South Shore Health System. Downtime Policy and Procedures

Transcription

1 South Shore Health System Downtime Policy and Procedures June 23, 2017

2 INDEX Page OVERVIEW OF DOWNTIME PROCESS: Activation Levels And BCA Capabilities Interfaced System Downtime o Fast Log in VDI Downtime o Citrix Downtime o Support Systems Ameltco Downtime Forms Downtime Form Scanning Recovery Planned Downtime Unplanned Downtime Labels CORE SYSTEMS PROCEDURES PATIENT ACCESS ADMISSION, DISCHARGE, TRANSFER CADENCE SCHEDULING CLINICAL LABORATORY - BEAKER PHARMACY - WILLOW RADIOLOGY RADIANT o Amicas /Merge PACS o Power Scribe o Pen Rad HEALTH INFORMATION MGMT o M-modal o Hyland NURSING HEMODIALYSIS PHYSICIANS RESPIRATORY THERAPY o Neurodiagnostics / PFT o Respiratory Care o Pulmonary Rehab FOOD AND NUTRITION SERVICES o Nutrition Services o CBORD CARE PROGRESSION TRANSITIONAL CARE - DOWNTIME BUNDLES SOCIAL SERVICES REHABILITATION SERVICES PASTORAL CARE / ETHICS EMERGENCY DEPARTMENT EMS 1

3 MATERNITY / MFM / LABOR AND DELIVERY PERI-OPERATIVE SERVICES o Optime o Anesthesia CARDIO VASCULAR - CATH LAB/EKG o Cupid o Ge Muse o Ge Dms ENVIRONMENTAL SERVICES TRANSPORT HEMODIALYSIS IV THERAPY SSHS Downtime Policy & Procedure NON CLINICAL / FINANCIAL DEPARTMENTS / REGULATORY MATERIALS MANAGEMENT FINANCE o Professional Billing o Hospital Billing REVENUE CODING CDI 3M o Experian HUMAN RESOURCES o API / PAYROLL QUALITY IMPROVEMENT QUANTROS SAFETY REPORT AMBULATORY CARE AMBULATORY CARE WOUND CARE CENTER SOUTH SHORE MEDICAL CENTER DIABETES CLINIC 2 POND PARK o Surgical Services o Pain Management o Diagnostic Imaging o Rehabilitation Areas o Lab 2 POND PARK SPECIALTY CLINICS NEURO-SPINE CANCER CENTER HOME AND COMMUNITY CARE HOME CARE 2

4 ADDENDUMS Future State Epic Interfaces Future State Is System Application Quick Guide To Downtime Recovery Work Flow Report Information Downtime Bca Computers - Locations Epic Tip Sheet Downtime Tools: BCA Computers and BCA Web Epic Tip Sheet Inpatient BCA Web Inpatient Notes Epic Tip Sheet - Out Patient BCA Computers Epic Tip Sheet BCA Web ED Patient Access Epic Tip Sheet BCA Web Patient Access 3

5 South Shore Health System (SSHS) shall provide for a standardized process of downtime procedures in the event of planned/unplanned computer system downtime. This process shall ensure that patient care continues in an environment focusing on patient safety and reflecting the best practice guidelines established by the Health System. This process shall ensure the medical record is reflective of current patient information, and provides downtime processes for documentation, orders, results retrieval and charging during system downtime. Business Purpose: To define the procedures that will be utilized during computer system downtime. To ensure an orderly process for managing business systems, workflow and patient care during planned and unplanned system downtime. To establish standards of documentation/information to be entered into the electronic medical record and provide a process for reconciling the electronic medical record post downtime. To support the environment of patient care and establish standard processes within the health system and between ancillary departments by defining the process for business systems, patient registration, ordering of diagnostics, reporting of results, providing treatments and patient services during downtime. Definitions Downtime and the processes put in place during downtime will be affected by variables that include: Whether the downtime is a planned downtime, or unplanned disruption The specific systems that are down application specific vs. organizational impact The estimated time the systems will be down. Ability to use Citrix and Fast Log In systems (VDI) Connection to the Internet / Rhapsody System Planned Downtime : Planned Downtime is advance notification of a planned computer system downtime that allows the departments to prepare for downtime procedures in advance. Unplanned Downtime: An unscheduled computer system downtime that occurs without prenotification. Impact is minimized by back-up systems and downtime documentation processes that are in place to cover during these rare occurrences. Production Server: Live Server: A production server is a type of server that is used to deploy and host live websites or Web applications. SRO: (Shadow Server Read Only) - Server that runs parallel to the production server, and refreshes/saves a snapshot of data from the production server. When the production server is the only server experiencing downtime, all end-users will be able access data from the Shadow Server. 4

6 BCWA: (Business Continuity Web Access) Secure Web-based tool at a local workstation connected to a browser and internal network that enables users to log in, view and print BCA reports during downtime. Data that is available will be from the last Shadow server refresh. This is available to end-users when internet access is available. BCA Web Data Entry: During a downtime allows ADT information (admissions, discharges, and transfers) to be entered into BCA Web when the shadow server is available and internet access is available. BCA Web Data Entry must be turned on by the IS team. Reduces manual data entry and improves recovery time and clinical access to the system. Allows clinical users a way to create and file inpatient notes. BCA: (Business Continuity Access) - Provides pre-configured patient reports that includes vital patient information for continuity of care. Reports and patient information can be printed from the BCA computer when there is no Production Server/Shadow Server/Web access to Epic information available. Reports will be printed from a designated BCA computer that has battery back-up (60 min) and it will be utilized in Level 1 Downtime. BCA Computer: A specifically labelled PC that has an independent power source 60 minute UPS if not connected to generator emergency power Connected to a local printer Has the BCA PC application installed Locally stores pre-defined reports with critical information Reports can be printed by clinicians to continue patient care Outpatient / Business locations typically have one BCA PC per department Inpatient locations have one or two BCA PCs per unit or one for approximately every 20 beds. CHECKED AND MONITORED: By shift in clinical patient care areas. Contact Serial Number (CSN): A unique number used to identify a patient encounter. Once it is assigned, the CSN does not change. The CSN number will be used in a downtime. The Hospital Account (HAR) will be get automatically assigned when the system comes back up. Hospital Account (HAR): Used to keep track of charges, payments, and adjustments related to hospital or technical fee billing. Hospital accounts are tied to a specific patient encounter and a single patient and guarantor account. These identifiers are not available in a downtime 5

7 BCA Computer Labels and Icons: Icons Shadow Read Only BCA Web Access to print reports and enter notes. Patient Access will enter patient ADT information BCA computer will print BCA reports (PMARS) BCA Report: See Addendum with location information BCA report information is stored and saved at varying timeframes based on the department or area. Most patient care information is saved every minutes. BCA reports may be viewed during level 3 and 2 downtimes and will be printed during level 1 downtime. 6

8 Responsibility for Downtime Readiness Clinical departments will define their intra-department downtime processes which support the utilization of the downtime forms. Shadow Server Read Only (SRO), BCWA, BCA and Interfaced system downtime information will be kept updated and maintained in a reference binder that is easily accessible on each unit. Clinical Departments will maintain all Downtime documentation forms in a specified location to be readily accessible when downtime occurs. Forms that will be part of the medical record should be bar coded in order to facilitate the use of Hyland application during the recovery phase. Upon notification of a system downtime, the onsite department leader or designee will pull the Downtime Tool Kit or binder and initiate downtime processes based upon the Downtime Level notification or Application/interfaced system notification. South Shore Health System Information Services (IS) department will be responsible for ensuring optimal system availability, and will promptly communicate situations of both planned/unplanned downtimes based on the existing policy and procedure. Initiation of Downtime Processes Upon notification of a planned/unplanned Epic downtime, downtime processes will be initiated based on the Downtime Policy and Level notification. See Code Technology Policy. 7

9 Levels of Downtime and Capabilities SSHS Downtime Policy & Procedure See Description Below. 8

10 Description of Downtime Levels SSHS Downtime Policy & Procedure LEVEL 3 DOWNTIME - EPIC PRODUCTION SERVER DOWNTIME (SRO) Epic Hyperspace is down, all information (system wide) & patient information contained in the Epic system is available in a read-only format called Shadow Read Only (SRO). Non Clinical / Business Functions: Each computer in the department will have access to department information. Sign in will utilize the end-user's normal windows sign-in. Reports will be available for read only format (SRO) and can also be printed Report List will be identified in each department downtime information o Schedules o Census o Other Clinical: Electronic Medical Record is available in read-only format (SRO) Patient MAR and other clinical documents needed for patient care should be printed and downtime documentation tools / paperwork will be used. BCA Web Data Entry will be used for Admission, Discharge, and Transfer (ADT) process to enter information during the downtime period. Bar Coded Bracelets and the Master Index Patient List will be available Labels: If EPIC is available, print labels from EPIC BCA printers will have the capability to print labels and band with patient information and bar Code. If EPIC is unavailable and Microsoft Word is available use Microsoft Word to make labels: Make one page and then copy onto Avery labels by using copier. Hyland Web Client if available may be accessed by the UC and labels will be printed on Avery (further education needed) If Internet access is unavailable to Hyland or Microsoft Word hand write labels. Documentation: o Notes may be entered electronically or dictated* by the providers they will be automatically transfer to the record upon recovery. * See Dictation Section. All order entry or other patient care documentation will take place on downtime requisitions and patient care forms see area/department specific plans. 9

11 LEVEL 2 DOWNTIME - EPIC DOWNTIME WITH BCWA (WEB In Level 2, Epic Hyperspace and the Shadow Read Only (SRO) environments are both unavailable, report and patient information is available via the web through Business Continuity Web Access (BCWA). Internet Access is available. Non Clinical / Business Functions: Identified computers in departments have a 'BCWA' icon on their desktops to access BCA reports. Sign in to the BCWA will utilize the end-user's normal Windows sign in. Print Reports and Information to be used for continuity of operations Use Downtime paperwork and forms to maintain operations. Clinical: Designated computers in the department have a BCWA icon on their desktops to access BCA reports BCA Web Data Entry will be activated by IS for Patient Access to enter admission, discharge and transfer activity during the downtime period. Print BCA report o PMAR (medication delivery documentation) o Lab, Radiology, and other patient information o Census List Downtime documentation tools / paperwork will be used. Labels: If EPIC is available, print labels from EPIC BCA printers will have the capability to print labels and band with patient information and bar Code. If EPIC is unavailable and Microsoft Word is available, use Microsoft Word to make labels: Make one page and then copy onto Avery labels by using copier. Hyland Web Client if available may be accessed by the UC and labels will be printed on Avery (further education needed) If Internet access is unavailable to Hyland or Microsoft Word, hand write labels. Documentation: o Notes may be entered electronically or dictated* by the providers they will be transferred to the record upon recovery. * See Dictation Section. o All order entry or other patient care documentation will take place on downtime requisitions and patient care forms see area/department specific downtime resources. 10

12 Code Technology may be declared. SSHS Downtime Policy & Procedure LEVEL 1 DOWNTIME EPIC DOWNTIME - BCA COMPUTER ONLY ONFODOWNTIME PROCESSES Internet is unavailable. The BCA designated computers will be used to print BCA reports. Because a Level 1 Downtime Scenario includes both the loss of internet and the active directory is unavailable an organizational password will be used to access the downtime BCA specific PC s to print BCA reports. The Information System Leadership team will coordinate the release of the organizational password with the HICS Team. Non Clinical / Business Functions: A pre- determined single BCA computer is either attached to the emergency power system of the building or an uninterrupted power source (UPS) with battery backup for 60 minutes. Print BCA reports using special password released by the HICS team. Use Downtime documentation tools, forms and requisitions for continuity of operations Clinical: BCA computers are attached either to the emergency power system of the building or an uninterrupted power source (UPS) with battery backup for 60 minutes. Print BCA report includes last information captured at time of the disruption o Patient care area census: Available in all patient care area o Hospital census: Available in Patient Access, Pharmacy, Lab, Food and Nutrition, HIM, Radiology, and Rehabilitation Department. Documentation: All order entry and patient care documentation will take place on downtime requisitions and patient care forms Labels: LEVEL 1 Downtime If EPIC is unavailable and Microsoft Word is available, use Microsoft Word to make label page template and then copy onto Avery labels using copier Hand write labels. HICS Planning Section - Labor Pool activation ~ Label making task force from non clinical areas to further assist with label making needs 11

13 INTERFACED SYSTEM DOWNTIME - EPIC SYSTEM FULLY AVAILABLE) Bridges is the Epic application for interfaces. Rhapsody is the interface engine. Each department will describe specific information for referenced Interfaced system. Reference sheets should be maintained in each Department Downtime Reference Manual. Interfaced System Severity Potential BCA Downtime Level Fast Log In VDI High Severity Level 1 Citrix High Severity Level 1 VOIP Phones (Voice over internet protocol) Beaker Lab Interface Orders on Downtime PACS System Interface TBD TBD TBD 12

14 Downtime Forms / Order Sets See application-specific section of this policy for application specific information which is labelled by name and also included in each department s information. Appropriate paper downtime requisitions, patient care documentation, and order sets (located on Route 55) will be utilized upon notification or discovery of an Epic downtime. Downtimes for Interfaced systems will have processes and paper documentation as outlined in the Interfaced system section for each application. Order sets should be printed from Route 55 and available in downtime boxes/files for each department as part of downtime readiness. All paper forms/documentation utilized during a Downtime will be labeled with the patient s label (both front and back). Each patient care floor - plans for 48 hours of supplies of labels and paperwork. The Print Shop has a backup supply of 8 hours and also the templates for each form. Master list and flash drive are located in HIM and the Logistics Section Chief Resource Book in the Command Center. Each patient care area and department should maintain the most up to date forms and assess their supplies yearly or sooner if changes to the plans occur. Downtime forms and requisitions should be barcoded to allow Hyland On Line systems to categorize the scanned documents into the proper section of the medical record. Forms without barcodes will need to be manually placed into the chart. ** Downtime paperwork will be reviewed in 2018 and updated as determined by each department and division based on cumulative knowledge of Epic and downtime process 13

15 Downtime Labels The Label making process is covered in each downtime level the grid below provides the overview of label making process. Each patient care area plans for a 48 hour back- up supply of blank labels. Patient care areas should plan to have an adequate supply of labels each shift. 14

16 Downtime Form Scanning For downtimes greater than one hour for the emergency department and inpatient areas. ED Discharged During Downtime Downtime Paperwork ED Patient HIM pickup paperwork IP Patient IP UC fax to HIM HIM will pick up documentation at discharge Begin Processing/ scanning Downtime Paperwork with HIM assistance but not Emergent ED Admitted during Downtime Remains in ED not admitted after Downtime Inpatient Discharged during downtime HIM will round and pick up all paperwork at discharge Admitted during downtime Unit Coordinator will fax to HIM during downtime. Remains inpatient post Unit Coordinator will fax to HIM during downtime downtime Downtime Over / Recovery IP UC s will resume faxing to HIM SSMC and Off Sites One day downtime Will scan internally in their department < One Day downtime HICS will work with Record Preservation Unit to determine plan For extended downtimes or if faxing capability is not available the HICS team and Record Preservation Unit will determine the plan to respond and recover from the disruption. Hyland On-base Scanning If the Web Client is available, all users will be able to view scanned documents in Hyland. Access to the Web Client is available through the SSHS Portal. Contact HIM for assistance. 15

17 Reports Information will be accessible and printed from the BCA and Shadow Server in Levels 2 and 3 downtimes per Application-specific sections of this policy. The Medication Administration Report will be printed manually for these levels. The BCA Computer will be accessed in a Level 1 downtime using a organizational password. This password will be released to the BCA users by the HICS team or Information System leadership Reports will be printed to the specific BCA printer. HIM will be the central location for all Hospital-based BCA reports. Information is stored on 2 BCA computers in HIM Home Care Division, South Shore Medical Center, 101 Columbian St. departments and other off sites will print out reports to their BCA computers and BCA printers. See Addendum section for report types and back up timeline for back up. 16

18 Downtime Recovery: South Shore Hospital and Other Clinical Areas Downtime Recovery Phase 1: This is the period where Patient Access/ADT forms are accumulated and manually inputted into the EHR system. Patient orders and documentation can ONLY be entered on patients that have not had an ADT event during the downtime Downtime Recovery Phase 2: Catch up period where orders and documentation are entered on all patients that have had an ADT event during downtime. Order entry and documentation back load is dependent on the patient's information being in the system first. Patient Access/ADT, Pharmacy, and Lab must do all of their recovery efforts prior to clinical staff entering data for their patients that have been admitted, discharged, or transferred during the downtime. Pharmacists must enter all of the medication orders prior to nursing entering the medication administration information. 1. If downtime is greater than 1 hour, all information from assessments, graphic and MARs are entered into the system. Discharge forms can be scanned in. 2. If downtime is less than 1 hour the following information is entered into the system by the clinician. A. Any updates to patient's height, weight, and allergies B. Any new lines, drains, airways, or wounds (LDAs) documented during downtime C. Medications that have been administered during downtime (MAR documentation) D. Education Assessment and/or teaching completed during the downtime E. Care Plan initialization and/or updates completed during the downtime F. Legal Requirement Birth Certificates, Vaccinations G. Core Measure requirement 3. Laboratory results will cross the interface once the system has recovered, thus laboratory orders that have been resulted will not need to be entered into the system. The laboratory orders that have not been collected and/or resulted will need to be entered into Epic during recovery by laboratory personnel. 4. Diagnostic Imaging orders that have been sent to Radiology on a paper requisition will be entered by diagnostic imaging staff. 5. All other orders will be entered into Epic during recovery. A. Respiratory Therapy staff will review, collaborate with nursing staff to ensure that all respiratory orders have been written and then entered into the computer system. The nurse will document on the paper order sheet that the orders have been entered electronically with date, time and initials. (Noting the orders) 17

19 7. All other paper documentation will be scanned, by HIM, into the medical record upon discharge. 8. All patients that have been admitted or transferred during the downtime must have a new patient identification band placed on them after Phase I recovery has been completed. 9. The downtime armbands will have the MRN identification number. Medication scanning requires the CSN number which will be put into place once Admitting has completed their process. CSN# is for billing purpose. 10. Information may be entered up to 24 hour after the return to normal operations. 18

20 Communication SSHS IS Department will be responsible for ensuring optimal system availability, and will promptly communicate situations of both planned/unplanned downtimes. The SSHS IS Department Alert Communication Process will be followed by SSHS IS department for any planned or unplanned downtime. Based on the event and scope of the Downtime communication tools will be used as needed if available. Overhead paging, SNAP pop up messages, Cortext, Calleague Alert or Send Word Now, Fax machines and Call trees provide redundant options for communication. Memo s and face to face messaging will also be used if needed. The HICS team when activated will assist with communication. Planned Downtimes: 1. These will be communicated utilizing prior to the event. Paging, cortext and snap messages will be used to communicate during the planned downtime. 2. Workflow prior to the downtime o PMARS will be printed from EPIC BCA computers o BCA PMAR will mirror the current PMAR o Additional incremental orders (refresh every 5 15 min) will be included in the BCA report o Order entry will not need to be taken down prior to the planned downtime 3. Downtime recovery procedures will begin upon notification by SSHS IS Department that the system(s) is/are once again available for full use. o Downtime recovery procedures will begin with Downtime Recovery Phase 1 where appropriate information is back loaded into the system for patient s that have not had an ADT transaction during downtime. o Downtime Recovery Phase 2 is when the complete update of all ADT transactions by the ADT departments at affected locations is complete and information can be back loaded into the system. Unplanned Downtime 1. End users will contact Customer Support/Help Desk at ext and notify their chain of command upon discovery of a down system and will begin using recommended downtime procedures immediately. 2. SSHS IS Department staff will work through existing procedures to determine the type and severity of the issue. 3. All issues relating to the Epic system being down will be assigned a Critical (Level 1). 4. SSHS IS Department Critical notification procedures are as follows: a. Notifications sent out to appropriate groups within 15 minutes of issue identified. 19

21 b. System Status Lines updated for *** I.S. Customer Support with detailed information on issue. c. Voic messages sent to selected areas. d. Notifications and status updates at least every 30 minutes or as new information becomes available. e. Pager/Core Text and Snap Messaging will be used to communicate to all users if available. f. Paper postings and overhead paging will be used if other systems are not available. 5. SSHS IS Department administration will initiate the Critical Response Team procedure within 15 minutes of Epic Downtime. 6. SSHS IS Department will communicate with Local SSHS Management or the Administrator on Call at the affected site and notify them of the type, severity, and other details of the downtime and downtime level. 7. A standard bridge line will be utilized by the Critical Response Team to allow efficient two way communication between the SSHS IS department management, analysts and HICS management. This number would be distributed at this time to the appropriate persons. 8. Each locations SSHS IS Management representative will communicate through appropriate channels as defined by the locations policy and procedure to inform the end users of the situation and to begin using downtime policies and procedures. 9. Downtime recovery procedures will begin upon notification by SSHS IS Department that the system(s) is/are once again available for full use. 10. Downtime recovery procedures will follow Downtime Recovery Phase 1 where appropriate information is back loaded into the system for patient s that have not had an Admission, Discharge, or Transfer (ADT) transaction during downtime. This is followed by Downtime Recovery Phase 2, which is the complete update of all ADT transactions by the ADT departments at affected locations. 20

22 Procedure: Application/Department Policy Sections PATIENT ACCESS (Admission/Discharge/Transfer) Grand Central Each area that creates downtime patient record using the Contact Serial Number (CSN) will be responsible for its re-entry into Epic. Patient information will be manually collected via an access database/downtime information form. Manager/Supervisors of each area registration will be responsible for acquiring necessary downtime forms. 1. Registration personnel will begin using manual downtime forms provided by the Manager/Supervisor of their department. 2. Each registration area will designate specific staff to maintain the downtime log and reconciliation of downtime CSN s. 3. Patient Access will provide downtime CSN s for manual patient registration during computer downtime. Registrars will place copies of the downtime registration form in a designated downtime file to be reconciled by the area when system comes up. 4. Area Manager/ Supervisor will ensure that registration areas they are responsible for have an adequate supply of downtime forms, consents, and a downtime CSN log for that area. Patient Access will document in the appropriate electronic log via BCA Web or the Web Portal numbers assigned to the registration area. 5. Each registration area is responsible for entering their patients on the above log. A. Document the following a. Patient name b. Date and time of registration/admission and location. B. When all numbers have been used on the log, turn into the appropriate supervisor. C. Manually write the registration information on the downtime form. a. Write legibly someone else may be entering the information into the system. b. Follow downtime instructions for labels if applicable for your area c. Make bracelet for patient if applicable for your area. d. Obtain signature from patient on Consent form. Be sure to write patient s name and CSN on the form. e. Make a copy of patient s insurance cards and photo ID if available. Write patient s name and CSN in the upper right hand corner of the copy. 21

23 f. Make a copy of patient s PHI Communication form. Be sure to write patient s name and CSN on the form. g. For ER Patients be sure to give the secretary a label with the patient s location as well as a copy of the PHI Form and the label template. D. Send a copy of the downtime form, signed consent, and PHI form along with any other necessary paperwork to the appropriate clinical area (if applicable in your area). In ER, the unit coordinator will be responsible for matching up paperwork with the patient s chart. 6. Nursing units will maintain a manual log of discharges and transfers. These forms will be faxed every 2 hours to Patient Access Bed Control. In the event that power is down or the fax system is not working, Floors should contact ext directly with information. Runners may be assigned by the HICS Team. 7. Bed Control will maintain the Master Patient Census. All admits, discharges, and transfers will be manually documented on the Master Patient Census. 8. Bed Control will have a current copy of the Master Patient Census. Pharmacy, Food and Nutrition Services, Diagnostic Imaging and Lab will also have a census report available in their BCA Reports. Bed Control will update the Master Patient Census and coordinate with the HICS team to provide updated census reports as needed. 9. Assigned Registration personnel will enter all downtime registrations when the system is back up and ready for downtime data entry. Conversions to In-House Admissions 1. When an outside department requests a CSN for the current date of service, follow these guidelines: A. Fill out reservation slip per normal. B. Staple Reservation Slip to downtime form and file for re-entry. Direct Admits 1. Fill out reservation slip per normal process Newborn Admissions 1. Fill out the reservation slip with the information from nursery. Be sure to obtain the date and time of birth, weight, and feeding type. 2. Assign a number from the downtime log. Follow Direct Admit procedures. 3. Place newborn s downtime form with mother s downtime information if applicable. 22

