Journal Entry 1

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Journal Entry 1

This week, you complete and submit your first journal entry. Your journal draws from evidence, concepts, and/or theories you have examined in this program, especially those related to your specialization. What have you observed during your Practicum Experience that you would like to analyze through your journal writing?

To prepare:

  • Reflect on your Practicum Experiences in Weeks 1–3.
  • Think about the evidence, concepts, and/or theories (evidence) learned throughout this program and your specialization.
  • Analyze a problem, issue, or situation that you have observed during your Practicum Experience. (There was an unplanned downtime of the electronic health system (EHR) which lasted an hour).
  • Using a minimum of three peer-reviewed sources of evidence, consider what you have observed within the context of your specialty using appropriate concepts, principles, and theories. Give special attention to observed events that vary from the scholarly literature. (See attached pdf of the peer-reviewed articles)
  • Determine how the problem, situation, or issue was handled in a manner that is consistent and a manner that is inconsistent with the theory, concepts, and principles detailed in the evidence. (Read attached pdf articles)
  • Given the various evidence-based approaches that can be used in handling the observed problem, situation, or issue, think about a plan for approaching the matter differently. (Read attached pdf articles)

To complete


  • Write a 250- to 300-word journal entry in APA format and at least 3 references (identified as Journal Entry 1) in which you do the following:

1)      Describe a problem, issue, or situation that you have observed during your Practicum Experience (no more than a half page). (There was an unplanned downtime of the electronic health system (EHR) which lasted an hour).

2)      Using no fewer than three peer-reviewed sources of evidence, analyze what you have observed within the context of your specialty using appropriate concepts, principles, and theories. Give special attention to observed events that vary from scholarly literature. (During downtime, the main issue was that the medication administration record [MAR] was unavailable for the whole 30 minutes which was critical and too long in case any of the patient may have required emergency medications to save their lives; also, the alarms on the babies leg in the NICU were deactivated which posed a security risk that may have caused a baby to be stolen).

3)      Explain how the problem, situation, or issue was handled in a manner that is consistent and a manner that is inconsistent with the theory, concepts, and principles detailed in the evidence. (Emergency meeting was held after the unplanned downtime, see attached plan for handling unplanned downtime)

4)      Given the various evidence-based approaches that can be used in handling the problem, situation, or issue, formulate a plan for approaching the matter differently. (See attached plan)


Foote, S. O., & Coleman, J. R. (2008). Medication administration: the implementation process of bar-coding for medication administration to enhance medication safety. Nursing Economic$, 26(3), 207-210.

Campos, F., Luna, D., Sittig, D. F., & Bernaldo de Quirós, F. G. (2015). Design, Implementation and Evaluation of an Architecture based on the CDA R2 Document Repository to Provide Support to the Contingency Plan. Studies In Health Technology And Informatics, 216173-177

Oral, B., Cullen, R. M., Diaz, D. L., Hod, E. A., & Kratz, A. (2015). Downtime procedures for the 21st century: using a fully integrated health record for uninterrupted electronic reporting of laboratory results during laboratory information system downtimes. American Journal Of Clinical Pathology, 143(1), 100-104. doi:10.1309/AJCPM0O7MNVGCEVT

Kolowitz, B. J., Lauro, G. R., Barkey, C., Black, H., Light, K., & Deible, C. (2012). Workflow continuity–moving beyond business continuity in a multisite 24-7 healthcare organization. Journal Of Digital Imaging, 25(6), 744-750. doi:10.1007/s10278-012-9504-4

