Hi Gerard, Having spent many hours specifying and validating software that checks that the output from pathology labs matches the patient the sample was collected from, I can't agree that such EHR data is inserted by the author/healthcare provider. Who would that be? The nurse at the clinic that labelled the sample, the technician that transcribed the label into the analyser, or the software development teams?
As far as I can see, the end result is trusted by the clinician when the data is subsequently displayed. Only the data that fails checks sits in limbo. Yes, we have inboxes, but the accountability in this case is down to the QA of the process outside the EHR. Regards, Colin ________________________________________ From: openehr-clinical-bounces at lists.openehr.org [openehr-clinical-bounces at lists.openehr.org] On Behalf Of Gerard Freriks [gf...@luna.nl] Sent: Thursday, 21 June 2012 9:09 PM To: Stefan Sauermann Cc: For openEHR clinical discussions Subject: Re: An ACTION or INSTRUCTION referencing an AGENT, is it possible? Stefan, I agree. For me the EHR contains data and information that is placed there because of an author/healthcare provider. In my 'book' all data and information must be there because of the execution of an act by a human. There is a strong legal requirement that always a human can be held accountable for what is in the EHR or is not in the EHR. The prime function of the EHR is to be the container where the healthcare provider as author documents the healthcare provision process. Next to the EHR data and information, there is a need for EHR-systems to hold data and information that has been received and is waiting to be inserted by the author/healthcare provider. In other words I see the need for an IN-box and an OUT-box where data and information sits in limbo until it is processed by the author/healthcare provider. Data and information in these boxes is NOT part of the EHR proper, but connected to, or associated with, it. Gerard Freriks +31 620347088 gfrer at luna.nl<mailto:gfrer at luna.nl> On 21 Jun 2012, at 12:18, Stefan Sauermann wrote: Hello! Just a few cents, as Gerard wrote: > Everything documented in an EHR is based on human interpretation. A raw, non-validated, blood glucose value is not based on human interpretation. It comes out of a machine. It is a requirement for EHRs to support the clinical validation process. I therefore conclude that some EHRs need to store information that is not based on human interpretation. Hope this helps, greetings from Vienna, Stefan Sauermann Program Director Biomedical Engineering Sciences (Master) ##################################################################################### This e-mail message has been scanned for Viruses and Content and cleared by MailMarshal ##################################################################################### #################################################################################################################### IMPORTANT NOTICE: This e-mail and any attachment to it are intended only to be read or used by the named addressee. It is confidential and may contain legally privileged information. No confidentiality or privilege is waived or lost by any mistaken transmission to you. The CTC is not responsible for any unauthorised alterations to this e-mail or attachment to it. Views expressed in this message are those of the individual sender, and are not necessarily the views of the CTC. If you receive this e-mail in error, please immediately delete it and notify the sender. You must not disclose, copy or use any part of this e-mail if you are not the intended recipient. #####################################################################################################################