24 Labor and Delivery Admissions New Admissions SSHS Downtime Policy & Procedure 1. Labor & Delivery will need to complete the downtime form. Downtime form, PHI Communication form, and insurance card copies will need to be faxed to Admitting. 2. Assign a downtime CSN to patient using the downtime log. 3. Document name, date, and time on the log. 4. Call Labor & Delivery with downtime CSN assignment. 5. Follow downtime instructions for labels. 6. Place one label with room number on downtime auxiliary form unless confidential patient. 7. Make bracelet for patient. 8. Send labels to Labor & Delivery by tube system or runner. 9. Keep the downtime form faxed, PHI Communication form and insurance card copies for reentry. Conversions 1. Labor & Delivery will fax Patient Status Change form to ER Admitting. If additional labels are needed please document on Status Change form. 2. Be sure to document date and time the change occurred. 3. Make new labels for admission if needed. 4. Place one label with room number on downtime auxiliary form (unless confidential patient) for the Information Desk. 5. Staple Patient Status Change form to downtime form and file for re-entry. Recovery: Phases of Downtime Recovery: See Addendum 2 Downtime Recovery Phase 1: All admission, discharges and transfer documentation will be completed prior to the clinical staff entering orders and documentation into the medical record. Patient orders and documentation can ONLY be entered on patients that have not had an ADT event during the downtime. 23

25 Downtime Recovery Phase 2: SSHS Downtime Policy & Procedure Catch up period where orders and documentation are entered on all patients that have had an ADT event during downtime. All ADT Downtime Event Forms are delivered to centralized ADT location from all units. ADT areas must do all of their recovery efforts prior to nursing entering data for their patients that have been admitted, discharged, or transferred during the downtime. 1. Assigned personnel will enter the downtime registrations into Epic. 2. Backdate to original date and time of registration. 3. Manually enter in the downtime CSN Do Not let the computer assign the CSN. 4. The designated Supervisors will direct activities, beginning with ER patient types and ending with Outpatient registrations. 5. Face sheets will be printed for appropriate patient types and distributed via runners and the tube system 6. Designated Patient Access personnel will enter discharges and transfers making sure the In House Census are balanced. Perform the following 1-2 hours after Downtime recovery phase 2 is completed, each area should check the BCA PC to verify the new patient information is filing to the department reports. Reports of department appointments and staff daily schedules for current and future dates will automatically uploaded to an FTP server on a nightly basis. If the system becomes unavailable, ambulatory and hospital service department staff will print the appropriate reports as necessary. Each Manager/Supervisor will be responsible for acquiring necessary downtime forms and printing necessary reports. Scheduling of future appointments and appointment reschedule requests: 1. Scheduling of future appointments and appointment changes will be handled by advising the patient or office of the downtime and logging the contact name, number and reason for the call on a Downtime Call Tracking Form. 2. Print a copy of the Downtime Call Tracking Form. 3. Advise patient or office of the downtime and that you will call them back when the system is available. 4. Offer to take the caller s name, number and reason for call and record on the tracking form. 24

26 5. If the patient doesn t want to provide their information, give the patient an approximate time they can call back. Tracking walk-in appointments, appointment cancellations, and check-out/in activities: 1. Tracking walk-in appointments, appointment cancellations, and check-out/check-in activities will be handled by utilizing the Department Appointments Report (DAR). 2. In addition, patients checked in and waiting in the waiting room for their appointments can be noted on the DAR. 3. Walk-in Appointments: Make note of the patient name, DOB, last 4 digits of SSN, provider, date, time and reason for the appointment on the printed DAR report. Make copies of insurance card, photo ID, etc. and consolidate for later scanning when the system is available. 4. Cancellations: Make note of any cancellations listed on the printed DAR. If a future appointment not listed on the printed DAR is canceled, record the patient name, number, provider, date, time and reason for the cancellation on the printed DAR. 5. Check-out: Make note of any patients checking out on the printed DAR. If a future appointment is needed, make note to contact the patient when the system is available. If an ABN is signed, consolidate for later scanning when the system is available. 6. Check-in: Make note of any patients checking in on the printed DAR. Note the time of their arrival. 25

27 CADENCE (SCHEDULING) Processing of co-pay and other payments: If Experian is available areas can manually process copayments during downtime and print a receipt. If Experian is not available copayments will not be collected. Order/Referral processing: 1. Scheduling of future appointments requested through the order and referral process will be handled by advising the patient or office of the downtime and logging the contact name, number and reason for the call on a Downtime Call Tracking Form. 2. Print a copy of the Downtime Call Tracking Form. 3. Advise patient or office of the downtime and that you will call them back when the system is available. 4. Offer to take the caller s name, number and reason for call and record on the tracking form. 5. If the patient doesn t want to provide their information, give the patient an approximate time they can call back. 6. Faxes received during downtime will be consolidated for later processing. Recovery: Assigned personnel will enter the downtime information into the system as soon as the system is available. 1. Appointments that were manually recorded must be entered. 2. Patients appointments checked-in and walk-in appointments should be entered and updated. Any documents pertaining to the check-in process should be scanned and updated. 3. Patients appointments checked-out should be updated. Any documents pertaining to the check-out process should be scanned and updated. Any patients needing follow-up appointments should be called. 4. Any appointment cancellations should be entered. 5. Any co-pays and other payments collected should be entered from the handwritten receipts. 26

28 Emergency Department Documentation Recovery to EMR Epic Downtimes greater than 1 Hour The following information will be entered into Epic when the system is available. 1. ED Tracking system will be updated by the appointed ED staff (Unit Coordinator/Bed Flow Facilitator) with discharges, admissions, transfers, etc. that occurred during the downtime. 2. Patients who arrived during Downtime will have a new identification bracelet placed that includes the updated information and CSN#/barcode by patient access. 3. All clinical documentation will be entered into the Epic system. 4. Downtime paper documentation will be scanned into system when entry into Epic is complete. 5. Charging processes will follow normal workflows. 6. Lab/Radiology will enter their orders from their paper requisitions and reconcile the system per policy. Epic Downtimes Less than 1 Hour The following information will be entered into Epic when the system is available: 1. ED Tracking system will be updated by the Unit Coordinator with discharges, admissions, transfers, expirations, etc., that occurred during downtime. Downtime Recovery Phase 1: Patient orders and documentation can ONLY be entered on patients that have not had an ADT event during the downtime Downtime Recovery Phase 2: Catch up period where orders and documentation are entered on all patients that have had an ADT event during downtime. Order entry and documentation back load is dependent on patient's information being in the system first. Patient Access / ADT must do all of their recovery efforts prior to nursing entering data for their patients that have been admitted, discharged, or transferred during the downtime. 27

29 Epic System is Down/ Lab Interfaced System is Down Procedure for New Orders: CLINICAL LABORATORY (BEAKER) 1. In the event of a downtime nursing departments will utilize the laboratory back-up requisition. 2. The laboratory back-up requisition must be filled out completely. Place a patient label on each copy of the laboratory back-up requisition. Legibly write time/date of collection Epic username of the person collecting the specimen, patient s room number, specimen source (if other than blood) and check the desired test(s). 3. If you do not have a label, you MUST WRITE on the requisition: A. Patient Name B. Account # C. Sex D. Date of Birth E. Physician F. Patient location G. Collection date and time H. EPIC username of person collecting the specimen 4. Label the specimens with a patient label. If you do not have a patient label, you MUST legibly handwrite on the tube or a blank label: A. Patient Name B. Account # C. Sex D. Date of Birth E. Physician F. Patient location G. Collection date and time H. EPIC username of person collecting the specimen NOTE: For blood bank tests hand label according to Blood Bank policy. 5. For a NURSE DRAW: Send the specimen along with the laboratory back-up requisition to the lab 6. For a LAB (PHLEBOTOMY) DRAW: A. Check off box to be drawn by lab. B. Clearly state time blood is to be drawn. C. Check off stat box if applicable. D. Hold the back-up requisition on the nursing unit for the inpatient phlebotomists to collect. E. Do not prepare requisitions more than four hours prior to the desired collection time. 28

30 7. For an ADD ON: A. Send laboratory back-up requisition to lab. B. Check off specimen already in lab, along with date and time specimen collected. Results and Reports: 1. Results will be called or faxed to the unit. 2. Lab results will be kept with the paper chart. 3. Critical results will continue to be called as per current policies. 4. Old results for patients available on Shadow Server/BCWA. Recovery: 1. Order as usual in EPIC (do not send back-up requisitions). 2. Do not place orders in EPIC that you PREVIOUSLY ordered on a lab back-up requisition. Laboratory personnel will follow their departmental downtime policy for order entry and reconciliation. Epic Available - Laboratory Interfaced System Down Procedure: 1. If the Nursing department has a lab collection label, collect the specimen, place label on specimen, and send to the lab. 2. For new orders or orders not released from Epic (Nursing Dept. will not have a label as no labels will print): A. Nursing departments will have to go through patient s charts and determine which labs need to be collected. B. Nursing departments will have to utilize the laboratory back-up requisition. Fill out the requisition completely. Place a patient label on each copy of the laboratory back-up requisition. Legibly write time/date of collection, Epic username of the person collecting the specimen, patient s room number, specimen source (if other than blood) and check the desired test(s). 3. If you do not have a label, you MUST WRITE on the requisition: A. Patient Name B. Account # C. Sex D. Date of Birth E. Physician F. Patient location G. Collection date and time H. EPIC username of person collecting the specimen 29

31 4. Label the specimens with a patient label. If you do not have a patient label, you MUST legibly handwrite on the tube or a blank label: A. Patient Name B. Account # C. Sex D. Date of Birth E. Physician F. Patient location G. Collection date and time H. EPIC username of person collecting the specimen NOTE: For blood bank tests hand label according to Blood Bank policy. 5. For a NURSE DRAW: Send the specimen along with the laboratory back-up requisition to the lab 6. For a LAB (PHLEBOTOMY) DRAW: A. Check off box to be drawn by lab. B. Clearly state time blood is to be drawn. C. Check off stat box if applicable. D. Hold the back-up requisition on the nursing unit for the inpatient phlebotomists to collect. E. Do not prepare requisitions more than four hours prior to the desired collection time. 7. For an ADD ON: A. Send laboratory back-up requisition to lab. B. Check off specimen already in lab, along with date and time specimen collected. Results and Reports: 1. Results will be called or faxed to the unit. 2. Keep lab results with the paper chart. 3. Critical results will continue to be called as per current policies. 4. Old results for patients are still available on Epic. Recovery: 1. Order as usual in EPIC (do not send back-up requisitions). 2. Do not place orders in EPIC that you PREVIOUSLY ordered on a lab back-up requisition. Laboratory personnel will follow their departmental downtime policy for order entry and reconciliation. 30

32 Epic Down Laboratory Interface Up Procedure: 1. If the Nursing department has a lab collection label, collect the specimen, place label on specimen, and send to the lab. 2. For NEW patient orders the laboratory back-up requisition MUST be utilized. Fill out the requisition completely. Place a patient label on each copy of the laboratory back-up requisition. Legibly write time/date of collection Epic username of the person collecting the specimen, patient s room number, specimen source (if other than blood) and check the desired test(s). 3. If you do not have a label, you MUST WRITE on the requisition: A. Patient Name B. Account # C. Sex D. Date of Birth E. Physician F. Patient location G. Collection date and time H. EPIC username of person collecting the specimen 4. Label the specimens with a patient label. If you do not have a patient label, you MUST legibly handwrite on the tube or a blank label: A. Patient Name B. Account # C. Sex D. Date of Birth E. Physician F. Patient location G. Collection date and time H. EPIC username of person collecting the specimen NOTE: For blood bank tests hand label according to Blood Bank policy. 5. For a NURSE DRAW: Send the specimen along with the laboratory back-up requisition to the lab 6. For a LAB (PHLEBOTOMY) DRAW: A. Check off box to be drawn by lab. B. Clearly state time blood is to be drawn. C. Check off stat box if applicable. D. Hold the back-up requisition on the nursing unit for the inpatient phlebotomists to collect. E. Do not prepare requisitions more than four hours prior to the desired collection time. 7. For an ADD ON: A. Send laboratory back-up requisition to lab. 31

33 B. Check off specimen already in lab, along with date and time specimen collected. Results and Reports: 1. Results will be called or faxed to the unit. 2. Keep lab results with the paper chart. 3. Critical results will continue to be called as per current policies. 4. Old lab results may be viewed on Shadow Server/BCWA. Recovery: 1. Order as usual in EPIC (do not send back-up requisitions). 2. Do not place orders in EPIC that you PREVIOUSLY ordered on a lab back-up requisition. Laboratory personnel will follow their departmental downtime policy for order entry and reconciliation. Bridges, Rhapsody, or Capsule DOWNTIME PROCEDURE INTERFACED SYSTEM DOWNTIME INFORMATION EPIC AVAILABLE LABORATORY ORDERS DURING RHAPSODY/INTERFACE SYSTEM DOWNTIME 1. When Rhapsody goes down, immediately cease placing lab orders in EPIC and go to downtime procedures. 2. When specimens are collected during Rhapsody downtime, a paper downtime lab requisition should accompany the specimens to the Lab. The lab request must have the location and call back #. 3. Results will be provided to the units using downtime processes. 4. POC results (Glucometer, i-stat, Creat) will not go thru the lab interface into EPIC during the downtime. Currently stored in handhelds and documented on paper. Enter/Edit results should be utilized for preliminary results. 5. When Rhapsody/Interface System comes back up, any lab orders placed while Rhapsody was down and the downtime process was not in place will go through the interface and accession labels will print. These need to be reconciled with results generated either by the nursing unit for nurse collected specimens or send to the Laboratory to reconcile for phlebotomy draws. 6. When Rhapsody/Interface System comes back up, POC test results will go thru the interface and show as final results in EPIC. 7. When Rhapsody/Interface comes back up, all orders in the system will flow to the Lab and results will flow into EPIC. : 32

34 Point of Care - UniPOC SSHS Downtime Policy & Procedure UniPOC is the middleware that interfaces Glucometer and i-stat results with Epic. If UniPOC is down, staff can continue to use meters/analyzers for patient testing. Wristbands will scan and results are stored in analyzers for review if needed. Once interface is back and meters/analyzers are docked, all results will flow into patient charts in Epic. Call IS Help Desk if any further interface issues 33

35 PHARMACY (WILLOW) Procedure: Planned Downtime For the specific timing and communication process of Planned Downtime, refer to the Overall Hospital Planned Downtime Procedures. Pharmacy Pre-Downtime Preparation 1. Obtain Pharmacy Downtime Bin. 2. Additional Staff is scheduled by Pharmacy Management to assist with order entry during the recovery phase. 3. Pre-printed generic IV piggyback labels for the most commonly used drugs are available in the downtime bin. 4. Pre-printed blank medication labels are available in the downtime bin. 5. Set up folders to hold orders during downtime. 6. Make sure fax machine is fully loaded with paper. 7. Run any cart fills that would normally run during the downtime and print most recent cart fill list for any other carts. 8. Obtain ADT report just prior to start of downtime 9. Omnicell cabinets on put on critical override during the length of downtime. Unplanned Downtime For the communication and escalation process of Unplanned Downtime, refer to the Overall Hospital Unplanned Downtime Procedures. Procedure Planned and Unplanned 1. Refer to Downtime Bin for policy and procedures 2. A call tree should be set up for downtime greater than 2 hours so that appropriate staff can be called in to assist during downtime and after the systems are available again to catch up as the manager deems necessary. 3. Print BCA Med Profile report from the BCA is to be utilized during downtime. 4. Pharmacy will receive an updated census report that can be accessed from the BCA Web and prnted from the BCA PC in the pharmacy at the start of the downtime. 5. New orders should be faxed or scanned to the pharmacy to be manually processed. These documents will be used to enter orders post-downtime. The Pharmacist is responsible for documenting the following information on the scanned or faxed copy of the physician s order if medications are dispensed: 34

36 6. Handwritten labels should include the following information: medications 1. Patient s name 2. Visit Number 3. Nursing Unit 4. Drug name 5. Dose 6. Frequency 7. Number of doses dispensed 1. Patient s name 2. Visit Number 3. Nursing Unit 4. Drug name 5. Dose 6. Frequency 7. Diluents 8. Amount of Diluents 9. Frequency 10. Date and time made 12. Expiration date and time 7. Packages returned from discontinued or changed orders shall be kept in a separate container clearly marked for CREDIT. Labels shall be credited by the pharmacy technicians when the system is up. 8. After notification by the Critical Response Team, Pharmacy Management will oversee that Omnicell cabinets are placed on critical override during the downtime. Existing orders will still appear on the patient's Omnicell profile; however, during the downtime, no new orders will crossover to Omnicell. Critical override allows nurses to obtain drugs for new orders. procedure for any type of downtime (planned/unplanned) 9. Bulk charge sheets received in the pharmacy shall be kept in a clearly marked folder to be processed once the system is back up. 10. As patient discharges occur the discharge notice and any medication order documents should be separated from the active orders and kept together for entry after orders for active patients are completed. Recovery: When the computer systems are restored, check the Omnicell/robot/carousels to ensure that interfaces are up and functioning. 35

37 ADT Recovery: Downtime Recovery Phase 1: This is the period where ADT forms are accumulated and input into system. Patient orders and documentation can ONLY be entered on patients that have not had an ADT event during the downtime Downtime Recovery Phase 2: Catch up period where orders and documentation are entered on all patients that have had an ADT event during downtime. Order entry and documentation back load is dependent on the patient's information being in the system first. 1. After ADT has finished processing all admissions, discharges, and transfers, Pharmacy will enter all downtime medication orders into EPIC. Orders should be entered in the order that they were written and back dated/timed to when they were written. Doses ordered that remain to be administered should be entered with the order. Any interventions and notes that would have occurred during downtime should also be entered. Discharge patient profiles should be entered last. A. An ordering mode of standard should be used for all orders faxed to Pharmacy during the downtime B. Pharmacy will link patients entered to the omnicell cabinets during downtime to the admit record after the downtime is over and the patient is admitted to EPIC in the Omnicell OCRA (OmniCenter) software. The patient location should be sorted so that the patients from the ED are linked first to all medication administration reconciliation. C. Doses administered will be documented by the RN and the override medication pulls linked to the order on the MAR. D Admission orders will be entered by the Pharmacy. Orders will show on the MAR once completed by Pharmacy. E. Discharge medications will be entered by the ED nurses for patients discharged from the ED and by the floor nurses for patients who are discharged from the floor during the downtime period. F. Patients who are kept in the ED for extended periods of time before going to the floors during the downtime will have to reconcile all medocations administered in the ED as Pharmacy enters ALL orders to account for all med administrations. G. Bulk charges/credits that occurred should be entered into Epic 2. Any carts that should have run during the downtime should be manually processed. 3. Once all orders have been processed, Omnicell cabinets should be taken off critical override only after system has been completely recovered 36

38 INTERFACED SYSTEM DOWNTIME INFORMATION EPIC AVAILABLE Omnicell System Downtime 1. Omnicell is placed on critical override during any Interface or Omnicell Server downtime. Notification is sent to Nursing via Snap alert and Nursing Administration is alerted. 1. Medication orders to be entered into Epic per normal inpatient workflow with documentation of medication administration per facility medication administration policy. This would not affect procedural Areas (OR, Cath Lab) as these machines operate on override without CPOE med orders. 2. Omnicell system post-downtime reconciliation/recovery. The inpatient nurses will link all medication administrations from Omnicell override pulls to the corresponding order on the patient's Epic MAR after the system interface is restored. These medications are identified by going to the MAR, to the "Override" tab. This tab will list medications that need to be linked to the med administered during the Omnicell downtime 3. Document meds given on paper in Epic post downtime OMNICELL/MEDICATION ORDERS DURING RHAPSODY/INTERFACE SYSTEM DOWNTIME 1. All new patients who arrive during the Rhapsody/Interface System downtime will need to be manually entered into the Omnicell by clicking the Add Patient button on the patient list screen. 2. All new medication orders entered during Downtime will be entered in Epic and need to be pulled using the override process in Omnicell under the Stocked Med Tab when removing a med. New orders are pulled on override because new orders will not transmit to omnicell during Interface downtimes. Only existing orders prior to the interface downtime will show on the Omnicell profile. 3. When Rhapsody/Interface System comes back up, all medication orders will flow into Omnicell. All medications pulled on override during the downtime will need to be reconciled on EPIC s MAR since these orders were not removed under the EPIC order. 37

39 DIAGNOSTIC IMAGING (RADIANT) Procedure: 1. Utilize the Downtime Tool kit 2. Diagnostic Imaging staff will use the shadow server read only (SRO) during a planned downtime to view hyperspace at the time of downtime. 3. In unplanned downtime with internet access, Diagnostic Imaging staff may log into the BCWA to view downtime reports. 4. In unplanned downtime with generator power only, Diagnostic Imaging staff may view downtime reports at the BCA at designated locations. 5. Review Downtime Clinical Summary Report from BCA. 6. Diagnostic Imaging department will utilize the Order Entry Requisition for Downtime to receive orders 7. Diagnostic Imaging department will fill out the Order Entry Requisition for Downtime for outpatients that present for treatment. 8. The radiology file room will be responsible for the Department Log unless the downtime happens after 9pm, and then the Technologist will be responsible for documenting on the log. 9. The Diagnostic Imaging department will be responsible for changing the procedure if the original exam was not correct or was modified and documenting corrections on the Diagnostic Imaging Log. Recovery: Downtime Recovery Phase 1: This is the period where ADT forms are accumulated and input into system. Patient orders and documentation can ONLY be entered on patients that have not had an ADT event during the downtime Downtime Recovery Phase 2: Catch up period where orders and documentation are entered on all patients that have had an ADT event during downtime. Order entry and documentation back load is dependent on the patient's information being in the system first. Patient Access/ADT must do all of their recovery efforts prior to radiology entering data for their patients that have been admitted, discharged, or transferred during the downtime. 1. The diagnostic imaging department area technologists will compare any requisitions received with the Department Log and enter orders as needed. 2. The Radiant department will be responsible for scheduling patients who had procedures performed during the downtime. A copy of the downtime log will be left in the department and distributed to the PAC s team following recovery. 38

40 INTERFACED SYSTEM DOWNTIME INFORMATION EPIC AVAILABLE PACS System Downtime 1. Diagnostic Imaging orders to be entered into Epic system per normal workflow. 2. Diagnostic Imaging personnel will receive orders from Radiant per normal workflow. 3. See Diagnostic Imaging PACS System Downtime Policy for PACS System downtime processes 4. Hard-copies of films, CD, or modality review will be provided for physicians for preliminary interpretation. 5. PACS interfaced system post-downtime reconciliation to be completed by Diagnostic Imaging per policy. 6. Previous Diagnostic Imaging study results will be still be available within the Epic system during PACS Downtime. Bridges, Rhapsody, or Capsule Downtime Procedure DIAGNOSTIC IMAGING ORDERS DURING RHAPSODY/INTERFACE SYSTEM DOWNTIME 1. Diagnostic Imaging orders are placed in Epic per normal Epic workflow 2. Diagnostic Imaging technologists process orders from Epic, and manually enter the order information from Epic into the imaging device so that the results will route back to the order. 3. PowerScribe does not receive orders during this time, so the order information used in step 2, ie the accession number, is added to the Radiologist dictation during interpretation. Transcription needs remain in PowerScribe. Results will be seen in Epic, once interface activity returns. 4. Diagnostic Imaging discrepancy workflow is unchanged with Rhapsody/Interface System downtime. 5. When Rhapsody/Interface System comes back up, the results will file to Emageon just as they would if they were transcribed in Powerscribe. PowerScribe Diagnostic Imaging Radiology Reports Transcribed; in-house transcriptionists are using server based PowerScribe to type reports; this is not internet based. During an EPIC downtime Radiology Reports may still be viewed in Amicas and the SRO as long as those platforms are not impacted by the downtime. Radiology reports must be signed prior to the downtime to be available The continuous processing of Radiology Reports is not impacted by an Epic downtime In the event of all systems are unavailable due to an unplanned downtime Radiologists will use M*Modal Transcription Services by dialing X4180, enter their Dictator ID# and use Work- Type #96 a blank miscellaneous document that should be titled at the beginning of the dictation Any report dictated using M*Modal that requires priority should be called into the HIM s Transcription Department at x

