As we all know, hospitals and medical practices around the country have replaced paper medical charts with electronic health records (EHR), which have changed how traditional paper records were kept and managed. This relatively “new” technology began in the 1960s and 1970s mostly in government military hospitals. Due to the high costs and privacy and confidentiality issues among others, this technology took a while to get the attention of resistant healthcare organizations and providers. By the 2000s better software and improved web capabilities brought funding towards the adoption of certified EMRs under the concept of “ meaningful use” through such federal regulations such as HIPAA and the HITECH Act and CMS incentives.
Today, there are many benefits of using EHRs such as:
- Easy on-line storage and access to records
- Minimize errors-less handwritten documents
- Information sharing and better provider communication
- Cost efficiency, time saving
One area EHRs are frequently used in is medical legal cases. When used in medical malpractice cases, the EHR is a form of electronic discovery that does not look or print out as paper records once did. Even though EHR technology has lots of benefits, it comes with a fair amount of problems and learning curves within the field of litigation. Most obvious is an EHR printout not looking the same as it does when providers are charting in it. I know first-hand this creates issues in depositions as experts and witnesses are trying to find information within a record format they have never seen before. Another important concern is whether the entire medical chart is complete; it’s difficult to tell when examining it from a non-medical background. Opportunities for data to continually update and be modified in the EHR was impossible with paper records which has created more confusion.
The EHR has resulted in better ability to electronically track activities that occur within a medical record. There is a way to investigate further into the EHR through metadata. This is simply data that describes other data. It’s like a data dictionary stored in tables and fields within the database. This information is kept in an audit trail.
Audit trails are a “steppingstone” to more discovery. The audit trail records provide basic information to backtrack through a trail of events. This may include user activities, who accessed the data, and when and where. It shows login attempts, and administrator activity such as when a risk manager accessed it. A good audit trail can be very helpful in malpractice cases that hinge on information about what a provider knew and when. It can even tell the location where the provider accessed it. For example, did a physician claim he/she was not aware of important lab results when the nurse insists a notification was made? The audit trail may help determine any liability by placing both providers in the record simultaneously establishing some communication or showing evidence the physician was on a laptop viewing reports from that patient at the time of the call.
Or perhaps, an audit trail might disprove a provider’s claim to have documented a note about a patient at the time of death, when in reality the note was entered weeks after the patient died casting suspicion about what additional information the provider knew.
There are many vendors of EHRs, like EPIC and CERNER, and they all are formatted different. There are disadvantages such as added costs involved in using an audit trail in litigation and in not understanding what is in the audit once you get it. There are many potential uses for audit trails in malpractice cases; many of which a legal nurse consultant with training and knowledge specific to audit trails could educate an attorney about. Audit trails may be in their infancy, but they are the tip of the iceberg in electronic discovery and should be used with discretion.
Contact me for information about what an audit trail could do for you!