Most hospitals and medical facilities have shifted from using paper medical records to electronic health records (EHR) to create, access and store patient information. For example, Epic Systems Corp. (Epic), a health care software company that provides EHR services, holds over half of all U.S. hospitals’ patient medical records. The self-proclaimed story behind Epic’s name is simple: “An ‘epic’ is a glorious recounting of a nation’s events. Like the Iliad or Odyssey, our electronic health records chronicle the story of a patient’s health care over time.”
However, in medical malpractice litigation involving claims such as the delayed diagnosis of or failure to treat a particular medical condition—where knowing the story of a patient’s health care over time is paramount—health care defendants refuse to provide plaintiff-patients access to their EHR. Instead, defendants will provide a paper printout of portions of the EHR, what medical facilities self-define as the “legal medical record,” and audit trails. Audit trails are spreadsheets created by medical facilities’ lawyers that show what times individual health care providers accessed a patient’s EHR; however, these spreadsheets fail to show what specific information was viewed, rendering them mostly useless. But because a patient’s EHR contains all of the information entered, viewable, modified, cut and pasted, and deleted by health care providers, in chronological and sortable order, access to a patient’s EHR can reveal crucial, detailed, and time-stamped information not otherwise knowable from select paper printouts and audit trails.
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