41 HEALTH INFORMATION MANAGEMENT (HIM) Procedure Request for Patient Information by caregiver 1. Information will be viewed via shadow servers for care givers Release of Patient information to outside requesters, caregivers 1. If request is for continued care, shadow server will be utilized, others requesters will be informed their request will be responded to once the system is operational. Request for EKG, EEG, Lab, etc. 1. Contact those departments and utilize their paper form Recovery: ED Discharged During Downtime Downtime Paperwork ED Patient HIM pickup paperwork IP Patient IP UC fax to HIM HIM will pick up documentation at discharge Begin Processing/ scanning Downtime Paperwork with HIM assistance but not Emergent ED Admitted during Downtime Remains in ED not admitted after Downtime Inpatient Discharged during downtime HIM will round and pick up all paperwork at discharge Admitted during downtime Unit Coordinator will fax to HIM during downtime. Remains inpatient post Unit Coordinator will fax to HIM during downtime downtime Downtime Over / Recovery IP UC s will resume faxing to HIM SSMC and Off Sites One day downtime Will scan internally in their department < One Day downtime HICS will work with Record Preservation Unit to determine plan For extended downtimes or if faxing capability is not available the HICS team and Record Preservation Unit will determine the plan to respond and recover from the disruption. 40

42 HYLAND Hyland On-base Scanning If the Web Client is available, all users will be able to view scanned documents in Hyland. Access to the Web Client is available through the SSHS Portal. Contact HIM for assistance. M Modal All Credentialed Providers are assigned a Dictator ID# and instructions within the M*Modal system This information is available in all patient care areas downtime resources (purple folder in the downtime drawer/file) and updated monthly by HIM M-Modal Dictation available for the following document types during downtime. History and Physical Exam Operative Report Consult Discharge Summary 41

43 Inpatient Clinical Documentation (EpicCare Inpatient) Procedure: NURSING 1. Retrieve Downtime Tool Kit. 2. New orders for laboratory, radiology, or ancillary department a. In the event of a downtime, paper requisitions will be utilized for all orders. b. Nursing departments will utilize the Order Entry Requisition for Downtime to communicate new orders to the other departments. The patient identification will be placed on the form using one of the following; patient ID label, or handwritten information that provides first and last name, visit number, date of birth. i. Labels will be made through the BCA computer/printer in Level 3 and 2 Downtimes. ii. Microsoft word template may be used. (see label section) c. Hyland label making may be used if Hyland is available. d. Stat orders will be followed up with verbal communication. 3. Results for laboratory a. Results will be communicated back to the unit via a paper form b. Paper forms with lab values will be kept with the paper chart. c. Verbal communication of critical results will continue per critical results policies. 4. Results for Radiology a. Results will be available via the PACS system. 5. New orders for Medications a. Nursing department will fax, or make copies of new orders to deliver to the pharmacy. b. Document on the order sheet to indicate that the copy has been sent to the pharmacy. This documentation should include date, time and initials of the individual sending. 6. Obtaining Medications for a new admission from the Omnicell a. The patient s name and downtime CSN must be entered into Omnicell when obtaining medications for a new admission. 42

44 7. Clinical Documentation a. Nursing will use the shadow server read only during a planned downtime to view hyperspace at the time of downtime. BCA Web Data Entry will allow nursing to enter inpatient notes during a Level 2 or 3 Downtime. b. In unplanned downtime with internet access, the nurse may log into the BCWA to view downtime reports. c. In unplanned downtime with generator power only, the nurse may view downtime reports at the BCA at designated locations. d. Downtime documentation forms will include: i. Admission Assessment ii. Daily/Shift Assessment iii. Daily Care Form iv. Vital Sign / I & O Flowsheet v. MAR (Printed from the BCA for all levels of downtime) vi. Blank MAR if new medications ordered during Downtime vii. Integrated Progress Notes viii. Order Sheet ix. Discharge Documentation x. Medication Reconciliation form xi. Medication Requisition form- If a medication is required form pharmacy that is not stored in Omnicell xii. Miscellaneous forms 1. Expiration Checklists 2. Restraint forms 3. Procedural Sedation 4. Transfusion 5. Transfer to another facility Recovery: Downtime Recovery: Downtime Recovery Phase 1: This is the period where ADT forms are accumulated and input into system. Patient orders and documentation can ONLY be entered on patients that have not had an ADT event during the downtime 43

45 Downtime Recovery Phase 2: Catch up period where orders and documentation are entered on all patients that have had an ADT event during downtime. Order entry and documentation back load is dependant on patient's information being in the system first. Patient Access/ ADT, Lab and Pharmacy must do all of their recovery efforts prior to nursing entering data for their patients that have been admitted, discharged, or transferred during the downtime. Pharmacists must enter all of the medication orders prior to nursing entering the medication administration information. 1. If downtime is greater than 1 hour, discharge forms can be scanned in. The following information should be entered into the system during recovery: A. Any updates to patient's height, weight, and allergies B. Last set of vital signs C. Any new lines, drains, airways, or wounds (LDAs) documented during downtime (insertion or removal) D. Medications that have been administered during downtime (MAR documentation) E. Order reconciliation should be performed, to ensure medication, lab, radiology and other non-medication orders have been placed. Nurses should enter all nursing, procedure orders written on paper during downtime. F. Intake & output during downtime (or last 8 hours if downtime is greater than 8 hours). 2. If downtime is less than 1 hour the following information is entered into the system by the clinician. A. Any updates to patient's height, weight, and allergies B. Any new lines, drains, airways, or wounds (LDAs) documented during downtime C. Medications that have been administered during downtime (MAR documentation) D. Education Assessment and/or teaching completed during the downtime E. Care Plan initialization and/or updates completed during the downtime F. Order reconciliation should be performed, to ensure medication, lab, radiology and other non-medication orders have been placed. Nurses should enter all nursing, procedure orders written on paper during downtime. 3. Laboratory results will cross the interface once the system has recovered, thus laboratory orders that have been resulted will not need to be entered into the system. The laboratory orders that have not been collected and/or resulted will need to be entered into Epic during recovery by Laboratory personnel. 4. Diagnostic Imaging orders that have been sent to diagnostic imaging on a paper requisition will be entered by diagnostic imaging staff during the recovery phase. 5. All other orders will be entered into Epic during recovery. Respiratory Therapy staff will review, collaborate with nursing staff to ensure that all respiratory orders have been written and then entered into the computer system. The nurse will document on the paper order 44

46 sheet that the orders have been entered electronically with date, time and initials. (Noting the orders) 7. All other paper documentation will be scanned, by HIM, into the medical record upon discharge. 8. All patients that have been admitted or transferred during the downtime must have a new patient identification band placed on them after Phase I recovery has been completed. The downtime armbands will have the MRN identification number. Medication scanning requires the CSN number which will be put into place once Admitting has completed their process. INTERFACED SYSTEM DOWNTIME INFORMATION EPIC AVAILABLE Laboratory System Downtime 1. Reference the Laboratory Section of the Policy Omnicell System Downtime 1. Medication orders to be entered into Epic per normal inpatient workflow with documentation of medication administration per facility medication administration policy. 2. Omnicell system post-downtime reconciliation/recovery. The inpatient nurses will link all medication administrations from Omnicell override pulls to the corresponding order on the patient's Epic MAR after the system interface is restored. These medications are identified by going to the MAR, to the "Override" tab. This tab will list medications that need to be linked to the med administered during the Omnicell downtime (Refer to Pharmacy's Omnicell downtime policy as necessary) 3. Document meds given on paper in Epic post downtime Bridges, Rhapsody, or Capsule DOWNTIME PROCEDURE LABORATORY ORDERS DURING RHAPSODY/INTERFACE SYSTEM DOWNTIME 1. Lab orders are placed in Epic per normal Epic workflow 2. When specimens are collected during Downtime, a paper Downtime lab requisition should accompany the specimens to lab 3. Results will be provided to the units using downtime processes 4. POC results (Glucometer, i-stat, Creat) will not go thru the lab interface into EPIC during the downtime. Currently stored in handhelds and documented on paper. Enter/Edit results should be utilized for preliminary results. 5. When Rhapsody/Interface System comes back up, lab orders placed during Downtime go thru the interface and ascension labels will print these should be sent to lab. Rhapsody/Interface System comes back up, POC test results will go thru the interface and show as final results in Epic. 6. When Rhapsody/Interface comes back up, all results will flow into Epic. DIAGNOSTIC IMAGING ORDERS DURING RHAPSODY/INTERFACE SYSTEM DOWNTIME 45

47 1. Diagnostic Imaging orders are placed in Epic per normal Epic workflow 2. Diagnostic Imaging technologists process orders from Epic, and manually enter the order information from Epic into the imaging device so that the results will route back to the order. 3. PowerScribe does not receive orders during this time, so the order information used in step 2, ie the accession number, is added to the Radiologist dictation during interpretation. Transcription needs remain in PowerScribe. Results will be seen in Epic, once interface activity returns. 4. Radiology discrepancy workflow is unchanged with Rhapsody/Interface System downtime. 5. When Rhapsody/Interface System comes back up, the results will file to Merge PACS OMNICELL/MEDICATION ORDERS DURING RHAPSODY/INTERFACE SYSTEM DOWNTIME 1. All new patients who arrive during the Rhapsody/Interface System downtime will need to be manually entered into the Omnicell 2. All new medication orders entered during Downtime will be entered in Epic and need to be pulled using the override process 3. When Rhapsody/Interface System comes back up, all medication orders will flow into Omnicell. All medications pulled on override during the downtime will need to be reconciled including overrides for patients who may have been sent to the inpatient setting during Downtime. DIETARY ORDERS DURING RHAPSODY/INTERFACE SYSTEM DOWNTIME 1. Orders for diet trays should be placed in Epic, and called to Dietary. 46

48 Procedures: PHYSICIANS These procedures apply whenever the Epic system is unavailable for the physician to enter orders or notes. Order Entry A. The physician will indicate the orders that he/she wishes to be carried out on his/her patient via the downtime order set or use the downtime documentation physician orders form. Documentation A. The physician will enter H+P, Progress Notes, Discharge Notes, Problems, Diagnosis, etc. either via dictation or via the facility s downtime documentation progress notes sheet. B. The physician will use the downtime medication reconciliation form available to perform meds reconciliation C. The physician will document Medical/Surgical/Social History via an available downtime form or via the same methods used for note entry D. Physicians will be able to use the BCA Web to enter inpatient notes during a Level 2 or 3 Downtime. Recovery: A. Notes entered via hand during the downtime will be scanned into Epic B. Dictations entered during downtime will be interfaced back into Epic and will be available for sign off in the physician Inbasket post downtime C. All orders written by the physicians and all verbal orders will be entered by the appropriate staff into Epic and the physician will co-sign those orders in Epic as well as the written copies of the orders. D. Any chart deficiencies noted during the downtime will be forwarded to the physician s inbasket for review post downtime E. Code Status Dictation Process During Downtime All Credentialed Providers are assigned a Dictator ID# and instructions within the M*Modal system. This information is available in all patient care areas downtime resources and updated monthly by HIM M-Modal Dictation available for the following document types during downtime. History and Physical Exam Operative Report Consult Discharge Summary 47

49 Procedure: RESPIRATORY THERAPY 1. Respiratory Care PROCEDURE: Nursing will call and or page respiratory with any new orders. In a planned downtime the respiratory therapists will print the RT downtime report 30 minutes prior to downtime. Charges are recorded on paper with the patients' names, date and times of therapy and then entered when the system is restored. If the system remains down beyond the end of the work shift, the therapist will submit the paperwork to the Respiratory Care Office for inputting when the system restored. Documentation of all administered therapy is to be recorded on paper and then entered into PCS when the system is restored. If the system remains down beyond the end of the work shift, the therapist will submit the paperwork to the Respiratory Care Office for inputting when the system is restored. Data that is input at a later time by someone other than the administering therapist will have a notation made in a note that the data was entered for the administering therapist. Therapists will be able to use the BCA web Data Entry to enter inpatient notes during a Level 2 or 3 Downtime. Downtime Blood Gas Procedure: The therapist will check 2 patient ID s at the patient bedside and label sample with generic patient label. (We will NOT be using downtime sample labels.) Therapist will run sample on analyzer, entering the data of the 2 confirmed patient identifiers into the analyzer within the Patient ID field. - First, last name and DOB Therapist will print out sample results and hand deliver to the appropriate provider. Copies of BG slips will be maintained by the therapist. Upon system restoration, labels will be printed and matched within the analyzer under pending results. When the label is scanned, the accession number and demographics will populate and enable the results to flow into the EMR and to be electronically released / verified & final verified. 48

50 NEURODIAGNOSTIC / PFT LAB 1. Neurodiagnostics/PFT Lab PROCEDURE: Nursing will fax/telephone/page the Neurodiagnostic technician with orders for testing. In a planned downtime the EEG tech/rt will print the department schedule prior to downtime. For unplanned downtime they will utilize designated computer to print most recent patient appointments. All tests will be performed on their current independent systems. The tech/therapist will keep a log of patients as well as the appropriate charges for services performed. Tests, reports and or results will be entered in to EPIC once the system is available. Charges are handled manually via the log sheet and entered when the system is restored. Any urgent/abnormal findings will be reported to the requesting area/physician immediately. PULMONARY REHABILITATION 1. Pulmonary Rehabilitation PROCEDURE: Patient schedules will be printed from designated computers. All assessments, activities and charges will be recorded on paper and entered when the system is restored. Recovery: Downtime Recovery Phase 1: This is the period where ADT forms are accumulated and input into system. Patient orders and documentation can ONLY be entered on patients that have not had an ADT event during the downtime Downtime Recovery Phase 2: Catch up period where orders and documentation are entered on all patients that have had an ADT event during downtime. Order entry and documentation back load is dependant on patient's information being in the system first. Patient Access / ADT must do all of their recovery efforts prior to respiratory therapist entering data for their patients that have been admitted, discharged, or transferred during the downtime. Pharmacists must enter all of the medication orders prior to nursing entering the medication administration information. 49

51 1. If downtime is less than 1 hour, all information from assessments, graphic and MARs are entered into the system. 2. If downtime is greater than 1 hour the following information is entered into the system by the clinician. A. Any ventilator changes that were made during downtime (latest settings) B. Any new lines, drains, airways, or wounds (LDAs) documented during downtime C. Medications that have been administered during downtime (MAR documentation) D. Education Assessment and/or teaching completed during the downtime E. Care Plan initialization and/or updates completed during the downtime 3. Respiratory Therapy staff will review, collaborate with nursing staff to ensure that all respiratory orders have been written and then entered by respiratory therapist into the computer system. The nurse will document on the paper order sheet that the orders have been entered electronically with date, time and initials. (Noting the orders) 4. All other paper documentation will be scanned, by HIM, into the medical record upon discharge. 5. Health Care providers will be able to use the BCA web to enter inpatient notes during a Level 2 or 3 Downtime. 50

52 NUTRITION SERVICES Procedure: Diet Office 1. Retrieve Downtime Plan from Yellow binder 2. Nutrition staff (Nutrition Coordinators, Supervisor/s, and Nutrition Guest Representatives) will use the shadow server read only (SRO) during a planned downtime to view hyperspace at the time of downtime. 3. In unplanned downtime with internet access, staff will log into the BCWA to view downtime reports. 4. In unplanned downtime with generator power only, staff will have viewing & printing access of BCA down time reports. PC E2NFSW04 is designated as the BCA for Diet Office. The EPIC report: Dietary Report will be accessible via URL from this PC. 5. Nursing will utilize the Dietary Requisition form (included in the units downtime plan) to fax diet changes including the following information: diet change (including NPO) and/or new diet order, food allergies or indicate NKA, room #, and a patient label. These orders will be faxed to Patient Access will generate ADT census. Copies will be available from the Command Center. Nutrition Supervisor will contact the Command Center 2 hours prior to meal service to request an updated census report and ask to have it ready to be picked up one hour prior to meal service. 7. If CBORD is available, Nutrition staff will update CBORD accordingly. If CBORD is not available, staff will follow CBORD down time plan manual processes for menus and meal tickets. ADT Census report will be used to reconcile tray tickets prior to meal service. 8. Once All Clear has been given, Nutrition staff will collaborate with nursing to reconcile any discrepancies in patient census reports (along with diet orders & any known food allergies) in both EPIC and CBORD Dietary Report BCA Workstation for the Diet Office SSH INPATIENT NUTRITION Fogg Rd - Emerson E2NFSW Workstation 1472 Workstation 51

53 Clinical Nutrition: 1. Retrieve Downtime Tool Kit Binder 2. Dietitians will use the shadow server read only (SRO) during a planned downtime to view hyperspace at the time of downtime. 3. In unplanned downtime with internet access, staff will log into the BCWA to view downtime reports. 4. In unplanned downtime with generator power only, nutrition staff will have viewing & printing access of BCA down time reports: PC E2NFSW16 (in dietitian room EM-262). 5. The downtime report is BCA Dietary Report, and if possible may include Census ADT. 6. Dietitians will document on downtime paper forms which will include: A. Assessment/Reassessment forms (specific for: Adult; Pedi; NICU; OB). B. Enteral Nutrition (Tube Feeding) Recommendations. C. CPN/TPN Order Recommendations. D. Education/Teaching Record. E. Discharge note, if needed. Dietitians will complete the form and will make 2 copies, one to place in the patient s paper chart, and one for the dietitian. These forms will have a bar code, which can be scanned into Epic EMR once downtime is cleared. Recovery: Downtime Recovery Phase 1: This is the period where ADT forms are accumulated and input into system. Patient orders and documentation can ONLY be entered on patients that have not had an ADT event during the downtime Downtime Recovery Phase 2: Catch up period where orders and documentation are entered on all patients that have had an ADT event during downtime. Order entry and documentation back load is dependent on patient's information being in the system first. Patient Access / ADT must do all of their recovery efforts prior to dietary staff entering data for their patients that have been admitted, discharged, or transferred during the downtime 1. If downtime is less than 1 hours, all information from paper forms are entered by the dietitian into the system. Discharge forms can be scanned in. 2. If downtime is greater than 1 hours the following high risk information is entered into the system by the dietitian: A. Enteral Nutrition (Tube Feeding) Recommendations B. TPN Order Recommendations Other forms can be scanned into the EMR: A. Assessment/Reassessment documentation B. Education/Teaching Assessment and/or teaching completed during the downtime C. Discharge forms or Care Plan initialization completed during the downtime 52

54 3. All other paper documentation will be scanned, by HIM, into the medical record upon discharge. DIETARY ORDERS DURING RHAPSODY/INTERFACE SYSTEM DOWNTIME 1. Orders for diet trays should be placed in Epic, and called to Nutrition Services. CBORD / CAFE 53

55 CARE PROGRESSION / SOCIAL SERVICES (Clin Doc and Orders) Procedure: 1. Retrieve Downtime Tool kit 2. Case Managers and Social Workers will use the shadow server read only (SRO) during a planned downtime to view hyperspace at the time of downtime 3. In unplanned downtime with internet access, the Care Progression and Social Workers may log into the BCWA to view downtime reports. 4. In unplanned downtime with generator power only, the Care Progression and Social Workers may view downtime reports at the BCA at designated locations. 5. Review Downtime Clinical Summary Report from BCA. 6. Care Progression department will utilize the Order Entry Requisition for Downtime to receive orders 7. Downtime documentation forms will include: A. Integrated progress notes Recovery: Downtime Recovery Phase 1: This is the period where ADT forms are accumulated and input into system. Patient orders and documentation can ONLY be entered on patients that have not had an ADT event during the downtime Downtime Recovery Phase 2: Catch up period where orders and documentation are entered on all patients that have had an ADT event during downtime. Order entry and documentation back load is dependant on patient's information being in the system first. Patient Access / ADT must do all of their recovery efforts prior to Case Managers or Social Workers entering data for their patients that have been admitted, discharged, or transferred during the downtime. 1. If downtime is greater than 1 hour, all information from progress notes are entered into the system. Discharge forms can be scanned in. 2. If downtime is less than 1 hour the following information is entered into the system by the clinician. A. Assessment documentation B. Education Assessment and/or teaching completed during the downtime C. Care Plan initialization and/or updates completed during the downtime 3. Case Managers and Social Workers will review and collaborate with nursing staff to ensure that all appropriate orders have been written and then entered into the computer system. The nurse will document on the paper order sheet that the orders have been entered electronically with date, time and initials. (Noting the orders) 4. All other paper documentation will be scanned, by HIM, into the medical record upon discharge. 54

56 Transitional Care Bundles Downtime Procedure ** In the event of Downtime which will effect Morissey MCCM, Continuum, and Edischarge the following procedure will occur I. Scheduled Downtime a. 1 hour prior to scheduled Downtime, all Continuum Reports will be printed out for use i. Bundled Discharged Patients Report ii. Bundle Inpatients w/ Antic DC Report iii. Bundle SNF patients, with the date range of at least one week prior to current date for the 9 preferred SNFs. 1. Alliance 2. BayPathe 3. Care One 4. Continuing Care at Linden Ponds 5. Harbor House 6. Hancock Park 7. Life Care of SS 8. Queen Anne 9. Webster Park b. Ensure communication via Edischarge to SNFs regarding Bundle patient identification c. Print out a Screen shot of your planned activities for the day d. Any documentation that needs to go into the EMR will be hand written on a bar coded Progress Note for scanning when the systems are retrieved e. Alternate forms of communication to SNF facilities (fax, telephone call) of identification of bundle patients II. Non Scheduled Downtime a. The most recent Continuum Reports should be used to maintain work until the system is back up b. Any documentation that needs to go into the EMR will be hand written on a bar coded Progress Note for scanning when the systems are retrieved c. Enlist alternate forms of communication to SNF facilities (fax, telephone call) of identification of bundle patients III. What to do when the Systems are Back Up? a. Refresh all Worklists b. Process any outstanding work on the worklists Depending on the length of the Downtime alternate forms of Bundle Patient Identification and Manual Enrollment may be necessa 55

57 REHABILITATION SERVICES In the event that there is an electrical, communications, and/or computer loss, which would not allow computer access (whether temporary or long-term), the following downtime procedures will be followed to provide a safe response so that all patients will be cared for as seamlessly as possible. The purpose of this document is to be a supplement to the general Health System procedure for downtime by outlining the module and department specific downtime processes. COMMUNICATING INFORMATION Updates from HICS huddles or chain of command will be communicated to staff through: Already scheduled staff huddles By pager if available, staff encouraged to use personal cell phones if no pagers are available to communicate information that does not contain PHI. Rounding to staff in person Updates written on staff room whiteboards to keep frontline team informed RA/secretary at office in each area may receive updated information first and they may be able to answer questions if staff calls. Rehab managers stationed in staff room at the start of downtime to coordinate efforts as needed Location of Downtime Forms: Inpatient: Top drawer of the filing cabinet in the Center 3 staff room Outpatient (55 Fogg Road): In the black file box in Emergency Resources Closet Outpatient (2 pond park): In the top drawer of the cabinet next to the ice machine Outpatient: Orthopedics, Spine and Sports Therapy (OSST at 2 Pond Park) and Outpatient Rehabilitation (OPR at 55 Fogg Road) LEVEL 3 DOWNTIME - EPIC PRODUCTION SERVER DOWNTIME (SRO) PT/OT/SLP will use the shadow server read only (SRO) during a planned downtime to view hyperspace at the time of downtime. Cadence: Patient Registration All Staff will use the shadow server read only (SRO) during a planned downtime to view hyperspace at the time of downtime. 1. Office staff will register patients scheduled to come in during the scheduled downtime. They will complete electronic a. Interactive Face Sheet (IFS) b. Consent c. Health History d. HIPPA Consent 56

58 e. Functional Outcome Measures f. Scheduling Sheet( Speech, OT & PT, Pedi) g. Copy of Insurance Card h. Interpreter Schedule when applicable 2. Office staff will print out the face sheets/labels of all new evaluations coming in during scheduled downtime the day before the downtime. 3. Any changes to the registration forms will be made once the system is live. 4. Place paperwork in folders labeled with the date of the Downtime. 5. Document any messages for patient accounts on registration form. Outpatient Ambulatory Therapy Documentation Scheduling o All scheduling of future (new or follow up) clinic visits will be done once the system is brought back up from Downtime. Insurance o Insurance verification is entered/updated in the system three days ahead of scheduled evaluations. o All new information (verification and authorization) would be held and reentered after Downtime is over. o New insurance verification is held until the system comes out of Downtime. Clinical o Documentation will be completed using Downtime paper forms that are discipline specific and are found on the S: Drive. o The patient s name, MR# and/or Date of Birth will be recorded on the forms. o Therapists will record chargeable services on the clinical downtime forms. o If by the end of a clinician s shift if the system is not available, that days documentation will be saved in the S: Drive in a folder with the date and clinicians name. Each note will be a separate Word Document. LEVEL 2 DOWNTIME - EPIC DOWNTIME WITH BCWA (WEB) Cadence: Patient Registration All Staff will use the BCWA icon in downtime to reports and patient information at the time of downtime. 1. Office staff will register patients scheduled to come in during the scheduled downtime. They will complete a paper a. Face Sheet b. Consent c. Health History d. HIPPA Consent e. Functional Outcome Measures 57

