How important are Electronic Medical Records (EMR)?

Have you or someone you know been involved in medical injury or accident? Do you want to win your case? Or…If you’re an attorney and have questions about a case involving medical malpractice, read this blog and contact Enigma Forensics for the “W”.

Were you or a loved one involved in a medical accident or injury? Are you an attorney who is representing an injured client?

If the answer is yes, take immediate action and file a Discovery request or subpoena to access all of your Electronic Medical Records (EMR). Why is this important? In order to prove injury or malpractice and win your case it’s imperative to discover what took place and the actions that caused an event. Your electronic medical records or EMR audit trail will document what transpired. EMR audit trails will include prescriptions, tests, treatments, transfers, operation notes, nurse practitioners and doctors notes and a ton more. Electronic Health Records (EHR) are rich with data information describing the care that was provided and decisions that were made good or bad. Some medical record systems such as Epic have sticky notes that are traditionally not part of the formal patient permanent electronic record. Those sticky notes are required to be stored by the Health Insurance Portability and Accountability Act (HIPPA), but are not part of the discharge report showing the patient electronic medical record history. The data does exist and working with a qualified medical record forensic expert can help you to gain a more complete record of the patient encounter with the health care provider.

What else does Electronic Medical Records (EMR) include?

Electronic Medical Records and the patient medical record audit trail include the original record and will note any modifications. It will also preserve dates, times, who accessed the record and whether the record was printed, viewed, deleted or otherwise modified. Many of the systems today, such as; Epic, Cerner, Meditech, All Scripts and others have reports that can be downloaded to reveal vital information about who has authorization to access and audit electronic health records.

Medical dictations are another vital piece to the puzzle. Dictation files are sometimes sent to third party transcription service providers as raw audio files called WAV files. After the WAV files are received they are typically transcribed to text files and fed back into the electronic health record software system. When modification of the patient medical record occurs after an injury or malpractice took place, comparing the transcription WAV files to the produced chart may help reveal alteration to the patient medical records.

Patient Electronic Medical Charts are often Incomplete. You could lose your case!

When electronic medical record discovery requests are made by plaintiffs to healthcare providers, it is common that the production lacks the complete patient medical record history. Healthcare providers facing litigation commonly provide a minimal amount of data in an often useless format. The form of production is often scanned copies of previously printed our documents or charts. Codewords for health care providers, departments and procedures often make interpretation even more challenging. Having an experience EMR computer forensics expert can help provide a more accurate interpretation of the complete Electronic Health Record (EHR) for the harmed patient.

The Health Insurance Portability and Accountability Act of 1996, or HIPAA is a federal law which requires your medical records to be retained for six years at a federal level. However, most states also have their own medical retention laws which can be more stringent than HIPAA stipulates. Check out this government website to learn about how different states interpret this governance. https://www.hhs.gov/hipaa/for-professionals/privacy/index.html

How important are faxes? This could win your case!

In some cases, Electronic Medical Records (EMR) are faxed to outside providers either to or from your primary physician. Software vendors such as Forward Advantage provide automated faxing capabilities integrating with the existing health care information management systems and patient medical records. It’s vital you request all communication between facilities to help prove or disprove what and when medical knowledge was presented to the provider to make an informative decision relatable to an event.

Let’s say you have already requested an EMR audit trail for a patient. Did you know that the Electronic Medical Records (EMR) audit trail you received contains cryptic codes that you will not be able to comprehend. It’s extremely helpful to request all of the underlying data dictionaries that will provide the definition of the codes used referring to the friendly name, including, the healthcare provider’s name, department, computer used to access the EMR, procedures, treatments, tests ordered, drugs prescribed and lab results.

Did you know that medical data is required to be retained for six years?

Do you want to to win your case! You need Enigma Forensics experts on your team! Hire a professional forensic expert to assist in writing a Discovery request to obtain, preserve and analyze ALL of the electronic medical records and to help you obtain the complete EMR audit trail. We can help uncover the truth of what took place and help tell the court the story about what happened to you or your client.

Call Enigma Forensics at 312-668-0333 to schedule a complimentary phone call to discovery how we can assist.

More about Electronic Medical Records

EMR or EHR what is the difference?

EMR or EHR are synonymous. Both are medical records. The electronic medical records or EMR reveal an audit trail of what transpired during a medical or health visit. Each record is unique and tells a story about the patient. We are experts that can assist you to win your case!

Electronic data records are taking the place of the old school hard copy files and completely revolutionizing the way data is gathered and stored. Electronic Health Records (EHR) or Electronic Medical Records (EMR) are synonymous with each other. (EHR) is data that includes the patient’s vital information such as an address, medical history, allergies, immunizations, lab tests results, radiology images, and vital signs, also, personal statistics like age, weight, sexual orientation, and insurance information. (EMR) is an individual’s private health data that is stored in a protected database only accessible to medical personnel in compliance with The Health Insurance Portability and Accountability Act (HIPAA) regulations. EHR’s or EMR’s make patient charting easier and results in fewer errors and keeps this delicate personal information private and secure.

