Metadata from emergency medical records (EMRs) can show when a chart entry was made, modifications to a chart entry, how long a chart was reviewed, and when it was accessed. This type of information can help determine the timing and substance of a plaintiff’s care. In other words, the information can help provide the evidence needed to show medical negligence. However, when plaintiffs conduct discovery requests, hospitals are not always forthcoming with EMRs and their accompanying metadata. In Gilbert v. Highland Hospital, the plaintiff moved to compel discovery of the EMR metadata to determine which physicians were involved in the plaintiff’s care, among other reasons. The court granted the plaintiff’s motion to compel discovery because the metadata was relevant to the medical malpractice claims and did not constitute a fishing expedition, a term used to describe overly broad discovery requests.
Another important New York medical malpractice decision regarding EMR metadata was Vargas v. Lee, although the court found that the plaintiff did not make the necessary showing to compel production of metadata. The case set a standard for plaintiffs seeking the production of such materials. The plaintiff in Vargas requested information related to the timing and substance of the plaintiff’s care in a specific three-week time frame. The plaintiff requested the EMR metadata for evidentiary reasons. The defendants objected to the disclosure because they alleged that the request was not relevant, overly burdensome, and administratively impossible. Interestingly, the court reasoned that metadata is discoverable when there are allegations of record alterations or manipulations or a “cover up” with regard to improper or negligent health care. Specifically, the court stated that metadata is relevant when the process of creation for a document is at issue or there are document authenticity concerns. The court ruled that the plaintiff could receive all of the information they needed from the patient treatment details from the already produced EMR.
EMR metadata may need to be requested separate and apart from the EMRs themselves. It could be extremely important in medical malpractice actions to receive this sort of information to determine the quality of care provided. In addition, this information is required to be kept by New York hospitals under Title 10 of the New York Codes, Rules and Regulations. Therefore, the metadata, assuming the hospital is following applicable law, should be available for production; it is a matter of requesting the information during pre-trial discovery. Commentators have noted that plaintiffs’ attorneys in medical malpractice actions should request metadata from EMRs, assuming it is useful in their case.
If you have been injured because of medical malpractice, it’s important to have the assistance of an experienced Rochester, New York medical malpractice attorney. Pre-trial procedures and discovery rules can be technical and difficult to navigate, and the attorneys at DeFrancisco & Falgiatano Personal Injury Lawyers can help. If you would like to talk to one of our lawyers about your case, call us at 315-479-9000.
More Blog Posts:
Expert Witness Fails to Properly Review Medical Evidence, Sinking Plaintiff’s New York Medical Malpractice Case, Rochester Medical Malpractice and Personal Injury Blog, October 2, 2017
Continuous Treatment Doctrine at Issue in New York Cancer Misdiagnosis Case, Rochester Medical Malpractice and Personal Injury Blog, September 21, 2017