59 f. Scheduling Sheet( Speech, OT & PT, Pedi) g. Copy of Insurance Card h. Interpreter Schedule when applicable 2. Office staff will print out the face sheets/labels of all new evaluations coming in during scheduled downtime the day before the downtime. 3. Any changes to the registration forms will be made once the system is live. 4. Place paperwork in folders labeled with the date of the Downtime. 5. Document any messages for patient accounts on registration form. Outpatient Ambulatory Therapy Documentation Scheduling o All scheduling of future (new or follow up) clinic visits will be done once the system is brought back up from Downtime. Insurance o Insurance verification is entered/updated in the system three days ahead of scheduled evaluations. o All new information (verification and authorization) would be held and reentered after Downtime is over. o New insurance verification is held until the system comes out of Downtime. Clinical o Documentation will be completed using Downtime paper forms that are discipline specific and are found on the S: Drive. o The patient s name, MR# and/or Date of Birth will be recorded on the forms. o Therapists will record chargeable services on the clinical downtime forms. o If by the end of a clinician s shift if the system is not available, that days documentation will be saved in the S: Drive in a folder with the date and clinicians name. Each note will be a separate Word Document. LEVEL 1 DOWNTIME EPIC DOWNTIME - BCA COMPUTER ONLY 1. The clinic/office manager will retrieve Downtime Paper Forms. 2. In unplanned downtime with generator power only, the therapists may view downtime reports at the BCA in the staff room. The clinic manager will print the BCA report. 3. Review Downtime Clinical Summary Report from BCA. 4. Downtime documentation forms will include Integrated Progress Notes templates to use for both evaluations and treatment notes. Therapists will use discipline specific forms for documentation, which are located in the black file box. Cadence: Patient Registration 58

60 Planned Downtime: 1. Office staff will register patients scheduled to come in during the scheduled downtime. 2. They will complete a paper a. Face sheet b. Consent c. Health History d. HIPPA Consent e. Functional Outcome Measures f. Scheduling Sheet( Speech, OT & PT, Pedi) g. Copy of Insurance Card h. Interpreter Schedule when applicable 3. Office staff will print out the face sheets/labels of all new evaluations coming in during scheduled downtime the day before the downtime. 4. Any changes to the registration forms will be made once the system is live. Non-planned Downtime: A three day pre-registration list is generated for the next day of service to inform us of any new patients. This list is kept filed at the front desk. Steps for patient registration in Downtime 1. using the Downtime Registration Forms handwrite in a legible fashion, the patient s information, including but not limited to: Patient s name Date of birth Social security number Other demographic information and contact information Put patient location on Outpatient forms. (? Pool vs Land vs 780) 2. Have the consent signed and witnessed. 3. Attach a copy of the patient s insurance card to the registration form, if able. 4. Place paperwork in folders labeled with the date of the Downtime. 5. Document any messages for patient accounts on registration form. Outpatient Ambulatory Therapy Documentation Scheduling o All scheduling of future (new or follow up) clinic visits will be done once the system is brought back up from Downtime. o Both OPR and OSST will keep a list of scheduled patients for 3 days out so that it can be referenced during short or long term downtime. Insurance o Insurance verification is entered/updated in the system three days ahead of scheduled evaluations. o All new information (verification and authorization) would be held and reentered after Downtime is over. o New insurance verification is held until the system comes out of Downtime. 59

61 Clinical o Documentation will be completed using Downtime paper forms that are discipline specific. o The patient s name, MR# and/or Date of Birth will be recorded on the forms. o Therapists will record chargeable services on the clinical downtime forms. o If by the end of a clinician s shift the system is not available, that day s documentation will be submitted to the downtime file box with a face sheet with the date and that clinicians name on it. The face sheet will be attached to the documents completed on paper during the Downtime for that date. They will then be placed into the Downtime file box so they can be secured until the downtime has ended. COMPUTERIZED EXERCISE PROGRAMS Rehab will use individual exercise cards to create written home exercise programs instead of entering the data into the computerized system. (WHERE ARE THE CARDS?) RECOVERY FROM DOWNTIME PROCEDURES Recovery from LEVEL 3 DOWNTIME - EPIC PRODUCTION SERVER DOWNTIME (SRO) Recovery from LEVEL 2 DOWNTIME - EPIC DOWNTIME WITH BCWA (WEB) Recovery from LEVEL 1 DOWNTIME EPIC DOWNTIME - BCA COMPUTER ONLY Prelude/Patient Registration Steps for office staff to enter data into system after downtime. o Conduct a thorough search on every patient to avoid creating duplicate medical record number. o Enter the correct spelling of the patient's last name, the first initial and the Social Security Number. If current patient, select the correct encounter for the month. o Enter all demographic data on the patient into the computer system from the hand written form. Schegistraction/Insurance o Insurance verification is entered/updated in the system three days ahead of scheduled evaluations. All new insurance (verification and authorization) would be held and reentered after downtime. o New insurance verification will resume per usual. Cadence/Scheduling o New patient and follow up patient scheduling will be entered per usual. 60

62 The printed list of patient appointments will need to be cross referenced with who came to visits and who did not. o The patients will be called to schedule appointments from the clinician s Downtime schedule sheets when the system is restored. o As soon as services are resumed, The Call Center/patient coordinators will contact and schedule patients from the incoming calls log created during Downtime. o Outpatient Ambulatory Therapy Documentation o All written documentation will be retroactively entered electronically into Epic that day by the clinician. If it was on paper if must be typed and if electronic it must be copied in. o If the system remains down at the end of the shift the clinician must back-load the information on the next working day. o All documentation should reflect the date and time the therapeutic intervention took place. o Therapists will record chargeable services from the scheduling sheets containing the patient s name, MR# and/or Date of Birth. o These charges will be re-entered into Epic as part of the documentation process. The scheduling sheets billing should be reconciled with the visit notes charges. Inpatient Rehab (Clindoc) 1. Retrieve Downtime Tool kit (Top Drawer of the filing cabinet in the Center 3 staff room 2. PT/OT/SLP will use the shadow server read only (SRO) during a planned downtime to view hyperspace at the time of downtime. 3. In unplanned downtime with internet access, the PT/OT/SLP may log into the BCWA to view downtime reports. 4. In unplanned downtime with generator power only, the therapists may view downtime reports at the BCA at designated locations. 5. Review Downtime Clinical Summary Report from BCA. 6. Department will utilize the Order Entry Requisition for Downtime to receive orders 7. Downtime documentation forms will include Integrated Progress Notes templates to use for both evaluations and treatment notes. Therapists will use discipline specific outlines for how to structure documentation, which are located in the documentation tool kit. How we receive Rehab orders: 61

63 1. Rehab Managers to round to nursing areas to ensure unit coordinators, nurse leaders, frontline RNs, and providers know the process for requesting rehab during downtime. This will occur on 1 st shift and the beginning of 2 nd shift. When rounding supervisors will ask charge nurse to pass information along to 3 rd shift. 2. Nursing Services will use the appropriate Downtime Requisition Form and may need to be re-educated how to request rehab during downtime 3. ROUTINE REQUESTS Routine requests will be sent via FAX to the department from which services being requested (781) STAT EXAMS/REQUESTS: The Rehab department will be called for STAT requests (781) If there are no faxing capabilities, runners will be used to deliver Downtime requisitions and the managers will round to all patient care floors to support this process. Masterlist -Most recent OT/PT/SLP patient lists will be printed from BCA workstation in a downtime by the rehab secretary -If BCA access is unavailable will reference paper master-list that is printed daily to reconcile patients on caseload -If downtime is continued into the next day the list will be transcribed to an excel spreadsheet for use to manually track caseloads. Documentation - Complete documentation on the Downtime paper forms All paper evaluation and treatment flow sheets are located in each area. -All paper forms/documentation utilized during a Downtime will be labeled with the patient s ADT label (both front and back). -If by the end of a clinician s shift the system is not available, documentation is placed in the paper chart and will be scanned into the electronic record by HIM when the system becomes available. -Therapist s complete a face sheet with the names of patients that have paper documentation completed -Inpatient will only complete/store the face sheet in the Downtime folders as their documentation will be in the paper chart. Billing and Charging For downtime, clinicians will continue with the paper system and enter all charges into the system when it becomes active. ** Document all charges via the charge capture navigator 62

64 Recovery: Downtime Recovery Phase 1: This is the period where ADT forms are accumulated and input into system. Patient orders and documentation can ONLY be entered on patients that have not had an ADT event during the downtime Downtime Recovery Phase 2: Catch up period where orders and documentation are entered on all patients that have had an ADT event during downtime. Order entry and documentation back load is dependent on patient's information being in the system first. Patient Access/ADT must do all of their recovery efforts prior to OT/PT/SLP staff entering data for their patients that have been admitted, discharged, or transferred during the downtime. 1. If greater than 1 hours, all information from progress notes are entered into the system. 2. If downtime is less than 1 hour the following information is entered into the system by the clinician. A. Assessment and treatment documentation B. Education Assessment and/or teaching completed during the downtime C. Assessment and treatment charges 3. OT/PT/SLP staff will review and collaborate with nursing staff to ensure that all OT/PT/SLP orders have been written and then entered into the computer system. Community Programs: (55 Fogg Rd Pool and 51 Performance Drive) 1. Community exercise programs can continue as scheduled as no documentation occurs within the system by the class instructor. 2. All attendance sheets and participant information is in the community program book as a hard copy for instructors to have access to participant information in case of emergency. 3. Payments will continue to be taken via check and logged on daily cash logs with all credit card payments deferred until system is reinstated. 4. Phone calls will be documented in message book and will be transferred to master spreadsheet when system is reinstated. 5. New program inquiries may be mailed or the participant address can be taken to send out paperwork when system is reinstated. 6. Medical clearance faxes will continue on paper if e-faxing is unavailable. If faxing completely unavailable, community programs receptionist will fax out when system is reinstated. 7. Entering participant information into CEP classes, registering participants for programs, and updating paperwork dates will resume when system is reinstated. Completed paper forms are necessary for new participants to begin exercise programs during downtime. 63

65 8. All completed forms which need to be scanned into Epic will be done when the system is reinstated. Community Exercise Programs: Aquatic Program, 55 Fogg Rd. 1. Community exercise programs can continue as scheduled as no documentation occurs within the system by the class instructor. 2. All attendance sheets and participant information is in the community program book as a hard copy for instructors to have access to participant information in case of emergency. 3. Payments will continue to be taken via check and logged on daily cash logs with all credit card payments deferred until system is reinstated. 4. Entering participant information into CEP classes, registering participants for programs, and updating paperwork dates will resume when system is reinstated. Aquatic Physical Therapy: Outpatient Rehab, 55 Fogg Rd. 1. Aquatic downtime forms are located in the pool office, top drawer of the middle filing cabinet underneath the counter. These forms should be accessed when Epic is unavailable. 2. Clinicians will document on downtime forms during patient treatment. This information will be added to Epic when system is reinstated. 3. If a question occurs about a patient treatment, pool clinicians will have a phone or face to face interaction with primary clinician prior to pool treatment. 4. The three day master list includes all patients coming in for pool therapy. If a master daily sheet could not be created prior to downtime, pool patient lists can be generated from the three day list. 64

66 PASTORAL SERVICES (CLIN DOC) Procedure: 1. Utilize the Downtime Tool kit in use on each unit 2. Pastoral Services staff will use the shadow server read only (SRO) during a planned downtime to view hyperspace at the time of downtime. 3. In unplanned downtime with internet access, Pastoral Services staff may log into the BCWA to view downtime reports. 4. In unplanned downtime with generator power only, Pastoral Services staff may view downtime reports at the BCA at designated locations. 5. Review Downtime Clinical Summary Report from BCA. 6. Pastoral Services department will utilize the Order Entry Requisition for Downtime to receive orders 7. Downtime documentation forms will include: A. Integrated progress notes Recovery: Downtime Recovery Phase 1: This is the period where ADT forms are accumulated and input into system. Patient orders and documentation can ONLY be entered on patients that have not had an ADT event during the downtime Downtime Recovery Phase 2: Catch up period where orders and documentation are entered on all patients that have had an ADT event during downtime. Order entry and documentation back load is dependant on patient's information being in the system first. Patient Access / ADT must do all of their recovery efforts prior to pastoral services entering data for their patients that have been admitted, discharged, or transferred during the downtime. 1. If downtime is greater than 1 hour, all information from progress notes are entered into the system. Discharge forms can be scanned in. 2. If downtime is Less than 1 hour the following information is entered into the system by the clinician. A. Assessment documentation B. Education Assessment and/or teaching completed during the downtime C. Care Plan initialization and/or updates completed during the downtime 3. All other paper documentation will be scanned, by HIM, into the medical record upon discharge. 65

67 EMERGENCY DEPARTMENT (ASAP) RESPONSIBILITIES The Emergency Department will maintain all Downtime documentation forms are located at each unit coordinators desk for easy accessibility when downtime occurs. Upon notification of a planned/unplanned Epic downtime, the Charge Nurse in the Emergency Department will: Pull the Downtime Clinical Reference Binder maintained on the unit and initiate downtime processes based on whether the downtime is a Level I, Level II, Level III downtime, or a downtime affecting an Interfaced system. Notify the Physician and clinical staff of the downtime, type of downtime, and processes during the downtime. Upon notification of a planned/unplanned Interfaced system downtime, the Charge Nurse in the Emergency Dept will follow the steps outlined above, and reference the Downtime Binder for specific Interfaced system downtime information. EMERGENCY DEPT PRE-DOWNTIME PROCEDURES Planned Downtimes: Prior to downtime, the Charge Nurse will take a census of the Emergency Dept and note patient names and locations on clipboard and white board as available in the department. Planned/Unplanned Downtimes: Downtime documentation forms will be provided to the Triage and Nursing stations. Each downtime form will have patient labels placed on the front and back of each paper form. These forms will include the following: 1. ED Downtime Triage/Charting Navigator form 2. ED Downtime Patient Assessment 3. ED Downtime Allergies/Home Medications/Med Reconciliation form 4. ED Downtime Nurse flowsheet 5. ED Downtime Order sheet that includes Downtime MAR 6. ED Downtime Nurse Flowsheet 7. ED Downtime Physician documentation, to include time contact with patient, HPI, ROS, assessment, diagnostics, disposition and follow up. 8. ED Downtime Discharge Instructions form 9. Downtime Requisitions for Labs, Radiology and other diagnostics. 10. Emergency Department Downtime Log of arrivals to ED during downtime will be maintained by ED Registration. 66

68 White Board for basic patient tracking/room assignment Notify end-users of system downtime including specific system availability, and the anticipated duration of downtime. EMERGENCY DEPT INTRA-DOWNTIME PROCEDURES 1. Patients who arrive in the Emergency Department during downtime will be registered per the Patient Access section of this policy. 2. A charting packet will be initiated for each new arrival. Each form will have the patient s Downtime label applied. The chart packet will include: 3. Utilize clip board and white board to track patients/room assignments 4. Patient care documentation will be done on downtime paper forms 5. Orders will be placed on the Emergency Downtime Orders/MAR and processed per below. 6. All Emergency Department documentation will have a patient label placed on each page (front and back where applicable). 7. Patient Access will maintain a log of all patients arriving in the Emergency Department per their component of this policy. This log will be used to ensure reconciliation of patient data post-downtime. 8. When the Emergency Dept Nurse obtains an order for admission of an ED patient, the ED Nurse/Secretary will fax that order from the ED Physician s Admit Order to ED Admitting. 9. When the patient arrives during Downtime, and is not in the Omnicell, the patient information to create the Omnicell contact includes: Patient name as written on the Downtime patient labels, and the Downtime HAR. 10. Complaint-specific ED Order Sets will be available in the Downtime binder for copying, and via the Intranet for printing. Copies should be distributed per this policy. Other orders should be written on the paper downtime order forms and processed as follows: ASAP DOWNTIME LAB ORDERS/RESULTS PROCESS 1. Orders written on Emergency Dept Downtime Orders, timed and signed by the ED Physician. 2. Orders are acknowledged by the Primary ED Nurse. 3. Lab Orders are transcribed to lab on the Lab Downtime requisition. A patient label will be affixed to each copy of the lab requisition. 4. Specimen collected from patient and labeled at bedside per facility policy. Specimens will be sent to lab with the paper Downtime requisition. 5. Specimens received and processed in lab system. 6. Results will be faxed to the ED per Laboratory s Downtime Policy. 7. Critical results will be called to department, and documented per facility policy. 8. If the Shadow Read Only (SRO) server is available, historic/existing results for patients are accessible. If these systems are not available, historic/existing lab results may be available from the facility's legacy lab system. 9. Post downtime recovery Laboratory personnel perform post downtime lab order and result entry. 67

69 ASAP DOWNTIME DIAGNOSTIC IMAGING ORDERS/RESULTS 1. Orders written on ED Downtime Orders and timed/signed by ED Physician. 2. Orders acknowledged by ED Nurse. 3. Diagnostic Imaging order transcribed to Downtime Diagnostic Imaging requisition. A patient label will be affixed to each copy of the Diagnostic Imaging requisition. 4. Stat orders are called to Diagnostic Imaging tech. 5. Study completed by Diagnostic Imaging Tech, and entered into PACS system where it is available for review in PACS by ED Physician and Radiologist.. 6. Key object entered as preliminary interpretation by ED Physician in PACS. 7. Radiologist interpretation dictated into Power Scribe. 8. If the Shadow Read Only (SRO) server is available, dictations of previous diagnostic imaging exams will be available. 9. Previous images available in PACS. 10. Diagnostic Imaging personnel will perform post- downtime diagnostic imaging order and result entry. EPIC DOWNTIME MEDICATION ORDERING/ADMINISTRATION 1. Medication orders written on ED Downtime Orders and timed/signed by ED Physician. 2. Orders on ED Downtime Orders/MAR acknowledged by ED Nurse. 3. ED Nurse to pull medication from Omnicell as an override pull. If patient is not in the Omnicell, ED Nurse should create the patient s encounter in Omnicell by entering the patient s name and Downtime CSN into the Omnicell. 4. Medication orders are verified by ED RN utilizing the five rights of medication administration and administered per facility policy. 5. Medication administration is documented on ED Downtime Orders/ MARS form by ED Nurse. Documentation will include the medication name, dose, route, site of administration for IM, and infusion times for IV and IVPB infusions. 6. Patient is reassessed per facility policy. Patient reassessment/response to medication and notification of physician are documented on the nursing flowsheet. 7. Post downtime reconciliation of medications administered in the ED during Downtime utilizing the following steps: A. The ED Nurse will enter all orders for medications given in the ED during downtime utilizing the ED Downtime Orders/MAR. B. The ED Nurse will fax the paper copy of Inpatient Admission orders to pharmacy. C. The ED Nurse will enter the medications administered in the ED into the Epic MAR, including any medications administered from the Admission orders (where applicable). These administrations will be immediately linked in the Epic MAR to the corresponding medication orders. D. The first priority in post-downtime recovery/reconciliation is the entry/reconciliation of medications administered to patients who are admitted to the Inpatient setting. ASAP DOWNTIME FOR EKG AND OTHER MISCELLANEOUS DIAGNOSTICS AND TREATMENTS 1. Order for EKG or other diagnostic/treatment written and timed/signed by ED Physician on ED Downtime Orders/MAR. 2. Orders on ED Downtime Orders/MAR form acknowledged by ED Nurse. 68

70 3. ED Nurse ensures EKG is performed and documented EKG is resulted/downloaded per facility policy. 4. Old EKG s will be available in scanned system via Shadow Server. If Shadow Server is not available, old EKG s are available from cardiovascular services from EKG storage system. 5. Post downtime recovery a. Order entered into Epic using the time the order was written on the ED Downtime Orders/MAR form. b. Order is completed using time stamp on the EKG. This will ensure accurate door to EKG reporting. EMERGENCY DEPT POST- DOWNTIME RECOVERY PROCEDURES Patient Access Services will process all Emergency Department arrivals, Admissions, Transfers, within the hospital. Emergency Department Unit Coordinators are responsible for processingemergency room discharges, external transfers and emergency room expirations. Downtime Recovery Phase 1: This is the period where ADT forms are accumulated and input into system. Patient orders and documentation can ONLY be entered on patients that have had an ADT event during the downtime Downtime Recovery Phase 2: Catch up period where orders and documentation are entered on all patients that have had an ADT event during downtime. Order entry and documentation back load is dependent on patient's information being in the system first. Admissions and transfers that happen within the hospital. The Unit Coordinator will be responsible for discharges, transfers out of the ED and expirations. Emergency Department Patient Access personnel will update: 1. Patients arrived in the Emergency Department during the downtime. 2. Patients transferred from the ED to the inpatient setting during the downtime. 3. Patients transferred out of the facility, discharged or expired during the downtime Will be maintained by the Unit Coordinator Emergency Department staff will then update: 1. The first priority after Patient Access downtime recovery is completed is updating the EMR and medication administration on patients who have been admitted to the inpatient setting (so that ongoing inpatient documentation/inpatient chart reconciliation can occur). 2. Update patients who were in ASAP before the system went down and are still in the Emergency Department (update patients to current ED locations, status, etc) 69

71 3. Place patients that arrived in the ED during Epic downtime in the current location in the ED. 4. All medication orders will be entered into Epic. 1. Medication reconciliation should immediately occur with linking of all override medications and updating of patient MARs. 2. Until medication reconciliation is complete, medication orders should be re-verified and compared against downtime documentation prior to medication administration. 3. All admission order sheets with orders from the Admitting physician should be faxed to Pharmacy, including any one time or Stat orders given in the ED. 5. The Unit Coordinator will verify that all ED patients are in appropriate status and location within Epic EMR. 6. Enter the order to admit for patients who had admissions requested during downtime. 7. Update documentation on expirations that occurred during downtime. 8. The same communication process that was used to notify users of the downtime should be used to notify users that they can resume their standard workflows. 9. Documentation from paper forms during downtime is transferred into Epic (based on parameters outlined in Emergency Dept Documentation Recovery to EMR section below). 10. Laboratory/Radiology will enter orders from downtime paper requisitions based on their policies. 11. Scan documents to HIM or Hyland as described in scanning section. Emergency Department Documentation Recovery to EMR Epic Downtimes less than 1 Hour The following information will be entered into Epic when the system is available. 1. ED Tracking system will be updated by the Unit Coordinator with discharges, admissions that occurred during the downtime. 2. Patients who arrived during Downtime will have a new identification bracelet placed that includes the updated information and CSN#/barcode by Patient Access. 3. All clinical documentation will be entered into the Epic system. 4. Downtime paper documentation will be scanned into system when entry into Epic is complete. 5. Charging processes will follow normal workflows. 6. Lab/Radiology will enter their orders from their paper requisitions and reconcile the system per policy. Epic Downtimes greater than 1 Hour The following information will be entered into Epic when the system is available: 1. ED Tracking system will be updated by ADT with discharges, admissions, transfers, expirations, etc., that occurred during downtime. 2. Patients who arrived during Downtime will have a new identification bracelet placed that includes the updated information and CSN#/barcode by Patient Access. 3. Patients will be moved by the Unit Coordinator to the assigned room in the system. 4. Patient charts will be updated per the ED Documentation section below. 5. All Lab, Radiology and diagnostic orders will be entered and reconciled by the resulting department. 70

72 6. Medication orders will be priority and entered/reconciled as outlined in the postdowntime recovery processes section. 7. Other orders will be entered into Epic by the appropriate department. Non-therapeutic orders can be entered by ED Secretarial staff. 8. Downtime paper documentation will be scanned into the system. 9. Charges are entered into the system per normal workflows. ED Nursing documentation to be entered into system: 1. Patient Acuity 2. Chief Complaint 3. Allergies. 4. Medications - documentation of home medications as well as reconciliation of medications ordered/ administered during downtime 5. Admission vital signs and any abnormal vital signs that need to be in the record. Upload vitals from monitor (if available through interface) 6. Previous Medical History 7. Patients to be moved through system to appropriate point in care (including discharge) utilizing events as documented in the ED Downtime documentation. 8. Height/Weight 9. Intake/Output 10. Procedures, LDA's, pertinent assessment information, etc. for admitted patients who will have ongoing inpatient assessment/documentation in these areas. 11. Disposition information 12. Supply Charges 13. Note referring to paper documentation that occurred during downtime. 14. All non-therapeutic outpatients follow up orders in system. (Isolation, Consults, Outpatient testing, Code status, etc). ED Physician Data Components to be entered into system: (May be entered by Emergency Department nursing staff) 1. ED Disposition and Follow Up 2. Patient referrals, consults and outpatient orders 3. Medication reconciliation including discharge prescriptions. 4. Patient history information INTERFACED SYSTEM DOWNTIME INFORMATION SYSTEM WITH EPIC SYSTEM AVAILABLE Laboratory System Downtime 1. Laboratory orders to be entered into Epic system. 71

