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Question regarding report formats and what’s “OK” to do is this legal or what?
I provide technical and integration services to my client. My client provides teleradiology services – let’s call them VG. We’re doing an HL7 ORU interface to send our reports to VG’s client, let’s call them DI, so that DI can post the reports directly into their EMR. DI uses several groups to provide reading services for them and they want to standardize how their reports look like to their own clients, so they ask the reading groups to modify the report format to abide by their “format”.
One of the first issues we encountered is that they want the heading PROCEDURE rather than TECHNIQUE, which is what we use. We use TECHNIQUE for all our clients and we don’t want to have to create a report template that’s different just for this client. We’re using Mirth as the Interface Engine, so I was OK to just replace TECHNIQUE by PROCEDURE with a regex. It works OK and it shouldn’t cause any side effects that I can think of.
The second issue is more touchy. Our PACS generates the report automatically based on speech recognition used by the rads. The report text itself always ends with the line: “Electronically signed by: <rad’s name> <dictation date/time>”.
However, the ORU contains the reading rad and the report date/time in one of the OBX fields. DI’s system actually generates their own report based on the information in the ORU. All metadata is extracted and displayed by DI’s EMR. The report text is displayed as well.
DI’s EMR actually contains a segment in their report viewer that contains the line: “ELECTRONICALLY SIGNED: <rad’s name> <dictation date/time>”
So, what happens is that the “report” shows the electronic signature twice, once inside the report text itself, and another in the report viewer using the metadata.
DI is requesting that we “clean this up” so that there’s no duplicate signature.
I know that the last OBX segment always contains the signature, and OBX-5 only contains “Electronically signed by: <name> <date>”, so I’m thinking I can just basically remove that last OBX-5 segment if it matches the regex “^Electronically signed by: “.
Now, my question. Is it kosher for the sending entity to alter the contents of the report so that the report displays properly on the receiving end? Is there any sort of medico/legal problem if a piece of software is modifying the report signed by a rad?
What are your thoughts?
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