Problem regarding signatures and amounts

[willcipriano]

As I have read in the documentation it appears that any changes to a particular treatment plan's:

• Date
  Note
  Description
  or Patient Portion

Result in the invalidation of said signature and require it to be resigned. In dealing with insurance companies, the amount to be paid for the procedure is not always known before it is sent in and thus as the amount may fluctuate (EX. The payment schedule only allows $50 for an exam when the base change is $65). My question is would it be possible to allow changes to this field without invalidation of the signature? If not what are best practices for dealing with the situation as it is relatively commonplace and causing quite a few headaches. Thank you for your time.

[tgriswold]

I don't see this functionality changing very much in the future. Once a patient has signed the treatment plan, it cannot change or it defeats the purpose of the signature. A saved treatment plan is a snapshot of what was treatment planned for that patient on that date, and will not change when the procedures affiliated with that saved treatment plan are changed (or even deleted). If the fees for the work that you have in a treatment plan changes in the chart, the saved treatment plan will never change.

In the case you describe, you can change the fee schedule for that patients insurance plan and it will not invalidate the signature on the saved treatment plan. It will change the charge on the procedures currently treatment planned in the chart, but will not change the saved treatment plan. And in the case where these fees have changed, you may want for the customer to sign a new version of the treatment plan so that you have an up to date agreement with the patient for these new fees. There are very few cases where you want to go in and manually change a saved treatment plan.

[willcipriano]

I'm sorry, I wasn't clear regarding this issue, Just got off the phone with OpenDental technical support regarding this situation. Here is the process that I use to reliably replicate this problem.

• 1. Open OpenDental 13.2.35.0 and login with my username and password (manager level access)
  2. Select our 'test patient' from the drop down menu on the 'appts' module.
  3. click on 'chart'
  4. select the 21st tooth
  5. select MOD via the buttons
  6. add procedure 'D2392'
  7. open the procedure in the "procedure window"
  8. write notes and sign the procedure
  9. press OK to save changes
  10. left click and select "set to complete"
  10. click on the Account module
  11. double click the just added procedure
  12. signature is invalid.

This error occurs even when different steps are followed but this is the best way I have seen to make it happen regularly. This represents a severe regulatory issue for us. We have multiple offices all with separate databases that all experience this same issue. It is also somewhat erratic and hard to track down. Technical Support was unable to help us, and referred us to "his programmers". I will post again if they present us with a solution.

Below I have screen shots to make clear what the issue is.

[willcipriano]

Just got off the phone with tech support again, It seems this version has an issue with 'Invisible return line characters' being injected via the Auto notes functionality, we were told to update to the latest version to attempt to resolve this issue. Will attempt and report results.

[tgriswold]

I apologize for my previous post, I thought you were talking about saved treatment plans, not treatment planned procedures (both can be signed).

With this information, I now understand what the issue is and I can confirm that it is working as intended. Your signature is invalid because the procedure note has changed, that is the underlying logic here. The note that you signed, is not the same note that is showing. Signatures are only valid for the text that was showing when you signed the note.

The note changed because you have an default note set for that procedure, and those are only inserted when the procedure is completed. To avoid having your signature invalidated, I would recommend completing the procedure before signing it. That will save you from having the signature invalided.

[willcipriano]

That is not the issue, I have attempted it in the manner that you describe and it still presents itself. I was told by opendental tech support that this is a known bug this version, and that we must update in order to fix it.

[willcipriano]

I did some digging and now have proof it isn't the auto note feature.

procnote before it is signed:
https://www.sendspace.com/file/6mjgeq

the procnote after signing it and clicking ok:
https://www.sendspace.com/file/4lminz

Everything is identical except a signature is added, the signature fails to decrypt when you load the form. This a major legal problem and disappointing that more testing had not been done on this functionality. Will attempt an update later in the day, hopefully it is fixed but that doesn't help with the records that have been lost already.

[willcipriano]

Ok, further digging this morning.

