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

[J Busser]

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 ...