Saturday, October 14, 2006

Lights out

Thursday was a terrible day. Our server went down at 2:30; then a transformer blew, and the electricity went out for my street at 3:30, for the rest of the day.

With no electricity, I could not even access my old charts, which are stored on my external hard drive. The data on those is already a couple of months old, but at least there is some information there. This is a risk of going fully paperless: if there is a major power interruption, I am stuck.

Having been through a couple of server problems earlier on, I had some idea of what to do: jot brief notes on paper; only give prescriptions that are not recurring (such as antibiotics), or recurring prescriptions for patients who were on only one medication and knew what it was (such as birth control pills). All complex renewals to be faxed to the pharmacy once the system was working again. It was difficult to function: people were asking me what the result of their tests were, and I could not tell them. None of my fancy recall systems were working: I had no flowsheets for a diabetic that came in; I could not remember exactly why I had asked an elderly patient with multiple problems and cognitive impairment to come in (and neither could he). I ended up rescheduling some appointments.

I work late on Thursdays; without access to the scheduler, we had no way to even call patients to ask them not to come if they were booked after sunset. My secretary brought some flashlights. One of my exam rooms has a window and faces West, so I saw patients there while there was still light.

The server came back on at 6:30 pm (which was of no use to me at the office, without electricity). I went home after seeing my last patient in the dark, and completed my charts remotely. I left for a conference the next day.

My group is very unhappy with this server interruption. We will be meeting with the company to discuss what happened: service interruptions can come from the hospital, from SSHA (which provides our internet access), and from the server itself. Since start-up, we have had interruptions caused by all three. Having a centrally managed server has advantages (managed backups, managed security, centralized upgrades, ability to securely share patient data between several providers), but also introduces complexity to the system. Along with this complexity come multiple possible failure points. I think my group is an early adopter of an enterprise-level system; down the line, it is probably the right way to go, but this week it just felt like a lot of birthing pains.

Michelle

10 comments:

Anonymous said...

That is horrible to hear about your server going down. Was it narrowed down to your vendor's problem? What was the process to get your server started again and how did you track down the responsible party? I find with our EMR that the software vendor will pass things off to SSHA or sometimes to the hardware vendor.

I'm also interested to hear your comments about how well the EMR process is received by your patients on a day to day basis. Some of the doctors in my clinic only enter in their notes at the end of the day while I can type fast enough to enter all the information in while I speak to the patient. But this makes me wonder if typing while talking to a patient disrupts the encounter or makes the patient feel uncomfortable.

Michelle Greiver said...

It appears to have been a server problem. The server had to be restarted. I'm away at a conference this week (and logging in remotely to the EMR), so I'm not sure yet.

When we have a problem, we call the company. It is too hard for us to know who is responsible; our contract states that we call Nightingale for both hardware and software problems.

Having said that, things don't always work perfectly: we don't always get a clear answer right away, and sometimes there is finger pointing. We do expect them to go to bat for us, no matter who is responsible; we get an email letting us know what is happening.

As far as my patients and the EMR, I really can't see a problem. They don't seem to see much of a difference. In fact, I just attended a research talk that found exactly that: patients don't really care one way or another, provided they trust you. The EMR has enabled me to show them more of their results, and also to print their CPP when they have a check up.

I do some typing during the encounter, and enter data that I'm likely to forget (numbers), or things that need to be done in the encounter, like prescriptions. The rest is typed after, because I'm much faster with templates when I can concentrate just on doing them. One thing that is different is that I type consultation requests during the encounter, which I didn't do on paper. I print a copy and give it to the patient; they then have the specialist's address and phone number. I print a second copy to fax along with the CPP and relevant results. That works better, because I don't have pending consultation requests to do, and I ask my patients as I'm typing to make sure that the information is correct.

Another study that I heard found that typing did not make the patient feel uncomfortable and did not disturb the encounter. They also found that the amount of chart information shared with the patients was much greater with EMR than with paper charts. That is very consistent with what I have found in my practice.