Medical data can be manipulated!

Medical data can be altered and inserted into EMR systems and made to look like it was there all the time or not there at all. Medical malpractice lawyers rely on EMR audit trails to tell the story of either side of a case; the plaintiff or the defendant. Medical records are marked by metadata or raw data. This data is developed separately from the EMR system making manipulation detection visible by reviewing the raw data and the database logs. Metadata can also be described as underlying data, like a digital footprint that creates an audit trail. In order to analyze raw data, you will need to hire Enigma Forensics; we are experts in the field of electronic medical records (EMR) or (EHR).

During a forensic review of EHR’s or EMR’s, we can authenticate or reveal backdating, back charting, data editing, or falsification of records. We have been on both sides of medical malpractice cases and almost always save our client a considerable sum of money. We work closely with the attorneys involved to help with eDiscovery verbiage and assist with what to look for.

Electronic Medical Records
Electronic Health Records and eDiscovery

Complete list of eDiscovery Questions For Electronic Medical Records

Enigma Forensics are experts in collecting and understanding electronic medical records or the EMR audit trail. Check out this blog to view our list of EMR Discovery Questions.

Electronic Medical Records (EMR) can be tricky! In most cases, during eDiscovery, you get what you ask for and only what you ask for! Every Discovery request involving a healthcare provider has unique aspects that need to be considered.

Enigma Forensics is an established Computer Forensic Expert Witness firm that has been involved in many medical malpractice cases and specializes in interpreting electronic medical records (EMR) audit trail or audit logs. Our staff has extensive experience with numerous EMR applications and can assist you with navigating through the challenges of EMR Audit Trails and/or Audit Logs. Electronic Medical Record a.k.a., EMR audit trail or log is the answer to who knew what when, in essence, it tells the story about what took place during the treatment of that patient.

The following is a list of important questions to file for the demand for eDiscovery for Electronic Medical Records, in a medical malpractice case.

  1. Provide the name of all medical software applications utilized to store [Patient Name]’s Electronic Medical Records (EMR).
  2. For each medical software application that contains [Patient Name]’s EMR, please provide the specific version of the software as well as the name of the company that produces the software during the relevant time period beginning on [beginning date] through the present date.
  3. For each medical software application that contains [Patient Name]’s EMR, please indicate if any of the specified software applications were migrated off to a new platform and what the current status is of [Patient Name]’s EMR on the original system.
  4. For each medical software application that contains [Patient Name]’s EMR, please provide the application administrators that have full access to the stored data and audit trails.
  5. For each medical software application that contains [Patient Name]’s EMR, please provide all user and administrator manuals for each of the medical software applications.
  6. For each application that contains [Health Care Provider Name]’s EMR, please provide the current retention settings for the audit trail for all patient’s EMR. Are the privacy log retention settings sent to a secondary audit log (e.g., Fair Warning)? Is the secondary audit log retention configurable within the systems and/or applications?
  7. For each application that contains [Health Care Provider Name]’s EMR, please provide the earliest date that [Patient Name]’s EMR appears in the application’s audit trail.
  8. Please provide the complete EMR audit trail for [Patient Name] detailing any health care provider’s access, review, modification, printing, faxing, or deletion activities in a comma-delimited format with any and all corresponding native files that may relate to the Electronic Medical Record for [Patient Name] as required by the Health Insurance Portability and Accountability Act § 164.312(a)(1).  Such an audit trail should include the original values and new values for any alteration of the EMR and shall indicate the user making the change and the date and time of the change.
  9. Please provide the data dictionary for each software application containing  [Patient Name]’s EMR.  Such dictionary shall include the username key that maps the real names of individuals to their unique user login account IDs for each medical software application containing any EMR for [Patient Name] as required by the Health Insurance Portability and Accountability Act § 164.312(a)(2)(i). Additionally, any lab test, codes, or other short-form identifiers included in  [Patient Name]’s EMR Chart or EMR audit trail should be provided as part of the data dictionary production.
  10. Please provide any and all original voice transcription recordings that were made by [Health Care Provider Name], or any other staff that related to [Patient Name].
  11. Please provide any other native electronic files or emails that relate to  [Patient Name] in the native format with an index containing the original unmodified metadata for each of the native files or emails produced.
  12. Please provide any DICOM files that were captured as part of [Patient Name]’s treatment by [Health Care Provider].
  13. Please provide electronic records of any outbound faxes and/or other methods of communication that were utilized by [Health Care Provider Name] to [EMR Recipient], in its native form with a corresponding comma file listing containing all available metadata in a delimited format with the corresponding file path to the native file produced for each record.
  14. Please provide the name and title of the person most knowledgeable for the [Health Care Provider Name]’s software/auditing and compliance system. 
  15. What customizations and settings were active at the time when the plaintiff was admitted into the hospital? What privacy-related logging is in place for each such system and/or application? Are privacy log retention settings in place for each such system and/or audit log?