EMR and health IT policy and procedure writing…boy, there’s a sleeper of a task, right? Wrong, suggests Dr. R. Dirk Stanley, who’s Chief Medical Informatics Officer at Cooley Dickinson Hospital in Northampton, MA. In fact, he says, doing a good job with policies and procedures is critical to a successful EMR implementation.
He suggests that EMR policies and procedures address at least the following:
- Electronic Documentation – How/when to create it, sign/authenticate it, use it?
- Medication Order Standards– How/when to order certain medications? Non-formulary medications? In code blue/emergency situations? Over the phone?
- Standards for lab/radiology orders– How/when to order certain tests?
- Training standards – How do you train new employees? Existing employees?
- Clinical Tool Development – How do you develop order sets? Policies? Protocols? Documentation?
If you already have useful standards set for your pre-EMR days, it’s good to pull them together and use them as a jumping-off point. But they’ll probably have to be tightened up when your EMR goes live, he says.
If you’re not sure how to begin writing policies and procedures that work well for EMR/health IT management, consider Dr. Stanley’s “should do” list:
1. Practice writing policies and have end-users review them for clarity
2. Study your organization’s existing policies, bylaws, and learn who works on and approves them
3. Consult your lawyer(s) as needed, especially on risk and compliance questions
4. Learn what you can from HIT colleagues
5. Keep developing your governance skills through classes and reading
When you publish these policies, they probably belong in the clinical policy manual, not administrative, he says. “When in doubt, ask yourself: ‘Who is the end user of this policy?” Dr. Stanley recommends.
For more background on these issues, I recommend you review Dr. Stanley’s excellent article directly. It’s great to see some thoughtful coverage of a less-than-sexy but important issue like this one, isn’t it? After all, it takes more than good technology to succeed with your EMR.