Having been away for a couple of days it's difficult to know where to start with so many responses!
I think that the basic problem lies in the way the documentation system is intended to be used. That is for "one off assessments" where every time you sign the document you are supposed to be signing that every piece of information on the form is correct and/or a new event. Therefore values are pulled through to be 'helpful' rather than to form part of a piece of ongoing documentation. Items not verified are meant to be deleted by the user I assume. Whilst this is useful for some forms e.g. a rating scale it is not helpful for most of the documenation we have designed. There are a number of different document behaviours I think we need to meet requirements. An example of recording a blood pressure is that in an assessment I may wish to record the blood pressure. This could be taken by me and recorded as such. This may however have been taken by the nurse during the nursing assessment 10 minutes earlier. I may wish to record in my assessment that I am happy with the value the nurse took and that it was part of this current assessment. Alternatively I may access the EHR and pull through a value 1 week ago and accept that (with an appropriate explanation of what I've done). I may even want to use an automatically calculated value to include the interquartile range of BPs over the past week and record that. Our system seems to either record a BP as new or not. Any inclusion of a BP value saves it as a new BP and all other controls seem to behave the same way. I can in theory have pulled through a blood pressure at every monthly appointment (from the value within the last month) for 5 years and the system would think the BP was being recorded as that every month. A human might find it suspicious that they are all the same looking back through the history but the system has no means of knowing this. I believe the system is appropriately storing the versions of the documents. When I do include nothing in a field when a document is signed I can open up that document at any point in time and see no value present. When I open a new document pulling through the last value this is when the previously mentioned error occurs. It is also true that the last value may be derived from the same concept recorded in another form or document. Some of this behaviour and functioning is desirable in some circumstances but it is assumed that it will work across all situations which I don't think it does. I shall take the issues about quality assurance to those in the project better equipped to deal with them. Thanks, Matt -----Original Message----- From: owner-openehr-techni...@openehr.org [mailto:owner-openehr-technical at openehr.org] On Behalf Of Sam Heard Sent: 08 March 2004 07:03 To: Tim Cook Cc: Thompson, Ken; 'openehr-technical at openehr.org ' Subject: Re: Basic EHR functionality Tim The openEHR and before it GEHR work on legality made it clear to me that a document has no legal status until it is saved in some voluntary manner - just as a correction in a written document has no status as fact (if you contemporaneously correct the document). Sam > On Sat, 2004-03-06 at 10:08, Thompson, Ken wrote: > >>Do you thing that a document being informally saved by an automated >>process designed to support recovery of the document should be subject >>to the same modification constraints as a formally saved document? > > > I would say that the data is not a formal document until a deliberate > action is made by the creator to commit it as such. > > Does anyone know if there is any existing legal precedent on this? > > Tim > > - > If you have any questions about using this list, please send a message > to d.lloyd at openehr.org > - If you have any questions about using this list, please send a message to d.lloyd at openehr.org - If you have any questions about using this list, please send a message to d.lloyd at openehr.org
