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Electronic health records - lawyers beware when requesting

Posted by Michael A. D'Amico of D'Amico & Pettinicchi, LLC on Oct 16, 2014 in Electronic Health Records

As medical records have transitioned to the era of the electronic health record(EHR), also electronic medical record(EMR), lawyers requesting records must beware. In the old days when records were written, regulations often provided that if a change was made to the record it was to be crossed out by a single line and initialed so that the change made was clear. With the rise of the EMR, changes are not known based on the records typically provided pursuant to authorization. As an analogy when a document is created in Word, unless the "track changes" feature is activated, any changes made are not visible in the final document. It is therefore imperative that when requesting an EMR that the audit log, sometimes referred to as audit trail, is obtained. This audit log will typically show when the EMR was accessed, by whom and why. Even still the audit log often does not show what the content was that was changed. To acquire the content change it is necessary to ask for what is colloquially referred to as the "edit trail" or edit history. Edit trails are not always maintained but regardless should be requested with the audit log. The audit log together with the edit trail will provide the majority of important information to the requesting attorney. There are other parts of an EMR referred to as clinical decision support(CDS) features. CDS includes alerts and reminders for the health care provider when certain data is input into the EMR. An example would be an alert that a new medication interacts with an existing medication. In sum, the world of medical records has become less transparent than in the past and a detailed analysis of the EMR is necessary to understand the care provided to a patient.