Journal Entry 1
100 Am J Clin Pathol 2015;143: 100 -104 DOI: 10.1309/ AJCPM0O7MNVGCEVT © American Society for Clinical Pathology AJCP / Original Article Downtime Procedures for the 21st Century Using a Fully Integrated Health Record for Uninterrupted Electronic Reporting of Laboratory Results During Laboratory Information System Downtimes Bulent Oral, 1 Regina M. Cullen, 1 Danny L. Diaz, 1 Eldad A. Hod, MD, 2,3 and Alexander Kratz, MD, PhD 2,3 From 1 Information Services, NewYork-Presbyterian Hospital, New York, NY; 2Department of Pathology and Cell Biology, Columbia University College of Physicians and Surgeons, New York, NY; and 3Clinical Laboratory Services, NewYork-Presbyterian Hospital, New York, NY. Key Words: Informatics; Management/administration; Generalist; Laboratory informat ion system; Downtime; Electronic medical record; Scanning Am J Clin Pathol January 2015;143:100-104 DOI: 10.1309/AJCPM0O7MNVGCEVT ABSTRACT Objectives: Downtimes of the laboratory information system (LIS) or its interface to the electronic medical record (EMR) disrupt the reporting of laboratory results. Traditionally, laboratories have relied on paper-based or phone-based reporting methods during these events. Methods: We developed a novel downtime procedure that combines advance placement of orders by clinicians for planned downtimes, the printing of laboratory results from instruments, and scanning of the instrument printouts into our EMR. Results: The new procedure allows the analysis of samples from planned phlebotomies with no delays, even during LIS downtimes. It also enables the electronic reporting of all clinically urgent results during downtimes, including intensive care and emergency department samples, thereby largely avoiding paper- and phone-based communication of laboratory results. Conclusions: With the capabilities of EMRs and LISs rapidly evolving, information technology (IT) teams, laboratories, and clinicians need to collaborate closely, review their systems’ capabilities, and design innovative ways to apply all available IT functions to optimize patient care during downtimes. Accurate, fast, and reliable communication of laboratory results to clinicians is a crucial prerequisite for effective and efficient patient care. In most hospitals, this communication is accomplished through interfaces that link laboratory instruments to the laboratory information system (LIS) and the LIS to the electronic medical record (EMR). This setup allows almost immediate transmission of verified laboratory results to all clinicians who have access to the EMR. Interfaces and LISs can become unavailable due to planned maintenance or because of unexpected hardware or software malfunctions. 1 Both scheduled and unscheduled downtimes occur with significant frequencies. In 1996, a College of American Pathologists Q-Probes study polled 422 laboratories and found a median of eight downtime episodes during a 30-day study period. 2 A follow-up study of 97 laboratories published in 2003 showed a decrease to a median of three events per 30-day period. 3 Downtimes can severely disrupt clinical workflows and affect patient care throughout a health care system. 4 They are also associated with the need for additional labor in the laboratory and for information technology (IT) teams; decreased patient, clinician, and laboratory personnel satisfaction; and significant costs. 5 Most hospitals have downtime procedures for times when the LIS or the interface between the LIS and the EMR is not available. These plans often include the use of phone calls, faxes, or the delivery of printed reports for the communication of urgent laboratory data such as critical values or results for patients in the emergency department (ED) or the intensive care units (ICUs). Most of these strategies are paper based; this limits the availability of the data and consumes significant amounts of valuable time of both clinicians and laboratory workers. AJCP / Original Article Am J Clin Pathol 2015;143: 100 -104 101 DOI: 10.1309/ AJCPM0O7MNVGCEVT © American Society for Clinical Pathology We describe a novel way to report laboratory results during LIS or interface downtimes. Our method maximizes the use of electronic resources before and during these events by combining the downloading of orders to laboratory instruments before planned downtimes with the scanning of urgent laboratory results directly into the EMR during the downtime. Materials and Methods Site The Columbia University Medical Center (CUMC) campus of NewYork-Presbyterian Hospital (NYPH; New York, NY) is a tertiary and quaternary care academic medical center with more than 1,000 adult and pediatric inpatient beds. Three EDs (adult, pediatric, and psychiatric) and eight ICUs (adult surgical, cardiac, cardiothoracic, and two medical ICUs; pediatric general, pediatric cardiac, and neonatal ICUs), together with active surgical, transplant, and interventional cardiology and radiology services, require reliably fast reporting of stat results to large teams of medical professionals. The laboratories receive on average over 10,000 samples a day. More than 25% of these samples are sent stat. Information Technology in Use Our hospital uses the Sunrise Enterprise Eclipsys 5.5 (Allscripts, Chicago, IL) as the EMR. Our LIS is Cerner Millennium, version 2012.1.19 (Cerner Corporation, North Kansas City, MO). Laboratory data generated in the hospital’s laboratories are transmitted via an interface from the LIS to the EMR and displayed in the EMR’s “Results” section. For patient information that is paper based, the RegScan document workflow solution from Streamline Health (Williamsport, PA) is used to display scanned documents in the EMR. The hospital uses this function for the display of paper documents provided by patients or outside providers or hospitals, forms, and laboratory reports from reference laboratories that are not interfaced to our LIS. The system allows full integration of the EMR with paper-based clinical documentation, allowing document management to be seamlessly integrated with the rest of the EMR. Clinicians can access all needed clinical information remotely via a single access point, the EMR. 6,7 Scanning of Instrument Printouts for Display in the EMR Laboratory personnel use the password-protected RegScan program to enter a patient’s medical record number and encounter number. The program then displays the patient’s name. The technologist verifies the patient’s name against the printout and chooses “Laboratory Report” as the document type. He or she then uses a Canon Imageformula DR-2510c document scanner (Canon USA, Melville, NY) connected to his or her computer to scan in the documents. Files are sent in TIFF format to a Streamline datacenter and stored there. When users at NYPH open the “Paper Documents” tab of Eclipsys and select a laboratory report, the documents are displayed by Streamline in an Eclipsys window via a live interface. Instrument Printouts Our laboratory compares instrument printouts with the displays in the inpatient and outpatient EMRs on a regular basis. This is part of our quality assurance program to ensure accurate transmission of results. Scanned instrument printouts included name and address of the reporting laboratory, patient’s name and medical record number, date and time of the release of the report, the specimen type, the test results with units of measurements, and conditions of the specimen that may have limited adequacy of testing (eg, hemolysis, icteric). The name of the physician of record or of the legally authorized person ordering the test was available in the EMR with other information about the test order; reference intervals were available in the laboratory’s online test dictionary, which remained functional throughout the downtime. The collection times for the specimens were recorded on paper by the phlebotomists but were not available in the EMR. In our hematology section, middleware (Sysmex WAM, Sysmex, Kobe, Japan) handles delta checks and autoverification. The LIS is set to autoverify all results sent by the hematology middleware. Technologists were therefore able to finalize hematology results during the LIS downtime in the middleware just like during normal operations. In our chemistry and immunochemistry sections, middleware is not used for autoverification and delta checks. We were therefore not able to perform delta checks or autoverification during the downtime. Flags (eg, hemolysis, icterus) were displayed on the instrument printouts. If a report needs to be amended, the amended printout would be marked “amended report” and scanned in. Results CUMC/NYPH experiences LIS or interface down – times of more than 2 hours approximately twice a year. Almost all these downtimes are planned in advance and are needed for upgrades or maintenance of the system. Our downtime procedures until 2013 called for all samples, Oral et al / LIS Downtime Procedure 102 Am J Clin Pathol 2015;143: 100 -104 DOI: 10.1309/ AJCPM0O7MNVGCEVT © American Society for Clinical Pathology including morning draws, to be sent labeled with the patient’s name and medical record number and a paper requisition. Laboratory staff then relabeled the samples with previously prepared, barcoded downtime labels and manually programmed the instruments to perform the ordered assays on each sample. After the downtime, all orders were entered from the requisitions into the LIS, the downtime numbers were electronically matched with the orders, and results were transmitted from the instruments to the LIS and from the LIS to the EMR. The protocols relied on phone calls, faxes, and printouts to communicate the most urgent laboratory results to clinicians during the downtime. Instrument printouts were hand-delivered by laboratory personnel to the EDs and ICUs. Due to the large number of patients in our medical center, these paper-based methods required