73 2. Epic system will contain order details. 3. ED Nurse will acknowledge new orders in Epic. 4. ED Personnel will label specimens with printed ADT patient labels, write the lab orders on the Downtime Lab requisition and send the requisition/specimens to the lab together. If there is an add on order and the specimen is already in lab, send a Downtime Lab Requisition marked specimen in lab. 5. Results will be faxed to Emergency Department via designated fax. Charge Nurse in the Emergency Department is responsible to ensure fax is stocked with paper, tested and working. Critical results will be called to department following laboratory policy. 6. See Laboratory System Downtime Policy for laboratory system specific downtime processes 7. Laboratory interfaced system post-downtime reconciliation to be completed by laboratory per the Lab Downtime policy. 8. PACS System Downtime 1. Diagnostic Imaging orders to be entered into Epic system per normal workflow. 2. Diagnostic Imaging personnel will receive orders from Radiant per normal workflow. 3. Hard-copies of films taken in the Emergency Department will be provided to the ED Physicians for preliminary interpretation. These preliminary interpretations are documented by the ED Physician using the Interpret link within Epic. 4. Radiologist will use Power Scribe to document final interpretation. 5. See Diagnostic Imaging PACS System Downtime Policy for PACS System downtime processes. 6. PACS interfaced system post-downtime reconciliation to be completed by Diagnostic Imaging per policy. 7. Previous Diagnostic study results will be still be available within the Epic system during PACS Downtime. Omnicell System Downtime 1. Medication orders to be entered into Epic per normal ED workflow with documentation of medication administration per facility medication administration policy. Omnicell system post-downtime reconciliation/recovery. 1. The ED Nurse should link all medication administrations from Omnicell override pulls to the corresponding order on the patient's Epic MAR when the system interface is restored. These medications are identified by going to the MAR, to the "Override" tab. This tab will list medications that need to be linked to the med administered during the Omnicell downtime. (Refer to Pharmacy's Omnicell downtime policy as necessary) Rhapsody/Interface System Downtime Processes for ASAP Rhapsody/ interface system carries messages between applications. End-users will be able to continue to use Epic, but messages will not go from Epic to integrated systems, nor will the 72

74 integrated systems carry messages back to Epic. The following is a brief outline for ASAP. Please refer to the facility downtime policy for Rhapsody as needed. LABORATORY ORDERS DURING RHAPSODY/INTERFACE SYSTEM DOWNTIME Lab orders are placed in Epic per normal Epic workflow When specimens are collected during Downtime, a paper Downtime lab requisition should accompany the specimens to lab Results will be provided to the units using downtime processes POC glucose/i-stat results, etc. will not go thru the lab interface into Epic during the downtime. Enter/Edit results should be utilized for preliminary results. When Rhapsody/Interface System comes back up, lab orders placed during Downtime go thru the interface and ascession labels will print these should be sent to lab. When Rhapsody/Interface System comes back up, POC test results will go thru the interface and show as final results in Epic. When Rhapsody/Interface System comes back up, all results will flow into Epic. OMNICELL/MEDICATION ORDERS DURING RHAPSODY/INTERFACE SYSTEM DOWNTIME All new patients who arrive during the Rhapsody/Interface System downtime will need to be manually entered into the Omnicell All new medication orders entered during Downtime will be entered in Epic and need to be pulled using the override process When Rhapsody/Interface System comes back up, all medication orders will flow into Omnicell. All medications pulled on override during the downtime will need to be reconciled including overrides for patients who may have been sent to the inpatient setting during Downtime. RADIOLOGY ORDERS DURING RHAPSODY/INTERFACE SYSTEM DOWNTIME Diagnostic Imaging orders are placed in Epic per normal Epic workflow Diagnostic Imaging technologists process orders from Epic, and manually enter the order information from Epic into the imaging device so that the results will route back to the order. PowerScribe does not receive orders during this time, so transcription is done in Radiant, results will be seen in Epic. Diagnostic Imaging discrepancy workflow is unchanged with Rhapsody/Interface System downtime. As long as the study is not resulted, the ED Physician will be able to enter a wetread in Epic, and the Radiologist will see this when they do their interpretation. When Rhapsody/Interface System comes back up, the results will file to Emageon just as they would if they were transcribed in Powerscribe. DIETARY ORDERS Orders for diet trays should be placed in Epic, and called to Dietary. 73

75 RESPONSIBILITIES SSHS Downtime Policy & Procedure Emergency Medical Services staff will use paper downtime forms and complete all fields. Reload information into EPIC once the system is back on line Communications Center Downtime Scheduled Downtime: 1) The dispatch center should be staffed for the entire down period and all Hospital units should be notified of staffing. 2) The phone system will be utilized for all transport requests. The dispatcher(s) will document all requests on paper/log with the Patient's name, M#, hospital location and destination. Any other information needed to complete the call should be documented. 3) The radio system will be used to contact Ambulance units and Dispatcher(s) will need to document arrival/departure times for each transport. 4) Expects will need to be documented on appropriate form and forwarded/faxed to the patient's location upon arrival. 5) All ambulance transports will need to be entered into rescuenet and V#s created for each transport once downtime has ended. Unscheduled Downtime: EMERGENCY MEDICAL SERVICES 1) In the event of an unscheduled downtime, the EMS manager and appropriate charge people must be notified immediately. 2) Dispatchers should then follow the procedures outlined in scheduled downtime listed above. 3) Dispatcher(s) should callback another Dispatcher(if available) to assist with call taking. 4) Ambulance crews should be utilized and staged at SSH during unscheduled downtime. These procedures are a guide for the Dispatcher(s) and emergency events may call for additional resources to be utilized to maintain the dispatch center operations. At any time Dispatcher(s) can call the EMS manager or appropriate charge person for further guidance. 74

76 EPCR Down time In the event there is computer down time. All EMS crews will use paper pcr's/trip sheets. These are located in the EMS closet in the emergency Room. The trip sheets will be turned into the same folder at dispatch that holds the medical necessity forms. This way the billing person will see them. They will then be scanned into Hyland so that they are inserted into the proper patient medical record. Also be sure to use paper medical necessity forms and get the appropriate signatures. In the case that down time does not affect logging on to the computer tablets all crews will continue the use of the e-pcr. 75

77 MATERNITY (STORK) RESPONSIBILITIES Maternity Refer to Nursing Downtime section RESPONSIBILITIES Any loss of GE Centricity Perinatal System functionality should be reported IMMEDIATELY to the Customer Support Center at Please be prepared to report the following information: A. Workstation(s) location and ID Tag number B. Number of PC workstations affected C. Specific issue in detail D. Any error messages that appear on the screen(s) Downtime Documentation: IF the system is down and the CSC is not able to immediately resolve the issue begin Downtime Documentation. During downtime, all documentation of vital signs will be transcribed into the Epic Stork electronic health record. All nursing care, interventions, and care management will continue to be documented in Epic Stork. Document a note in both the paper documentation and on the paper EFM tracing to reflect Electronic documentation system downtime. When the system is fully recovered and the archive function has been verified, document Electronic Documentation Restarted and change back to Electronic documentation. When restarting electronic documentation note See paper chart for documentation between and. Reconciliation of Admission, Discharge and Transfer data will be completed in GE Archiving capability of the Central Monitoring System When archiving of the Fetal heart monitor information is affected or a single workstation is not functioning for >60 minutes, documentation of vital signs will revert to written forms. No attempt will be made to reenter data once the system is restored if the system has been down for greater than 30 min. for an active labor patient or 60 min for an early labor/ observation patient. Save all paper documentation in the patient s medical record (paper chart) as the permanent record during this period. Birth Log ADT: At the time of restoration of GE Centricity, the Charge Nurse/Nurse Manager, along with the Unit Coordinator will be responsible for reviewing the system database to ensure that all patients who were admitted during the downtime have been correctly entered into the system. 76 LABOR AND DELIVERY GE Centricity

78 Epic Stork Downtime GE Centricity Perinatal running If Epic Stork is down and GE Centricity is running, new patients will not be entered into GE Centricity from the ADT interface. New patients will need to be entered into GE Centricity using the Create Patient Record under Patient Administration. The patient ID will be the Patient's last name and the Patient name should be entered in capitals, LAST NAME, FIRST NAME., and MI. Clinical Care: Loss of Surveillance Loss of Central Surveillance for greater than 5 minutes may require a change in nursing assessment frequency. The CSC should be immediately notified at x8827. All patients should be rounded on immediately and the charge nurse should be notified as to the status of the GE Centricity Perinatal system in each patient room. The charge nurse should notify the Nurse Manager/ ACC of the need for any additional nursing staff required for direct fetal surveillance. Nurse Patient ratios for the duration of any downtime should be as follows: 1:1 Patient in second stage labor, patient with medical and/or obstetrical complications, initiation of epidural analgesia, non-reassuring FHR tracing. The FHR tracing should be assessed every 5 minutes for these patients and documentation occur every 30 minutes. 1:2 all other patients in the BU FHR should be assessed every 15 minutes for all patients in active labor, every 30 minutes for patients in early labor. Documentation should occur every 30 minutes. II. No elective C/Sections or inductions will take place. III. All attempts will be made to ensure strict adherence to admission criteria. Recovery and Charges: Document all charges via the charge capture navigator MATERNAL FETAL MEDICINE (GE VIEWPOINT) RESPONSIBILITIES MFM - GE Viewpoint 1. In the event of a downtime in GE Viewpoint, paper worksheets will be utilized to document ultrasound findings a. Correct gestational worksheets will be utilized based on gestational age of patient 2. Worksheets will be scanned into the electronic record and utilized by provider for interpretation of findings. 3. Interpretation of ultrasound findings will be documented in the electronic record by the MFM provider 77

79 PERI-OPERATIVE SERVICES (OPTIME and Anesthesia) RESPONSIBILITIES The PeriOperative Department will maintain all Downtime documentation forms in a drawer in PACU and the Operating Room location (PACU in a drawer). Upon notification of a planned/unplanned Epic downtime, the Charge nurse in the PeriOperative Department will; 1. Pull the Downtime Clinical Reference Binder maintained on the unit and initiate downtime processes based on whether the downtime is a Level I, Level II, Level III downtime, or a downtime affecting an Interfaced system. 2. Notify the Physician and clinical staff of the downtime, type of downtime, and processes during the downtime. Upon notification of a planned/unplanned Interfaced system downtime, the Charge Nurse in the Peri - Operative Department will follow the steps outlined, and reference the Downtime Binder for specific Interfaced system downtime information. Procedure: Prior to Down Time: 1. Scheduling of Cases A. Paper copies of the Master Daily Schedule daily schedules should be printed nightly. B. Scheduled downtime, or short duration downtime: Cases are booked with a paper booking sheet faxed to the schedulers. Offices with self-scheduling will fax their request and a copy will be kept for reconciliation. C. For urgent and emergent cases, as well as for extended downtimes - Urgent and emergent are a phone call that goes on the add on list and prioritized 2. Preference Cards OR Procedure File in Meditech A. Send the Epic ORP file to the downtime PC on a regular basis. Preferences cards on emergency cart Preference cards are available for emergency cases B. For add-on cases during the scheduled/unscheduled downtime refer to the Preference Card back up for a pick list for the case. 3. Clinical Documentation in Log Entry A. Printed paper forms that mirror the Epic charting forms in Log Entry should be readily available. B. Available Downtime forms for Pre-Admission Testing are: a. Peri-Op PAT Downtime Tool b. Clinical Allergies History Downtime Tool Do Not use this tool currently, depending on what is down 78

80 79 SSHS Downtime Policy & Procedure PSE may not be able to work if they cannot receive Electronic communication or get into outside records. C. Available Downtime forms for the Pre-Procedure Area are: 1. Peri-Op Pre-Op Downtime Tool 2. Medication Administration Downtime Form On PACU checklist D. Available Downtime forms for the Intra-Procedure Area are: 1. Peri-Op Intra-Op Downtime Tool 2. Medication Administration Downtime Tool E. Available Downtime forms for the Post-Procedure PACU Area are: 1. Peri-Op PACU Downtime Tool 2. Medication Administration Downtime Tool 3. Clinical Transfusion Downtime Tool F. Available Downtime forms for the Post-Procedure 3. If Needed, Post-Op Phone call Downtime Call Tool G. Other Downtime Forms: 1. Clinical Expiration Checklist Downtime Tool 2. Restraint forms 3. Transfusion 4. Transfer to another facility 4. OpTime Reports OpTime Log Summary or OpTime Log Detail Summary that is accessible from Chart Review should be accessible from a shadow server during downtimes, as a supplement to all other IP reports. Peri-Operative Department Intra-Downtime Procedures 1. Retrieve Downtime Tool Kit for your area. 2. Patient care documentation will be done on downtime paper forms. 3. Orders will be placed on the Medication Administration Downtime Tool. Current downtime order sets and a guide for residents on how to write orders is available in the resource book. 4. All Peri-Operative Department documentation will have a patient label placed on each page. 5. Patient Access, PACU - OR will maintain a downtime log of all patients arriving in the Peri- Operative Department. 6. When the patient arrives during Downtime, and is not in the Omnicell, the patient information to create the Omnicell contact includes: Patient name as written on the Downtime patient labels, and the Downtime HAR. Omnicell is placed on override in a downtime. Peri-Operative Downtime Lab Orders/Results Process 1 Paper requisitions will be utilized for all orders. 2 The Peri-Operative Department will use the Order Entry Requisition for Downtime to communicate new orders to the other departments. The patient identification will be placed on the form using one of the following: patient ID label, or handwritten information. 3 Specimen collected from patient and labeled at bedside per facility policy. Specimens will be sent to lab with the paper Downtime requisition. 4 Results will be faxed to the OR per Laboratory s Downtime Policy. 5 Critical results will be called to department, and documented per facility policy.

81 6 If the Shadow Read Only (SRO) server is available, historic/existing results for patients are accessible. If these systems are not available, historic/existing lab results may be available from the facility's legacy lab system. 7 Post downtime recovery Laboratory personnel perform post downtime lab order and result entry. Peri-Operative Downtime Diagnostic Imaging Orders/Results Process 1. Stat orders are called to Diagnostic Imaging tech. 2. Study completed by Diagnostic Imaging Tech, and entered into PACS system where it is available for review in PACS by the Surgeon. 3. If the Shadow Read Only (SRO) server is available, dictations of previous diagnostic imaging exams will be available. 4. Previous images available in PACS. 5. Diagnostic Imaging personnel will perform post- downtime diagnostic imaging order and result entry. Peri-Operative Downtime Medication Ordering/Administration 1. Peri-Op Nurse to pull medication from Omnicell as an override pull. If patient is not in the Omnicell, Peri-Op Nurse should create the patient s encounter in Omnicell by entering the patient s name and Downtime HAR into the Omnicell. 2. Medication order verified by Peri-Op RN utilizing the five rights of medication administration and administered per facility policy. 3. Medication administration is documented on the Blank MAR if new medications ordered form. Documentation will include the medication name, dose, route, site of administration for IM, and infusion times for IV and IVPB infusions. 4. Patient is reassessed per facility policy. Patient reassessment/response to medication and notification of physician are documented on the nursing flowsheet per facility policy. 5. Post downtime reconciliation of medications administered in the Peri-Operative during Downtime utilizing the following steps: A. The Nurse will enter all orders for medications given in the ED (Periop)during downtime utilizing the ED (Periop)Downtime Orders/MAR. B. The Nurse will fax the paper copy of Inpatient Admission orders to pharmacy. C. The Nurse will enter the medications administered in the Peri-Operative Department into the Epic MAR, including any medications administered from the Admission orders (where applicable). These administrations will be immediately linked in the Epic MAR to the corresponding medication orders. D. The first priority in post-downtime recovery/reconciliation is the entry/reconciliation of medications administered to patients who are admitted to the Inpatient setting. 80

82 Peri-Operative Downtime for EKG and Other Miscellaneous Diagnostics and Treatments A. Order for EKG or other diagnostic/treatment written and timed/signed by Surgeon on the Downtime Orders/MAR. B. Orders on Downtime Orders/MAR form acknowledged by the Peri-Operative Nurse. C. The Nurse ensures EKG is performed and documented EKG is resulted/downloaded per facility policy. D. Old EKG s will be available in scanned system via Shadow Server. If Shadow Server is not available, old EKG s are available from cardiovascular services from EKG storage system. E. Post downtime recovery i. Order entered into Epic using the time the order was written on the ED (Periop) Downtime Orders/MAR form. ii. Order is completed using time stamp on the EKG. This will ensure accurate door to EKG reporting. Recovery: Downtime Recovery Phase 1: This is the period where ADT/Patient Access forms are accumulated and input into system. Patient orders and documentation can ONLY be entered on patients that have not had an ADT event during the downtime Downtime Recovery Phase 2: Catch up period where orders and documentation are entered on all patients that have had an ADT event during downtime. Order entry and documentation back load is dependent on patient's information being in the system first. Patient Access / ADT must do all of their recovery efforts prior to nursing entering data for their patients that have been admitted, discharged, or transferred during the downtime. Peri-Operative Department Post-Downtime Recovery Procedures 1. OpTime Post-Downtime Recover A. When less than 4 hour: All paper documentation will be entered into the electronic record. B. When greater than one hour: All medical & surgical history information, medication administration and order information documentation will be entered into the electronic record by the nurse. Notes activities and discharge instructions will remain on paper and be later scanned into the record. I & O and Vital Signs will be entered as summaries or documentation of any aberrant or out of normal values. All other paper documentation identified will be entered into the electronic record by the available clerk / secretary. 81

83 INTERFACED SYSTEM DOWNTIME INFORMATION EPIC AVAILABLE Laboratory System Downtime 1. Laboratory orders to be entered into Epic system per normal OpTime workflow. 2. Laboratory personnel will receive order details from Epic system. 3. Results will be faxed to OR/PACU via designated fax. Charge Nurse in the 4. OR/PACU is responsible to ensure fax is stocked with paper, tested and working. Critical results will be called to department following laboratory policy. 5. Laboratory interfaced system post-downtime reconciliation to be completed by laboratory policy. PACS System Downtime 1. Radiology orders to be entered into Epic system per normal workflow. 2. Radiology personnel will receive orders from Radiant per normal workflow. 3. See Radiology PACS System Downtime Policy for PACS System downtime processes 4. Hard-copies of films or CDs taken in the OR/PACU will be provided to the Physicians for preliminary interpretation. 5. PACS interfaced system post-downtime reconciliation to be completed by Radiology per policy. 6. Previous Radiology study results will be still be available within the Epic system during PACS Downtime. Omnicell System Downtime 1. Medication orders to be entered into Epic per normal OR/PACU workflow with documentation of medication administration per facility medication administration policy. 2. Omnicell system post-downtime reconciliation/recovery. The OR/PACU Nurse should link all medication administrations from Omnicell override pulls to the corresponding order on the patient s Epic MAR after the system interface is restored. These medications are identified by going to the MAR, to the Override tab. This tab will list medications that need to be linked to the med administered during the Omnicell downtime (Refer to Pharmacy s Omnicell downtime policy as necessary) 82

84 Cardiac Cath Lab RESPONSIBILITIES The CCL will maintain all Downtime documentation forms in a specified location that is easily accessible when downtime occurs. Upon notification of a planned/unplanned Epic downtime, the Charge nurse in the CCL will; 1. Pull the Downtime Clinical Reference Binder maintained on the unit and initiate downtime processes based on whether the downtime is a Level I, Level II, Level III downtime, or a downtime affecting an Interfaced system. 2. Notify the Physician and clinical staff of the downtime, type of downtime, and processes during the downtime. Upon notification of a planned/unplanned Interfaced system downtime, the Charge Nurse will follow the steps outlined above, and reference the Downtime Binder for specific Interfaced system downtime information. Prior to Down Time: A. Copies of the Master Daily Schedule daily schedules should be printed prior to downtime B. Urgent and emergent cases, shall be called to CCL as per routine. In extended downtimes, routine CCL cases will follow the downtime procedures of Central scheduling. Refer to CS downtime procedures Clinical Documentation 1. Printed paper forms that mirror the Epic charting forms in Log Entry should be readily available. 2. Procedure- Printed forms of the Cupid procedure charting should be readily available.centricity documentation will continue unaltered if not involved in downtime. 3. Pre Procedure- Printed forms of the pre-procedure Cupid procedure charting should be readily available. 4. Post procedure- Printed forms of the post procedure Cupid procedure charting should be readily available. Downtime Procedures 1. Retrieve Downtime Tool Kit for your area. 2. Patient care documentation will be done on downtime paper forms. 3. Orders will be placed on the Medication Administration Downtime Tool. 4. All documentation will have a patient label placed on each page. 5. CCL UC will maintain a log of all patients arriving in the Department. 6. When the patient arrives during Downtime, and is not in the Omnicell, the patient information to create the Omnicell contact includes: Patient name as written on the Downtime patient labels, and the Downtime HAR. Available Downtime forms for Procedure 83 CARDIOVASCULAR / EKG / CATH LAB

85 1. Clinical Allergies History Downtime tool- MD/APC Pre procedure assessment, history, physical if needed or H&P unavailable. 2. RN procedure assessment paper copy of Cupid pre, intra and post procedure assessment 3. Paper Medication Administration this will follow patient through the 3 phases of procedure and sent to inpatient floor with patient transfer 4. MD/APC note paper to document post procedure note. Downtime Lab Orders/Results Process 1. Paper requisitions will be utilized for all orders. 2. CCL will use Order Entry Requisition for Downtime to communicate new orders to the other departments. The patient identification will be placed on the form using one of the following: patient ID label, or handwritten information. 3. CCL will use the Specimen collected from patient and labeled at bedside per facility policy. Specimens will be sent to lab with the paper Downtime requisition. 4. Results will be faxed to the CCL per Laboratory s Downtime Policy. 5. Critical results will be called to department, and documented per facility policy. 6. If the Shadow Read Only (SRO) server is available, historic/existing results for patients are accessible. If these systems are not available, historic/existing lab results may be available from the facility's legacy lab system. 7. Post downtime recovery Laboratory personnel perform post downtime lab order and result entry. Radiology Orders/Results Process 1. Stat orders are called to Radiology Tech. 2. Study completed by Radiology Tech, and entered into PACS system where it is available for review in PACS by the Surgeon. 3. If the Shadow Read Only (SRO) server is available, dictations of previous radiology exams will be available. 4. Previous images available in PACS. 5. Radiology personnel will perform post- downtime radiology order and result entry. Downtime Medication Ordering/Administration 1. CCL Nurse to pull medication from Omnicell as an override pull. If patient is not in the Omnicell, CCL Nurse should create the patient s encounter in Omnicell by entering the patient s name and Downtime HAR into the Omnicell. 2. Medication order verified by RN utilizing the five rights of medication administration and administered per facility policy. 3. Medication administration is documented on the Blank MAR if new medications ordered form. Documentation will include the medication name, dose, route, site of administration for IM, and infusion times for IV and IVPB infusions. 4. Patient is reassessed per facility policy. Patient reassessment/response to medication and notification of physician are documented on the nursing flowsheet per policy. 84

86 5. Post downtime reconciliation of medications only administered during time in CCL during downtime utilizing the following steps: A. The Nurse will enter all orders for medications given in CCL B. The Nurse will fax the paper copy of CCL meds orders to pharmacy. C. The Nurse will enter the medications administered in the CCL into the Epic MAR, These administrations will be immediately linked in the Epic MAR to the corresponding medication orders 6. The first priority in post-downtime recovery/reconciliation is the entry/reconciliation of medications administered to patients who are admitted to the Inpatient setting. CCL RN will perform entry/reconciliation of medications administered to patients while in the CCL if system comes up while patient in CCL. All other medications and orders written or given before patient went to CLL will be reconciled and entered by receiving unit RN when patient returns to floor. Downtime for EKG and Other Miscellaneous Diagnostics and Treatments 1. Order for EKG or other diagnostic/treatment written and timed/signed by MD/APC on the Downtime Orders/MAR. A. Orders on Downtime Orders/MAR form acknowledged by the Nurse. B. The Nurse ensures EKG is performed and documented EKG is resulted/downloaded per policy. C. Old EKG s will be available in MUSE. D. Post downtime recovery i. Order entered into Epic using the time the order was written on the ED Downtime Orders/MAR form. ii. Order is completed using time stamp on the EKG. This will ensure accurate door to EKG reporting. Recovery: Downtime Recovery Phase 1: This is the period where ADT forms are accumulated and input into system. Patient orders and documentation can ONLY be entered on patients that have not had an ADT event during the downtime Downtime Recovery Phase 2: Catch up period where orders and documentation are entered on all patients that have had an ADT event during downtime. Order entry and documentation back load is dependent on patient's information being in the system first. Patient Access / ADT must do all of their recovery efforts prior to nursing entering data for their patients that have been admitted, discharged, or transferred during the downtime. 85

