EHR outages and patient safety

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On October 4, 2021, the social media platform Facebook and its subsidiaries Instagram and WhatsApp experienced an unprecedented system outage lasting over six hours. While the computer glitch inconvenienced 18 million users and adversely affected small businesses dependent on the technology for sales, it’s doubtful that anyone died. Unfortunately, the same can’t be said when system outages affect healthcare facilities.

For example, a recent lawsuit alleges that a 2019 computer crash at a Mobile, Alabama hospital contributed to the brain injury and subsequent death of a newborn baby. According to reports, when Springhill Medical Center lost access to computer systems due to a ransomware cyber-attack, staff lost functionality of critical monitoring systems including those in the obstetrics department where patient Teiranni Kidd was in labor. The suit alleges that because electronic fetal monitoring systems were down, doctors were unable to diagnose and treat the fetal distress that ultimately led to serious brain injury and later death of the baby.

Responding to the lawsuit, Springhill denied responsibility for the baby’s injuries, pointing the finger instead at Dr. Katelyn Braswell Parnell, the obstetrician on duty. The hospital argued that the doctor chose to deliver the baby despite knowing that the computer systems were down at the facility, and that if she felt it was a risk, she should have transferred the patient.

While the answer to who is ultimately responsible for this outcome will be examined by the legal system, it begs the question of how physicians should handle patient care during a catastrophic system failure. After all, what doctor hasn’t been faced with a waiting room full of patients and a sudden unexpected EHR outage?

When computer systems crash, physicians face a serious dilemma. While administrators scramble to follow ‘downtime’ protocols, handing out paper forms to capture billing and coding and reminding doctors to enter data when systems return, physicians are faced with the question of patient safety and liability. Do we try our best to aid our patients with limited information, hoping that we don’t make a life-threatening error, or do we turn the patient away under the principle of primum non nocere?

According to Tony Quang, MD, JD, who is not involved with the ongoing case, the answer comes down to standard of care. “Ultimately physicians are responsible for the care that they provide. If you can provide standard of care despite your system limitations, then go ahead. But if it breaches standard of care, you need to stop.” If you must continue to provide care during a system outage because of an urgent or emergent clinical situation, Quang advises immediately documenting the situation as soon as the electronic medical record becomes available. “You also want to document the situation in detail as soon as possible to justify your actions. Document that the EHR was down; I had to see the patient and perform said procedure because it was urgent or emergent in nature, and by not intervening at the moment, the patient would have been harmed.”

If caring for the patient would be unsafe without electronic systems in a non-urgent/emergent situation, Quang urges physicians not to accept the risk. “You need to remember that protocols are in place for a reason. Never override or ignore them.” Quang acknowledges that this full stop can be difficult for physicians who are by nature resourceful and used to doing their best with what is available to care for patients—even going so far as try to compensate for system failures and limited resources.

Doctors may also be pressured by their employers to continue ‘business as usual’ despite a lack of medical records critical to ensuring safe patient care.For example, a public statement released by Springhill Medical Center during the cyberattack reassured patients that care was ongoing and would not be compromised during the outage, stating that the hospital, “has continued to safely care for patients and will continue to provide the high quality of service that our patients deserve and expect.”

The decision to continue care without necessary resources outside of the physician’s control can be difficult. Tina Adams, MD, an obstetrician in Jacksonville, FL, says that there are circumstances in which she would be forced to continue to treat patients even in a major systems failure. “As an obstetrician, I’m subject to the Emergency Medical Treatment and Labor Act (EMTALA). I can’t turn laboring patients or those with a medical indication for delivery away. And even if I tried to transfer, the other hospital likely wouldn’t accept the patient.”

While Adams does not have any specific knowledge of the details of the Springhill Medical Center case, she suspects that the obstetrician may have been ‘between a rock and a hard place:’ “If a patient arrives in labor, and I send her away, it’s an EMTALA violation. If the hospital is open and staffed and I have a patient who needs induction for a medical reason and they can normally deliver that patient there, I have no choice but to deliver her because she is my patient, and I don’t have privileges elsewhere.”

Regarding the hospital’s responsibility, Adams notes that when electronic fetal monitoring systems are down, labor and delivery floors usually shift to a 1:1 nursing model for laboring patients in which obstetric nurses stay at a patient’s bedside to continuously watch the tracing for signs of fetal distress. “If the hospital didn’t think it was safe to function, they should have closed the unit.”

Physicians must realize that they are likely to be held responsible for bad outcomes that occur during system failures, even if they are urged to continue to provide care by their employers. “If you think something is unsafe, don’t ever do it,” advises Tony Quang MD, JD.“While this decision may appear to conflict with employers’ wishes, it may prove to be a win-win for all—the patient, who does not want to be harmed, the physician, who does not want to cause harm, and the employer who wants to avoid legal action against them.”Quang notes that exceptions may be necessary in emergency situations and suggests that physicians who face this circumstance immediately activate the chain of command and document their decision-making carefully.

With an increased dependence on electronic systems in healthcare, physicians are likely to face unexpected outages—after all, even giants like Facebook can’t keep things running all the time.We must be prepared to evaluate the situation to determine whether standard of care is possible. If not, we must not compromise patient safety. Above all, do no harm.

Rebekah Bernard MD is a family physician in Fort Myers, FL and the author of How to Be a Rock Star Doctor.