extensive sorting of printouts by labora – tory and clinical staff, distracting them from their patient care responsibilities. For patients who were not in ICUs and EDs, clinicians had to call the laboratory for urgently needed results. Technologists would then find the instru – ment printouts with the patients’ results and read them to the clinical staff, who would write them down and read them back to the technologists. Due to staffing limitations in the laboratory and the clinical units, this approach could only be applied to the most urgent cases ❚Table 1 ❚. Since 2010, our IT system has allowed trained users to scan document files for display in a “Paper Documents” sec – tion of the EMR. The laboratories were using this function mainly to display reports from noninterfaced reference laboratories. In 2013, the leadership of our IT group sug – gested incorporating the scanning functionality into our LIS downtime procedure. Our new downtime protocol ❚Table 2 ❚ was developed in meetings of the LIS team, laboratory leadership, and representatives of the clinical staff of the ICUs, the EDs, and routine inpatient units. The goal of the new downtime procedure was to provide laboratory results electronically to clinicians in critical care areas and in ED settings while the LIS or interface was still down. For stable patients in other units, the goal was to keep the turnaround times for morning draws as close to normal as possible. The protocol empha – sized communication among the IT team, the laboratory, and clinical staff, both before and during the downtime. Our new standard operating procedure was first used in early 2013 in a planned downtime scheduled for a routine upgrade to the LIS. The downtime was scheduled from midnight to 10:00 am during a night between Friday and Saturday. Clinical staff were asked to place all orders for morning draw and timed draw phlebotomies by 10:00 pm on the evening before the downtime. Shortly after 10:00 pm , before the start of the downtime, barcode labels for these orders and draw lists were printed, and the IT team changed the order status of all orders for morning draws and timed draws from “ordered” (and awaiting collection) to “received in the laboratory.” This caused all the orders to download from the LIS to the instruments. Custom interface scripting ❚Table 1 ❚ Methods for Communicating Laboratory Results to Clinical Staff During LI S or Interface Downtimes Method Advantages Disadvantages Dedicated printers in EDs and ICUs that are directly connected to the LIS Can easily be initiated if the interface to the EMR or the EMR itself is down Not applicable during LIS downtime Provides laboratory results without need for significant additional labor in the laboratory Clinical staff needs to distribute printouts within the unit Only one hardcopy of the results is available; no electronic access Instrument printouts are hand-delivered to EDs and ICUs by laboratory staff Provides clinicians with clinically necessary information Laboratory staff needs to sort and deliver printouts to units Clinical staff needs to distribute printouts within units Only one hardcopy of the results is available; no electronic access Clinical staff calls laboratory for results on patients with urgent clinical needs; laboratory then reads results over the phone or faxes them to the unit Targeted use of resources—communication efforts are concentrated on patients with greatest clinical needs Requires significant time and effort of laboratory staff (answering phones, finding results on instruments, calling or faxing results) Requires significant time and effort of clinical staff (calling, spending time on hold, finding a specific patient’s results among other patients’ faxes) Scanning laboratory results as TIFF files into the EMR Laboratory results become available electronically during the downtime with minimal delay Requires scanning equipment and a system for display of scanned documents in the EMR Can be efficiently performed for large numbers of reports, allowing the reporting of morning draws of entire units Uses laboratory personnel time Requires advance education of clinical staff on location of reports in the EMR ED, emergency department; EMR, electronic medical record; ICU, intensive care unit; LIS, laboratory information system. AJCP / Original Article Am J Clin Pathol 2015;143: 100 -104 103 DOI: 10.1309/ AJCPM0O7MNVGCEVT © American Society for Clinical Pathology built in house was used to block the bogus collection and in-labeling times from being displayed in the downstream systems; this avoided confusion of the clinical staff. The custom interface scripting was done by a member of our LIS team (R.M.C.). The time required (including testing and validation) was approximately 3 hours. During the downtime from midnight to 10:00 am , morning draws took place like any other night, using the labels and draw lists created before the downtime. Upon arrival in the laboratory, samples from the morning draws could be analyzed as usual, since the orders had already been downloaded to the instruments. After analysis, results from ICU patients were printed from the instruments, matched with the patients’ encounter numbers, scanned, and downloaded for immediate availability in the “Paper Documents” section of the EMR. The advance ordering of laboratory testing was not practical for patients in the EDs, operating rooms, interventional cardiology units, or any other situation in which an urgent need for laboratory testing arose after the 10:00 pm deadline. For these patients, clinicians were instructed to use paper requisitions for the ordering of laboratory tests and to note the patients’ encounter number on the requisition. Upon arrival of the samples in the laboratory, the orders were manually placed in the instruments, samples were analyzed, results were printed out, and printouts were scanned and downloaded to the EMR. After the downtime, orders were placed in the LIS and connected to the downtime accession numbers of the results already obtained, and results were downloaded from the instrument. Results from morning draws from routine, non-ICU patients were held in the instruments and not reported during ❚Table 2 ❚ Procedure for Planned Downtimes of the LIS or LIS-EMR Interface Using an Integrated EMR One to 2 weeks before planned downtime Emails are sent to hospital staff to inform them of the planned downtime . Clinical leadership, senior hospital administrators, laboratory IT team, and laboratory management meet and finalize details of the downtime (start time, duration, areas affected, etc). Two days before planned downtime All hospital staff are reminded of coming downtime via emails and messag es on their computer screens. Emails are sent to all clinicians who have ordering privileges (residen ts, attending physicians, nurse practitioners), reminding them of the planned downtime and asking them to place all orders for morning draws 2 hours before the beginning of the downtime. One to 2 hours before the downtime Reminders of the planned downtime continue to be sent to clinicians. The IT team generates an Excel file of all inpatients’ names, their m edical record numbers, and their encounter numbers. This file is sent to the laboratory. Morning-draw labels are printed to colored label stock to distinguish th em from nonmorning-draw labels. Draw lists for morning draws are printed. The status of all morning-draw samples is changed to “received” in the LIS (even though they have not been drawn yet). This downloads all morning-draw orders from the LIS to the instruments, allowing for an alysis when the samples arrive in the laboratory later during the downtime. Custom interface scripting blocks the bogus collection tim es and in-laboratory updates from being displayed in the downstream systems, thereby avoiding confusion of clinical staff. During downtime Morning-draw ICU samples All morning-draw phlebotomies proceed as usual, using draw lists and lab els printed before the downtime. As far as possible, separate instruments are sequestered for use for spe cimens from the ICUs. These instruments are programmed to print out paper reports for all completed orders. Using the Excel file with the financial (encounter) number, technologi sts match each result printout with the correct financial number and scan the printout into the patient’s EMR file. Results are available in the “Paper Documents” section of the EMR to all staff during the downtime. All clinically urgent samples that are not from the ICU morning draws (eg, all ED samples, all samples from the operating rooms and interventional cardiology suites) Staff are instructed to use paper requisitions during downtime and to wr ite the patient’s encounter number on each requisition. Label color is used to identify these samples as urgent. Upon arrival in the laboratory, orders are manually entered into the ins truments, samples are analyzed, and results are printed from the instruments. Result printouts and requisitions (which contain the financial number) are paired up, and result printouts are scanned into the EMR. Results are available in the “Paper Documents” section of the EMR to all staff during the downtime. Nonurgent samples from routine care units Morning draws proceed as usual, using the draw lists and labels printed before the downtime. Upon arrival of these samples in the laboratory, they are analyzed on de dicated instruments (in-labing and downloading of orders to the instruments has occurred before the downtim e). Results are held in the instruments until the end of the downtime, unles s a clinician calls and asks for the results. After downtime After downtime ends, all results obtained during the downtime are transm itted from the instruments to the LIS and EMR, making the results available in the “Results” section of the EMR. The comment “Processed during system downtime. Collect