- ruption and delay in notification to go to full paper downtime could be improved in the future:

"One of the major issues was - my experience at the time, there was a delay with notification that we were switching from EHRs to go over to paper. . . " (P1 Aug23 2017)

Workload and fatigue were acknowledged by executives seek- ing answers to how best to address ‘burnout’ and m̈aintain the

organisation at that high level of readiness and responsiveness in these situations(̈E1 Aug24 2017).

Other participants expressed their concerns:

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ig. 6. Network visualisation of codes and categories representing ‘Challenges and rst-level categories, and node colour corresponds to main category.

¨We had a very high activity, high acuity workload at that time. I think the level of fatigue wasn’t recognised. . .(̈N4 July24 2017)

Some participants expressed that having more practice with igital disruption during business hours would improve future esilience:

"In this case it’s imperative for our staff to understand how we understand the downtime viewer and to understand how to do that. They have to practice with it and they have to know what’s in the computer system, how to access the computer and what’s in the downtime viewer box." (N4 July24 2017)

A similar approach as an emergency team designated for re-related events could be implemented for iEHR disruption mergencies.

. Discussion

This study described and analysed management of a critical ICT vent at a large hospital, identifying core strengths to overcome hallenges, and key learnings to improve future responses. Induc- ive content analysis of interview data of staff involved in the critical ncident revealed four contextual categories pertaining to 1) impact f the event; 2) response to the event; 3) resilience and institutional eserve and; 4) challenges and learnings. Overall, the experi- nces of the participants interviewed were predominantly positive

remised on effective use of “face-to-face communications”, “sup- ortive” work environment at all levels, “positive teamwork” in dverse situations, “strong leadership” at all levels, and efficient nd proactive “planning and management”. Below is a summary

ings’. Edge links are weighted by code frequency, edge line colours correspond to

of analysis findings including discussion of issues highlighted by participant comments.

To recap, the event commenced with transient problems with access, later identified as login-related. Diagnostics was difficult in the first 24–48 hours, but the disruption was eventually linked to the application of multiple security patches to existing systems. Face-to-face communication was the most effective means of dis- seminating information although participants expressed a need for formalised communication infrastructure to allow instantaneous message delivery. The initial disruption involved concurrent use of paper and electronic records, classified as a ‘dangerous zone’ by a number of participants. Development and testing of a safety check- list enabled transition back to digital records without incident. Participants noted that, despite the extended downtime, clinical services continued without any noticeable interruptions or safety concerns.

3.1. Communication

Communication is acknowledged as a critical challenge and key focus for improvement by health facility stakeholders who have experienced unplanned downtime events (Coffey et al., 2016; Genes et al., 2013; Larsen et al., 2019; Primeau, 2018). Information sharing, a reciprocal process of sending and receiving informa- tion, predicts effective team performance (Mesmer-Magnus & DeChurch, 2009). In the initial stages of the event, the leadership

team needed to get vital information to staff, offer reassurance that a solution was being sought, and provide clear directives. Similarly, feedback from the clinical setting was critical to inform problem- solving and decision-making in the command room.

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Although notifications were dispatched via multiple modes, here remained a risk that some staff did not receive the original

essage or subsequent status updates. Dynamic staff move- ent defined by multiple employee conditions (e.g., roles, hours,

bsence) and characteristic of large complex health settings, have mplications for information sharing strategies (Australian Institute f Health and Welfare, 2015). The decision to operationalise the A system was crucial, despite concerns regarding misapplication f equipment commissioned for emergency use, and perceived isk of provoking anxiety of patients. The action was not unprece- ented; Coffey et al. (2016) reported making PA notifications uring an unexpected computer hardware failure in a large US esearch hospital. During the current event, steps to mitigate atient anxiety included reassurance by staff as they interacted ith patients and regular official update notices delivered with atients’ meals. Interestingly, although communication using the A system was effective, participants most strongly endorsed ‘face- o-face’ communication as it was direct, personally delivered, and eassuring.

Face-to-face communication and reciprocal flow of information etween staff on the floor and the leadership team contributed to he sense of comradery expressed by participants who referenced he support, cooperation, and cohesion observed during the event.

any felt it noteworthy that hospital and IT executives walked hrough the hospital talking to staff and checking on their wellbe- ng. This corresponds to the insights gained from a 10-day system utage in a Canadian hospital, where the presence of the leader- hip team on the wards was acknowledged as important to staff orale (Minghella, 2013). Large health service institutions need

olicies for communication strategies and procedures relative to EHR disruptions. In particular, to establish a mechanism of verti- al communication that encourages participative involvement and upports judicious decision-making and staff cooperation within rganisations (Bartels, Peters, de Jong, Pruyn, & van der Molen, 010).

.2. Teamwork

The process of safely restoring patients’ medication records to he digital platform was conducted by multidisciplinary teams omprising nursing, pharmacy and medicine–quickly assembled nd without familiarity and stability normally established in teams ver time (Marks, Mathieu, & Zaccaro, 2001). Nevertheless, the olossal task was accomplished by the ad hoc teams during two ays of intensive activity, comparably quicker than over a week as eported following a US hospital downtime event of 33 h (Coffey t al., 2016). Attitudes critical to cooperative teamwork include a ense of competence to achieve team goals, trust in others to con- ribute, and a belief in the importance of teamwork (Salas, Shuffler, hayer, Bedwell, & Lazzara, 2015). The success of the hastily-formed eams may be attributable to the collective strength of diverse rofessional roles and skills, key to solving complex real-world roblems (Haynes et al., 2019) and motivated through sharing

meaningful goal (Van Der Vegt & Bunderson, 2005). Although ospitals are traditionally hierarchical (Taran, 2011), research con- istently shows that multidisciplinary teams comprising many evels or specialties of health professionals are associated with mproved patient outcomes and satisfaction (Epstein, 2014).

