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Re: [Gnumed-devel] on meaningfully signing off reviewed items

From: J Busser
Subject: Re: [Gnumed-devel] on meaningfully signing off reviewed items
Date: Sun, 29 Jan 2006 00:05:21 -0800

At 7:36 PM +0100 1/28/06, Karsten Hilbert wrote:
Later that letter arrives and my locum scans it
but fails to bring it to my attention. The additional page
is *added on* to the original letter.

Sorry to ask (again) what is actually "done" with a letter/document/file when it arrives, only later to be followed by a "supplemental" or "extra" page or a corrected "replacement" report.

Supposing it were a digital file, would a copy of this file be imported to live "inside" a Postgres table row presumably as data type "blob", permitting the EMR to archive or delete the original however they choose, or will GNUmed instead write into a table row only a "link" (file specification) for the file?
I suspect *not* the latter though it be how documents are handled in some EMRs!

So if, after the initial import of a document into a row, an entire replacement copy or an extra page later arrives, there can only be two options(?). Modify the original row, or create a new row purely to hold the newer corrected & complete version of a document or the additional page, however the case may be.

If we modify the original row, it either accepts the replacement in place of the original, or in the case of "extra" information it accepts an additional blob (if even Postgres can hold two blobs inside one field, and if we don't constrain to forbid it).

So if a row becomes modified, it becomes subject to the audit trail which would make it clear that it had been altered, potentially by someone other than the person who signed it. So the only remaining problem is our contention that the doctor carries the responsibility to view and acknowledge the alteration. While the record would carry the modified_by value that pertains to the user who did it, any existing value for "signed by" would no longer have clinical meaning. So we should specify "on update, signed_by is NULL" which would require the widget to write a "null" for signed_by?

Three years later
carcinoma of the colon is found in the followup colonoscopy.
Had I known about the high-grade dysplasia I would have
scheduled a half-year followup. Now I am busted.

#1: This shows why we need to sign off single objects as
reviewed, not entire documents - as long as we don't use
crypto for signing. If I had signed off the *document* the
additional page would have fallen under my "reviewed" flag
while never having been reviewed, actually.

#2: Even if we flagged individual objects as reviewed we are
still prone to manipulation: Assume the original letter
stated: "low grade dysplasia, no sign of malignancy,
follow-up in 3 years". Now, the patient is, again, diagnosed
with carcinoma of the colon. The patient is the father of
the IT student of my practice management service company.
She decides to get some money out of this and manipulates
the scan to say "high-grade dysplasia, re-colonoscopy in 6
months is recommended". Now, even though I reviewed and
ticked off the document I cannot prove what I saw back then ...

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