Tech Advisory

When the EHR goes offline: Building a downtime drill for your clinical team

EHR downtime can disrupt essential clinical workflows, delay access to patient information, and complicate medication management. Without clear procedures and adequate preparation, these disruptions can put patient safety and continuity of care at risk. A written contingency plan is a starting point, but regular drills help staff practice the workflows they need to maintain care when the system goes offline.

Why drills expose what plans miss

When the EHR is unavailable, clinicians face specific, concrete problems: How do you confirm a patient’s identity without a pull-up? Where are the paper order forms? Who decides when to escalate a medication question that normally gets answered by checking the chart? These are procedural muscle-memory questions, and they are only answered reliably by practice rather than by reading a checklist.

The Academic Medical Center Patient Safety Organization’s downtime task force guidelines specifically recommend running drills as part of a complete downtime preparedness program, alongside staff training and a communication triage procedure. The US Department of Health and Human Services’ Administration for Strategic Preparedness and Response (ASPR) also provides a collection of EHR downtime resources to help healthcare organizations prepare for outages and maintain patient safety.

Patient identification: The highest-risk workflow

Analysis of patient safety events during EHR downtime consistently highlights patient identification and clinical information communication as the two areas of greatest risk. When the EHR system is unavailable, clinicians cannot verify patient identity through the standard electronic process, and the manual alternatives need to be established and practiced before they are needed.

The drill should walk through how staff confirm patient identity using two manual identifiers, where paper wristbands are stored and how they are applied, and what process is used to flag patients whose records may have been updated during the outage and need to be reconciled once the system returns. This is one of the areas where badge buddy cards, which are laminated reference sheets that attach to staff ID badges, have been shown in published implementation studies to improve nurse readiness.

Medication safety during downtime

Medication errors are among the most documented harms associated with EHR downtime. When the system is offline, pharmacy, nursing, and prescribing teams may lose access to current medication lists, allergy records, and order histories simultaneously. The drill should therefore test how each group handles this gap.

Specific scenarios to rehearse include:

Verifying an existing medication order without EHR access
Managing a new prescription when clinical decision support is unavailable
Communicating a critical allergy flag from nursing to pharmacy by paper
Handling a controlled substance order when the usual electronic verification cannot be completed

The Institute for Safe Medication Practices recommends assigning a dedicated downtime response team, with designated leaders on call to oversee medication safety during extended outages.

Documentation and order management

All orders, assessments, and clinical notes generated during downtime need to be documented on paper, tracked, and then entered into the EHR system during the recovery phase. The drill should confirm that paper forms are stocked, accessible, and understood by staff in each unit; that there is a defined process for numbering and collecting downtime documents; and that staff know which actions require immediate documentation versus which can be logged during recovery.

A standardized naming convention for patients seen during downtime is important for laboratory and radiology workflows, in particular, where specimens and images may need to be matched to a patient record that was created or updated while the EHR was unavailable.

Internal communications and escalation

When the EHR is offline, the communication infrastructure that coordinates care across departments also degrades. Automated alerts, results notifications, and order confirmations stop flowing. The drill should establish and test an alternative communication protocol: who notifies each clinical area when downtime begins, what the expected update frequency is, and what channel (telephone tree, whiteboard, radio) carries clinical communications during the event.

Escalation criteria should also be established in advance, since not every situation that triggers an EHR alert during normal operations warrants the same response during downtime. The drill should clarify which conditions require immediate escalation to a physician or charge nurse, regardless of system availability.

Recovery and reconciliation

Returning to full EHR functionality is not a passive event. Paper records created during downtime need to be scanned and entered, orders verified and reconciled, and any discrepancies between downtime documentation and the pre-downtime record resolved. The drill should cover who is responsible for each component of this reconciliation, how long it is expected to take, and what the priority order is for entering data generated during the outage.

A safe return to normal operations depends on how well these steps are coordinated. Research examining a major EHR downtime event in Australia highlighted the importance of effective communication during the transition back to electronic records. This recovery phase, sometimes called the uptime procedure, requires as much planning and coordination as the downtime response itself.

Our team helps healthcare practices and facilities develop and update EHR downtime procedures and clinical IT continuity plans, including practical drill programs tailored to their needs. Get in touch to discuss how we can help your organization prepare for EHR outages.