87 Cath Lab Post-Downtime Recovery Procedures 1. OpTime Post-Downtime Recovery: A. Inpatient :When less than four hours: All paper documentation will be entered into the electronic record by receiving unit. CCL staff will not be entering orders or documentation that occurred outside the Cath Lab. CCL paper documentation will be sent with patient to their unit. B. When greater than one hour: CCL staff will not be entering orders or documentation that occurred outside the Cath Lab.CCL paper documentation will sent with patient to receiving floor. All medical & surgical history information, medication administration and order information documentation will be entered into the electronic record by the receiving unit nurse. Notes activities and discharge instructions will remain on paper and be later scanned into the record. I & O and Vital Signs will be entered as summaries or documentation of any aberrant or out of normal values. All other paper documentation identified will be entered into the electronic record by the available clerk / secretary. INTERFACED SYSTEM DOWNTIME INFORMATION EPIC AVAILABLE Laboratory System Downtime 1. Laboratory orders to be entered into Epic system per normal workflow. 2. Laboratory personnel will receive order details from Epic system. 3. See Laboratory System Downtime Policy for laboratory system specific downtime processes 4. Results will be faxed to designated fax. 5 Critical results will be called to department following laboratory policy. 6. Laboratory interfaced system post-downtime reconciliation to be completed by laboratory policy. PACS System Downtime 1. Diagnostic Imaging orders to be entered into Epic system per normal workflow. 2. Diagnostic Imaging personnel will receive orders from Radiant per normal workflow. 3. See Radiology PACS System Downtime Policy for PACS System downtime processes Omnicell System Downtime 1. Medication orders to be entered into Epic per normal OR/PACU workflow with documentation of medication administration per facility medication administration policy. 2. Omnicell system post-downtime reconciliation/recovery. The CCL Nurse should link all medication administrations from Omnicell override pulls to the corresponding order on the patient s Epic MAR after the system interface is restored. These medications are identified by going to the MAR, to the Override tab. This tab will list medications that need to be linked to the med administered during the Omnicell downtime (Refer to Pharmacy s Omnicell downtime policy as necessary) 86

88 ENVIRONMENTAL SERVICES Procedure: 1. Retrieve Downtime Tool kit 2. Use the most current sign in sheet for staff on duty and pagers numbers assigned to staff. 3. EVS Managers and Supervisors will notify all EVS Staff via pagers that the EPIC system is down and they will have to call down to Supervisor or Secretary to let them know the status of discharge process 4. Supervisor or Secretary running the Bed Board will utilize the Bed Board Form in the Downtime Tool Kit to track discharges,(bed #, Time Requested, Who is assigned, Time Assigned, Time in Process, Time Completed, Time notified nursing unit room is cleaned). 5. Supervisor or Secretary will receive calls from nursing units or bed flow requesting room to be discharge cleaned. 5. Supervisor or Secretary will page appropriate Housekeeper to assign the discharge and log info in Bed Board Form. 6. Housekeeper will call Supervisor/Secretary when they are in the room and starting the discharge cleaning. 7. Supervisor/Secretary will log time in process on the Bed Board Form. 8. Housekeeper will call Supervisor/Secretary when they are finished with the discharge cleaning. 9. Supervisor/Secretary will log time completed on Bed Board Form. 10. Supervisor/Secretary will call Nursing Unit to let them know the bed is cleaned and log the time called on the Bed Board Form Recovery: 1. Supervisor/Secretary will notify all EVS staff via the paging system that they can resume the use of the EPIC System. 2. Supervisor/Secretary will enter completed discharges into EPIC EVS Module to update the EPIC system. 87

89 TRANSPORT Procedure: 1. Retrieve Downtime Folder 2. Use the most current sign in sheet for staff on duty and phone numbers assigned to staff. 3. Transport Manager, Supervisor, or Dispatcher will notify all Transport Staff on duty that the EPIC system is down, and the Transporters will have to call the Transport Office via wireless phone or wall phone to let Dispatcher know the status of their Transport Jobs. 4. Dispatcher will utilize the Transport Downtime Log in the Downtime Folder to track Transport Requests. (Patient Name, Origin, Destination, Mode of Transportation, IV/02/monitor, Time Requested, Transporter Assigned, Time Dispatched, Time Completed). 5. Dispatcher will receive Transport Requests by phone from Units and Testing areas. 6. Transporters will notify the Dispatcher by phone from the Units and Testing areas when their Transport job is complete, and the Dispatcher will assign them their next Transport Job 7. Dispatcher will record Transporter Assigned, Time Dispatched, and Time Completed in Transport Downtime Log. Recovery: 1. Manager, Supervisor, or Dispatcher will notify all Transport staff on duty when they can resume the use of the EPIC System. 88

90 HEMODIALYSIS Procedure: 1. Retrieve downtime tool book for Hemodialysis 2. In the event of a downtime, paper requisitions will be utilized for all orders 3. Refer to the Inpatient Clinical Documentation (Epic Care Inpatient) for Nursing Downtime policy & Procedure section. 4. For the planned downtime, the hemodialysis RN will print the dialysis orders prior to the scheduled downtime. 5. The patient s reports will have to be printed off the BCA computers from the patient s primary location. (ED, M/S or ICU) 6. In Level 3and 2 we will have SRO View Only to see each patient s information from the BCA downtime computer. 7. In level one, the dialysis unit will not be able to view the patient s information. Call the patient s current location for the printed downtime forms. 8. Hemodialysis RN will fax a copy of the Hemodialysis schedule 9. Hemodialysis RN will call for the scheduled patients, obtain report and request the paper chart be sent with the patient including MAR, lab labels, orders, and other reports pertinent for their care. 10. The Hemodialysis Physicians Paper Order form will be used for all treatment orders.(if not previously entered into EPIC) 11. All other orders will be on the downtime order/requisition forms. 12. Hemodialysis downtime forms will be used to document the treatment. 13. Charging: Hemodialysis Downtime documentation forms includes: Hemodialysis schedule Hemodialysis Physician Orders form Pre Hemodialysis assessment During Hemodialysis assessment Post Hemodialysis assessment Pain assessment Teaching record Restraint assessment Restraint outcome Medication requisition form-if a medication is required from pharmacy 89

91 The following reports are configured to be sent to the P6HEM03 PC in hemodialysis. ADT House Census Dietary Report IP Extended Ifo BCA MAR IP Clinical Summary IP OT Patient Summary IP PT Patient Summary IP SLP Patient Summary IP RT Patient Summary 90

92 VASCULAR ACCESS Vascular Access Department PROCEDURE: Nursing will call and or page Vascular Access nurse with any new orders. In a planned downtime the vascular access nurses will have available the Downtime Documentation Book located in the IV office.. Documentation of all vascular access interventions is to be recorded on the paper copies and then entered into EPIC when the system is restored. If the system remains down beyond the end of the work shift, the IV nurses will leave the paper copy in the patient medical record Vascular Access nurses will make a copy of all the PICC line placed during downtime and place in the Downtime folder. In an unplanned downtime (level 1). The vascular access nurses will immediately contact the ACC to have all the IV consult requested by phone or page and record all the IV documentation on the paper copies designated for downtime. We will utilize the active PICC line placement census. That is located in our shared folder (Excell document). We have access to a daily paper copy printed every day. 91

93 BEHAVIORAL HEALTH SERVICES Procedure: 1. Retrieve Downtime Tool kit 2. Behavioral Health Clinicians will use the shadow server read only (SRO) during a planned downtime to view hyperspace at the time of downtime 3. In unplanned downtime with internet access, the Behavioral Health Clinicians may log into the BCWA to view downtime reports. 4. In unplanned downtime with generator power only, the Behavioral Health Clinicians may view downtime reports at the BCA at designated locations. 5. Review Downtime Clinical Summary Report from BCA. 6. Behavioral Health Services department will utilize the Order Entry Requisition for Downtime to receive orders 7. Downtime documentation forms will include: A. Integrated progress notes B. Substance Use Disorder Evaluations (SUDE), with bar code Recovery: Downtime Recovery Phase 1: This is the period where ADT forms are accumulated and input into system. Patient orders and documentation can ONLY be entered on patients that have not had an ADT event during the downtime Downtime Recovery Phase 2: Catch up period where orders and documentation are entered on all patients that have had an ADT event during downtime. Order entry and documentation back load is dependent on patient's information being in the system first. Patient Access / ADT must do all of their recovery efforts prior to Behavioral Health Clinicans entering data for their patients that have been admitted, discharged, or transferred during the downtime. 1. If downtime is > 1 hour, all information from progress notes is entered into the system. Substance Use Disorder Evaluation forms can be scanned in. 2. If downtime is less than 1 hour the following information is entered into the system by the clinician. o Evaluation and Assessment documentation o Any Care Plan initialization and/or updates completed during the downtime 3. Behavioral Health Clinicians will review and collaborate with ED nursing staff to ensure that all appropriate orders have been written and then entered into the computer system. The nurse will document on the paper order sheet that the orders have been entered electronically with date, time and initials. (Noting the orders) 4. All other paper documentation will be scanned into the medical record upon discharge. 92

94 Non Clinical and Financial Departments 93

95 Human Resources is not impacted when EPIC is unavailable. Payroll is not impacted when EPIC is unavailable, If Meditech is unavailable: Summary: In the event Meditech is unavailable during a payroll week, payroll will use the information in the safe housed in the Payroll Office to issue payments to employees in the amount and manner (direct deposit or check) of their last paycheck. These payments will be referred to as advances and will be the employee s previous net pay amount. As these are advances there will be no deductions withheld. Preparation: After each bi-weekly payroll run Payroll will download and save the direct deposit files (SSH, SMC, MON & CMA) onto a flash drive. Payroll will print the check registers for a record of the live checks and the termed employee list for the current payroll. The flash drive and the printed check register report will be kept securely locked in a fire proof safe in the Payroll Office. Additionally, an Audit Log will be stored in the safe and each time the files are saved and/or printed, it will be recorded on the Audit Log. Other supplies stored in the locked box will be blank checks, envelopes, signature stamp, paper, pens, battery/solar operated calculator, stamps, ACH Reversal Forms, and Santander Bank downtime procedures including bank account numbers, downtime process and contact information. Process in Event of Disaster: HUMAN RESOURCES HUMAN RESOURCES Payroll Payroll will send the direct deposit file (SSH, SMC, CMA & MON) that is saved on the flash drive to Santander (via lab top). Santander will accept and re-run the direct deposit files from the previous payroll. Terminated employees may be deleted from the file manually prior to sending the file to Santander or we can notify bank personnel by ing them an ACH reversal spreadsheet form to retract the direct deposit for terminated employees. Manual checks will be hand written for employees that are not on direct deposit and the advance amount will be based on the check register from the previous pay period. Our bank, Santander will be notified that we are in disaster mode so they will accept the manual checks. The checks will be written out of the Core account which does NOT have positive pay. 94

96 A check register of the check #, name, employee number and amounts will be manually recorded and used to update the Meditech system after the system is restored. Process after Systems Restored: After all systems have been restored payroll will process the missed payroll and deduct the advanced amounts from each employee. To do this a receivable withholding will be set up and the amount Advanced to each employee will be entered (manually or scripted) into the Meditech system as a receivable balance. After processing this payroll three scenarios could exist. The employee covered the advance and is owed a balance. This payment will be processed as a regular payment as soon as possible and issued to the employee in the manner they normally receive their bi-weekly pay. The employee s regular paycheck did not cover the entire advance and a balance remains on the receivable withholding. The remaining balance will be deducted from future paychecks until the balance is reduced to zero. The advance was the exact amount of the paycheck and SSH does not owe the employee money and the employee does not owe SSH. All of the above must be complete prior to the next payroll being processed. Accounts Payable Downtime Procedures The Accounts Payable department will not process a check run or ACH file during downtime. Any vendor payments needed for critical supplies or services will be written out of the same core account. After all systems have been restored Accounts Payable will enter any invoices and checks into the system. 95

97 Audit Log for Direct Deposit Files Downloaded on Flash Drive Today's Date Check/DD Date SSH, MON,SMC CMA DD File downloaded Check Register Printed Termed Employee List Printed Initials 96

98 MATERIALS MANAGEMENT RESPONSIBILITIES Materials Management Uses Meditech Follow current downtime process 97

99 FINANCE Professional Billing (PB) Charge Reconciliation Process Medical Records will Reconcile Billing Tickets/scanned Progress Notes to scheduled appointments; open encounters from the schedule; enter.scan in the Progress Note section; enter the diagnosis as indicated on the Billing Ticket and close encounter. Billing will receive the tickets from Medical Records and manually enter all charge tickets. Billing will reconcile charges to the schedule and contact Operation Managers for missing charge tickets. Department Procedures Patient calls Explain to patient that the computer system is down and they will receive a call back when it is available. If patient wants to make a payment, take the information, process the payment when the system is available. Mail patient a receipt. Create list of patients that need return calls. Return all calls when system is available. Hospital Billing (HB) Charge Reconciliation Process Current process is for each department to enter charges when system is restored and reconcile as per routine process Department Procedures Only manual checks would be an issue, EFTs are already automatically deposited in banks Paper checks can be copied or scanned (if scanning is available) and deposited In the event of full power outage, a copy machine in another department with generator supplied power would be utilized Cashier operations would remain the same in that security would continue to send courier between facility and bank 835/Electronic Remits cannot be read into Epic and will need to be held. Credit Card payments that interface with Epic cannot be accepted. These can be entered online through Passport and subsequently into Epic once systems are back up. 98

100 EXPERIAN Level 3 & Level 2 Downtime: If internet access is available copayments can be collected through Passport / Eperian s Onesource tool which is not connected to EPIC. Level 1 Downtime: Copayments will not be collected and insurance companies will not be connected. 99

101 REVENUE INTEGRITY HOSPITAL CODING - CDI 3M Revenue Integrity - Hospital Coding/CDI Downtime Policy I. Downtime Procedure - Revenue Integrity Hospital Coding Hospital Clinical Documentation Improvement (COl) II. PURPOSE To provide an overview of the Revenue Integrity processes when the main hospital electronic health record (EHR) is not readily available. III. SUMMARY Revenue Integrity will have a process for coding, abstracting and reviewing, querying physicians when the EHR has been down and becomes available. IV. PROCEDURE INFORMATION A. Coding I. Abstracting Module Unavailable - If the abstracting system is unavailable, coding will be manually coded utilizing available coding reference books and paper abstracts. Once the Epic Abstracting Module is back on-line, the data from the paper abstracts will be entered into the 3M/Epic applications and finalized for billing. In the event that manual billing is utilized, the Coding Manager will coordinate with Patient Accounts, as appropriate. II. Should the full EHR be unavailable, coders will not be able to code without view of discharged records. It will be up to the Coding Manager and/or Revenue Integrity Director to determine how coders use this time (e.g., review of AHA Coding Clinic Guidelines, quality reviews, etc.) or allow coders to leave work with the understanding they can make up hours once the system becomes available. B. COl I. EHR unavailable - refer to IV, A, 1 directions. In addition to above, CDls can work on reconciliations and any other functions available in 3M. 100

102 [ REGULATORY 101

103 QUALITY Chart-abstracted Measures 1. QM is responsible for chart abstracting and reporting data to regulatory agencies such as CMS, MassHealth and the Joint Commission. SSH's annual Quality Payment Update from CMS is linked to whether we meet requirements under the Inpatient Quality Reporting Program and Outpatient Quality Program. MassHealth payments are also linked to successful reporting under its quality reporting program. 2. Once cases are final coded, we use a third party, web-based software (Press Ganey's Quality Performer) to pull applicable cases from Meditech and abstract the required information. Press Ganey then submits the information to the regulatory agencies directly. 3. While we report data monthly to regulatory agencies, we generally have several months to make corrections before final deadlines close. 4. With chart abstracted measures, our main concern is that during downtime our clinical partners have the appropriate Meditech/Epic screens printed out so they are documenting the elements we need to meet the quality measures - and that of course these documents are scanned into the medical record. Electronic clinical quality measures 1. In 2017, SSH is required to report eight ecqms to CMS and six to TJC for the full calendar year (we will report stroke measures and ED throughput measures). 2. As opposed to chart abstracted measures, ecqms require discrete data elements to be documented in the record and are reported electronically to CMS and TJC via a QRDA file (reporting is done once a year - we will report in spring 2018 for 2017 performance). If during downtime, these things aren't electronically documented, measure performance will be impacted. It is important to note however, that ecqms are in a pilot phase and aren't publicly reported. We are just evaluated on whether we report, not performance. 102

104 QUANTROS In the event of a Quantros Downtime Safety reports may be filled out on paper and given to the manager / supervisor / ACC. Information will be entered into the system by the Risk Management Department. 103

105 AMBULATORY CARE 104

106 SOUTH SHORE MEDICAL CENTER EpicCare Downtime Procedures for each Job Responsibility In the event the Epic System experiences downtime (inability to use the system) the Epic Support Team will declare a downtime event and will notify SSMC staff as outlined in the Downtime Communication Plan. This will take effect immediately upon the system becoming unavailable Responsible Staff Epic Support Team Responsibilities Notify Clinical Managers, Supervisors and other designated staff that a downtime event has occurred and that all departments/sites must be instructed to implement downtime procedures. Receptionists Prepare Billing Tickets with codes. Write Pt Name, Date of Birth, Today s Date, Provider s Name and MRN# (if available) Complete the Pink Appointment Scheduling Form and attach the billing ticket. Place Billing Ticket and Pink Appointment Scheduling form in Yellow Downtime Bin in clinical area. Nursing Supervisors Retrieve and distribute prescription pads and Red Downtime Recovery Folder to each provider. Login to Epic SRO-5D (if available). If Epic SRO-5D is available - Instruct Nursing/MA staff to print a copy of the View Schedules for each Provider in your Dept and distribute to Providers and staff. If Epic SRO-5D is not available - pick up a copy of the Clinical Summary Schedules from Reception (weekdays only). Instruct Nursing/MAs to hand write patient labels (#) with o Patient Name o Date of Birth o Provider s Name o Medical Record # (if available) o Today s date Nursing Log into Epic SRO-5D environment (if available) in each exam room and at nurses station. Print a copy of the schedule from Cadence View Schedule for each provider. Hand write changes and add on patient 105

107 appointments periodically throughout the downtime event. Retrieve Blue Downtime Packets located in each exam room and make available for provider. Hand writes extra labels (7) and attaches a label to the Visit Note Slip (or blank paper) and any other paper documents as indicated. Leave additional labels in room for use by provider. Pick up Billing Ticket and Pink Appointment Scheduling Forms from Yellow Downtime Bin Confirm Pt Name and DOB is clearly written on the ticket. Room the patient. Document the reason for visit, vitals and notes on the Visit Note Slip or blank paper. Give to provider (Visit Note Slip and Billing Ticket). Keep track of all Imm/Inj given on IMM Form. Document all Nurse Only Visits on blank paper, complete billing ticket and staple together. Place all Nursing documentation in the Red Downtime Recovery Folder Floor Nurse. Providers Log into Epic SRO-5D environment (if available). A copy of the schedule will be printed from Cadence (by Nursing) and updated throughout the downtime event. Place a patient label on all paper documents, including yellow copy of each RX. Document complete visit on Visit Note Slip (or blank paper). Prescriptions should be written on carbon copy pads. Original given to patient with instructions to bring to the pharmacy. Yellow carbon copy of scripts should be placed in the Red Downtime Recovery Folder. When system becomes available, Nursing will enter as historical RX in Epic. Provider will contact nursing if an RX needs to be called into pharmacy immediately. (Give nursing yellow copy of RX and pharmacy information). Complete billing ticket. Place all charting documents and Billing tickets in Red Downtime Recovery Folder (staple together by patient). LAB and RAD Orders should be ordered on relevant Reqs and sent with the patient. Immunizations should be noted on the IMM Form and entered on the Billing Ticket. Referrals will be entered on the Referral Form o If patient is sent immediately to the Hospital (with referral in hand), create a 2 nd referral and send to PSO. 106

108 Document Phone Encounters on Message Slips. Paper phone messages directed to the provider should be answered and given to the nurse if an immediate response is required. Otherwise, write your response on the message slip and place in the Red Downtime Recovery Folder. Use the Red Downtime Recovery Folder to hold all downtime paper documents such as Progress Notes, Billing Tickets and Clinical Documents (EX: Copies of Scripts, Phone Messages etc.). Keep the completed billing tickets and progress notes in the Red Downtime Recovery Folder until the end of the downtime event. At that time, you must decide if you will enter Progress Note and Billing information directly into Epic OR you want the Recovery Team to scan your Progress Note and enter your charges. NOTE: Discard the Progress Note and/or Billing Ticket for encounters entered directly into Epic by the provider. Upon your final review of the Red Downtime Recovery Folder, place in the Medical Records Bin for entry by Recovery Team. Triage Log into SRO-Epic 5D environment (if available). Telephone Encounters will be documented on Memo Message Slips and sent to appropriate staff. Authorized Prescriptions and Refill requests will be phoned into the Pharmacy. All Rx information called into Pharmacy should be documented, placed in Red Downtime Recovery Folder-Triage Nurse and entered as historical meds when the system becomes available. Same day appointment requests will be directed to Triage. If an appointment is deemed necessary, patient will be transferred to the department secretaries for scheduling. EpicCare Recovery from Downtime Procedures Responsible Staff Epic Support Team Responsibilities Notify Captains, Supervisors and other designated staff of the All Clear and that all departments/sites should resume normal operations and the recovery process initiated. 107

109 All Staff Continue to use the paper process until an All Clear is received. Do not try to access EPIC until an All Clear message is received. Upon receiving All Clear, log out of 5D environment immediately. Radiology Enter all Radiology orders in Epic Once all the information has been entered, discard all paper in the black confidential trash Laboratory Enter all Lab orders into LabDaq (orders will be created on the fly into Epic when resulted). Once all the information has been entered, discard all paper in the black confidential trash Nursing Supervisors Pick up carbon copy prescription pads from providers Collect Red Downtime Recovery Folders from each provider once it has been placed in the Medical Records bin (this indicates it has been final reviewed by the provider). Remove Clinical Documents from Red Downtime Recovery Folders for data entry by nursing staff (ex: copies of RXs, phone messages etc.). Send Red Downtime Recovery Folders to Medical Records. (Note: The folder may contain Progress Notes and Billing Tickets which Medical Records will process.) Enter Result Notes to document action taken on all lab results received on paper during the downtime event. (these results will be available in each providers In-Basket following the all clear ). Note: Stat and critical lab result notes should be considered high priority and entered immediately. Return Red Downtime Recovery Folders to storage location upon receipt from Medical Records. Nursing Log out of 5D environment in exam rooms and nurses station. Check provider offices to be sure they are logged out of 5D as well. Enter Nurse Only Visit from the schedule per routine procedure, if the downtime event is limited to one calendar day. Should the downtime event extend beyond one calendar day, 108

110 enter all immunizations and injections as historical and send Progress Notes and Billing Tickets to Medical Records for recovery. Enter all immunizations and injections as historical. Restock Blue Downtime Packets in each Exam Room and return to designated bin. (As soon as time allows) Triage Meds prescribed during visit will be entered as historical with a comment of prescribed during downtime. Enter all phone calls/refills (from message form) in Epic o If message is finished, close encounter o If message is not finished, enter and route to appropriate pool or provider Once all the information has been entered, discard all paper in the black confidential trash. Billing Key in all charges PSO Enter Referrals Medical Records Reconcile Billing Tickets/scanned Progress Notes to scheduled appointments; open encounters from the schedule; enter.scan in the Progress Note section; enter the diagnosis as indicated on the Billing Ticket and close encounter. Note: You will receive a Warning No LOS when trying to close, click Close Encounter. Notify the Epic Support Team of missing Billing Tickets or Progress Notes. Return Red Downtime Recovery Folders to the Nursing Supervisor in each Department. 109

