Ask any doctor about the Electronic Health Record: most of them will tell you it’s a nightmare. Here is a new twist to this: the Audit Trail. Any time a provider logs into a patient’s chart on an EHR the software creates a record of that login. With some systems, if the provider makes a change to that record at that login, that change is also memorialized in a separate record. If the doctor gets sued those records of logins — known as the Audit Trail — are theoretically available to the lawyer doing the suing (on behalf of the plaintiff). If the doctor found out he was being sued and attempted to change that part of the chart he viewed as damaging, the date of that login would be tracked. The availability of the Audit Trail to the opposing attorney is a matter of intense debate. Many defense attorneys claim that it is a violation of attorney/client confidentiality for the Audit Trail to be made available (“discoverable” in legal jargon). This issue is being battled out in various courtrooms around the country. Another issue: the copy of the EHR provided attorneys on both sides looks nothing like the EHR as seen on a computer screen. Many plaintiff’s lawyers want to look at the EHR on the computer screen. This has set of another legal wrangling. What does all of this mean? If you are representing injured parties seeing the Audit Trail is a welcomed breath of fresh air. If you are the doctor, not so much. Stay tuned for future developments.
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