External to EHR? (was An ACTION or INSTRUCTION referencing an AGENT, is it possible?)

Clinical (archive)
1

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

2

In my ‘book’ any document without a person responsible and accountable is something I will not trust.
In Australia you might organise around it and use a QA process to make somebody else accountable. (the organisation?)
This is not what I would advocate, personally.

When something else places data and information in ‘my EHR’ about a specific patient and when that is not under my control, I would feel very uncomfortable.
It no longer is my account of what I think needs to be documented about that patient.

Gerard Freriks
+31 620347088
gfrer@luna.nl