111 RESPONSIBILITIES SSMC All Hazards EOP SSHS Downtime Policy & Procedure 10 Information Systems Disruption (Plan in SSMC Intranet) Downtime procedures and back up paper documentation forms are available for documentation in order to provide continuity of operations and documentation of patient care in a disruption. Plan includes specific responsibilities and procedures for staff and providers Upon identification of any Information technology issues or disruption, the SEV1 will be activated by the designated IT personnel Planned Downtime Planned EPIC downtime is typically scheduled when the least amount of access by providers and staff is needed. SSMC staff and providers will be notified in advance of any EPIC downtime that is scheduled. Date, start and finish times will be included in the notification 10.2 Unplanned Downtime The EPIC team responds to unplanned downtime and areas/departments will go to paper documentation after 15 minutes The Recovery group is activated post downtime and patient records are scanned into the medical record. Purpose To notify appropriate staff of events causing an interruption in the operations of South Shore Medical Center. 3.1 SSMC Local SEV 1 Notification Procedure Events that may initiate a Local SEV1 SSMC computer system down Epic log in or slowness issues Phone system interruption at any site Laboratory computer system or major instrument down Radiology computer system or major equipment down Power outage at any site Evacuation event at any site Kronos downtime Catastrophic weather conditions SSMC staffing groups to be included in the Local SEV1 notification. These members are responsible for further notification of staff as necessary. If your area is not affected ignore message. SSMC Captains SSMC Directors SSMC Managers and Supervisors 110

112 SSMC IT SSMC Facilities Person responsible for calling the Local SEV1 and scripting the message The director or manager of the site or department where event first occurred or their designee. The director or manager calls the help desk at Person responsible for sending the Local SEV1 ONLY Information Technology, IT, can send out the Local SEV1 Method of notification Notification messages will be sent 24 x 7 x 365 to a list of and cell phone pager addresses determined by Operations and IT. All clear message The person / persons initiating the Local SEV1 are/is responsible for calling the all clear when the situation has been resolved 111

113 Procedure: NURSING 1. Retrieve Downtime Tool Kit. 112 SSHS Downtime Policy & Procedure AMBULATORY CARE CENTER 55 FOGG ROAD (EpicCare Ambulatory Infusion) 2. New orders for laboratory, radiology, or ancillary department A. In the event of a downtime, paper requisitions will be utilized for all orders. B. Nursing departments will utilize the Order Entry Requisition for Downtime to communicate new orders to the other departments. The patient identification will be placed on the form using one of the following; patient ID label, or handwritten information that provides first and last name, visit number, date of birth. the BCA computer/printer in Level 3 and one downtime PC. Microsoft word template may be used. (see label section) C. Hyland label making may be used if Hyland is available. D. Stat orders will be followed up with verbal communication. 3. Results for laboratory A. Results will be communicated back to the unit via a paper form B. Paper forms with lab values will be kept with the paper chart. C. Verbal communication of critical results will continue per critical results policies. 4. Results for Radiology A. Results will be available via the PACS system. 5. New orders for Medications A. Nursing department will fax, or make copies of new orders to deliver to the pharmacy. B. Document on the order sheet to indicate that the copy has been sent to the pharmacy. This documentation should include date, time and initials of the individual sending. 6. Obtaining Medications for a new admission from the Omnicell A. The patient s name and downtime HAR must be entered into Omnicell when obtaining medications for a new admission. 7. Clinical Documentation A. Nursing will use the shadow server read only during a planned downtime to view hyperspace at the time of downtime. B. In unplanned downtime with internet access, the nurse may log into the BCWA to view downtime reports. C. In unplanned downtime with generator power only, the nurse may view downtime reports at the BCA at designated locations. D. Downtime documentation forms will include: a. Admission Assessment b. Shift Assessment c. Daily Care Form

114 d. Vital Sign / I & O Flowsheet e. MAR (Printed from the BCA for all levels of downtime) f. Blank MAR if new medications ordered during Downtime g. Nurses/ Integrated Progress Notes h. Order Sheet i. Discharge Documentation j. Medication Reconciliation form k. Medication Requisition form- If a medication is required form pharmacy that is not stored in Omnicell l. Miscellaneous forms/transfusion forms Recovery: Downtime Recovery: Downtime Recovery Phase 1: This is the period where ADT forms are accumulated and input into system. Patient orders and documentation can ONLY be entered on patients that have not had an ADT event during the downtime Downtime Recovery Phase 2: Catch up period where orders and documentation are entered on all patients that have had an ADT event during downtime. Order entry and documentation back load is dependent on patient's information being in the system first. Patient Access/ ADT, Lab and Pharmacy must do all of their recovery efforts prior to nursing entering data for their patients that have been admitted, discharged, or transferred during the downtime. Pharmacists must enter all of the medication orders prior to nursing entering the medication administration information. 1. If downtime is less than 1 hour, all information from assessments, graphic and MARs are entered into the system. Discharge forms can be scanned in. 2. If downtime is greater than 1 hour the following information is entered into the system by the clinician. A. Any updates to patient's height, weight, and allergies B. Any new lines, drains, airways, or wounds (LDAs) documented during downtime C. Medications that have been administered during downtime (MAR documentation) D. Education Assessment and/or teaching completed during the downtime E. Care Plan initialization and/or updates completed during the downtime 3. Laboratory results will cross the interface once the system has recovered, thus laboratory orders that have been resulted will not need to be entered into the system. The laboratory orders that have not been collected and/or resulted will need to be entered into Epic during recovery by Laboratory personnel. 113

115 4. Diagnostic Imaging orders that have been sent to diagnostic imaging on a paper requisition will be entered by diagnostic imaging staff during the recovery phase. 5. All other orders will be entered into Epic during recovery. 6. Respiratory Therapy staff will review, collaborate with nursing staff to ensure that all respiratory orders have been written and then entered into the computer system. The nurse will document on the paper order sheet that the orders have been entered electronically with date, time and initials. (Noting the orders) 7. All other paper documentation will be scanned into the medical record upon discharge. 8. All patients that have been admitted or transferred during the downtime must have a new patient identification band placed on them after Phase 1 recovery has been completed. The downtime armbands will have the MRN identification number. Medication scanning requires the CSN number with will be put into place once Patient Access has completed their process. 114

116 INTERFACED SYSTEM DOWNTIME INFORMATION EPIC AVAILABLE Laboratory System Downtime 1. Reference the Laboratory Section of the Policy Omnicell System Downtime 1. Medication orders to be entered into Epic per normal inpatient workflow with documentation of medication administration per facility medication administration policy. 2. Omnicell system post-downtime reconciliation/recovery. The outpatient nurses will link all medication administrations from Omnicell override pulls to the corresponding order on the patient's Epic MAR after the system interface is restored. These medications are identified by going to the MAR, to the "Override" tab. This tab will list medications that need to be linked to the med administered during the Omnicell downtime (Refer to Pharmacy's Omnicell downtime policy as necessary) 3. Document meds given on paper in Epic post downtime Bridges, Rhapsody, or Capsule DOWNTIME PROCEDURE LABORATORY ORDERS DURING RHAPSODY/INTERFACE SYSTEM DOWNTIME 1. Lab orders are placed in Epic per normal Epic workflow 2. When specimens are collected during Downtime, a paper Downtime lab requisition should accompany the specimens to lab. 3. Results will be provided to the units using downtime processes 4. POC glucose/i-stat results, etc. will not go thru the lab interface into Epic during the downtime. Enter/Edit results should be utilized for preliminary results. Currently stored in hand held documented on paper 5. When Rhapsody/Interface System comes back up, lab orders placed during Downtime go thru the interface and ascension labels will print these should be sent to lab. When Rhapsody/Interface System comes back up, POC test results will go thru the interface and show as final results in Epic. 6. When Rhapsody/Interface comes back up, all results will flow into Epic. DIAGNOSTIC IMAGING ORDERS DURING RHAPSODY/INTERFACE SYSTEM DOWNTIME 1. Diagnostic Imaging orders are placed in Epic per normal Epic workflow 2. Diagnostic Imaging technologists process orders from Epic, and manually enter the order information from Epic into the imaging device so that the results will route back to the order. 3. PowerScribe does not receive orders during this time, so the order information used in step 2, ie the accession number, is added to the Radiologist dictation during interpretation. Transcription needs remain in PowerScribe. Results will be seen in Epic, once interface activity returns. 4. Radiology discrepancy workflow is unchanged with Rhapsody/Interface System downtime. 5. When Rhapsody/Interface System comes back up, the results will file to Merge PACS 115

117 OMNICELL/MEDICATION ORDERS DURING RHAPSODY/INTERFACE SYSTEM DOWNTIME 1. All new patients who arrive during the Rhapsody/Interface System downtime will need to be manually entered into the Omnicell 2. All new medication orders entered during Downtime will be entered in Epic and need to be pulled using the override process 3. When Rhapsody/Interface System comes back up, all medication orders will flow into Omnicell. All medications pulled on override during the downtime will need to be reconciled including overrides for patients who may have been sent to the outpatient setting during Downtime. DIETARY ORDERS DURING RHAPSODY/INTERFACE SYSTEM DOWNTIME 1. Orders for diet trays should be placed in Epic, and called to Dietary 116

118 WOUND CARE CENTER 90 LIBBEY Responsible Staff Epic Support Team Responsibilities Notify Clinical Managers, Supervisors and other designated staff that a downtime event has occurred and that all departments/sites must be instructed to implement downtime procedures. Front Desk Prepare downtime documentation packets Photocopy individual provider schedules Write Pt Name, Date of Birth, Today s Date, Provider s Name and MRN# (if available) Hand write changes and add on patient appointments periodically throughout the downtime event. Give individual patient downtime packets to MA when patient is taken to exam room MA/Nursing Login to Epic BCA if possible Instruct Nursing/MAs to hand write any additional patient labels (#) with o Patient Name o Date of Birth o Provider s Name o Medical Record # (if available) o Today s date MA rooms the patient, takes vital signs and documents on downtime paper chart. Nursing Document the reason for visit, vital signs and notes on the Visit Note downtime paperwork. Document any procedures performed Document wound measurements Document dressings/supplies Take photograph if appropriate and save in camera to upload when system is up. Nurses complete documentation Any cultures / biopsies document in downtime documentation for entry when system restored. Send to SSH in the usual manner with handwritten label. Give documentation to provider Nurse Only Visits to be documented on separate downtime 117

119 documentation, complete superbill. Place all Nursing documentation in the Downtime Recovery Folder at nurses station to be entered when system is up. Providers Log into Epic BCA (if available). A copy of individual provider schedules will be printed the night before and updated throughout the downtime event by the front desk. Place a patient label on all paper documents Document complete visit on downtime documentation. Any prescriptions should be written and photocopied for scanning in later. When system becomes available, Nursing will enter as historical RX in Epic. Provider will contact nurse navigator if an RX needs to be called into pharmacy immediately. Complete superbill. Place all charting documents and superbills in Downtime Recovery Folder (staple together by patient). Any LAB and RAD Orders should be ordered on relevant Reqs and sent with the patient. Copy should be made to enter in system. Referrals will be entered on the Referral Form o If patient is sent immediately to the ED/Direct admit to SSH work with nurse navigator to facilitate Document Phone Encounters on Message Slips. Paper phone messages directed to the provider should be answered and given to the nurse if an immediate response is required. Otherwise, write your response on the message slip and place in the Downtime Recovery Folder. Use the Downtime Recovery Folder to hold all downtime paper documents such as Progress Notes, Superbills and Clinical Documents (EX: Copies of Scripts, Phone Messages etc.). Keep the completed superbills and progress notes in the Downtime Recovery Folder until the end of the downtime event. At that time, you must decide if you will enter Progress Note and Billing information directly into Epic, or you want the front desk to scan your Progress Note and for your charges to be entered. NOTE: Discard the Progress Note and/or Superbill for encounters entered directly into Epic by the provider. Upon your final review of the Downtime Recovery Folder, place in 118

120 the Medical Records Bin for entry by MA??. Nurse Navigator Log into BCA (if available). Telephone Encounters will be documented on Memo Message Slips and sent to appropriate staff. Authorized Prescriptions and Refill requests will be phoned into the Pharmacy where requested by provider. All Rx information called into Pharmacy should be documented, placed in Downtime Recovery Folder-Nurse Navigator and entered as historical meds when the system becomes available. Any VNA order confirmations will be documented on downtime entered into system at end of downtime event. Patient sent to ED / direct admit SSH with copy of provider documentation. Same day appointment requests will be directed to Triage. If an appointment is deemed necessary, Triage nurse will determine appointment time with provider and front desk will schedule. Epic Support Team Notify Supervisors and other designated staff of the All Clear and that all departments/sites should resume normal operations and the recovery process initiated. All Staff Continue to use the paper process until an All Clear is received. Do not try to access EPIC until an All Clear message is received. Upon receiving All Clear, log out of 5D environment immediately. Laboratory Enter all Lab orders into LabDaq (orders will be created on the fly into Epic when resulted). Once all the information has been entered, discard all paper in the shred it bins. Nursing Supervisor Collect Downtime Recovery Folders from each provider once they have completed their documentation. Each nurse should retrieve their patient documentation from the downtime recovery folder for data entry Enter Result Notes to document action taken on all lab results received on paper during the downtime event. (these results will 119

121 be available in each providers In-Basket following the all clear ). Note: Stat and critical lab result notes should be considered high priority and entered immediately. Nursing Enter Nurse Only Visit from the schedule per routine procedure, if the downtime event is limited to one calendar day. Should the downtime event extend beyond one calendar day, enter all nurse visits as historical and give Progress Notes and Superbill to front desk to scan in. Triage Meds prescribed during visit will be entered as historical with a comment of prescribed during downtime. Enter all phone calls/refills (from message form) in Epic o If message is finished, close encounter o If message is not finished, enter and route to appropriate pool or provider Once all the information has been entered, discard all paper in the shred it bin. HBO Tech Insurance Verification Billing Further planning needed Enter Referrals / authorizations where appropriate Reconcile Billing Tickets/scanned Progress Notes to scheduled appointments; open encounters from the schedule; enter.scan in the Progress Note section; enter the diagnosis as indicated on the Billing Ticket and close encounter. Note: You will receive a Warning No LOS when trying to close, click Close Encounter. Notify the Epic Support Team of missing Billing Tickets or Progress Notes. Return Downtime Recovery Folders to the Nursing Supervisor in each Department. 120

122 DIABETES CLINIC 121

123 2 POND PARK Operating Room / Pre-op/PACU/PSE Downtime Procedures for the OR at Pond Park would include: OR schedules with staffing are printed out one day in advance with multiple copies available for staff, Reception desk,pre-op desk, PACU desk, each OR room and Central Processing. Preference Cards are printed out the day before the scheduled day of surgery. We also have printed copies of preference cards for each surgeon, should we not be able to print for the following day. Central Processing could reference these cards to prepare for the following days cases. If the patient tracker is down we will refer to the printed schedules. If the Omnicell is down we will use the overide function. OR and Treatment room documentation during downtime will be completed on paper downtime forms and then entered into the medical record when downtime has finished. Specimens will be documented and sent to the lab on paper specimens forms as well as documented on the paper downtime OR record to be entered into the medical record after downtime is complete. This form is not bar coded for scanning since the record will be entered by the circulating nure and not scanned. The downtime computer is available as an additional information resource for next day cases that were scheduled prior to downtime. Downtime Procedures for the Pre-Op/PACU/PSE at Pond Park would include: OR Schedules are printed and placed in pre-op/pacu/pse one day in advance in all areas, copies are printed and available to all staff, including front desk, pre-op, PACU, PSE and med room. If the Omnicell is down, we will use the override function and nursing staff will chart using the paper pmar's (barcoded copies in the 'downtime folder') In the Pre-Op area, nurses would utilize the paper version of the 'nursing assessment/plan of care for surgical patients/pre-op checklist' and the 'medication reconciliation intake form' (barcoded copies in the 'downtime folder) 122

124 Anesthesia documentation for pre-op--will all be on paper (barcoded copies in downtime folder) PACU documentation will be done on the traditional 'blue PACU record' (barcoded copies in downtime folder) Glucometer and istat can still be used in both areas--neither of these will be 'docked' until we are off of downtime-results will automatically transfer into electronic record once docked PSE will use their current assessment on paper (copy in drawers in pretest area/downtime folder)-this assessment will then be transferred into EPIC by the nurses once off downtime Downtime computer is available if needed for any additional add-ons in any of these areas. Pain Management Responsibilities The Pain management will keep a binder in the office (extra sheets are in the file cabinet in the unit) with downtime barcoded documentation to be used in the event of planned/unplanned Epic downtime. 1. Pull Downtime Clinical Reference Binder and initiate downtime process based on whether the downtime is a level l, level ll, level lll downtime, or a downtime affecting an interfaced system. 2. Notify the Physicians/Nurse Practitioners and clinical staff of downtime, type of downtime and processes during downtime. 3. Copies of the master Daily Schedules should be printed prior to downtime. Downtime Procedures 1. Retrieve Downtime Binder 2. All Patient care documentation will be done on downtime paper forms. 3. All documentation will have a patient label placed on each page. 4. Patient Access/ Practice Coordinator will maintain a log of all patients arriving in the department. 5. When the patient arrives during Downtime, and is not in the Omnicell, the patients information from the label will be put into Omnicell, and staff will use a PMAR to document delivery of medication. Available forms for Procedure RN procedure assessment paper copy of the screening, procedure, post procedure, follow up telephone call, medication list with allergies and discharge instructions. 123

125 If Shadow Read Only (SRO) server is available, dictations of previous radiology exams, past dictations are accessible. They can be accessed on the Downtime Computers PPAMBW03 (Patient Coordinator Computer at nurses station). Recovery Downtime Recovery Phase 1. When less than 8 hours: All paper documentation will be entered into the electronic record by the nurse. If greater than 8 hours (end of the shift) paper documentation will be scanned into Hyland scanning. If Hyland scanning is also down, then scanning will be done the following work day. Paper Documentation will be stored in a safe secure place. 2. Omnicell Systems Medication orders to be entered into Epic per normal Pain workflow with documentation of medication administration per facility medication administration. Medications pulled on override should correspond with the order on the patients Epic MAR after the systems interfaced is restored. The nurse should link all medications pulled on override to the corresponding order on the patients Epic MAR. (Refer to Pharmacy s Omnicell downtime policy as necessary). 3. PACS Radiology orders to be entered into the Epic system per normal work flow. Radiology personnel will receive orders from Radiant per normal workflow (See Radiology PACS System Downtime Policy). PACS interfaced system post-downtime reconciliation to be completed by Radiology per policy. 124

126 2 POND PARK - SPECIALTY CLINICS In the event the Epic System experiences downtime (inability to use the system) the Epic Support Team will declare a downtime event and will notify Specialty Clinic staff as outlined in the Downtime Communication Plan. This will take effect immediately upon the system becoming unavailable Responsible Staff Epic Support Team Responsibilities Notify Practice Manager, Office Manager and other designated staff that a downtime event has occurred and that all departments/sites must be instructed to implement downtime procedures. Front Desk Prepare downtime documentation packets Photocopy individual provider schedules Write Pt Name, Date of Birth, Today s Date, Provider s Name and MRN# (if available) Hand write changes and add on patient appointments periodically throughout the downtime event. Give individual patient downtime packets to MA when patient is taken to exam room MA s Login to Epic BCA if possible Instruct MAs to hand write any additional patient labels (#) with o Patient Name o Date of Birth o Provider s Name o Medical Record # (if available) o Today s date MA rooms the patient, takes vital signs and documents on downtime paper chart. MA s Document the reason for visit, vital signs and notes on the Visit Note downtime paperwork. Document any procedures performed MA s complete documentation Any cultures / biopsies document in downtime documentation for entry when system restored. Send to SSH in the usual manner with handwritten label. Give documentation to provider Place all MA documentation in the Downtime Recovery Folder at nurse s station to be entered when system is up. 125

127 Providers Log into Epic BCA (if available). A copy of individual provider schedules will be printed the night before and updated throughout the downtime event by the front desk. Place a patient label on all paper documents Document complete visit on downtime documentation. Any prescriptions should be written and photocopied for scanning in later. When system becomes available, MA s will scan historical RX in Epic. Provider will contact MA s if an RX needs to be called into pharmacy immediately. Complete superbill. Place all charting documents and superbills in Downtime Recovery Folder (staple together by patient). Any LAB and RAD Orders should be ordered on relevant Reqs and sent with the patient. Copy should be made to enter in system. Referrals will be entered on the Referral Form Document Phone Encounters on Message Slips. Paper phone messages directed to the provider should be answered and given to the MA s if an immediate response is required. Otherwise, write your response on the message slip and place in the Downtime Recovery Folder. Use the Downtime Recovery Folder to hold all downtime paper documents such as Progress Notes, Superbills and Clinical Documents (EX: Copies of Scripts, Phone Messages etc.). Keep the completed superbills and progress notes in the Downtime Recovery Folder until the end of the downtime event. At that time, you must decide if you will enter Progress Note and Billing information directly into Epic, or if you want the MA s to scan your Progress Note and for your charges to be entered by Provider. NOTE: Discard the Progress Note and/or Superbill for encounters entered directly into Epic by the provider. Epic Support Team Upon your final review of the Downtime Recovery Folder, place in the Medical Records Bin for entry by MA. Notify Practice Manager, Office Manager and other designated staff of the All Clear and that all departments/sites should Resume normal operations and the recovery process initiated. All Staff Continue to use the paper process until an All Clear is received. Do not try to access EPIC until an All Clear message is received. 126

128 Upon receiving All Clear, log out of 5D environment immediately. Laboratory Enter all Lab orders into LabDaq (orders will be created on the fly into Epic when resulted). Once all the information has been entered, discard all paper in the shred it bins. Managers Collect Downtime Recovery Folders from each provider once they have completed their documentation. Each MA should retrieve their patient documentation from the downtime recovery folder for data entry Enter Result Notes to document action taken on all lab results received on paper during the downtime event. (these results will be available in each providers In-Basket following the all clear ). Note: Stat and critical lab result notes should be considered high priority and entered immediately. Provider/MA s Meds prescribed during visit will be entered as historical with a comment of prescribed during downtime. Enter all phone calls/refills (from message form) in Epic o If message is finished, close encounter o If message is not finished, enter and route to appropriate pool or provider Once all the information has been entered, discard all paper in the shred it bin. Insurance Verification Practice Manager Needs review Enter Referrals / authorizations where appropriate Reconcile Billing Tickets/scanned Progress Notes to scheduled appointments; open encounters from the schedule; enter.scan in the Progress Note section; enter the diagnosis as indicated on the Billing Ticket and close encounter. Note: You will receive a Warning No LOS when trying to close, click Close Encounter. Notify the Epic Support Team of missing Billing Tickets or Progress Notes. Return Downtime Recovery Folders to the Practice Manager 127

129 CANCER CENTER CANCER CENTER/Multi Specialty Clinic and Breast Care Center In the event the Epic System experiences downtime (inability to use the system) the Epic Support Team will declare a downtime event and will notify Cancer Center staff as outlined in the Downtime Communication Plan. This will take effect immediately upon the system becoming unavailable. Of note: These clinics use Partners Epics for all clinical documentation. SSHS Epic is currently being used for scheduling registration and billing data. Below reflect the processes that would be necessary to followed during SSHS downtime. Should a Partners Epic downtime occur the downtime procedures for Partners Epic would be followed. EpicCare Downtime Procedures for Staff Epic support Staff Notify Clinical Managers, Supervisors and other designated staff that a downtime event has occurred and that all departments/sites must be instructed to implement downtime procedures. Clinical Operations Manager will communicate downtime to all staff and help support and facilitate responsibilities as listed below Front End Staff/Medical Assistant Several schedules are printed the day before-photocopy and distribute to all providers and staff. Face sheets for patients are also printed prospectively. In the event of SSHS downtime the schedules would be available in Partners Epic via an interface. Of note no new patients could be added during SSHS downtime and procedure below would need to be followed. If possible, log into SSHS EPIC BCA (Presently the BCA Computer is located on the first floor in radiology) Add on patient or any changes in the schedule should be written on the front ends paper copy of the schedule and communicated out to RNs and providers during the downtime period. A downtime registration/facesheet is available for new patients or adds on if needed. Obtain front end downtime folder and prepare patient downtime packet. If labels are available downtime paperwork should be labeled. If unavailable, the following information should be hand written on all paperwork or use blank labels located in the downtime toolbox. Patient Name Date of Birth 128

130 Provider s Name Medical Record # (if available) Today s date Medical Assistant/RNs/Providers: SSHS Downtime Policy & Procedure If only SSHS Epic is experiencing downtime the remaining clinical documentation and billing would be performed in Partners Epic. Should Partners Epic be down as well. Please refer to those downtime procedures and forms. Check out Downtime follow up appointment log will be used to track patient appointments that need to be made in SSHS. EpicCare Downtime Recovery Procedures for Staff Epic support Staff Notify Clinical Managers, Supervisors and other designated staff of the All Clear and that all departments/sites should resume normal operations and the recovery process initiated. All downtime documents should be collected in Red downtime recovery folders. All Staff- Once All Clear confirmed. The BCS downtime computer should be logged out of and any 5D environments should be logged out of. Any downtime documentation such as new patient information, arrival/no show status, and referral information should be entered manually into Epic. Any billing reconciliation should be done via Partners Epic and documented into SSHS Epic. 129

