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Sandeep Napa

Graduated: June 14, 2019

Thesis/Dissertation Title:

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

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


Mark Whipple, Thomas Payne