Policy & Procedure on Clinical Applications

[lorazepam]

Do any of you have policies & procedures on the intended use of your clinical applications? I heard about a surveyor asking a facility on their p&p on an application. The facility shared with them the p&p regarding security of usernames/passwords but the surveyors were asking about the intended use of the application, level of access, competencies, etc.

Honestly, I'm surprised that in the past facilities I've worked in, I have not seen a policy regarding any clinical application. I've seen policies on documentation (for paper, ex: SOAP charting, PIE charting) but nothing that clearly states, "Here at ABC Hospital, documentation is done on XYZ EHR. In the event XYZ EHR is down, please refer to downtime procedures."

Maybe it's just me and I haven't been exposed to much, but can anyone else share their experience with this topic?

[rninformatics, DNP, RN]

Yes Best Practice is that the organization have P&P that outline the functionality, user group/dept that the particular application supports/is used in/by.

Additionally the organization should also have clinical downtime policies and procedures that clearly spell out what happens and how the order entry, medication rec, documentation and how ancillary services will be ordered/communicated with, how clinicians will get lab results,etc during both scheduled and unscheduled down times.

Every facility I have worked at has had these.........that may be because I'm ususally the one that writes and revised these P&P so I may be biased :)

Do any of you have policies & procedures on the intended use of your clinical applications? I heard about a surveyor asking a facility on their p&p on an application. The facility shared with them the p&p regarding security of usernames/passwords but the surveyors were asking about the intended use of the application, level of access, competencies, etc.

Honestly, I'm surprised that in the past facilities I've worked in, I have not seen a policy regarding any clinical application. I've seen policies on documentation (for paper, ex: SOAP charting, PIE charting) but nothing that clearly states, "Here at ABC Hospital, documentation is done on XYZ EHR. In the event XYZ EHR is down, please refer to downtime procedures."

Maybe it's just me and I haven't been exposed to much, but can anyone else share their experience with this topic?

[lorazepam]

Thank you so much for the reply! Everything you mentioned is not the case at my facility. I want the right thing to happen and have a P&P that outlines the use, who it is used by, etc. I have brought it up to my manager, and the senior analyst, but there hasn't been any initiative. We currently have 3 applications related to documentation on patients and are in the process of going live with another application. There are no p&p on these applications. Any advice on what I should do? If anything?

[rninformatics, DNP, RN]

I dont know if this is necessarily the hill you want to die on.........know what I mean?

The processes involved are bigger than just placing a policy in the P&P book. It takes more than just submitting a policy to get it approved, staff educated, communciate of the change or new policy out to all and the policy implemented.

The procedures within the policy have to be followed by all the departments and staff that the clinical application impacts, is used in or are effected by.

I also dont know your role in the organization and what your authority is ..............you need buy in from leadership to get such an organizational or even departmental initiative as a new policy and procedure implemented.

Unfortunately Best Practices are often not implemented until something negative - Sentinal Event or JC survey sitation occurs.

Good Luck!

[lorazepam]

My thoughts exactly! I had a feeling it was out of my immediate responsibility/job description to draft a policy. (And I don't really want to!) My role though, is to orient users to the application. My worry is that I will teach them what the application is, and then a piece of documentation is missing and it would fall back on me. How should I proceed with teaching an application?

[Mijourney]

Wow, thanks for bringing this issue to our attention. This topic will be food for thought when I get into a clinical informatics position.

[lorazepam]

Interesting, right?! I only became concerned about it because a facility in our region had a member of the Joint ask about an applications intended use, user competency, etc. We currently have "blanket" policies regarding the security of patient health information, but nothing about it's end users. I felt it was important to discuss, since Health Information Companies can create these wonderful applications, but not all states may need all it's intended capabilities. I believe a facility policy on it's use at the facility would maybe deter future questions on why/or why not a piece of documentation was left blank, like any other piece of paper documentation.

More opinions on this topic are certainly welcome! I'd like to keep this thread going :)