Today, most EMRs are cloud applications running on servers located in data centers or cloud vendors. Occasionally you will face situations when EMR is down for various reasons. Some of the causes are:

1. Connected Service has Outage:  EMRs are connected with multiple 3rd Party services for various features and functionalities such as prescription gateways,  fax services, claim clearinghouses, credit card merchants, labs, hospitals, quality alliances, HIEs, and other data exchange networks. Depending on the service any 3rd party is providing, their outage will cause problems for that functionality and dependant functionalities. Until the 3rd party service is back online, that service/function will remain down.

2. Software and Technical Issues: EMRs are built over multiple software systems like virtualization platform, operating system (OS), program runtime platform, database server, backup software, replication system, file service, 3rd party libraries, authentication system, etc. These are routinely patched and updated for security, bug fixes, performance fixes, new features, and active support. Any problem in these components can cause a problem with EMR. The most common issue in this category is browser updates - commonly resolved by additional updates from the browser or reversal of updates. Problems caused by these components are generally minor and get fixed when they surface.

3. Hardware Failures: Cloud infrastructure contains redundant infrastructure for applications and data. Any failure with the hardware may cause an outage for some services in EMR. The failover process may take zero downtime to a few hours, depending on the failed component.

5. Routine Maintenance: Scheduled maintenance outside business hours are performed to keep the service running at its peak performance. EMR may be slow or unresponsive during these scheduled maintenance periods.

6. Unexpected Resource Consumption: Every server and storage is allocated with more than sufficient computation, memory, storage, and network resources. Occasionally, an unforeseen spike in certain activities may consume more than allocated resources and cause temporary performance bottlenecks.

7. Power Outage: Power outage can happen in the data center. Datacenters have many redundancies built to handle power outages, such as battery backup, diesel generators, and dual circuits. Though this is rare, the EMR service will be entirely out if all power redundancies fail.

8. Network Outage: Datacenters have blended network connectivity using multiple internet service providers. So few service outages generally do not affect the network connectivity. Sometimes area-wide network outages occur with a network provider affecting service in those areas. Your Internet Service Provider (ISP) may cause outages due to local connectivity and configuration issues.

9. Cyber Threats: Cyber-attacks such as the Distributed Denial of Service (DDoS) cause perimeter security appliances and service endpoints to overload with spurious incoming traffic, preventing legitimate users from accessing the service. Despite adequate protection systems, attackers exploit hidden loopholes and cause a denial of service and downtime. Your EMR vendor will resolve it with alternate temporary access channels.

10. Malware: Malware like ransomware can affect the services entirely. No one in the IT world can guarantee 100% safety from cyberattacks. Most EMRs keep multiple backup copies that can be reverted when malware/ransomware attacks happen, and EMR vendors usually have recovery plans in place.

How to be prepared?

While it is possible to mitigate the issues leading to a cloud outage, unknown factors can cause an outage. This unpredictability must be compensated by acknowledging that a cloud outage will happen and applying corrective measures to reduce the impact. A recent example of a ransomware attack that crippled the University of Vermont Health took weeks and $50+ million to resolve https://healthitsecurity.com/news/uvm-health-continues-to-feel-effects-of-ransomware-attack.

As a user, have a well communicated written plan for such situations. With GlaceEMR, Glenwood generates an encrypted collection of files every morning for the patients scheduled for that day. This collection includes an Appointment List (DSR) for the day, a Facesheet, a Medical Summary of the patients with appointments, and the Patient’s outstanding balance. In case of a complete outage, you can use this data collection to assist you with the visits. Prescriptions, lab orders, and documentation can be done on paper and scanned into the system later. Appointment requests can be noted on a calendar and reconciled later in the system.

At Glenwood, we have not encountered extensive system outages with our clients in our long history. Nevertheless, you should have a written contingency plan accessible to all your staff to run your practice smoothly in such circumstances.