When the signature is signed on a computer in the local network (topaz or not doesn't matter), it is valid and remains valid when viewed locally. When I attempt to connect via a Web Service* the connection succeeds and I'm able to use most functions normally, but this signature issue presents itself.

The server only reports error code 200 (OK) in the connection logs, so I doubt it is injecting anything to the responses, Also everything is encrypted before it goes to Comcast/Verizon so I doubt they are doing anything.

*Web Service Configuration:
Windows 8, 7 pro client machines
Multiple offices with a VPN (zyXEL gateway - DES encryption - MD5 authentication)
Server running windows server 2012 R2, MySQL database, ISS, returning a asmx (etc 192.168.1.100/OpenDentalServer/ServiceMain.asmx)

Is there any reason ISS might interfere? When I do database queries everything seems to check out. If this is the problem are there any alternate configurations that someone can recommend? Any help or ideas will be appreciated.

[jsalmon]

Is there any reason ISS might interfere? When I do database queries everything seems to check out. If this is the problem are there any alternate configurations that someone can recommend? Any help or ideas will be appreciated.

Very much yes. The web service has to make lots of data manipulation due to sending the payload through the internet (basically making it URL safe). We try to preserve the payload the best we can but may have missed something that IIS is changing behind our backs. I'll create a task for our debugging department to test signature validation using the middle tier to make sure it is working as expected.

[willcipriano]

I've figured it out, I played around with fiddler a little bit and captured the actual request. When I query the database I get newline chars that aren't there when opendental makes the request. Oddly OpenDental seems aware of these newline as they are displayed. It seems the logic for the signature is different than the logic used for display in the text box(displayed correctly). Please forward this to the developers as it may save them some time.

EXAMPLE:

Code: Select all

Fiddler
"Pt presents for root canal tooth #19 . Clinical exam large carious lesion that is sensitive to cold and percusion. Radiographic exam reveal decay extending into pulp. Pt opted for RCT/BU/CROWN. Dx: Irreversible pulpitis tooth # 19 Recommended treatment: endodontic therapy #19 Med history reviewed and consent form signed 2 carpules 2 % xylocaine with 1: 100 k epi via infiltration. Rubber dam isolation. removed decay and accessed all canals. Apex located used for working distance: MB/ML/DB/DL: 23mm Irrigated with copious amounts of sodium hypochlorite and EDTA. Worked with hand files and rotary files to protaper F2. Obturated canals using lateral condensation with seal apex. Cotton pellet and cavit placed in access and cemented temporary crown with tempbond. Occlusion verified. Post-op instruction given."

Database:
"Pt presents for root canal tooth #19 . Clinical exam large carious lesion that is sensitive to cold and 

percusion. Radiographic exam reveal decay extending into pulp. Pt opted for RCT/BU/CROWN. 

Dx: Irreversible pulpitis tooth # 19
Recommended treatment:  endodontic therapy #19 
Med history reviewed and consent form signed

 2 carpules 2 % xylocaine with 1: 100 k epi via infiltration.  Rubber dam isolation.  removed decay and accessed 

all canals.  Apex located used for working distance:
MB/ML/DB/DL: 23mm
Irrigated with copious amounts of sodium hypochlorite  and EDTA. Worked with hand files and rotary files to 

protaper F2.   Obturated canals using lateral condensation with seal apex. Cotton pellet and cavit placed in 

access and cemented temporary crown with tempbond.  Occlusion verified.  Post-op instruction given."

Above in .txt form:
http://www.filehostfree.com/?d=53EBBD831

TLDR;
OpenDental when used as a webservice(HTTP) though IIS might show valid signatures(usually when they contain newlines) as invalid, but when accessed locally over IP everything works fine. No regulatory worries.

Thanks for the help everyone.

[jsalmon]

I just saw a commit go through for this issue. Looks like it will be released with v14.2.26:

Signatures were being invalidated by Middle Tier sometimes.

http://opendentalsoft.com:1942/ODBugTra ... sions.aspx

[jwhitney]

This issue has been resolved and will be implemented in further versions starting upon the release of version 14.2.26.

[willcipriano]

Thanks for the rapid fix.