and received date not updated” is added to all results from the morning draws and timed draws. ED, emergency department; EMR, electronic medical record; ICU, intensive care unit; IT, information technology; LIS, laboratory information syst em. Oral et al / LIS Downtime Procedure 104 Am J Clin Pathol 2015;143: 100 -104 DOI: 10.1309/ AJCPM0O7MNVGCEVT © American Society for Clinical Pathology the downtime unless clinical staff called and indicated that results were urgently needed. After the end of the downtime, all results obtained during the downtime were downloaded from the instruments to the LIS and from the LIS to the EMR. The comment “Processed during system downtime; collect and received date not updated” was automatically added to all results. Twenty randomly selected reports from ED and ICU patients indicated that the average time between availability of printouts for scanning and completion of scanning was 64 minutes (range, 20-118 minutes). Review of the reporting of the morning draws showed that results started to appear in the results section of the EMR within minutes of the end of the downtime. By 9:00 am , 27% of the routine morning draws had been transmitted to the EMR. This compared favorably with 38% on the Saturday before and 13% on the Saturday after the downtime. By noon, 71% of all morning draws were transmitted, compared with 98% one week before and 92% one week after the downtime. One week after the downtime, a meeting was held to assess the success of the new downtime procedure. Clinicians’ feedback was obtained in meetings of laboratory leadership with IT and clinical staff. The feedback was consistently positive; clinicians appreciated the ability to access laboratory results during the downtime electronically and the fact that morning draw results were available with only minimal delays. The laboratory staff noted that the new system made recovery after the downtime much easier than the previous approach. Discussion Growing multisite health care organizations, interfaces with often dozens of upstream and downstream systems, and changing regulatory requirements that require updates to the LIS all contribute to the frequency with which IT systems need to be taken down for upgrades and maintenance. These factors also make networks more complicated and thereby increase the likelihood of unexpected system failures. Most laboratories are aware that conventional ways to communicate laboratory results during downtimes, such as printouts, faxes, and phone calls, are not able to adequately transfer the large amount of information produced by modern laboratories with the needed reliability and speed. We describe a novel method to provide laboratory results to clinical staff during downtimes. Our approach combines the advance downloading of orders for scheduled phlebotomies from the LIS to laboratory instrumentation for planned downtimes with the scanning of instrument printouts into the EMR during all downtimes. The approach can be modified for unplanned downtimes and emergency testing to a process consisting of manually programming the laboratory instruments to perform the testing and then scanning the instrument printouts into the EMR. Advantages of our approach over conventional methods include fast availability of large amounts of data to clinical staff in electronic format, accessible through the EMR from multiple locations. Our protocol also reduces the amount of time laboratory staff have to spend to answer phones, track down clinical staff, or send faxes. Most important, it eliminates patient safety issues caused by transcription errors when results are orally communicated over the phone or sent via fax to the wrong location. The ability to continue analysis of morning draws during planned downtimes should allow faster recovery after the downtime and has the potential to improve clinical outcomes and to decrease hospital length of stay, all important factors for patient and physician satisfaction. Like all procedures in modern medicine, the success of a downtime procedure depends on the close cooperation of multiple teams. IT staff, laboratory employees, and clinicians need to work closely together on the design of the downtime procedure, the timing of the event, and the training of all levels and groups of staff. Service expectations, both during and immediately after the downtime, need to be carefully managed. Address reprint requests to Dr Kratz: Columbia University Medical Center, NewYork-Presbyterian Hospital, Core Laboratory, 622 W 168th St, PH3-363, New York, NY 10032; [email protected] References 1. Nelson NC. Downtime procedures for a clinical information system: a critical issue. J Crit Care. 2007;22:45-50. 2. Valenstein P, Treling CP, Aller RD. Laboratory computer availability: a College of American Pathologists Q-probes study of computer downtime in 422 institutions. Arch Pathol Lab Med. 1996;120:626-632. 3. Valenstein P, Walsh M. Six-year trends in laboratory computer availability. Arch Pathol Lab Med. 2003;127:157-161. 4. Campbell EM, Sittig DF, Guappone KP, et al. Overdependence on technology: an unintended adverse consequence of computerized provider order entry. AMIA Annu Symp Proc. 2007;2007:94-98. 5. Hoot N, Wright JC, Aronsky D. Factors contributing to computer system downtime in the emergency department. AMIA Annu Symp Proc. 2003;2003:866. 6. Streamline Health. EMR integration. 2014. http://www. Accessed February 4, 2014. 7. Sarasota Memorial Health Care System. One door to the electronic health record. 2013. Accessed February 4, 2014. Copyright ofAmerican JournalofClinical Pathology isthe property ofAmerican Societyof Clinical Pathologists anditscontent maynotbecopied oremailed tomultiple sitesorposted to alistserv without thecopyright holder’sexpresswrittenpermission. However,usersmay print, download, oremail articles forindividual use.
Journal Entry 1
Design, Implementation and Evaluation of an Architecture based on the CDA R2 Document Repository to Provide Support to the Contingency Plan Fernando Campos a,c, Daniel Luna a, Dean F. Sittig b, Fernán González Bernaldo de Quirós a a Health Information Department, Hospital Italiano de Buenos Aires, Argentina bSchool of Biomedical Informatics, University of Texas Health Sciences Center at Houston, Houston, TX, USA cHL7 Argentina Abstract The pervasive use of electronic records in healthcare increases the dependency on technology due to the lack of physical backup for the records. Downtime in the Electronic Health Record system is unavoidable, due to software, infrastructure and power failures as well as natural disasters, so there is a need to develop a contingency plan ensuring patient care continuity and minimizing risks for health care delivery. To mitigate these risks, two applications were developed allowing healthcare delivery providers to retrieve clinical information using the Clinical Document Architecture Release 2 (CDA R2) document repository as the information source. In this paper we describe the strategy, implementation and results; and provide an evaluation of effectiveness. Keywords: Electronic Health Record; CDA repository; Contingency plan. Introduction There is an increasing use of electronic health record, specifically the replacement of paper-based health record with Electronic Health Records (EHR) [1]. Therefore, every healthcare delivery process relies on information systems to ensure patient care. This brings up the threat of a lack of information for decision making in case of system downtime. One of the biggest risks in this scenario is inaccessibility of information needed to administer medication [2, 3]. Unexpected information technology (IT) downtime occurs more and more often with widespread adoption of electronic systems in healthcare [4]. Although the reliability of computing hardware has improved significantly, the complexity of software has escalated, especially in healthcare [4]. Risk identification and risk assessments are essential steps for developing preventive measures. Equally important is institutionalization of contingency plans as our data show that not all failures of health IT can be predicted and thus effectively prevented [5]. Most institutions had only partially implemented comprehensive contingency plans to maintain safe and effective healthcare during unexpected EHR downtimes [6]. Preparing for these unexpected downtimes should be a part of every EHR-enabled healthcare organization’s overall patient safety strategy. As most experts state, an effective contingency plan should address the causes and consequences of EHR unavailability, triggering processes and preparations that can minimize the frequency and impact of such events, ensuring continuity of care [7-9]. The objective of this paper is to describe the design, implementation, and evaluation of the IT component of a contingency plan that uses the Clinical Document Architecture (CDA) Release 2 (R2) document repository to support continuity of care during system downtime. Methods Settings The Hospital Italiano of Buenos Aires (HIBA) is a nonprofit academic medical center founded in 1853. HIBA has a network of two hospitals with 750 beds (250 for intensive care), 800 home care patients under care, 25 outpatient care centers, and 41 operating rooms. There are more than 2,800 physicians, an equal number of medical team members and 1,900 administrative and support staff. During 2013-2014 there were 45,000 admissions, 3 million outpatient visits and 45,000 surgeries (half of them ambulatory). In 1998 HIBA began the gradual implementation of a Healthcare Information System (HIS) developed in-house, from data capture to analysis. It includes a web based, modular, problem-oriented and patient-centered EHR. This EHR is known as Italica and allows inpatient, outpatient, home care, and emergency care records. Italica also allows users to order ancillary tests, prescribe