With the advent and transition of records into the electronic realm, metadata has become an increasingly integral aspect of personal injury litigation. Specifically, in medical malpractice litigation, electronic discovery (e-discovery) of the electronic medical record (EMR) and the analysis of metadata offers valuable information. While electronically recording patient information generally encourages complete documentation and results in the streamlining of patient care, frequently issue arise as to the integrity of the EMR. Unlike paper charts, an EMR is able to track and store information regarding access to and manipulation of the patient’s record. This information, referred to as metadata, provides insight as it pertains to a health care provider’s code of conduct or the manner in which he or she delivered medical or nursing care. In this sense, metadata has the potential for exposing wrongdoings and brings into question the credibility of the defendant health care provider.

Metadata is ubiquitous to all EMR systems and, most often, is an automatically generated computer record detailing audit trails including user access and activities while in the EMR. Most importantly, metadata certifies how, when, where, and by whom electronic documents and files have been authored, viewed, altered, printed, or otherwise accessed. By using experts to analyze said metadata, critical alterations in the EMR may be identified. In medical malpractice, metadata is increasingly driving case theories and generating case value through the identification of post-injury alterations to the medical record. The universe of data that is unveiled by peering behind the final electronic medical chart is a fertile ground for the identification of “smoking guns.”

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