Maybe this is a good discussion. If the patient has access to their own
health record, then any information inappropriately in that record is a
violation of privacy to the person to whom that data belongs.
In this case, actually what I must do is to move the data from the
inappropriate person to the appropriate person.
It is likely that this error has been discover by the healthcare provider
on a subsequent encounter and reported to the IT department for correction.
In some cases, it is discovered by the patient.
Perhaps some of this opinion is biased by what I think an EHR is and what I
think its purpose is. I think if a provider has delivered inappropriate
care as a result of bad information, that constitutes a violation of
patient safety and must be reported. That action constitutes a legal
action, at least in the reporting sense.
Whether the data is logically or physically removed might be a legal issue;
however, if it is logically removed, there must be an indicator or such and
a process in which the logically removed data can be revealed.
Ed
"Sebastian Garde"
<s.garde at cqu.edu.au> To:
<openehr-technical at openehr.org>
Sent by: cc:
owner-openehr-technical@ Subject: RE: removal of
data
openehr.org
04/18/2006 11:05 PM
Please respond to
openehr-technical
Dear Ed,
I don't believe that this is a case for physically deleting data in the
record:
If data was attributed to the wrong patient, for medico-legal reasons it
still must be posssible to recreate the record exactly the way a physician
saw it during that period of time. You however should delete it logically
and give a reason for this.
Sebastian
________________________________
From: owner-openehr-techni...@openehr.org on behalf of William E Hammond
Sent: Tue 18/04/2006 10:06 PM
To: openehr-technical at openehr.org
Cc: openehr-technical at openehr.org; owner-openehr-technical at openehr.org
Subject: RE: removal of data
Maybe we Americans are the only ones who screw up, but one of the reasons I
have to remove data from the EHR is when the data manages to get into the
wrong patient's record. Unfortunately for every right way to do something,
there are many wrong ways. I have said that if I did not have to design
for human errors, I could do the work 4 times as fast.
Result, we need to have the ability to remove data physically and
completely from the EHR. To leave the data is a breach of privacy.
Ed Hammond
Mikael Nystr?m
<mikny at imt.liu.se> To:
<openehr-technical at openehr.org>
Sent by: cc:
owner-openehr-technical@ Subject: RE: removal
of data
openehr.org
04/18/2006 04:53 AM
Please respond to
openehr-technical
I know that it is very hard to completely remove (parts of) an electronic
health record, but the law is still the law and we therefore must follow
it.
It happens now and then in Sweden that we must remove (parts of) an
electronic health record completely (and not only logically). The removal
is
mainly done manually and to a high cost. In Sweden we therefore also need
to
record where we send electronic health record data and where we back the
data up.
/Mikael Nystr?m
________________________________
From: owner-openehr-techni...@openehr.org
[mailto:owner-openehr-technical at openehr.org] On Behalf Of Gerard Freriks
Sent: den 17 april 2006 08:28
To: openehr-technical at openehr.org
Subject: Re: removal of data
I agree that is very seldom.
For many (technical) reasons it is completely impossible to remove all
information as if it was never written.
for example:
- The information is communicated with others before it has to be removed
- the information is part of an archive on CD-ROM
- the information is indexed somewhere
Laws (as far as I know) cannot force healthcare providers to change the
history of things.
Each healthcare provider has the obligation to document itself.
The law, my personal opinion, most often is written by legal persons.
Therefor what they prescribe is legally correct but many times impossible
to
execute.
My solution is to translate the legal terms in a requirement to LOGICALLY
remove the information,
It is there.
But it is not used any longer.
Gerard
(See attached file: winmail.dat)
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