Ensuring Legality of Electronic Medical Records through Audit Trail

Medical records are literally the basis of an injury claim and are the key players in proving or refuting injury. It is only after a comprehensive medical chart review that injury lawyers take up a case and prepare for trial. Medical documents are maintained electronically by physicians, hospitals and surgical clinics. Given their extremely sensitive nature, they are protected from disclosure by the HIPAA Act. The patients themselves can obtain them only after signing an official medical records release form. Insurance defense lawyers who need the medical records relevant to their case obtain them through legal discovery process. This process allows both parties involved in the case to obtain the medical information applicable to the legal claims and defenses in a particular case.

Ensuring EHR Reliability via Audit Trail

At present, in keeping with federal mandates, hospitals, physicians and healthcare facilities across the United States have started adopting the electronic health record system or EHR. These replace traditional paper records and store a patient’s medical information such as patient demographics, progress notes, medical history, medication lists, clinical test results and other details. An important concern related to EHRs is whether they are secure and can maintain the confidentiality and accuracy of patient healthcare information. This is where the concept of audit trail becomes significant. An audit trail is a record of computer events about an operating system, an application and/or user activities, as per the National Institute of Standards and Technology’s Computer Security Resource Center (CSRC). This system maintains an accurate record of the activity of the computer system in terms of system and application processes as well as in terms of user activity of those systems and applications. Audit trail is advantageous in the following ways:

• It helps managers maintain individual responsibility.
• Employers can ensure righteous user behavior by notifying users that their actions are being tracked via the audit trail that logs user activity.
• An audit trail tracks EHR access and changes made chronologically by making a record of data such as date, time and user information with each update made to an EHR.
• It can provide information about system users who modify data inappropriately by revealing before and after versions of the electronic records.

In this way, audit trails are immensely helpful to medical negligence and personal injury lawyers who depend extensively on electronic medical record review to argue their cases.

Ensuring Infallible Audit Trail with Effective Measures

According to the U.S. Department of Health and Human Services, most US hospitals with EHR technology have audit trail capabilities. However, many of these systems still allowed improper opportunities for users to alter, disable or even delete audit trail data. This is a serious concern that needs to be immediately addressed not only from the point of view of patient safety but also from that of healthcare fraud. To make sure that the medical data made available for litigation and healthcare purposes is accurate and reliable, healthcare systems need to ensure the following:

• Have a foolproof audit trail system in place.
• Ensure that the audit trail data is secure against modification.
• Audit logs should remain operational and stored securely as long as the patient record itself.
• Hospitals and other healthcare facilities must preserve audit trail information and have the capability to retrieve it when needed.

Alerts for Lawyers Requesting Medical Records

• Lawyers requesting medical records must also ask for audit trail information for a better view of the medical events.
• They must have a clear idea regarding the EHR system involved and whether there are hybrid records – both paper and electronic records.
• They need to make sure that the information received is complete with no gaps or missing data. This means that the time each entry was made, the identity of each user accessing the record, the time of access, the part of the record accessed, and the activity of the user (viewing the record, changing an entry or creating an entry) must all be clear.

Medical records retrieval services provide the support lawyers need to retrieve the medical records relevant to a particular case. In case they need external support in having the records reviewed or for assistance in trial preparation, a medical record review company can help.

Managed Outsource Solutions (Mos) has providing value-added medical record review services for the medico-legal industries.