medications and view results including imaging through an integrated picture archiving and communications system (PACS). The EHR has a relational database record and also a CDA R2 document-based repository, which is digitally signed by professionals participating in healthcare delivery. This repository is used to interoperate with payers and other EHRs, and to make information portable for patients or other external healthcare providers. The system architecture for sharing medical information is based on HL7 CDA and a repository/registry XDS (Cross Enterprise Document Sharing) model defined by IHE ( Integrating the Healthcare Enterprise). The document repository currently contains 36.4 million CDAs [10]. This repository allows the organization to operate without need for paper records, because information exchange between actors or systems is facilitated by these documents. For instance, for ancillary systems like imaging or laboratory, order is no longer paper-based but a digitally signed CDA R2. Likewise, result reports are not printed, but reviewed directly in the EHR through a CDA R2 sent by the ancillary service. Since 2012, and based on this implementation, all procedures and communications for healthcare continuity while systems recover from a meaningful interruption have been redesigned, mainly for the inpatient setting. Two levels of contingency were identified: MEDINFO 2015: eHealth-enabled Health I.N. Sarkar et al. (Eds.) © 2015 IMIA and IOS Press. This article is published online with Open Access by IOS Press and distr ibuted under the terms of the Creative Commons Attribution Non-Commercial License. doi:10.3233/978-1-61499-564-7-173 173 The d e docu m Desi gn A la b effecti differ e from downt i This i n differ e each p the c u the lis t down comp a Resu In or d navig a eleme n Doc Doc Ser v Pat i Pat i Firs Las Using based patien t After docu m This a EHR, Level 1 is t h not availab l deploymen t of the com p networking , Level 2 is t o contingenc y or halted d u data center p storage, net w ecision was t o ment repositor y n boratory fun c veness and 2 ent days and the last exe c ime. nvolved simu l ent times of d patient had at urrent list of p t had been g e at 12:16 am, p ared for additi lts der to mitiga t ator was de v nts in the CD A cument date cument type vice ient id ient root st name st name this index, a on patient t), timeline f o selecting a s p ments for the v application is and with a d i he applicatio n le. 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EHR at lack of ricity or ncy care is most nts was atient’s abeling ned that for the or each al disk npatient d label rs. The m. This ters in used in printer e power wntime, mputers critical y system bles for queries need to F. Campos et al. / Design, Implementation and Evaluation of an Architecture Based on the CDA R2 Document Repository 174 Using the CDA repository, only 1 query is needed, involving a snapshot of the current active inpatients or emergency care episodes, and the query to the document repository for the URL for the patient’s last prescription CDA. Rendering the information only requires transformation of the XML using an XSLT stylesheet. The downtime record between March 2012 and June 2014 is presented in Table 2. This table shows dates and times when the EHR was not available, and for how long. The column ‘Type’ indicates if the lack of EHR was programmed or not, and then the cause. The column “Level” indicates the severity level assigned to the cause and for each event, the quantity of pages printed. Table 2 – Downtime Record and Pages Printed Date Begin Time Duration (Hrs.) Type * Motive Level Pages 08/03/12 09:15 05:55 U EHR bug 1 365 05/04/12 23:10 02:00 U DB issue 2 301 07/04/12 20:00 02:00 P DB mainte- nance 2 10 27/04/12 09:50 06:15 U EHR bug 1 303 12/05/12 22:40 07:50 P Upgrade DB 2 1254 09/06/12 22:00 07:00 P Upgrade Server memory 2 867 29/12/12 05:30 04:30 U EHR bug 1 425 23/04/13 05:30 25:01 U Shut- down power 2 1450 26/04/13 12:30 01:00 U Router down. 2 23 27/04/13 18:00 03:00 P Server mainte- nance 2 150 25/05/13 16:00 05:05 P Server mainte- nance 2 1050 15/06/13 17:00 07:38 P Server mainte- nance 2 1080 26/07/13 20:00 13:30 P New DB cluster 2 1250 14/09/13 18:00 02:00 P Update switches firmware 2 306 11/01/14 02:00 04:30 P Update switches firmware 2 309 24/06/14 12:10 01:10 U DB issue 2 124 *Type: U: Unplanned – P: Planned As an example, a change of servers’ operating system produced downtime of 13:30 hours. In this contingency, all prescriptions were printed, and 1,250 sheets of paper were used to print 759 prescriptions in 1 hour 15 minutes. In the contingency Level 1 case, even though the CDA browser was used, the critical care units and emergency care areas preferred to print out the prescriptions in order to be able to make written notes of instructions and any other changes. Details of each test simulation are presented in Table 3, including the time elapsed since last generation (mins), the number of inpatients at that moment, records that matched at the simulated downtime and the differences found. Table 3 – Evaluation Cases Case # Minutes elapsed since last generation Inpatients at down- time Matches Diffe- rences 1 2 654 650 4 2 10 695 667 34 3 18 712 668 44 4 25 730 666 64 5 5 759 723 36 6 12 759 707 52 7 26 762 686 76 8 5 771 759 12 9 5 721 697 24 10 15 678 630 48 11 14 699 643 56 12 10 712 680 32 13 17 734 686 48 14 5 723 707 16 15 15 745 709 36 16 13 711 671 40 17 22 733 657 76 18 5 732 712 20 19 1 722 722 0 20 25 745 673 72 14,497 13,713 784 The differences were evaluated in each case: how many were caused by a patient being admitted or discharged, how many were caused by a change in medications. Medications for newly admitted patients and missing updates were deemed errors. New inpatients with no medications and discharged patients still in the contingency system were not deemed errors. For example, for the second case, 34 differences were found, 22 of them due to patients admitted during the 10 minutes from the listing generation but with no prescription, 6 patients with their prescriptions updated, 13 patients discharged and 3 patients had new prescriptions. The evaluation result is presented in Table 4. Table 4 – Evaluation Results for Contingency Listing Case # Diff.: New Admissi on (1) Diff. Medicat ion Change Diff.: Dischar ged patient (2) New patient with prescripti ons Errors (1) + (2) 1 1 1 2 0 1 2 12 10 6 6 16 3 22 6 13 3 9 4 34 10 17 3 13 5 18 3 15 0 3 6 26 4 20 2 6 7 8 10 55 3 13 F. Campos etal. /Design, Implementation andEvaluation of an Arc hitectur eBased onthe CD A R2 Document Repository 175 8 6 3 3 0 3 9 12 3 9 0 3 10 22 2 20 4 6 11 29 6 19 2 8 12 16 5 11 0 5 13 23 10 6 9 19 14 8 2 6 0 2 15 17 5 12 2 7 16 20 7 13 0 7 17 39 17 16 4 21 18 10 3 7 0 3 19 0 0 0 0 0 20 36 9 23 4 13 359 116 273 42 158 The results show that printed prescriptions concur in 98.91% (14,339/14,497) of those registered in the EHR. The relationship between the time elapsed since the last generation and the differences found after downtime are presented in Figure 3. Figure 3 – Differences (Time) Discussion This architecture allows information to be available from all delivery care locations, and allows every actor requiring the information to access it. The printing process has a predefined sequence for the various locations, prioritizing critical care units, emergency care, pediatric care, and then other services. The more time elapses between the generation of the latest list and the EHR unavailability, the greater the difference in the prescription record. Although the medical staffs understand that any changes made in less than 30 minutes could be re- prescribed, they are aware that the nurse work based on the lists received and these should be corrected manually after the EHR disruption. In the real scenario, other times should be evaluated because doctors do not make decisions on every patient immediately after the system goes down. Other changes could have been made during the downtime and will not be represented in the print version (prescriptions, bed changes, etc.). So we have two mechanisms that generate gaps between the information documented and the reality: gaps between the last local backup and the down time and gaps between the down time and the moment at which the caregiver uses the print version. This study evaluated the differences between Point 1 and Point 2. The effectiveness of this architecture at Point 3 is pending evaluation and will be the subject of a future study. The alternating folder strategy was required because in one of the tests if network connectivity or power was interrupted just when the folder was being generated, its structure could be corrupted. If this happens, the other folder can be accessed. Prescription printed forms are used mainly by the nurses to ensure care continuity for patients. They continue recording their actions there in order to update the EHR when the system comes back, or scanned as part of the care record. One limitation, as shown by the evaluation of the results, is that not all the information is available because there can be changes between the executions of the refresh process: patient transfers, new prescriptions, admissions or discharges. No other experience in creating this kind of repository was found in the literature, either as a redundant repository or for use on a contingency basis. Conclusion Downtime in information systems, both planned and unplanned, is inevitable, even in the healthcare environment, where systems need to be available 24-7-365. Implementing tools such as the one presented in this paper provides contingency plan support and helps mitigate many risks that threaten information availability at the point of care. References [1] Wright A, Henkin S, Feblowitz J, McCoy AB, Bates DW, Sittig DF. Early results of the meaningful use program for electronic health records, N. Engl. J. Med. 2013;368:779– 780. http://dx.d . [2] Hanuscak TL, Szeinbach SL, Seoane-Vazquez E, Reichert BJ, McCluskey CF. Evaluation of causes and frequency of medication errors during information technology downtime. Am J Health Syst Pharm. 