Court Refuses to Require Party to Produce Medical Record Audit Trail
The Supreme Court of Kings County, New York, recently ruled that a hospital could not be compelled to produce the audit trail for its electronic records without a showing of good cause from the patient. In Vargas v. Lee et. al., 2015 NY Slip Op 31048(U) (Jun. 5, 2015), the court held that Plaintiff had not demonstrated good cause and that Defendants were not required to produce an audit trail.
Plaintiff underwent surgery at the defendant hospital. Due to complications, his left leg had to be amputated. The hospital produced Plaintiff’s electronic medical records; Plaintiff requested that the audit trail for these records also be produced, and the hospital objected.
The court noted that it typically only requires a party to produce metadata related to medical records if the party seeking it can demonstrate good cause. The court held that Plaintiff did not adequately describe how the audit trail would provide information different from that already provided by the produced electronic medical records. Plaintiff argued that he needed the audit trail to discover information regarding the “timing and substance” of his care; however, the court decided that such details existed in the documents Defendants already produced. Because Plaintiff did not seek to show that Defendants had altered the records or that the records were inauthentic, nor did Plaintiff put at issue the manner in which Defendants created the documents, the court ruled that Plaintiff did not meet its burden to show sufficient good cause to require Defendants to produce the audit trail.