Baker v. Geisinger Cnty. Med. Ctr., 2017 Pa. Dist. & Cnty. Dec. LEXIS 11277
(Lackawanna County Court of Common Pleas, April 7, 2017) (Nealon, J.)
In this malpractice litigation against a hospital, the plaintiff has filed a motion to compel the hospital to produce the “audit trail” for her electronic medical records from the date of her admission to the hospital to the present. Electronically stored information is discoverable if it is relevant and can be produced without undue cost, burden or delay, and substantially similar information is not available with less burden. An audit trail documents every occasion that an electronic medical record is accessed, what specific information is reviewed, who entered or altered any information in the chart, what information was entered or later changed, who accessed, reviewed or added information to the chart, and when and where that activity occurred. Plaintiff has produced discovery depositions reflecting disparities between the testimonial recollections of her healthcare providers and the entries contained in her hospital chart. The audit trail will reveal which healthcare providers reviewed what information, when they acquired that knowledge, where and when they made their respective entries, and whether those entries have ever been edited or altered. Since the audit trail is relevant to the claims at issue and may be secured and produced without significant cost or hardship, it is discoverable under the proportionality standard governing discovery requests for electronically stored information, and plaintiff’s motion to compel the audit trail will be granted.
Neither party has cited any reported case in Pennsylvania addressing the discoverability of audit trails, nor has our independent research unearthed any such authority.
Other state and federal courts have found audit trails to be discoverable and have rejected arguments that audit trails of patients’ electronic medical records are irrelevant or protected from discovery by the peer review privilege or the work product doctrine. See Gilbert v. Highland Hospital, 52 Misc. 3d 555, 558-559, 31 N.Y.S. 3d 397, 400 (Sup. Ct., Monroe County 2016); Hall v. Flannery, 2015 U.S. Dist. LEXIS 57454, 2015 WL 2008345, at *4 (S.D. Ill. 2015); Osborne v. Billings Clinic, 2015 U.S. Dist. LEXIS 38716, 2015 WL 1412626, at *4 (D. Mont. 2015); Fernandez-Rajotte v. Dartmouth Hitchcock Medical Center, 2014 WL 12540494. (N. H. Super. 2014). Under the proportionality standard for ESI discovery requests, Baker is entitled to discovery of the audit trail for her EMR at Geisinger CMC from the date of her admission on January 7, 2015, through April 3, 2017, which is the last date for which Geisinger CMC has retrieved an accurate audit trail.
