dgold123 wrote on Wednesday, May 04, 2011:
I searched and couldn’t find an answer for the best way to integrate electronic signatures (some form of signature pad). Is it recommended that I use Word, PDF, or HTTP forms (the app itself) to develop documents that require signatures (like disclosures)? The goal, of course, is to save paper and save real (not digital) signatures. Thanks.
aethelwulffe wrote on Thursday, May 05, 2011:
Perhaps you might examine your paradigm. Allow me to express my opinions, and perhaps you might take some things in consideration:
“Real” signatures are meaningless. Really. Their effectiveness in acting as a control of authority is a tiny fraction of that of a embossed seal.
Print scans are not even that good. The goal is to get rid of the ridiculous concept of signing with a pen. The US government, wherever practical, has gotten rid of it through use of CAC cards and the like. A digital signature traceable by location and many other factors, using public and private keys approaches credulity and has real usefulness.
There is no purpose, use, (or legal requirement) for making a chicken scratch image on paper or screen other than to convince the signator themselves of it’s validity.
tmccormi wrote on Thursday, May 05, 2011:
What Art says i complete true … on the other hand perception is everything… I have seen a pure HTML 5 implementation of a form you can freehand draw on in OpenEMR using touch screen or sig pad. I am having difficulty getting the author to let me have it, even though he said he would. Mostly it’s a time and logistics issue.
I’ll push some more 
-Tony
mike-h30 wrote on Thursday, May 05, 2011:
Our solution was to have our physician sign his name on paper. I scanned it to JPEG. I put JPEG in CAMOS directory ( we use CAMOS for all doctor notes), then modified notegen.php to include JPEG when printing note to PDF. I also have this done on any custom forms I converted to electronic forms. Works perfectly.
-Mike
aethelwulffe wrote on Thursday, May 05, 2011:
More arguments, the purpose of which is to merely discuss to find best solutions:
I can steal your jpg and put it on anything I like. It’s only use if you used it in any other manner is for you YOURSELF to know if you produced the document, and you KNOW if it matches the data in your system… once again it is pointless.
Ah, but when people want a signature, they want to be seeing it on printed matter. I postulate that the impression generated when seeing an electronic document that has been scanned (and the signature thereon) is generally negative in terms of perceived validity. When there is a signature (such as the pdf style) where the image of the signature (or logo, or mug-shot) ONLY shows up when the public key matches the private.
Better is one that also (in printed mode) has a scannable bar code that contains a date-seed scrambled portion of the key. Using a CAC card plus a password to attach your private key onto an electronic document gives a real sense of security to most, and is secure certifying in reality.
I define reality as: That which does not change to match whatever it is that you believe.
Perception is not everything, but if you want people to believe something, why not make it real? Personally, I think that many of my generation (40+) well understand that a scrawl on the pad at the checkout counter is meaningless. It trusts to the fact that if someone steals your credit card and uses it, it will work when they scrawl “Zahopd Breeblebrox” on the pad. It’s just that when you get the bill and report the card stolen, security cameras (a much better security device) will bust them, and an alarm gets sent the next time it is used.
Signing into the EMR as a specific user and printing a form IS trackable, logged, and relatively a verification of authenticity. “Signature on file” is as much good as anything. Even with a signature method like adobe, a printed document is just a forgery of the “real” data document. We are at the extreme trailing end of the signature era. It is going the way of the bank book (anyone remember those?).
Ultimately (and very shortly) documents that have veracity requirements will not be valid in printed form. Prescriptions, hospital orders, and many other things will have to be electronically certified. The only need for paper documents will be for people that want the data for their own use, and who obtain it directly from the source. When you have a printed signature on that, it loses something. It becomes what any child of the 70’s would call a “Form Letter” that was always used in junk mail scams.
nursejeff wrote on Wednesday, October 03, 2012:
Mike,
Referring to your above note:
Can you tell me how you put JPEG in the your CAMOS and how to modify the notegen.php file?
Thanks a bunch
Jeff Guillory
NP Health Clinic
mike-h30 wrote on Thursday, October 04, 2012:
Hi Jeff,
Create a jpg file of your signature and name it “sigYourUserID.jpg” then place the file in the CAMOS directory. There is code in notegen.php that will display the jpg file on the PDF if the jpg file exists. Here is the code in notegen.php that looks for the jpg file. Hope that helps.
Mike
$query = sqlStatement("select t2.id, t2.fname, t2.lname, t2.title from forms as t1 join users as t2 on " .
"(t1.user like t2.username) where t1.pid=$pid and t1.encounter=$encounter");
if ($results = mysql_fetch_array($query, MYSQL_ASSOC)) {
$name = $results['fname']." ".$results['lname'].", ".$results['title'];
$user_id = $results['id'];
}
$path = $GLOBALS['fileroot']."/interface/forms/CAMOS";
[b]if (file_exists($path."/sig".$user_id.".jpg")) {[/b]
//show the image herecverk wrote on Thursday, October 04, 2012:
I just made a simple layout based form that inserts a note stating that the encounter has been electronically signed by me, which I believe since it is added under my sign-in should help validate it. I dictate a note in the speech dictation , save that and then open and save the electronic signature form. I suppose it could be made to be time stamped if it was needed.
anonymous wrote on Monday, October 15, 2012:
I was looking at a government system in the US. They use the electronic signatures especially for e-prescriptions (saved signature jpg or something similar) which is helpful for controlled drugs.
It would be nice if there was a way for the electronic signatures to automatically be applied to a finished visit though (despite the redundancy) isntead of having to click and navigate through the CAMOS engine.
tmccormi wrote on Monday, October 15, 2012:
There seems to be some confusion about what Electronic Signature is as compared to inserting a JPG of a signature. The graphics part, while comforting, is not legally of any importance and is, really, only useful for thing you are going to print (or store as if you had printed them).
You need only to actively acknowledge that you are “signing” a document and include the signers name and the date-time stamp. The issue with data stored electronically is making sure the “signature” is somehow applied to all the parts (tables/fields/scanned documents) of set of things that are being signed.
-Tony
jojohit wrote on Monday, October 15, 2012:
What if you can “can” (like a canned package) all of the pertinent documents that need to be submitted and signed as if you were making a snapshot of the patient’s medical record in that point of time that the documents is signed. The canned output must be in a readable format (similar to the proposition from sunset regarding “printing a patient report”). That document can be closed and signed by the provider. In theory.
tmccormi wrote on Monday, October 15, 2012:
That is an acceptible model by some folks. We have done something similar to that for one very customized OpenEMR derivative.
Adding “signoff” to Rods print to PDF would be a way to do that. pdftk allows you to append a page to a PDF, we did that with a signature page (and addendum logs)
-Tony
-Tony
advancedmedical wrote on Thursday, October 25, 2012:
Hi Mike,
I followed your guide and instruction, but still can not have it print at the last step with PDF that would generate the sigYourUserID.jpg
Please help
did I miss any steps?
mike-h30 wrote on Thursday, October 25, 2012:
Could be permissions related on the image file that would prevent it from displaying. Make sure permissions set to 644.
Mike
advancedmedical wrote on Saturday, October 27, 2012:
Hi Mike,
could you please provide little more hint of where i can change or locate the file to change the permission?
thank you.
AMC
mike-h30 wrote on Wednesday, October 31, 2012:
Did you scan an image of your signature to a jpeg and place it in the CAMOS forms directory? That is where your image file should be placed. What I have found is that if the permissions are not set correctly on that jpeg file you created, it will not display.
Mike