I do not profess to be an expert in the complexities of metadata in an electronic medical record (EMR). In simple terms, it is analogous to leaving footprints in the sand; although these do not wash away with high tide. In fact, the simple act of logging in and out of an electronic medical chart, and more significantly, viewing and creating records, is indelible. Most health care providers never even consider the impact of logging on and viewing a medical chart in their daily practice.
The metadata can be compiled into an audit trail that shows the date, time and user who accessed a patient’s chart. It even shows whether the user created or added to an existing record. Consequently, audit trails from a patient’s EMR can either support or discredit the testimony of medical providers during medical malpractice litigation. Plaintiffs’ attorneys are becoming more sophisticated and now ask for these audit trails as part of their standard discovery requests.
Where the significance of an audit trail typically comes into play is at deposition when a health care provider is asked whether he reviewed a prior record, which likely contains information that would impact the clinical decision-making of the provider. Whether the provider was aware of the information in that earlier record is often a critical factor as to whether he met the standard of care.
With paper medical charts, a provider could testify that he reviewed an earlier record or lab result based on his routine and practice. It would then be up to a jury to determine the provider’s credibility as to whether he reviewed the record. With the advent of EMR and the request for an audit trail, a provider’s testimony can be discredited before he is sworn in as a witness.
Another example of the significance of an audit trail is when there is a negative event and one or more providers go back to review a chart. Subsequent review of the chart outside of the peer review or risk and quality assurance context can impact the ways in which an event is viewed by plaintiffs’ counsel, plaintiffs’ experts and a jury.