2009;66(12):1119-1124. [3] Koppel R, Metlay JP, Cohen A, Abaluck B, Localio AR, Kimmel SE, Strom BL. Role of computerized physician order entry systems in facilitating medication errors . JAMA. 2005;293:1197-1203. [4] Lei J, Guan P, Gao K, Lu X, Chen Y, Li Y, Meng Q, Zhang J, Sittig DF, Zheng K. Characteristics of health IT outage and suggested risk management strategies: an analysis of historical incident reports in China. Int. J. Med. Inform. 2014;83(2):122-130. [5] Sittig DF, Singh H. Electronic health records and national patient-safety goals. N. Engl. J. Med. 2012;367(19):1854– 1860. [6] Sittig DF, Gonzalez D, Singh H. Contingency planning for electronic health record-based care continuity: a survey of recommended practices. Int J Med Inform. 2014;83(11):797-804. doi: 10.1016/j.ijmedinf.2014.07.007. Epub 2014 Aug 7. [7] Kilbridge P. Computer crash – lessons from a system failure. N. Engl. J. Med. 2003;348:881–882. [8] Merrick J. ‘Serious’ computer crash hits hospital trusts. Daily Mail (July 31, 2006) 3984, Available at: crash-hits-hospital-trusts.html . [9] Sittig DF, Ash JS, Singh H. The SAFER guides: empowering organizations to improve the safety and effectiveness of electronic health records. Am J Managed Care. 2014;20(5):418-423. F. Campos et al. / Design, Implementation and Evaluation of an Architecture Based on the CDA R2 Document Repository 176 [10] Campos F, Plazzotta F, Luna D, Baum A, de Quirós FG. Developing and implementing an interoperable document-based electronic health record. Stud Health Technol Inform. 2013;192:1169. PubMed PMID: 23920943. Address for correspondence MSc. Fernando Campos Chief of Software Engineering Health Informatics Department Hospital Italiano de Buenos Aires HL7 Argentina Chairman [email protected] F . Campos etal. /Design, Implementation andEvaluation of an Arc hitectur eBased onthe CD A R2 Document Repository 177 Copyright ofStudies inHealth Technology &Informatics isthe property ofIOS Press andits content maynotbecopied oremailed tomultiple sitesorposted toalistserv without the copyright holder’sexpresswrittenpermission. 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Journal Entry 1
Workflow Continuity—Moving Beyond Business Continuity in a Multisite 24–7 Healthcare Organization Brian J. Kolowitz &Gonzalo Romero Lauro & Charles Barkey &Harry Black &Karen Light & Christopher Deible Published online: 6 July 2012 # Society for Imaging Informatics in Medicine 2012 AbstractAs hospitals move towards providing in-house 24 × 7 services, there is an increasing need for information systems to be available around the clock. This study inves- tigates one organization’s need for a workflow continuity solution that provides around the clock availability for in- formation systems that do not provide highly available services. The organization investigated is a large multifacil- ity healthcare organization that consists of 20 hospitals and more than 30 imaging centers. A case analysis approach was used to investigate the organization’s efforts. The results show an overall reduction in downtimes where radiologists could not continue their normal workflow on the integrated Picture Archiving and Communications System (PACS) solution by 94 % from 2008 to 2011. The impact of un- planned downtimes was reduced by 72 % while the impact of planned downtimes was reduced by 99.66 % over the same period. Additionally more than 98 h of radiologist impact due to a PACS upgrade in 2008 was entirely elimi- nated in 2011 utilizing the system created by the workflow continuity approach. Workflow continuity differs from high availability and business continuity in its design process and available services. Workflow continuity only ensures that critical workflows are available when the production systemis unavailable due to scheduled or unscheduled downtimes. Workflow continuity works in conjunction with business continuity and highly available system designs. The results of this investigation revealed that this approach can add significant value to organizations because impact on users is minimized if not eliminated entirely. KeywordsWorkflow continuity. Business continuity. PACS planning. PACS integration. PACS downtime procedures. PACS administration. PACS. PACS service. Software design. Systems integration. Workflow. Productivity. Management information systems. Information system. Image retrieval. Health level 7 (HL7). Efficiency Background Recently, the US government mandated the use of health information technology for healthcare providers [1]. The legislation outlines financialpenalties for providers that choose not to adopt technologies as well as benefits for those that do adopt the technologies. As the adoption of health information technology increases, so will the need for information systems that allow critical organizational work- flows to continue when those systems are unavailable due to either scheduled or unscheduled system downtimes. This paper is a case analysis of one organization’s solu- tion to a need for a system that provides workflow continu- ity around the clock. Workflow continuity moves beyond business continuity because the focus is placed on the con- tinuity of critical clinical workflows rather than creating a fully featured redundant system. A review of the organiza- tion’s existing business continuity solutions for the Radiol- ogy Information System (RIS) and Picture Archiving and Communications System (PACS) was performed. The B. J. Kolowitz (*) :C. Barkey :H. Black :C. Deible UPMC, Enterprise Imaging Informatics, 450 Melwood Avenue, Pittsburg, PA 15213, USA e-mail: [email protected] G. R. Lauro UPMC, Clinical Department Systems, 450 Melwood Avenue, Pittsburg, PA 15213, USA K. Light UPMC, Radiology Informatics, 450 Melwood Avenue, Pittsburg, PA 15213, USA J Digit Imaging (2012) 25:744–750 DOI 10.1007/s10278-012-9504-4 system requirements were reevaluated using the workflow continuity approach. The organization studied consists of 20 hospitals and more than 30 imaging centers. The hospitals investigated are distributed across geographical area contained within a 125 mile radius. More than 2.2 million radiology procedures per year are performed across these hospitals. This case spans 4 years of work analyzing and improving the organ- ization’s business continuity solution. The business continu- ity solution was a key component in the design of the workflow continuity system. Throughout the process, nearly every aspect of information technology and workflow was evaluated for inefficiencies and workflow impact. Findings are presented along with a discussion of the results, practical implications for the organization, delimitations, and recom- mendations for further research. The makeup of the organization’s radiology Information System (IS) infrastructure consists of 12 independent PACS silos, one consolidated RIS and one consolidated PACS integrated voice recognition application. A teleradiology solution allows radiologists to view and read imaging stud- ies for any location within the organization, regardless of the physical site of the radiologist. This subspecialist radiology coverage provides subspecialist services 24 × 7 seven days a week. The centralization and availability of the subspecialist 24 × 7 service required an IS infrastructure that allowed the users to continue to provide patient care around the clock. Planned maintenance and unplanned downtimes inhibit the user’s ability to perform their jobs and provide patient care efficiently and may affect their ability to provide care effec- tively. The Workflow Continuity approach identified a sub- set of the Information System features required to support the most critical user workflows. Business Continuity Business continuity plans typically revolve around identify- ing risks and creating redundant systems. A business conti- nuity plan may identify risks and provide operational and information technology solutions to mitigate or eliminate those risks. One plan in particular identifies an eight step cycle used to protect the business needs of the organization including the following: (1) initiate the business continuity plan (BCP) project, (2) identify business threats, (3) conduct risk analysis, (4) establish business continuity plan, (5) design business continuity plan, (6) define business conti- nuity process, (7) test business continuity plan, and (8) review business continuity plan [2]. Each step identifies substeps, objectives, and goals. The purpose of such a detailed procedure is to protect the business against all of the threats to the organization, or at least the ones that would have the most critical impact on the organization. Threatsmay be technological, operational, or anything else such as hackers’attacks, earthquakes, or other disasters. Once threats are identified and system requirements are scoped, the BCP is at the mercy of the information systems ability to meet those requirements. Cost and information systems flexibility become considerations when attempting to exe- cute the business continuity plan. The business continuity plans offered by the organiza- tion’s vendors did not meet the changing 24 × 7 service needs of the organization. Offsite backups are available to rebuild the system in the event of a disaster but this solution requires a minimal turnaround of 96 h per server. The PACS infrastructure alone consists of over 300 servers. The tech- nology and architecture of the PACS platform does not allow for a highly available solution to be created. High availability does not imply constant availability, and there may be times when the highly available system is unavail- able. In