4-2 Milestone Two: Downtime Procedures and Resources

Question: Downtime Procedures and Resources

In this milestone, you will identify the key stakeholders and their needs, develop downtime procedures for accessing and storing patient information, identify organizational tools and external resources to support these procedures, and explain how the procedures protect the privacy and security of patient information.

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3-1 Discussion: Downtime Interoperability


4-2 Milestone Two: Downtime Procedures and Resources

Internal Stakeholders And The Impact of The Crisis onThem

When ransomware attacks a healthcare organization and creates a crisis, several key stakeholders across the healthcare organization will be affected. As a result, multiple responsibilities arise that must be addressed to mitigate the impact on patient care and the organization’s overall operation. Some common stakeholders that the crisis will impact include the HIM director, physicians and nurses, IT staff, patients, the CEO, the chief information officer (CIO), and medical records staff.

The HIM Director is one of the common stakeholders in charge of safeguarding patient health information’s security and privacy and ensuring that all legal and regulatory standards are met. As a result, personal patient health information may be exposed without authorization, violating legal and regulatory standards. In a crisis, they may struggle to safeguard patient privacy and security. To reduce these risks, the HIM Director requires tools and resources, including incident response plans, regular risk assessments, backup and recovery systems, and more. These tools and resources will help the director monitor the crisis and lessen its effects on patient health information.

Physicians and nurses are other stakeholders responsible for treating and feeding patient data to electronic health records (EHRs). Their ability to obtain patient health information may be compromised in a crisis, affecting the care they deliver to patients. These health professionals require access to patient health information to guarantee appropriate care and make informed clinical decisions. IT staff is another stakeholder responsible for maintaining and managing the EHRs that transmit and store patient health information. When dealing with a crisis, they could delay maintaining and restoring electronic systems, resulting in more downtime and subpar patient care. To lessen these risks, they require cybersecurity vendors, the Health Cybersecurity and Communications Integration Center (HCCIC), incident response plans, backup and recovery systems, and personnel training and awareness to recognize and address the problem quickly.

Patients are also stakeholders impacted by the crisis in the healthcare organization. For them to make informed decisions about their care, they require access to their health information and high-quality care from the healthcare institution. They could have trouble accessing their medical records in a crisis, which affects the standard of care they get. They require access to their medical records and confirmation from the healthcare institution that the information is secure and safe from unauthorized persons. Besides, the CEO ensures the healthcare enterprise functions and operates effectively and is impacted by the crisis because patient care would be compromised, the healthcare system would be dysfunctional, and operational and financial stability becoming unstable. They require a quick-to-implement contingency plan and cybersecurity suppliers who can offer an incident response, network monitoring, and threat intelligence to reduce these risks.

The healthcare organization’s information technology infrastructure is controlled by the chief information officer (CIO), who is vulnerable to the crisis’ impacts. The CIO may have trouble coordinating the IT response to the attack in a crisis and re-establishing the IT infrastructure. Clear instructions on managing IT operations, security precautions like firewalls, access controls, intrusion detection systems to safeguard patient data, and backup systems to restore IT systems are all required to reduce these risks. Lastly, medical records staff who maintains the accuracy and completeness of patient health information would lack access to patient health information during the crisis, thus affecting the accuracy of the medical records. They need paper-based records, physical security measures for paper-based records, and adequate training on managing patient information to ensure the continuity of patient care.

Comparison of Stakeholders

Although each stakeholder in a healthcare organization has unique or specific roles and responsibilities, they all work toward the same objective of giving patients high-quality treatment and care. All parties involved must have access to patient health information to make informed decisions and deliver the proper care to patients. Nevertheless, each stakeholder has unique needs depending on their roles within the organization. For instance, the HIM director oversees maintaining the privacy and security of patient health information, while physicians and nurses need immediate access to patient information to offer prompt care. Moreover, the contingency plan is essential to address the needs of all stakeholders in a crisis. The contingency plan can assist stakeholders in reducing the crisis’ impact on patient care and resuming normal quickly by offering clear instructions, resources, and tools.

Alternative Solution for Essential Patient Information

A secure cloud-based electronic health record (EHR) system can be an effective alternative for giving staff members access to crucial patient information during a crisis. This solution will enable healthcare workers to view patient records or information from any place with internet access to maintain continuity of treatment even when staff members are not physically present in the clinic or hospital (Liao et al., 2019). With this alternative approach, staff members will have immediate access to patient information, such as test results, medical histories, and medication lists, which are crucial for delivering high-quality treatment.

The cloud based EHR system will meet HIPAA regulations, guaranteeing patient data security and privacy. Furthermore, adopting strong EHR system security measures such as frequent security audits, multi-factor authentication, and data encryption will provide a secure environment for storing and sending patient data. In order to prevent data breaches and ensure the proper management of patient information, staff employees will receive the necessary training on how to use EHR systems and data security processes (Xie et al., 2018). Healthcare organizations can maintain continuity of service and ensure that patient information is secure and confidential during a crisis by implementing this alternative solution.

