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Re: [Gnumed-devel] state of test results handling

From: James Busser
Subject: Re: [Gnumed-devel] state of test results handling
Date: Thu, 03 Apr 2008 21:47:07 -0700

On 1-Apr-08, at 1:28 AM, Karsten Hilbert wrote:
- they *may* (in some jurisdictions) need to be signed by the ordering
physician, even if already signed by someone else
No problem. Each physician can have their own review.

But I would make the case against preserving *multiple* reviews per test result (even if it is only one per user) and, for each result, would instead obsolete all but the most recent review.

The associated table clin.reviewed_test_results has been designed to record, for each test, one or multiple rows each of which includes all of the following:

- acknowledgment that each has been "reviewed" i.e. the "signing" function - agreeing or correcting whether results had been correctly identified by the test_org as technically_abnormal
- interpreting whether each is noteworthy (clinically significant)

As far as signing, even in a multi-clinician practice, there will be cases where a single signing "row", when the signing was done by the clinician who ordered of the test, will be enough. In a circumstance where --- in the absence of the ordering doctor --- results were signed by a colleague, then at most only two signings may be required. The second signing would be by the doctor who ordered the test. This would complete any statutory or jurisdictional requirement, where this existed, and could (in fact) obsolete a signing row that had been created by the previous doctor (a copy would exist in the audit table).

I am still trying to understand the rationale behind maintaining more than one non-obsolete signing row per test. Presently, health issues carry an attribute as to whether or not they are clinical significant and for each item there exists only a *single* active value reflecting the decision of whichever clinician last defined or changed it. There is no provision for each of multiple reviewers deciding and keeping active in the EMR whether the individually (and differently) believe it to be clinically significant therefore I don't understand the reasoning behind supporting multiple different judgments by different clinicians whether a lab test is clinically significant. I am now wondering how this is framed for the document archive items. I think clinical relevance should be managed under the same approach across all three.

Working through some test result use cases:

1. say an in-praxis colleague (of a patient's usual doctor) orders tests, and becomes (by default) the intended reviewer. If this ordering doctor is the first to sign, they could (as part of signing) "refer" responsibility to the usual doctor, who would become the new intended reviewer. The requirement for the ordering doctor to have signed the results would have already been satisfied, and would be verifiable from the audit log. Any required action on these results would remain with the ordering doctor, until other arrangements are (in the meantime) made or another doctor in the group (e.g. the usual doctor) intercepted and took action. The intended reviewer should have to remain the ordering doctor until they had been able to sign. Therefore instead of users "taking" responsibility for results, it should be the intended reviewer who, if it would be the agreed procedure within a praxis (as part of signing), can redirect the role of "intended reviewer" to the patient's usual doctor.

2. next suppose the ordering and patient's usual doctors (whether or not they are the same person) have "both" signed and a colleague sees the patient and, in examining the already-signed results, notices one or more that warrant editing of their test_abn and clin signif values. Altering these values could only be done as part of signing, making evaluable and identifiable any results that are the responsibility (based on fk_intended_reviewer) of, yet not currently (re)signed by, the current user

Technically_abnormal will most often already be correct as supplied by the test org. The first review by any clinician can confirm what was received, or can compensate for situations where test abnormalities had been unaccompanied by flags. A second review, for example by the ordering clinician, could carry-forward everything that was correct from the first signing as well as fixing any disagreement or failure in what the lab had provided. But we are really here talking about carrying forward into a new state the most- correct picture of technical abnormality. There is no question of merit... we are not aiming to weigh the first clinician's judgement against the second. It is not a question of opinion. Therefore any new reviewed value for technically_abnormal should deprecate the previous. I cannot understand why different clinicians should want to re-examine results through the lens of "personal definitions of technically_abnormal".

It seems to me that for any test result, the newest signing should obsolete not only the current user's row but any user's row.

BTW clin.reviewed_test_results needs a foreign key "" defined for fk_reviewer

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