Michelle

Anonymous said...

From Anony-mouse - you should consider running the patient summaries and recent copies of the reports, at night, in-batch, a few days in advance of an appointment and print them to Adobe PDF. The PDFs should be stored on a local password-protected machine that is also backed-up to a password-protected drive. This way, the files can be printed if required or deleted and removed from Trash if not. This works for our group and a number of others.

Michelle Greiver said...

Yikes!! That's a quite a bit beyond what I can do. It also wouln't have helped me, since I had no electricity.

Michelle

Jel Coward said...

It sounds like you are suffering the classical problems of a remote server EMR ie you are falling victim to the multiple failure points (server at their end, power at your end). I am amazed that a remote server EMR doesn't have any 'fail over' capacity ie so that if the server goes down, another one kicks in. Am I allowed to ask which EMR you are using?

Michelle Greiver said...

I've now heard from several people whose (local) servers failed at some point in time. Servers are machines, and can fail. I think it is good to be prepared. What is likely to happen over time is that the failure rates will decrease, both because of better engineering and because of increased redundancy (which is what you are talking about). I had several home broadband interruptions in the first few years, but none recently.

I think a difference between paper and electronic records is that the paper record involves regular, daily, on-going failures (chart can't be found; lab not there; no alerts; no drug interactions etc). With electronic charts, you remove a large proportion of the chronic failures, but you do have the risk of discrete failures. This should be minimized, but can't be eliminated. I think, over time, that the cumulative effects of paper-based failures will dwarf those of electronic failures. I would not view this as a valid reason to avoid EMRs.

I use myNightingale.

Michelle

Anonymous said...

Re: print to PDF on secured PC - Dr. Greiver - I would not think you should have to do this. Your vendor should be doing this on your behalf, especially if they are at-fault for the outage(s). A small uninterruptable power supply (UPS) can be placed on a PC, printer, and your network gear in the office (~$200/each) and the vendor can setup a report with the critical elements you need. The report "prints" to a PDF file that can be read by you/your staff and printed in the event of an outage. The UPS provides temporary power in the event of an outage. Some of the better UPS' provide automation software that can be used to automatically kick-off a script in the event of a failure (i.e., print all reports in this directory then shut-down).

Anonymous said...

If you have no electricity in your clinic, why would you continue to see patients? This was NOT a server problem. You mentioned seeing patients using flashlights!!!
The fact that your EMR was not available was not a server issue but a Power issue. While I applaud your commitment to not cancel appointments, can you really continue to provide the best care when you have NO electricity in the building?
The only remedy to this situation is a emergency generator for the building. You can work out how much power you would need for BASIC operations. Lights, Some computer workstations, servers ect. Then you woudl have to create a dedicated electrical circuit within your building, plugging those systems into that curcuit.
We used to have a 2000W gas generator that we pulled outside and fired up when the power went of to keep our phone and computer systems up and running.
Do you have a disaster recover plan in place?

Jel Coward said...

Alanc wrote: 'We used to have a 2000W gas generator that we pulled outside and fired up when the power went of to keep our phone and computer systems up and running.
Do you have a disaster recover plan in place?'
Good question. My point earlier is that if Nightingale don't have a 'fail over' plan when the server at their end crashes then that is unbeleivable. Michelle can have all the 'disaster recovery' plans she likes but they will not protect her if the company hosting the EMR don't have one. I like to have my server and backup server available to me, locally, in an environment where I can always connect to them and can restore power as necessary (with a generator).

Michelle Greiver said...

It is interesting how much feedback this is generating, more than for any other posting. I wonder if that is because the situation is so vivid.

While "disasters" (and I'm not so sure I would call this a disaster, nobody died) require planning, they are only a small part of daily practice. I am not sure how much time/money/energy should be spent on trying to avoid them; all of those will be either extra or diverted from daily EMR implementation, which is a much bigger part of practice.

Michelle