addition, the PACS Failover system did not meet functionality needs of the users. Methods This case study is built upon data collected over a 4-year period. The investigators are also members of the informa- tion system team responsible for developing and implement- ing the solution. Informal interviews with the information system designers were performed, information system doc- umentation was reviewed, and quantitative data in the form of system down times was collected. Descriptive statistics were used to analyze the data, findings presented, and a discussion concludes the investigation. Results This article evaluated the existing RIS and PACS failover strategies and compared the system downtimes utilizing those strategies versus the system downtimes after the im- plementation of the workflow continuity system. The fail- over strategies were designed around the limitations of the information systems when taking a business continuity plan approach. The design of these systems was reevaluated using the workflow continuity approach and results of the approach taken are presented. RIS Failover Strategy The organization’s RIS failover strategy consisted of manual processes by which radiology technologists entered order information directly into the modalities whenever the pro- duction RIS was unavailable. The radiology technologists would then record the order information for the exams J Digit Imaging (2012) 25:744–750745 performed though a pen and paper process. Radiology tech- nologists would then key the order information from the paper record into the production RIS whenever the system became available. This translates into approximately 251 duplicate order entries per hour of downtime [2.2 million exams/(24 h per day × 365 days per year)]. This calculation does not account for the actual distribution of exams across hospitals and time of day, which can make the number of duplicate order entries per hour significantly higher. More procedures are performed during an hour of downtime at a core hospital than a community based hospital during and during peak hours than off-peak hours. Radiologists or other physicians that required viewing access to the performed exams were only able to view exams that had orders prescheduled in the RIS prior to the downtime. The PACS system requires both DICOM images and health level 7 (HL7) messages for the user to view the exams within their normal workflows. Man- ual procedures were implemented for physicians to call the radiology reading rooms for STAT exams. The radi- ologist would then have to search through a list of exceptions in order to locate the appropriate exam for review. Relevant clinical information for exams that were not pre-ordered prior to the RIS downtime was verbally relayed over the phone. PACS Failover Strategy The organization’s existing PACS failover strategy con- sisted of a single failover PACS for each of the hospitals with a limited set of prior images. Each failover PACS only contained images for the particular hospital the PACS serves. The effects of being on the PACS Failover system are felt by the entire enterprise because physicians typically cover patients by divisions that span hospital boundaries. The independent PACS failover servers were not HL7 enabled or integrated with the production PACS. The ab- sence of HL7 limited the trust in the information contained within the system because the pairing process between DICOM image and HL7 order did not exist. Fat-finger errors performed at the modality could not be easily caught by the users. This might result in incorrect patient demo- graphics being associated with a series of images. Therefore, users were not allowed to perform final interpretations and dictate findings. A business process was enacted where physicians would call the radiologists in the reading room for the most critical exams. The radiologists would then perform the interpreta- tion on-demand and relay the findings over the phone to the physician requesting an interpretation. Once the systems became available, the radiologists would then interpret the exams in the production system and dictate the exams within the PACS integrated voice recognition system.The absence of HL7 also eliminated the effectiveness of fine-grained user filters. Academic zone hospitals that pro- vide subspecialist coverage may have specialized work lists such as display only MR and CT neurology exams for the emergency department. Whereas the radiologists at the com- munity zone hospitals cover all exams for the hospital regardless of modality or location. Some of the fields need- ed to create these filters including patient location and exam code reside in HL7 messages. Since there was no HL7 interface on the PACS failover system, many of these filters were unable to be provided requiring the radiologist to search though larger lists of patients to find the set of exams he or she was required to interpret. As a result, the users had to user more general filters which resulted in a longer list of exams to navigate. The longer list of exams on PACS failover is only related to the most recent hospital exams. The PACS failover servers only contain 1.6 TB of image cache storage. The oldest and least accessed exams are purged from cache when space is needed. The largest hospital contains approximately 4 weeks of recent patient history on the image cache whereas the smallest hospital con- tains nearly 2 years. A complete breakdown of available PACS workflow continuity systems (WCS) storage and exam history is shown in Table1. The inability to access relevant prior images may limit the radiologists’ ability to provide detailed subspecialist interpretations. RIS/PACS Failover Impact on Workflow The users’workflows were negatively impacted when users were required to use either the RIS or the PACS Failover systems. The primary workflow impact on the technologists resulted from duplicate entry in both the paper based and Table 1Available WCS storage and exam history Hospital Storage (terabytes) History on WCS Production WCS % Months 1 144.0 1.6 1.1 1 2 17.6 1.6 9.1 6 3 49.6 1.6 3.2 2 4 46.4 1.6 3.5 2 5 46.4 1.6 3.5 2 6 9.6 1.6 16.7 8 7 33.6 1.6 4.8 2 8 35.2 1.6 4.6 3 9 4.8 1.6 33.3 48 10 4.8 1.6 33.3 5 11 19.2 1.6 8.3 4 12 14.4 1.6 11.1 5 746J Digit Imaging (2012) 25:744–750 then electronic records. The primary workflow impact on the radiologists was their inability to provide final interpre- tations within the integrated voice recognition system. As a side effect, the radiologists were also distracted by the large number of phone calls requesting STAT interpretation. The fully integrated production system provides status indicators that identify STAT exams whereas the PACS Failover sys- tem does not. Radiology Workflow Continuity Workflow continuity is a term created by the organization to describe the information system architecture, flow of infor- mation, contingency procedures, and workflow that allows physicians to continue an uninterrupted workflow while the production information systems are unavailable due to both scheduled and unscheduled outages. Workflow continuity includes information system concepts such as highly avail- able system design and disaster recovery but the design focus is different. Highly available information systems provide services on demand quickly [3]. Redundancy is a key component so that parts of the system can continue working as other parts are unavailable [3]. A system is considered to provide Workflow Continuity if the core set of features users require are available for use when the primary system is unavailable due to a scheduled or un- scheduled downtime. Workflow continuity systems do not require redundant systems, but redundant system designs may provide workflow continuity. RIS/PACS Workflow Continuity Design A comparison of features available between the Production system, the former PACS Failover System, and the new WCS is shown in Table2. The core set of features from the radiologists’perspectives is the ability to view and dictate an exam. Other cursory features may not be available but are not missed by the radiologists’during these down- times. The system diagram for the RIS/PACS Workflow Continuity System implemented is shown in Fig.1. The production RIS has HL7 orders and results interfaces with both the production and WCS PACS. In addition, the WCS RIS has orders and results interfaces with the produc- tion and WCS PACS. A DICOM interface forwards images from the production PACS to the WCS PACS so that the twosystems are in sync. A special HL7 interface exists between the WCS RIS and production RIS. This interface allows the migration of orders placed on the WCS RIS to be registered into the production RIS. The production and WCS PACS remain in sync with regards to orders and results. In order for the production RIS and WCS RIS to remain in sync, a series of manual procedures needs to occur when moving between the two systems. One-way transaction log shipping is set up from the production RIS to the WCS RIS. Other key identifiers such as accession number are set by the Database Administrator. Other Aspects of Workflow Continuity The focus of the workflow continuity approach should not only include information technology solutions, but also preventative maintenance and vendor relations. Regular preventative maintenance such as operating system patch- ing, firmware upgrades, and hardware refresh are key com- ponents in minimizing the risk of impact on workflow. Sometimes business process redesign for the organization and its vendors is also needed. Workflow continuity will be difficult to achieve if the organization does not understand its own workflows as well as how the information systems affect those workflows. The organization studied invested a significant amount of effort to understand the technical architecture of the vendor pro- vided solutions. In