An Evaluation of the Insidious Consequences of Clinical Computing Infrastructure Failures at a Large Academic Medical Center

Abstract

Electronic Health Records (EHRs) are intended to make healthcare delivery safer, more effective and accountable. They are complex socio-technical systems that are dependent on the proper functioning of many individual components that comprise the clinical computing infrastructure (CCI), such as networking equipment, message routing systems, departmental clinical computing systems and many others. However, on occasion these CCI components fail or need maintenance, causing clinical workflow and data flow disruptions called downtimes. Considering the inherently disruptive nature of EHR downtimes, organizations typically have mitigating procedures in place. However, many other small hardware or software CCI components also fail, causing loss of EHR functionality, sometimes insidiously. To our knowledge, systematic analysis of CCI failures has not been undertaken. In this work, a dataset of CCI failure logs gathered at one health care system was classified and categorized to shed light on the nature, diversity, frequency and user impact of such failures. ORCA (Online Record of Clinical Activity), Epic and Mindscape are EHR components. By number of records, the top 3 components that had the highest frequency of failure are: Network (393 incidents, 59.5% of which were unscheduled) the inpatient EHR (ORCA) (372 incidents, 49.5% unscheduled) the outpatient EHR (Epic) (228 incidents, 12.3% unscheduled). In terms of user impact, components that accumulated the most failures are: the inpatient EHR (ORCA) (284.8 hours among under 5 users), Cloverleaf (interface engine) (263.5 hours among under 200 users), imaging (205.8 hours among under 50 users), and network (193.9 hours among under 50 users, and 193.4 hours among under 10 users). It is interesting to note that 4 of the 5 aforementioned components affected under 50 users. For the data with user impact estimates, cumulative EHR downtime (687.3 hours) is less than cumulative downtime for small impact non-EHR CCI failures (1131.1 hours). So, it is possible that cumulatively these small-impact but more frequent CCI component failures may approach or exceed the clinical impact of EHR downtimes. Although the data used in this work have important limitations in their accuracy and completeness, this exploratory analysis is the first step towards a better understanding on how to build a safe, resilient CCI that more reliably serves the needs of patients and providers.