Alternative Solution to Capture and Store Patient Information

An alternate solution to capture and store patient information is implementing a secure, web-based portal that allows patients to feed and update their medical information. The patient’s vital information, including medical background, present prescriptions, allergies, and emergency contacts, would be captured via the portal and safely stored in a central database accessible to authorized healthcare professionals to prevent cyberattacks (Boycki et al., 2019). It is worth noting that the web-based portal will allow staff to manage patient care effectively during the crisis by enabling them to access patients’ medical information remotely from any location with internet connectivity. As a result, staff will have access to the information required to deliver quality care even if they are not physically present in the hospital or clinic.

Additionally, the web-based portal will be built with robust security features, like password protection, data encryption, and safe data transmission to the centralized database, to protect patient information’s privacy and security and comply with HIPAA laws. The healthcare organization will inform patients about safeguarding their private health information. They will also receive detailed instructions on how to use the portal safely. The staff members will be trained on the proper use of the web-based portal and data security procedures to protect the privacy and security of patient health information. Lastly, the organization will conduct regular security audits of the database to find any flaws or potential dangers to patient information and fix them (Shickel et al., 2018). By putting these procedures in place, Shoreline Health System will ensure that patient data is securely obtained, saved, and accessed following HIPAA rules, even during the crisis.

Information Management Tools

Information management tools are crucial in healthcare organizations for ensuring the security and privacy of patient information. A password manager is one of the tools that healthcare organizations can use to securely manage and store user passwords and prevent unauthorized access to confidential patient information (Ghezzi & Masciadri, 2017). Another crucial tool for safeguarding patient health information is a firewall, which can be used to regulate access to a network and assist in preventing illegal entry. Besides, theft or loss of health information during a crisis can be avoided using data loss prevention software to restrict and monitor data transfer.

Another essential tool is encryption software, which can encode data and guarantee that only authorized users can access it. It prevents cyberattacks and access to private patient health information by malicious individuals. Also, multi-factor authentication is an information management tool that can prevent unauthorized access to sensitive data like health records by requiring users to present several forms of identification (Kuo & Rajan, 2017). Systems for data backup and recovery are crucial tools for safeguarding against data loss and ensuring that health data is accessible in times of emergency.

By establishing a secure connection between two sites on the internet, virtual private networks are information management tools that can protect sensitive health information during data transfer to avoid any information loss (Ghezzi & Masciadri, 2017). In addition, systems for controlling user identities and information access are crucial for ensuring that only authorized users can access private health information to make informed clinical decisions. Lastly, a network can be protected against data breaches and cyberattacks using intrusion detection and prevention systems, which can identify and prevent illegal access (Kuo & Rajan, 2017). In conclusion, information management tools are crucial to maintaining the confidentiality and security of patient data in healthcare organizations so that they store sensitive patient data and adhere to legal obligations.

External Resources

The healthcare organization will use several external resources to help with contingency plans and keep PHI private and secure during the crisis. In the event of natural disasters and fires in my location (Hooksett), the Hooksett Fire-Rescue Department will offer emergency medical assistance while maintaining the security and privacy of PHI. The EMS personnel will receive training on responding to emergencies while maintaining patient confidentiality and protecting patient information. Similarly, the Hookset Police Department will support emergency medical response, secure the emergency scene, and uphold order while guaranteeing the security and privacy of PHI.

Additionally, the healthcare organization will receive guidance on effectively communicating any updates on PHI’s privacy and security during the crisis from the Manchester-based Cookson Strategic Communications agency. This public relations specialist will offer instructions on keeping lines of communication with patients and staff regarding safety measures. During the crisis, The Grady Law Firm in Hooksett will offer legal assistance and advise the healthcare organization on PHI security and privacy laws. This legal firm will support the healthcare organization in adhering to all legal standards for safeguarding PHI and assist in reacting to any legal issues that may arise due to the crisis.

To ensure the security and privacy of PHI during the crisis, the New Hampshire Society for Technology in Education in Hooksett will provide IT vendors who will offer technical support for the equipment and systems employed. This approach will guarantee that the IT infrastructure of the healthcare organization is safe and complies with HIPAA regulations. 


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Ghezzi, P., & Masciadri, A. (2017). Information security and privacy in healthcare: managing healthcare information. IEEE Access, 5, 15567-15587. https://doi.org/10.1109/ACCESS.2017.2712021.

Kuo, Y. F., & Rajan, S. S. (2017). Information technology applications for healthcare: A review of the literature. Journal of Medical Systems, 41(8), 130. https://doi.org/10.1007/s10916-017-0772-0.

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