131 HOME AND COMMUNITY CARE OPERATIONS 130

132 HOME CARE Defined Downtime Levels: Level 3 Downtime: Production server is down. All patient information is available in read only format on the Shadow Server Users may access this information utilizing their normal windows sign in on any computer in the department. Remote users will be unable to synchronize during this time. BCA Web Data Entry will not be available to Home Care to enter admissions, discharges or transfer activities. Level 2 Downtime: Both production and shadow servers are down, and internet service/power is available. Reports may be printed from the BCA computer at the IS Analyst s desk. Remote users will be unable to synchronize BCA Web Data Entry will not be available to Home Care to enter admissions, discharges or transfer activities Level 1 Downtime: Only power is available Reports may be printed from the BCA computer at the IS Analyst s desk Remote users will be unable to synchronize BCA Reports Available: Detailed census Abbreviated census Staff Schedule Schedule by Patient Clinical Summary by Patient Procedure: 1. In the event of interruption to a core system, including hardware, software, electrical or other problem that prevents many or all users from being able to access the Home Care Information system, staff will notify the Help Desk at X8827 and notify their supervisor/manager of the issue. 2. The SSHS IS Department will utilize pager/ SNAP messaging/ s to notify of an existing issue. 3. The Home Care Administrator on Call will be notified of the type, severity, and other details of downtime. The HCD Administrator on Call with be included in IS HICS huddles. 4. The call of a CODE TECHNOLOGY can only be activated by the IS Department at SSH. 5. The Administrator on Call or designee will assess the impact the downtime will have for the end user in collaboration with the IS Department. 6. Downtime procedures will be initiated as appropriate. 131

133 Intake/Patient Registration: A. Registering a patient during downtime: 1) The intake department will hand write the patient information on the paper intake form kept in the Intake department. 2) The intake personnel will enter onto the downtime log the name and referral source of each patient referred. 3) In a Level 2 or Level 1 downtime, the intake personnel will use the printed Patient Summary form BCA computer to confirm whether or not the patient is currently on service. 4) Photocopies of the paper intake form and all faxed referral information will be made and distributed to the appropriate departments. One copy will be kept in the Intake department and attached to the downtime log. 5) Patients will be assigned a number on the downtime log until the patient registration can be data entered and a medical record number created for the patient. This number will be written on the referral information attached to the log. B. Entering patient into system after downtime: 1) Patient registration will be created/updated prior to any documentation for patient referrals received during downtime. 2) Conduct a thorough search on every patient to avoid duplicate medical record numbers. Enter the correct spelling of the patient s last name and first name. Verify Date of birth. 3) Enter the correct date that the referral information was received. 4) Enter new or confirm previous demographics. 5) Verify against the downtime log that all registrations have been entered into the electronic 6) Print the Interactive Face Sheet and distribute copies to appropriate departments, including Medical Records. The Interactive FaceSheet will have the Medical record numbers. 7) Scan the original referral information into the patient record. ( For H&HR patients, the original referral information should be given to Medical Records for filing in the patient s medical record.) Visiting Clinician: A. Visiting Patients during Downtime: 1) Clinicians may continue documenting on laptops during downtime for all patients on their census as long as they are able to charge their laptops. They will be unable to access data on any new patients. 2) Patient information on Hyperspace will be unavailable to clinicians during downtime. 3) During all levels of downtime, clinicians will be unable to synchronize records from the Remote client. Any documentation on the field devices will not be available for view in Hyperspace until the clinician performs a synchronization. 4) When a clinician does not have the patient chart on their field device, downtime paper documentation will be completed. A clinical summary is available from the BCA Computer for patients unknown to the clinician. 5) Clinicians may obtain paper documentation forms from Medical Records. See Appendix J for which forms to complete. 132

134 6) All paper documentation should be brought to the office each day from the previous day, as able. 7) Clinicians will complete a paper daysheet documenting all the patient visits made. 8) Clinicians should telephone their manager/designee at the end of each day to give report on patients seen that day. Dependent on the emergency, it may be necessary for staff to come to the office daily for briefings/updates. This will be decided by the Home Care Incident Commander B. Completing paperwork once downtime is restored: 1) Clinicians will be notified once the system is restored to synchronize all patient information on their field device. 2) Daysheets will be compared to all the documents both electronically entered and hand written to ensure all notes and visits are accurately recorded. Daysheets will be verified by Data Processing to ensure that visit information is available in the appropriate electronic record. 3) All physician orders, medications, and OASIS assessments will be entered in the electronic record to create orders and allow for electronic transmission of OASIS. The clinician will be expected to complete the care plan in the patient record for any new or changed interventions 4) The paper documents will be scanned into the electronic record for Hospice and VNA. H&HR documents will be filed in the paper medical record. Tele-monitoring: 1) Patient vital signs can be accessed through Phillips web site if internet service is up. 2) If just SSHS internet is down, the telemonitoring coordinator will work from home to access data. 3) All data will be stored in Phillips until Epic is back up. Data will then flow over to Epic. Medical Records: 1) Medical Records will print a Downtime Census for H&HR at end of business day M-F. in the event of an unplanned downtime. (The electronic report is available in Allscripts: Query/Medical Records/Downtime Census). During a downtime, the most recently printed census will be utilized in conjunction with the patient log created in Intake to maintain a current census. Hospice and VNA will print a census from the BCA computer. 2) Posting of incoming signed verbal orders will be completed when the electronic record becomes available. 3) Upon conclusion of downtime, documents will be scanned to the electronic record. 4) The Medical Records Department will maintain the paper medical record according to established department filing, retrieval and storage procedures. Data Processing: 1) All data entry tasks will be placed on hold until computerized systems have returned to normal. 2) During downtime, documents to be data entered (OASIS, MD orders, medications and daysheets) will be sorted according to date and type of documentation in preparation for resumption of department activities. 133

135 3) Documentation will be prioritized based on type of documentation, length of downtime, month end closing and specific requests by leadership. Scheduling: 1) Staff and patient schedules can be printed from BCA computer for VNA and Hospice. H&HR schedulers maintain paper copies of schedules for planned downtimes. 2) Schedules during downtime will be maintained on paper for each team. 3) The schedulers will communicate with the clinicians about changes/updates to schedule 4) When the system is available and clinicians have synchronized, the schedulers will compare patient schedule in the electronic record to printed schedule and update the system accordingly. 5) HHR and Contract home health aides will be instructed to follow their printed weekly schedules. Any changes to the schedule should be called in to the schedulers. Accounts Receivable: A. Anticipated Downtime: 1) AR staff will complete insurance verifications, prompted by copies of handwritten referrals provided by Central Intake. AR staff will call patients per normal insurance verification process and make comments on the referral to input upon resumption of system. 2) AR staff will print out the AR report and biller queue for their respective payers to allow them to follow up with payers via telephone. Handwritten notes will be transcribed to the Payer comments section once the system is operational. 134 B. Unscheduled Downtime: 1) AR staff will complete insurance verifications prompted by copies of handwritten referrals provided by Central Intake. AR staff will call patients per normal insurance verification process and make comments on the referral to input upon resumption of system. 2) Staff will assist in filing patient folders and other billing documents. Insurance Authorization: 1. Print a weekly report from Epic documenting authorizations scheduled to expire. 2. During downtime, staff will utilize this Report to assess which patients require immediate authorization updates. 3. The paper Universal Authorization form will be utilized. The first page will be completed using paper files; the second page will be completed by the liaison after speaking with the primary nurse. 4. If there are no phones or fax machines working, calls will be made utilizing a cell phone to obtain verbal authorization or approval for delayed faxing. 5. The Insurance Authorization Supervisor has a folder of contact information for each insurance company which she could access if necessary 6. Patient folders are maintained with hard copies of all authorizations which could be accessed as needed. HHR Fiscal: Anticipated Down Time:

136 1) Print out monthly statements and reports for the HHR department. 2) Print Patient Schedules to identify expected visits/charges. 3) Print Unverified Services report. 4) Compare calendars against Unverified Services report so that phone calls may be made to providers with incomplete paperwork. Unanticipated Down Time: 1) General monthly functions: a. Code daysheets for payroll purposes b. Record on a daily basis client/provider hours and discipline for billing purposes, if needed. c. Record payments received (as forwarded by A/R Department or if specified as credit card payment) on manual ledger d. Classify cash by payer source e. Manually adjust detailed A/R summary to reflect payment 2) Month end processing: a. Verify via phone calls to providers and/or client if needed, that all billing information has been received. b. Generate manual invoices from verification obtained via day sheets recorded throughout month or relayed verbally at month s end. c. Hand write addresses via information provided on Service Agreements d. Mail invoices e. Complete manual billing of insurance claims 3) Financial statement production: a. Record total of each invoice b. Classify by payer source c. Classify by discipline d. Manually update A/R Summary e. Manually update A/R Detail f. Manually update General Ledger g. Manually update Cash Receipts Report via collection process recorded throughout month. 4) All information will be recorded into the computer when access is restored 135

137 Addendum 1: Epic Interface Model 136

138 Addendum 2 Future State IS System Application Quick Guide to Downtime 137

139 System Service Provided Connected Systems Services Lost if System is Compromised Epic Emergency Department All Core All health system wide downtime Ancillary (Lab, Radiology, Cardiology) Health System wide system Inpatient (Orders, Clinical documentation, BPAM, Pharmacy) Revenue Cycle: Billing, Patient Access, Scheduling Home Care Ambulatory 3M Abstracting/coding Epic Cannot code accounts Amicas/iConnect PACS (Picture Archiving and Communication System) Radiology images Amtelco Telecom: web paging, oncall schedules, directory Epic, Powerscribe, Viewpoint Epic Radiologists unable to review images. Radiology images unable to be launched via EMR Web paging, on call schedules, or hospital directory unavailable Angel Eyes Neonatal camera system Patient contacts cannot view babies API Time and attendance Staffing and scheduling Epic Unable to see timecards, quick badge, approve timecards. Unable to enter requests or see staff schedule. Aqure Lab Gas Analyzer CareFusion PFT (Viasys) Blood gas orders/results Epic Blood gas orders/results unavailable Pulmonary Function Testing Epic PFT recordings and reports unavailable CBORD Dietary system, Patient Menus via ipads, Cash Registers n Dining room and Café Data Innovations (DI) Connects lab instruments to Epic Epic Epic Cash registers and inventory in Dining Room and Cafes, Patient Menus via ipads unavailable Lab orders/resulted will not be transmitted Dragon Voice recognition software Epic Voice recognition for documentation unavailable 138

140 Experian Claims Epic Cannot transmit claims Can t take credit card payments File Shares/Amon GE Centricity Cardiology Access to H, S, and P drives Lotus Notes (requires N drives) Cardiac Cath lab images and charges Epic, Amicas Network drives and Lotus Notes (N drive) unavailable Cardiac Cath Lab images unavailable GE CPN Perinatal OB fetal monitoring strip Epic Fetal monitoring strips unavailable GE Connect GE DMS Cardiology Procedure Reports Epic Echo and cardiac catheterization procedures unavailable GE Muse EKG EKG tracings and reporting Epic EKG tracings, reports and Stress EKG tracings unavailable GE Viewpoint MFM ultrasounds and reports Epic, Amicas MFM reports will not be sent to Epic or Amicas Hologic Bone Density Bone density screenings and reports Epic, Powerscribe, Amicas Reports/images will not be sent Hyland Onbase Scanning Epic Scanning unavailable Image Vault Cardiac Echo images Epic, GE DMS Cardiac Echo images unavailable Imprivata Single Sign on = Fast Log In Cortext Unable to use badge tap, single sign on InterQual Utilization Review decision support tool for patient class determination Lotus Notes Administration LMS/Databases Meditech MM, Material Management Payroll Epic (embedded in CM Navigator) Epic, API Unable to access computers Unable to send cortext messages Unable to determine patient class Lotus Notes databases unavailable Financial applications unavailable 139

141 GL, AP, PP General Ledger SSHS Downtime Policy & Procedure M Modal Dictation System Epic Dictation system unavailable Morrisey MSOW Credentialing system Medical staff unable to access credentialing system Natus EEG EEG recordings and reports Epic EEG recordings and reports unavailable NDD Spirometry Respiratory program used mostly by SSMC for spirometry Epic Unable to take spirometry recordings Omnicell Medication Dispensing Epic Medication dispensing unavailable (can run on override) Outlook Calendar PenRad Mammography ordering, reporting, statistics Epic, Powerscribe Unable to access or calendars Mammography orders and reporting unavailable Powerscribe Dictation Radiology Epic, Amicas, Powerscribe Unable to send out Radiology reports QTEL Cardiac Rehab EKG/O2 recordings, exercise tracking for Cardiac Rehabilitation Epic Reports not available to be launched from Epic, cannot record/report QuadraMed Nursing acuity tool Epic Nurses are unable to classify ICU/NICU patients for acuity levels Quantros Incident tracking Unable to document incidents Rhapsody Interface infrastructure Communication between hospital systems (Epic/PACS, CBord, etc) and with remote partners (Harbor Medical, SSOrtho, SSPen, Atrius, Crown OB, etc.) unavailable rl Solutions Web based patient feedback software Patients are unable to enter feedback SnapComms SNAP messaging Snap messages unavailable Soft Bank/Soft Blood bank system Epic Blood bank tests and results 140

142 Lab Spacelabs/Full Disclosure unavailable Vital sign monitoring Epic Vital sign monitoring unavailable Stanley RFID RFID tracking of equipment location, temperature monitoring Cannot see locations of equipment, no alerting mechanism Surescripts E-prescribing Epic Unable to e-prescribe UniPOC Glucometers Epic Glucometers unavailable Zoll Rescue Net EMS EMR Pre hospital documentation EMS EMR Dispatching System Epic Pre hospital EMR information will not cross. EMS dispatch unavailable for tracking paper process Addendum 3: Recovery Work Flow 141

143 HIM Clinicians Willow Beaker BCA Administrator ADT (without Data Entry) ADT (with Data Entry) SSHS Downtime Policy & Procedure Downtime Recovery ADT Backfill with BCA Web Data Entry Process Exceptions Admissions reconciliation All other ADT reconciliation BCA Backload Flag Lab results reconciliation Reconcile medications by department (ED first) Back document recovery clinical documentation Scans downtime documentation Addendum 4: BCA reports 142

144 Census Inquiry Report ASAP Every 30 minutes Home Care (Hospice and VNA) Every 60 minutes ADT/Grand Central Every 30 minutes BCA MAR ASAP Every 30 minutes Cupid Every 60 minutes Inpatient Willow Microbiology Report Beaker Every 60 minutes Outstanding List Beaker Every 60 minutes Sendouts Beaker Every 60 minutes Department Appointment Report Cadence 0100 daily Cupid Every 720 minutes Home Care Every 720 minutes Radiant Every 120 minutes Status Board Cardiac Cath Cupid Every 60 minutes Schedule Orders report Cupid Every 120 minutes Radiant Every 30 minutes Clinical Summary Ambulatory Every 720 minutes Home Care Every 720 minutes Inpatient OB ASAP Every 30 minutes Staff Daily Report Home Care Every 720 minutes Diet Orders Report Inpatient 143

145 PT Patient Summary Inpatient OT Patient Summary Inpatient SLP Patient Summary Inpatient RT Patient Summary Inpatient OB Delivery Information Inpatient Case Detail Reports (Case and Log Information - Today, next 3 days) OpTime Every 160 minutes Master Daily Schedule (Scheduled cases today, next 2 weeks) OpTime Every 160 minutes Status Board OpTime Every 60 minutes Anesthesia Cardiology Physician Today s Cases SSH OR Periop PPK PSE PPK OP Periop SSH PSE Med Profile (Willow) Rx Cart Fill (Willow) ] 144

146 ADDENDUM 5: BCA Downtime Computers Across The Health System VNA 30 Reservoir Park Dr Rockland 30HCDW87 OPS PEDI REHAB OT 780 Main St 1 78REHW01 PSE PRESURG EVALUATION 780 Main St 1 79PSEW03 LTT LAB 85 Columbian St 1 85LABW30 LTT LAB 85 Columbian St 1 85LABW33 LTT LAB 85 Columbian St 1 85LABW34 LTT LAB 85 Columbian St 1 85LABW75 LTT LAB 85 Columbian St 1 85LABW78 LIB WOUND CENTER 90 Libbey St 90WCCW30 SSH DIABETES CENTER 55 Fogg Rd - Center 1 C1AMBW12 SSH CARDIAC NIC 55 Fogg Rd - Emerson 1 C1CARW03 SSH INFECTIOUS DISEASE 55 Fogg Rd - Emerson 1 C1PHYW05 SSH COUMADIN CLINIC 55 Fogg Rd - Center 3 C3EDUW02 SSH C4 SHORT STAY UNIT 55 Fogg Rd - Center 4 C4NSGW02 CC US IMAGING 101 Columbian St 1 CCRADW08 SSH PULMONARY LAB 55 Fogg Rd - Emerson 1 E1CVSW10 SSH EMERGENCY 55 Fogg Rd - Emerson 1 E1ED_W01 SSH HEALTH INFO MGMT 55 Fogg Rd - Emerson 2 E2MRCW19 SSH HEALTH INFO MGMT 55 Fogg Rd - Emerson 2 E2MRCW40 SSH INPATIENT NUTRITION 55 Fogg Rd - Emerson 2 E2NFSW04 SSH INPATIENT NUTRITION 55 Fogg Rd - Emerson 2 E2NFSW16 SSH EMERSON 3 55 Fogg Rd - Emerson 3 E3NSGW06 SSH EMERSON 4 55 Fogg Rd - Emerson 4 E4NSGW06 SSH EMERSON 5 55 Fogg Rd - Emerson 5 E5NSGW01 SSH EMERSON 6 55 Fogg Rd - Emerson 6 E6NSGW01 SSH EMERGENCY 55 Fogg Rd - Emilson 1 L1ED_W16 SSH MATERNAL SCU 55 Fogg Rd - Emilson 2 L2OBSW03 SSH SCN 55 Fogg Rd - Emilson 2 L2OBSW15 SSH EMERGENCY 55 Fogg Rd - Messina 1 M1ED_W11 SSH EMERGENCY 55 Fogg Rd - Messina 1 M1ED_W48 SSH EMERGENCY 55 Fogg Rd - Messina 1 M1ED_W56 SSH EMERGENCY 55 Fogg Rd - Messina 1 M1ED_W57 SSH EMERGENCY 55 Fogg Rd - Messina 1 M1ED_W69 SSH EMERGENCY 55 Fogg Rd - Messina 1 M1ED_W70 SSH EMERGENCY 55 Fogg Rd - Messina 1 M1ED_W71 SSH MIU SOUTH 55 Fogg Rd - Messina 2 M2OBSW04 SSH MIU NORTH 55 Fogg Rd - Messina 2 M2OBSW08 SSH ENDOSCOPY 55 Fogg Rd - Emilson 3 M3ENDW05 SSH PERIANESTHESIA 55 Fogg Rd - Emilson 3 M3OR_W31 145

147 SSH OPERATING ROOM 55 Fogg Rd - Messina 3 M3OR_W99 SSH CARDIAC CATH LAB 55 Fogg Rd - Pratt 1 P1CARW04 SSH IR IMAGING 55 Fogg Rd - Pratt 1 P1DI_W12 SSH XR IMAGING 55 Fogg Rd - Pratt 1 P1DI_W37 SSH EMERGENCY 55 Fogg Rd - Pratt 1 P1ED_W05 SSH TRANSPORT 55 Fogg Rd - Pratt 1 P1ENVW05 SSH ENVIRONMENTAL SVCS 55 Fogg Rd - Pratt 1 P1ENVW07 SSH NICU 55 Fogg Rd - Pratt 2 P2NCUW03 SSH BIRTHING UNIT 55 Fogg Rd - Pratt 2 P2OBSW08 SSH MFM 55 Fogg Rd - Pratt 2 P2OBSW75 SSH PRATT 3 SOUTH 55 Fogg Rd - Pratt 3 P3NSGW08 SSH PRATT 3 NORTH 55 Fogg Rd - Pratt 3 P3NSGW30 SSH PRATT 3 SOUTH 55 Fogg Rd - Pratt 3 P3NSGW34 SSH PRATT 4 NORTH 55 Fogg Rd - Pratt 4 P4NSGW08 SSH PRATT 4 SOUTH 55 Fogg Rd - Pratt 4 P4NSGW26 SSH PRATT 5 NORTH 55 Fogg Rd - Pratt 5 P5NSGW06 SSH PRATT 5 south 55 Fogg Rd - Pratt 5 P5NSGW12 SSH CARDIAC CARE UNIT 55 Fogg Rd - Pratt 6 P6CCUW14 SSH NEURO DIAGNOSTICS 55 Fogg Rd - Pratt 6 P6CVSW07 SSH NEURO DIAGNOSTICS 55 Fogg Rd - Pratt 6 P6CVSW08 SSH HEMODIALYSIS 55 Fogg Rd - Pratt 6 P6HEMW03 SSH MICU 55 Fogg Rd - Pratt 6 P6MCUW01 SSH SICU 55 Fogg Rd - Pratt 6 P6SCUW01 PPK PAIN CLINIC 2 Pond Park 2 PPAMBW03 PPK PAIN CLINIC 2 Pond Park 2 PPAMBW09 PPK PRESURG EVALUATION 2 Pond Park 2 PPCHTW01 PPK PODIATRY 2 Pond Park 3 PPCVSW01 PPK XR IMAGING 2 Pond Park 1 PPDI_W04 PPK PHARMACY 2 Pond Park 2 PPPHAW01 PPK REHAB PT 2 Pond Park 3 PPREHW02 COH XR IMAGING 223 Chief Justice Cushing Highway Cohasset RMDI_W16 KIN XR IMAGING 5 Tarkiln Rd - Kingston SSMCKIN1026BCA KIN ADMINISTRATION 5 Tarkiln Rd - Kingston SSMCKIN1050BCA LNG ADMINISTRATION 143 Longwater SSMCNOR1284BCA LNG XR IMAGING 143 Longwater SSMCNOR1315BCA LNG LAB 143 Longwater SSMCNOR1401BCA LNG ADMINISTRATION 143 Longwater SSMCNOR1751BCA LNG ADMINISTRATION 143 Longwater SSMCNOR2276BCA LNG ADMINISTRATION 143 Longwater SSMCNOR2467BCA WW OBSTETRICS 51 Performance Dr SSMCWEY2103BCA SSH REHAB PT 55 Fogg Rd - Brooks 1 W1REHW16 146

148 SSH RESPIRATORY CARE 55 Fogg Rd - Brooks 3 W3CVSW01 SSH PHARMACY 55 Fogg Rd - Brooks 3 W3PHAW59 SSH PHARMACY 55 Fogg Rd - Brooks 3 W3PHAW60 SSH AMBULATORY CARE 55 Fogg Rd - Brooks 4 W4AMBW11 SSH CARDIAC REHAB 55 Fogg Rd - Brooks 4 W4AMBW12 147

149 Addendum 6: Epic Tip Sheets Downtime Tools BCA PC and BCA Web 148

150 149 SSHS Downtime Policy & Procedure

151 150 SSHS Downtime Policy & Procedure

152 151 SSHS Downtime Policy & Procedure

153 152 SSHS Downtime Policy & Procedure

154 Addendum 7: Epic Tip Sheets Inpatient BCA Web Notes 153

155 154 SSHS Downtime Policy & Procedure

156 155 SSHS Downtime Policy & Procedure

157 156 SSHS Downtime Policy & Procedure

158 Addendum 8: EPIC Tip Sheet BCA Computers Outpatient Areas 157

159 158 SSHS Downtime Policy & Procedure

160 Addendum EPIC Tip Sheets BCA Downtime Tools ED Patient Access 159

161 160 SSHS Downtime Policy & Procedure

162 161 SSHS Downtime Policy & Procedure

163 162 SSHS Downtime Policy & Procedure

164 163 SSHS Downtime Policy & Procedure

165 Addendum EPIC Tip Sheets BCA Downtime Tools Patient Access 164

166 165 SSHS Downtime Policy & Procedure

167 166 SSHS Downtime Policy & Procedure

168 167 SSHS Downtime Policy & Procedure

169 168 SSHS Downtime Policy & Procedure