When faced with developing a Health Information Systems (HIS) policy, I was overwhelmed by the idea of writing something that would directly affect the way my unit did business. My unit manages the hospital and troop medical clinics throughout Kuwait, and although many of us have used MC4 or similar systems before, many had not – and I stood in the latter category. Soon after taking over the mission in Kuwait, we realized we needed one overarching policy that provided clear guidance on maintaining and updating electronic medical records (EMR), so we wrote a HIS policy.
First, I think it’‘s important to clarify the purpose of a HIS policy, for the 325th Combat Support Hospital, the primary purpose was to ensure all patient records actually make it into the patient’‘s electronic record. There are too many stories of Soldiers coming home from deployments, looking to continue their medical care with the Veteran’‘s Administration (VA), only to discover their records are incomplete or missing altogether (especially records associated with deployments). This is unacceptable in this electronic age. Our HIS policy clearly established which medical applications would be used in Kuwait; next, it set the standards for how each of those systems would be used at the different levels of care; and finally, it documented the required system maintenance for both the users and the system technicians.
As with any other Standard Operating Procedure, you don’‘t really understand the importance until you see it in action. Our nursing staff keeps it on hand and references it regularly. As a result of the policy, our network runs smoother because it receives the proper maintenance. We recently expanded our medical information system network to include the aid stations run by other units. By including all clinics on the same network, providers at a troop medical clinic and at the hospital are able to easily access notes written by a Soldier’‘s aid station provider. These units agree to follow our HIS policy as a precondition to being granted access to our network. This overall integration of medical treatment facilities enables us to provide quality control over the medical records, and it provides secure and appropriate information sharing between providers.
My second recommendation is not to write your HIS Policy in a silo; you will need the input (and ultimately the cooperation) of all unit stakeholders (doctors, physician assistants, nurse practitioners, nurses, technicians, communications support, etc.) who will be using the system. And once the policy is ready for publication, you will need your command to champion and enforce the policy to ensure it is followed!
My third recommendation is to review other units’‘ HIS policies; when writing our unit’‘s policy, I reviewed policies previously used in the Army Central Command (ARCENT) and Iraq as a starting point. This helped to ensure we included all key points and provided a couple of different examples of how other commands operated. This review also helped us understand the importance of establishing a quality assurance (QA) program. We now have an established QA team that conducts weekly checks of the electronic health records; which helps us identify both system and user errors, further ensuring the accuracy of the patient’‘s medical record.
And finally, I strongly recommend that you establish and practice this policy prior to your deployment. It might be a pain, but it will be worth the effort when you don’‘t have to back track to change procedures after people start working.
Capt. Colleen Chianese, Systems Administrator, 325th Combat Support Hospital, Kuwait