addition, the organization educated the vendor on how the vendor product was used within the organization. This educational process is bidirectional Table 2Radiologist capabilities by system aCritical workflow as defined by the usersProduction RIS Failover RIS WCS RIS Production PACS Full workflow View only Critical workflow a Failover PACS View only View only View only WCS PACS Critical workflow a View only Critical workflow a RIS (Production) PACS(Production) PACS(WCS) RIS (WCS) HL7 InterfaceDICOM Interface Fig. 1RIS/PACS workflow continuity system J Digit Imaging (2012) 25:744–750747 where the vendor learns specific ways in which the organi- zation differs from other customers as well as the organiza- tion learning ways in which they are similar to other customers. Once a shared understanding of the way the vendor solution integrates into the workflow was met, the parties involved could reevaluate maintenance and up- grade processes. One of the hospital PACS systems consists of two application servers, two database serv- ers, and over 60 storage modules where DICOM images reside. Prior to the workflow continuity approach, the entire system was unavailable until all 64 servers were upgraded. The organization was able to propose a new upgrade process because they understood the architec- ture as well as the impact on workflow. The organiza- tion’s suggestion that the vendor implemented as a result of the workflow continuity approach drastically minimized the time the system was unavailable. Now priority is given to the application and database servers as well as the storage modules with the most recent images. Working from most recent to oldest allows the entire system to come online quicker because the only impact is that the oldest exams are unavailable for a period of time. The users accepted this limitation be- cause many cases do not require prior images for com- parison, at least for a preliminary interpretation. PACS Workflow Continuity Impact As previously stated, patient care was still required even though the RIS and PACS were operating on their failover systems. Exams that were interpreted and relayed to physi- cians over the phone were also dictated into the PACS integrated voice recognition system. This required the phy- sician to interpret and dictate the exam twice. Total down- time (scheduled and unscheduled) experienced by each of the 12 different PACS implementations across the organiza- tion is outlined in Fig.2. Moving from the existing failover model to a sys- tem based on the concept of workflow continuity resulted in significant reductions in downtime over the last 4 years. Downtime data prior to 2008 was unavailable for analysis. By focusing on proper planned maintenance, the organization was able to reduce their unplanned downtime by 72.06 %. Conse- quently, proper maintenance and the workflow conti- nuity approach reduced the planned downtime by 99.66 % (Table3). The case study covers two major PACS upgrades. The first upgrade occurred in 2008 and the second upgrade occurred in 2011. Software on all application and database servers was upgraded. The amount of time spent on the PACS failover system in 2008 is equivalentto the amount of time radiology workflow was interrup- ted. The amount of time spent on the PACS WCS solution in 2011 is equivalent to a savings of radiologist interruption, or workflow continuity (Table4). The 2011 PACS upgrade utilizing the workflow continuity ap- proach saved the organization in 98 h and 36 min in terms of interruptions to radiologist workflow. Discussion Continuity of workflow and core functionality are very valuable to radiologists [4] and the solution imple- mented at the organization has virtually eliminated radi- ology workflow interruptions during downtimes. The unconventional system development approach and oper- ational workflow procedures implemented at the organi- zation under the workflow continuity guidelines almost entirely eliminated the radiologist workflow interrup- tions due to planned or unplanned system downtimes. Workflow continuity does not exclude business continu- ity but builds on top of it. Advantages of business continuity solutions available offer a level of redundan- cy that can fully restore functionality when part of the system fails [5]. Many companies develop disaster con- tingency recovery plans that include alternative proce- dures and workflows [6,7] which inevitably disrupt the normal flow of operations. Business continuity solutions require a system architecture that can support the 2008 2009 2010 2011 Planned Downtime 10440 3623 2467 36 Unplanned Downtime 2448 2080 1275 684 0 2000 4000 6000 8000 10000 12000 14000 Minutes Fig. 2Total planned and unplanned downtimes by year Table 3Percent im- provement from 2008 to 2011Downtime type % improvement (2008–2011) Unplanned 72.06 % Planned 99.66 % Total 94.41 % 748J Digit Imaging (2012) 25:744–750 functionality. Workflow continuity is not bound by this constraint because the focus is not on a fully redundant system, but a system that allows the critical workflows within the organization to continue. Critical workflows are those workflows that are essential to the delivery of patient care. In this instance, there were three critical workflows defined including the following: the ability for radiology orders to flow from the RIS to the PACS, the ability for radiologists to interpret exams and dictate the PACS without disruption to their normal workflow, and the ability for results to file in the RIS and PACS from the voice transcription service. In addition, an emphasis was put on the reduction of manual effort by radiology technologists and PACS administrators when resolving PACS exceptions. These exceptions occur when there is a discrepancy between DICOM images and HL7 order messages as a result of system unavail- ability or human error. Workflow continuity should not be thought of as a system design but a mindset for designing systems. Highly available systems that allow workflows to con- tinue without significant interruption provide work- flow continuity. Other workflow continuity system configurations might include two systems, A and B, that have bidirectional synchronization, one-way syn- chronization, or no synchronization at all (Fig.3). The key concept in workflow continuity is not the techni- cal architecture of how the information systems pro- vide continuity, but only that continuity of critical workflows exists.Delimitations of Workflow Continuity Workflow continuity should not be thought of as the only solution needed for an organization. Highly avail- able systems, business continuity, and disaster recovery are all critical components to the organization’s overall information system enterprise architecture. Workflow con- tinuity systems are bound by the same architectural restrictions as the fully functional production systems. In the case studied, the workflow continuity system does not address 1.6 TB image cache issues that existed with the PACS failover system. During the workflow continuity de- sign sessions, it was determined that the prior history restric- tions were acceptable to the users. Extended periods of downtime might change the users’perceptions of what level of acceptable history is required, and those situations are where disaster recovery fit in. A 96-h disaster recovery turnaround becomes more acceptable when the users are able to continue their normal workflows during that period of time. Conclusion The organization has implemented a comprehensive workflow continuity solution that significantly improved uptime and enabled the success of a centralized 24 × 7 subspecialty radiol- ogy coverage across multiple hospitals. While workflow con- tinuity does not provide 100 % of the functionality available during normal operations, it delivers the most critical function- ality which allows radiologists to continue working uninter- rupted. The solution is relatively low cost, highly effective, and requires only limited changes in the architecture of existing systems. The organization is applying this methodology to other departments and information systems. Table 4Failover interruption vs. WCS continuity Hospital 2008 PACS failover duration and radiologist workflow interruption2011 PACS WCS duration and radiologist workflow continuity (min) 1 278 min 554 2 575 min 307 3 424 min 535 4 1,112 min 494 5 360 min 720 6 527 min 299 7 555 min 327 8 386 min 458 9 555 min 397 10 569 min 600 11 575 min 500 12 a 0 min 424 Total workflow interruption98 h, 36 min 0 aHospital 12 was not part of the organization in 2008 Workflow Continuity Highly Available System Workflow Continuity System A System B Workflow Continuity System A System B Workflow Continuity System A System B Fig. 3Possible workflow continuity system configurations J Digit Imaging (2012) 25:744–750749 References 1. American Recovery and Reinvestment Act of 2009, HR 1, 111th Cong., 1st sess, 2009 2. Lam W: Ensuring business continuity. IT Prof 4(3):19–25, 2002 3. Lampson B: How to build a highly available system using consen- sus. Distributed Algorithms, 1151:1–17, 19964. Joshi V, Lee K, Melson D, Narra V: Empirical investigation of radiologists’priorities for PACS selection: an analytical hierarchy process approach. J Digit Imaging 24:700–708, 2011 5. Khorasani R: Business continuity and disaster recovery: PACS as a case example. J Am Coll Radiol 5(2):144–145, 2008 6. Cerullo V, Cerullo MJ: Business continuity planning: a comprehen- sive approach. Inf Syst Manag 21(3):70–78, 2004 7. Keene S, Auger L: Continuity of business: does your hospital have a plan.Internet J World Health Societal Polit 4(2), 2007 750J Digit Imaging (2012) 25:744–750 Copyright of Journal of Digital Imaging is the property of Springer Science & Business Media B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use.

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