When the Electronic Medical Record Goes Down

Shortly after 10 am on a busy morning not too long ago, our office electronic medical record system went down. It was a system-wide failure, and it lasted for over 12 hours.

Given that we had been online since last June, I was actually pretty impressed when I realized that we had gone as long as we had without a major glitch. But that realization didn’t help much while I was in the midst of busy office hours.

Because, as these things always go, we had done nothing in advance to prepare ourselves for the inevitability of a major EMR down time. Now, of course, we know what to do, and that is the point of this post – to prepare you for the same inevitability in the hopes that you won’t have to go through what we did.

Twelve Steps to Recovery from an EMR Downtime

Step 1 – Admit that you are powerless over the EMR – and that your practice has become unmanageable without it… Oops, sorry. Wrong 12 step program…

Step 1. Don’t panic. There is a back up. If you work in a big place like I do, I can’t imagine you don’t have a mirror server. Have you IT folks prepared to give you read-only access to it while they work on the problem in the background.

Step 2. Be prepared. You would be surprised how quickly all the paper disappears once you’ve been online for a few months. By the time we went down, we had nothing left but a few old lab reqs and blank computer paper. So, long before you ever need it, make a list of paper supplies necessary to function during a prolonged down time. Things like your old visit templates, superbills, radiology and lab requisitions, labels, receipts, message books, etc. Ask input from the entire office staff on this one. Gather a supply of these things (enough for several days if need be) and put it all in a big box or file drawer labeled “EMR Downtime supplies”. Make sure everyone knows where it is, and check it periodically to be sure no one has rifled through it.

And keep a supply of prescription pads locked away in your desk drawer. I had none, and ended up calling in all my scripts that fateful day.

Step 3. Go back to the future. While you are down, shift into paper mode, just like the old days. Write your SOAP notes, check off those boxes in your paper exam template and write your assessment and plan. Write full notes. (Don’t worry – I’ll tell you what to do with those notes in step 9). Don’t count on having the time to recreate it all later – you won’t. I spent an entire Saturday in the office getting back on track because I only wrote little shorthand notes and brief exam summaries, and then had to create the visit note once we were back online.

Step 4. Don’t try to do it all. Patients calling for non-emergent appointments should be asked by your staff (nicely and with profuse apologies) to call back tomorrow. Better yet, have your staff take their number and call them back the next day to schedule. Tell patients needing refills that you’ll get to it tomorrow unless it’s urgent. No point overburdening the staff and you at this moment.

Step 5. Manage the Spin. Make sure your staff notify patients in the office about what’s going on, so they understand if things seem a bit chaotic. No whining and complaining, just cheerful efficiency and mild jokes. Don’t lose track of what’s important – your interaction with the patient. When he/she leaves that day, they should remember that they were the focus, not the office systems.

Step 6. Don’t expect yourself to remember everything. If you can’t get read-only access to your patients’ online records, ask them to fill out a new patient history form in the waiting room before you see them. Since you’ll be running way behind anyway, it’ll give them something to do to feel useful while they’re waiting. I told my patients – “Pretend this is your first visit, and I don’t have your chart – because essentially, I don’t have it. So don’t assume I know everything about your medical history, and tell me anything you think I need to know. You won’t insult me.” No one complained.

Step 7. Don’t compromise patient care. If it’s not an emergency, and you’re uncomfortable starting a new treatment or medication without access to the record, don’t. Tell the patient you’ll review her record once you are back online and call her to finish up the treatment plan at that point. I did this with several patients, and was I glad I did – one woman had forgotten to note in her history form a condition which happened to be a major contraindication to the very treatment option we were discussing. I saw it immediately upon reviewing my records the next day and was able to switch gears with no harm done.

Step 8. Enjoy the down time. Take the time you would have used online checking email or writing consult letters to get to know your office staff. Maybe even order in lunch for everyone. And, since there’s nothing anyone can do once the last patient is seen, you all get to go home early. (That’s the best part…)

Step 9. Plan for an easy catch-up. Next day, when you get back on line, open up your visits from yesterday and write a (very) brief online visit note summarizing any info you’ll need later on to care for the patient. Have your staff scan your paper notes in to the electronic chart as support documentation, and you’re done.

Step 10. Check your charge interface. If you have a direct EMR to billing interface (we don’t – yet), check to be sure that no charges were lost during the down time. Charges from the previous day may have been transferring in at the time of the crash, or been lost during recovery.

Step 11. Learn something from the experience. As soon as possible, meet with your IT team to debrief and plan for the next downtime. Because you all know now that it’s going to occur again. But hopefully, not in the near future.

Step 12. Carry the message. If any of you have gone through a similar experience, and have additional suggestions, do drop a comment below. After all, we’re all in this together.

And, having had a spiritual awakening as the result of these steps, we must try to carry this message to other EMR users, and to practice these principles in all our electronic affairs…