The Supreme Court of the State of New York Appellate Division: Second Judicial Department (“New York Appellate Court”) stated in its Decision & Order dated March 20, 2019: “[a]though [the defendant hospital] argued that the audit trail may contain information that would not be useful to the plaintiffs, it did not dispute that the audit trail would nevertheless contain information pertaining to the medical care that it provided to the injured plaintiff in the wake of his foot surgery … Under the circumstances of this case, the Supreme Court improvidently exercised its discretion in denying that branch of the plaintiffs’ motion which was to compel [the defendant hospital] to produce the audit trail of the injured plaintiff’s patient records for the period of May 1, 2012, through May 17, 2012.”
The plaintiff filed his New York medical malpractice lawsuit against the defendant hospital, alleging that the defendant hospital, through its employees and agents, undertook to provide medical services to the plaintiff between February 6, 2012 and May 17, 2012, and that on May 1, 2012, the plaintiff underwent surgery on his left foot but the defendant hospital “failed to timely and properly manage and treat [the injured] plaintiff’s ischemic injury following [the] surgery,” leading to “substantial swelling, infection and gangrene that ultimately required the amputation of his leg from the knee down.”
The plaintiff sought from the defendant hospital the audit trail of his patient records for the period of May 1, 2012 through May 17, 2012, contending that every time the plaintiff’s electronic medical records were accessed during the relevant period, an entry was created in the defendant hospital’s database which contained “information about the [injured plaintiff’s] care” (i.e., the audit trail of the injured plaintiff’s patient records). The plaintiff argued that since the allegations of medical negligence included “the failure to timely and properly diagnose and treat [the injured] plaintiff’s medical complications following his foot surgery,” the requested portion of the audit trail was relevant to “the timing and substance of [the injured] plaintiff’s care following [that] surgery.”
The trial court denied the plaintiff’s motion to compel the defendant hospital to produce the audit trail of the injured plaintiff’s patient records for the period of May 1, 2012 through May 17, 2012, stating that the requested audit trail constituted metadata, and that metadata was not routinely produced unless the requesting party shows good cause. The trial court determined that the plaintiff failed to sustain his burden of demonstrating the necessity and utility of audit trail production.
The New York Appellate Court stated that disclosure in civil actions is generally governed by CPLR 3101(a), which provides that “[t]here shall be full disclosure of all matter material and necessary in the prosecution or defense of an action, regardless of the burden of proof.” The New York Appellate Court stated that if there is any possibility that the information is sought in good faith for possible use as evidence-in-chief or for cross-examination or in rebuttal, it should be considered matter material in the action.
The New York Appellate Court stated that the plaintiff demonstrated, and the defendant hospital did not dispute, that an audit trail generally shows the sequence of events related to the use of a patient’s electronic medical records; i.e., who accessed the records, when and where the records were accessed, and changes made to the records. The New York Appellate Court held: “the requested audit trail was relevant to the allegations of negligence that underlie this medical malpractice action in that the audit trail would provide, or was reasonably likely to lead to, information bearing directly on the post-operative care that was provided to the injured plaintiff. Moreover, the plaintiffs’ request was limited to the period immediately following the injured plaintiff’s surgery. The plaintiffs further demonstrated that such disclosure was also needed to assist preparation for trial by enabling their counsel to ascertain whether the patient records that were eventually provided to them were complete and unaltered.”
Source Vargas v. Lee, D58587.
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