.3. Contingency planning

A challenge identified was delay as ICT staff sought to accurately

iagnose and treat the problem. This led to confusion and false- tarts but ensured solutions were tested and safe for patients. Other ospitals reported an interim period of instability while the source f iEHR disruptions were identified and solutions provided (Coffey

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et al., 2016; Genes et al., 2013). In the current study, concurrent use of digital and paper records introduced the risk of missing or dupli- cated documentation, particularly in relation to medication. This prompted the decision to adopt a multidisciplinary checklist model for prescription, administration and documentation of medication during the recovery transition back to digital health records.

Contingency planning is essential in preparing for iEHR dis- ruptions (Sittig, Ash et al., 2014) to minimise untested response strategies while ensuring health services (Jalali et al., 2018). Whether ICT disruptions are caused by software malfunction or cyberattack, policy, training, and decision-making frameworks are instrumental in strengthening hospital preparedness and safe and effective healthcare during an event. Evidence-based measures to prevent, reduce, or mitigate iEHR-related patient safety issues are provided by the Safety Assurance Factors for EHR Resilience (SAFER) guides, sponsored by the US Office of the National Coordi- nator for Health Information Technology (Sittig, Ash et al., 2014). Recommendations include strengthening technological hardware and software, and developing policy and procedures to optimise safe use of electronic health records and guide activities in the event of the system being compromised (Sittig, Ash et al., 2014).

The SAFER Guides recommends the development of written pro- cedures for substitute workflows to guide staff in how to function in a paper-based environment (Oral, Cullen, Diaz, Hod, & Kratz, 2015). Feedback resulting from this extended downtime revealed the high use of paper charts and assessment tools led to a shortage of supplies. In response, the hospital developed formal downtime procedures such as the transition checklist to ensure wards had adequate stationary supplies. Similarly, two US hospitals (Coffey et al., 2016; Genes et al., 2013) reported being ill-equipped in access to paper documents for use during extended downtime events. For example, forms stored on the web were poorly indexed and diffi- cult to locate (Coffey et al., 2016). It is commonly recommended that health facilities ensure availability of paper forms in all patient care areas (Primeau, 2018). Coffey et al. (2016) reviewed and updated paper downtime forms and created a ‘downtime toolkit’ to be installed, maintained, and restocked by each individual area.

Participants expressed a need for more digital disruption training during business hours to improve familiarity in off-line operations. While planned downtimes were embedded in organ- isational policy and undertaken every three months (during the night to reduce disruption to the delivery of patient services), this approach may not have adequately prepared staff. Well- intentioned policies and procedures may inadvertently disrupt work patterns and relationships that underlie resilience to unex- pected operational challenges. In this study, analysed participants interviews identified effective, emerging work patterns that may contribute to best practice to safely recover from unplanned down- time events and provide guidance to other health services (Hegde et al., 2020.

3.4. Study limitations

While many participants noted there was no patient harm dur- ing the downtime event, this study did not interview patients or analyse clinical data to assess the consequences of the digi- tal disruption from patients’ perspectives. The adverse impact of unplanned downtime on patient safety and management of clin- ical services has been documented. A review of patient safety data from multiple US facilities for three years to 2016 identified 76 downtime-related incidents (Larsen et al., 2017). The majority were laboratory issues (49%), often resulting in specimens hav-

ing to be redrawn and delays in reporting results (Larsen et al., 2017). Medication-related incidents, involving administration of the wrong dose/medication or incorrect ordering, was the sec- ond most common (14%). An Australian hospital study showed

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hat even brief system outages can cause delays in pathology pro- esses and impact on patient safety (Wang et al., 2016). Observation f emergency department activities during unexpected downtime vents revealed increased patient length of stay (Genes et al., 2013; retborn et al., 2019), higher patient walk-out rate (Genes et al.,

013), and an increase in perceived workload by staff (Wretborn t al., 2019). Surgeries conducted during downtime were typically onger (Genes et al., 2013; Harrison et al., 2019).

. Conclusions

Analysis of nine interviews of clinicians across the care contin- um identified that the magnitude and complexity of the problems ue to iEHR disruption were unprecedented and unpredictable. ultiple layers of decision-making, proactive initiatives with keen

ocus on patient safety, and strong horizontal and vertical leader- hip were crucial elements in successful recovery and operational ormalisation. The computer-assisted qualitative data analysis trategy enabled a reproducible, transparent, valid and rigorous pproach to inform downtime preparedness for digital health ser- ices.

unding

The Division of Surgery at the Princess Alexandra funded the rofessional transcription of interviews.

thical statement

Ethical approval was granted for this study. Following initial eview by the health service Human Research Ethics Committee, he project was considered to be exempt from full ethical review HREC/17/QPAH/451; HREC/17/QPAH/539).

onflict of interest

We wish to confirm that there are no known conflicts of interest ssociated with this publication and there has been no significant nancial support for this work that could have influenced its out- ome.

RediT authorship contribution statement

All persons who meet authorship criteria are listed as authors, nd all authors certify that they have participated sufficiently in he work to take public responsibility for the content, including articipation in the concept, design, analysis, writing, or revision of he manuscript. Furthermore, each author certifies that this mate- ial or similar material has not been and will not be submitted o or published in any other publication before its appearance in ollegian.

cknowledgements

We would like to thank the participants for their time and nsights.

ppendix A. Supplementary data

Supplementary material related to this article can be found, in he online version, at doi:https://doi.org/10.1016/j.colegn.2020.02. 02.

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